The same group confirmed these findings in a month follow-up study in 12 patients with obstructive tonsil hypertrophy Friedman et al. The amount of tonsil reduction had a wide range and was unpredictable.
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Only mild postoperative pain was observed in all patients. No intra- or postoperative bleeding was noticed. However, radiofrequency tonsil reduction was not recommended as a standard technique for tonsil reduction. The tonsillotomy group had less intra-operative bleeding and no postoperative bleeding, while the tonsillectomy group had six postoperative bleedings.
Postoperative pain was significantly less in the tonsillotomy group. In a follow-up study 1 yr after radiofrequency tonsillotomy, Ericsson and Hultcrantz showed that both tonsillotomy and tonsillectomy equally and effectively improved quality of life.
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Radiofrequency tonsil reduction appears to be a minimally invasive procedure with limited morbidity compared with tonsillectomy. The amount of tonsil reduction is significant but unpredictable. No conclusion on efficacy in OSA can be drawn since none of the studies included polysomnographic data. Radiofrequency tonsil reduction appears to have fewer side-effects such as intra- and postoperative bleeding and less postoperative pain. Tonsil re-growth might occur but has not been studied thoroughly.
Radiofrequency tonsil reduction is not recommended as a single procedure for the treatment of OSA D. UPPP and laser-assisted uvulopalatoplasty LAUP aim to diminish anatomical upper airway obstruction at the oropharyngeal level by reducing soft palate redundancy UPPP enlarges the retropalatal airway by trimming and reorienting the posterior and anterior lateral pharyngeal pillars, and by excising the uvula and the posterior soft palate LAUP is an office-based surgical procedure that progressively shortens and tightens the uvula and palate through a series of carbon dioxide laser incisions and vaporisations In the large majority of apnoeic patients, upper airway collapses occur at multiple levels, i.
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Therefore, a surgical success with UPPP or LAUP can only be anticipated when pharyngeal collapse is limited to the retropalatal area, which is rarely the case in obese patients or those with severe sleep apnoea For these reasons, surgical procedures dedicated to the soft palate have been essentially studied in selected mild to moderate OSA populations with predominant oropharyngeal narrowing. Keyword combinations: sleep apnoea AND uvulopalatopharyngoplasty. Limit: clinical trial; no other limitations. Only prospective studies were taken into account.
Overview of the evidence. Randomised clinical trials comparing UPPP to no treatment or sham surgery groups are lacking. The number of patients assessed is generally limited, with only few publications evaluating UPPP alone without adjunctive surgical procedure. Even prospective studies demonstrate nearly systematic inclusion biases.
At the end, the majority of the available papers are clinical case series ranked as level 4 evidence. Such differences from one study to another are probably reflecting selection biases with potential good candidates being previously selected These studies also mainly included young or middle aged and lean subjects with mild to moderate sleep apnoea.
Failure of UPPP is usually attributed to secondary sites of obstruction located more caudally in the upper airway or to persistent retropalatal collapse due to an increased thickness of the soft palate after the procedure , However, selecting appropriate patients for UPPP surgery remains challenging, as physical examination, imaging techniques, upper airway pressure measurements and endoscopic examination are not systematically used, and no evidence exists demonstrating that any criteria are sufficiently useful in predicting good surgical outcomes In a case series, changes in AHI were significantly correlated with Friedman tongue position and tonsil size In the few studies having examined long-term evolution after surgery, efficacy of UPPP seems to diminish over time This seems to justify a long-term follow-up of these patients.
UPPP is substantially less effective than the use of oral appliances 88 , Other outcomes, such as subjective , or objective sleepiness, sleep structure and fragmentation, quality of life or cardiovascular changes, have been rarely reported. Serious life-threatening complications, including intubation difficulties, bleedings and acute upper airway obstruction, have been observed after UPPP with a 1.
Long-term side-effects e. Conclusions and recommendations. UPPP is a single-level surgical procedure working only in selected patients with obstruction limited to the oropharyngeal area. When proposing UPPP, potential benefits should be weighed against the risk of frequent long-term side-effects, among which velopharyngeal insufficiency, dry throat and abnormal swallowing, are the most common. Analysed studies were prospective but with selection biases, and therefore do not provide high-level evidence C.
Two randomised controlled trials are available , Ferguson et al. Surgery reduced snoring intensity and frequency. Larrosa et al. After LAUP surgery, the airway is further compromised by oedema in the early postoperative period with a potential risk of OSA exacerbation table e Conclusion and recommendation. Furthermore, cutting devices based on radiofrequency energy have also been developed to excise palatal tissue radiofrequency assisted uvulopalatoplasty, RAUP — Finally, various combinations have been proposed, for example the combination of interstitial radiofrequency surgery and RAUP Tissue excision is usually performed as a single step procedure, whereas the interstitial application routinely requires repeated treatment session.
Only studies using radiofrequency surgery as an isolated approach were analysed. Studies with patients with primary snoring were only selected with regard to morbidity and complications.
In addition, a recent review was evaluated regarding potential additional publications The data concerning OSA is limited and can hardly be compared due to the differences in devices and surgical techniques. Improvements in respiratory parameters have been described in groups of mild to moderate and more severely affected patients under interstitial radiofrequency at the soft palate , Moreover, RAUP has been shown to be superior to interstitial radiofrequency surgery, but was associated with higher postoperative morbidity However, there are inconsistent findings in daytime sleepiness or other sleep parameters.
A more recent, placebo-controlled study has shown that a single step radiofrequency intervention at the soft palate is not effective for the treatment of OSA table e20 Postoperative pain was minimal in nearly all published papers — No significant impact on fundamental frequency and formant frequency of vowels was detected.
Postoperative morbidity of radiofrequency tissue resection or combined approaches appears higher , Nevertheless, postoperative pain after RAUP is still significantly less pronounced and postoperative morbidity is still significantly lower compared to LAUP No controlled trials are available in sleep apnoea.
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All case series demonstrate a significant reduction in AHI after radiofrequency surgery. Radiofrequency surgery cannot be recommended, except in carefully selected patients C. The uvulopalatal flap has been introduced as a modification of the classic UPPP By the removal of the oral mucosa and salivatory glands, and incisions bilaterally into the posterior pillar an uvulopalatal flap is created. This flap is rotated upwards and sutured into the defect. The main disadvantage compared to UPPP is that despite preservation of all muscles no visible uvula is left acting as lubricating structure for the palate.
The evidence levels of the studies identified vary between 3b and 4. The data's evidence is restricted by the fact that the 12 studies are published by only three working groups. Therefore, it seems possible that several subjects might be included in multiple publications. The procedure can be performed under local and general anaesthesia — Complaints and complications are similar to a gentle UPPP Permanent velopharyngeal incompetence or nasopharyngeal stenoses have not been reported so far.
Powell et al. The tongue base procedures were identical in both study groups. Six papers investigated the effect of an isolated uvulopalatal flap without any other surgeries at the same time , — The AHI decreased significantly from 45 to 14 within 6—12 months after surgery. Significant improvement of quality of life as measured with the Mental Health 5 questionnaire All series were done by the same working group table e21 and e Studies investigating the uvulopalatal flap with tonsillectomy for OSA show a significant improvement of the severity of OSA and quality of life.
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No controlled studies exist comparing the uvulopalatal flap to other treatment modalities for OSA. The levels of evidence of all studies were classified as 4 C. Various study groups found that the uvulopalatal flap may be combined with other surgeries of the nose and the tongue base in the sense of MLS with acceptable perioperative risk 3b. The uvulopalatal flap turned out to be as effective as UPPP 3b. Due to a lack of evidence, uvulopalatal flaps are not recommended to treat simple snoring.
Uvulopalatal flaps can be recommended for OSA in patients with palatal obstruction C.
riadaribdai.tk Uvuloplatal flaps are a safe procedure that can be combined with other types of surgery within the upper airway to address OSA B. The Pillar method consists of placing three cylindrical, nonresorbable polyethylenterephthalate implants 18 mm long into and parallel to the midline of the soft palate with a distance of 3 mm to each other. The implants themselves, as well as the surrounding fibrosis, are intended to reduce three-dimensional flutter of the soft palate and therefore inspiratory airway resistance Only prospective studies were included.
Studies concerning snorers were only selected with regard to morbidity and complications. There is no experience in children so far. There are six case series and two randomised, placebo-controlled, double-blind trials table e Placebo treatment consisted of inserting an empty delivery tool no implant preloaded.
Only Friedman et al. Both randomised, placebo-controlled, double-blind studies show a superiority of implants over placebo. However, results are conflicting, as Steward et al. The ESS showed significant improvement in all case series and in the level 1b study conducted by Friedman et al. No difference was found compared to the placebo group in the study of Steward et al. Functional parameters as assessed by questionnaires such as the SF and the Functional Outcomes of Sleep Questionnaire demonstrated a significantly greater improvement in the treatment group compared to placebo.
Only minor discomfort, such as minor sore throat or foreign body sensation, was reported within the first 4 days post-procedure. Pain could be managed with simple analgesics such as paracetamol. There was no significant speech or swallowing disturbance after the procedure — A partial extrusion happened in Therefore Pillar implants cannot be recommended and may only be considered in patients with mild to moderate OSA, who are suitable with regard to their overall physical condition not or only moderately obese, no or small tonsils, no sign of retrolingual obstruction , if conservative approaches are not accepted by the patient B.
Interstitial radiofrequency surgery of the tongue base was first investigated in a porcine model using a temperature-controlled radiofrequency device. The procedure turned out to be safe and was transferred to the use in patients suffering from OSA. Various different devices are available, although the majority of the published trials have used temperature-controlled radiofrequency surgery.
In addition, a recent review was evaluated regarding potential additional publications.