- Email: [email protected]
Carbon dioxide laser surgery for snoring: Results in 192 patients
Carbon dioxide laser surgery for snoring: Results in 192 patients DAVID SHOOU-TAW CHENG, MD, JIMMY CHIH-MING WENG, MD, PO-WEN YANG, MD, and LIANG-HSIN STEPHEN CHENG, MD, Bellflower, California, and Tainan, Taiwan
Laser-assisted uvulopalatoplasty has been introduced as an alternative to uvulopalatopharyngoplasty for treatment of snoring and potentially of obstructive sleep apnea syndrome. Between July 1994 and June 1996, 192 patients underwent 227 laserassisted uvulopalatoplasty procedures. Loud habitual snoring was evaluated in 42 women (21.8%) and 150 men (78.2%), who were then treated with laser-assisted uvulopalatoplasty. Among the 192 patients (227 procedures), with ages from 18 to 81 years (mean 42.6 years), 15.6% (30 patients) had more than one laser-assisted uvulopalatoplasty treatment. In our series, 80 patients (42.1%) had a history of obstructive sleep apnea syndrome in addition to snoring. Laser-assisted uvulopalatoplasty treatment in patients with loud snoring resulted in elimination of snoring in 61%, partial improvement of snoring in 26%, and no improvement in 13%. The overall success rate was 87%. The mean body mass index was significantly higher in the patients with no response after the operation (27.9 kg/m2) compared with that in the patients with a good response (25.9 kg/m2). Obese (body mass index >30 kg/m2) patients were more likely to have no response to laser-assisted uvulopalatoplasty treatment of snoring than patients with an ideal body weight (body mass index <25 kg/m2) (p < 0.01). We conclude that the body mass index may be of significant value in the postoperative success rate of laser-assisted uvulopalatoplasty for the treatment of snoring. (Otolaryngol Head Neck Surg 1998;118:486-9.)
Snoring is a feature of upper airway obstruction that can be annoying to the snorer’s bed partner. Snoring can cause severe discord between the snorer and the bed partner, a great deal of tension, and even marital conflict. It is also a great embarrassment for the snorer. Habitual snoring affects 20% of the population, and its prevalence increases with age, with as many as 50% of men older than age 55 being affected.1 In 1990 Kamami introduced an approach to the treatment of snoring that combines the technology of the CO2 laser with the previously developed surgical approach of uvulopalatopharyngoplasty. This technique, termed laser-assisted uvulopalatoplasty (LAUP), allows progressive shortening and tightening of the uvula and palate to be done with the patient under general or local anesthesia.2 This approach has subsequently been popularized in the United States by Krespi et al.3 Its use has been expanded to include treatment of From Kaiser Hospital, Bellflower, Calif. (Dr. D. S.-T. Cheng), and Sin-Lau Christian Hospital, Tainan, Taiwan (Drs. Weng, Yang, and L.-H. S. Cheng). Reprint requests: David Shoou-Taw Cheng, MD, 9449 Imperial Highway, Building C, Suite 138, Downey, CA 90242. Copyright © 1998 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/98/$5.00 + 0 23/1/83799 486
patients with obstructive sleep apnea syndrome. We conducted a prospective study in 192 patients with loud habitual snoring at Sin-Lau Christian Hospital in Tainan, Taiwan, between July 1994 and June 1996. METHODS AND MATERIAL
The patient’s parents or spouse is an invaluable resource in obtaining an accurate history of snoring, apnea, and sleeping habits. A thorough history was taken with emphasis on detecting nightly snoring, tiredness, awakening, gasping for breath, headache on awakening, nasal obstruction, observation of sleep apnea, weight gain, alcohol use, or drug use. At Sin-Lau Christian Hospital in Tainan, Taiwan, 192 consecutive patients were selected for participation in the study between July 1994 and June 1996. A complete history was obtained and thorough physical and otolaryngologic examinations were performed. The nasopharynx, hypopharynx, and larynx were visualized with the use of a fiberoptic flexible nasolaryngoscope, with Müller’s maneuver performed at the levels of the nose, the nasopharynx, the oropharynx, and the base of the tongue. A radiologic sinus or lateral skull x-ray film, or both, was routinely taken and medical or surgical treatment was requested first if the patient was found to have a nasal pathologic condition, such as hypertrophic
Otolaryngology– Head and Neck Surgery Volume 118 Number 4
CHENG et al. 487
Table 1. Preoperative classification of patients by AAS value AAS*
No. of patients % Mean BMI (kg/m2) *Values
0
1
2
3
4
0
0
17 9 24.9
27 14 26.6
42 22 25.1
5
106 55 26.8
Total
192 100 26.1
given from 1 to 5, where 0 = none; 1 = extremely soft; 2 = soft; 3 = moderately loud; 4 = loud; and 5 = extremely loud.
Table 2. Response rate Factor evaluated
Total patients BMI (kg/m2) Mean SD LAUP + nasal operation LAUP + tonsillectomy LAUP alone
Good response (drop more than 1 AAS unit)
Some response (drop 1 AAS unit)
Success rate (good response + some response)
95 (61%) 25.9 4.1 17 (59%) 11 (100%) 67 (58%)
41 (26%) 27.0 3.6 11 (38%) 0 (0%) 30 (26%)
136 (87%)
rhinitis, sinusitis, or septal deviation of the nose or hypertrophic adenoid that caused nasal obstruction. An overnight polysomnogram at the medical center was recommended if severe apnea was observed by the bed partner. All patients completed a questionnaire to assess the severity of snoring and sleep apnea on the basis of the acoustic auditory scale (AAS) (Table 1) and the sleep apnea scale.3 If the patient was scheduled for LAUP with tonsillectomy general anesthesia was used for the procedure. Otherwise most patients were placed in an upright or semi-Fowler position and the procedure was done with local anesthesia. Anesthetic treatment began with 8% lidocaine spray (Xylocaine) applied to the palate and the base of the tongue. This was followed by infiltration of the base of the uvula and soft palate with a mixture of lidocaine and epinephrine. The procedure was done with a CO2 laser that had pieces designed to protect the posterior pharyngeal wall. The laser power was set at 15 to 20 W and vertical transpalatal incisions, approximately 1 cm long, were made bilaterally, through the soft palate just lateral to the base of the uvula.4 This was followed by partial vaporization of one half or one third of the uvula. The procedure was done in stages, with at least 6 weeks between treatments. Some patients also required septal and turbinate surgical procedures because of nasal obstruction or tonsillectomy because of enlarged tonsils. A questionnaire was completed after the laser surgical treatment at each follow-up visit. Subjective reports of improvement in snoring were obtained from the bed partners, who were asked to estimate the severity of the snoring volume on the basis of the AAS scale (Table 1).
28 (97%) 11 (100%) 97 (84%)
No response
Total (N = 156)
20 (13%) 27.9 4.4 1 (3%) 0 (0%) 19 (16%)
156 26.1 29 11 116
The partner or patient completed the AAS for snoring at the first month of follow-up and at 3 and 6 months. Pain was recorded daily for 3 weeks after the operation. The patient’s need for analgesics was also noted, in addition to any bleeding, dysphagia, change in appetite, postoperative evaluation, nasal regurgitation, or change in body weight. Patients and bed partners were also asked whether there was subjective improvement in other symptoms such as respiratory disturbance or sleep apnea. Preoperative and postoperative data were compared with use of the AAS scale of snoring severity. Good response was defined as a drop of 2 or more AAS units; some response was defined as a drop of 1 AAS unit. The success rate included patients with good response plus those with some response (Table 2). RESULTS
Of the 192 patients 167 (87.3%) were married and 25 (12.7%) were single or divorced; 42 (21.8%) were female and 150 (78.2%) were male. The mean age of the patients was 42.6 years with a range of 13 to 82 years. Initial body weight and height were recorded and the body mass index (BMI; weight in kilograms divided by the square of the height in meters) was calculated. The mean BMI was 26.1 kg/m2 with a range of 18.4 to 41.9 kg/m2. Among 227 procedures performed, 203 (89.7%) were done with the use of local anesthesia and 24 (10.3%) were done with general anesthesia; 197 (86.7%) procedures were done on an inpatient basis and 30 (13.3%) on an outpatient basis. Among the 192 patients, 15.6% (30 patients) had more than one LAUP treatment. We had a minimum follow-up of at least 4
Otolaryngology– Head and Neck Surgery April 1998
488 CHENG et al.
Table 3. Postoperative reduction in AAS value
Mean drop in AAS SD No. of patients
Ideal body weight
Overweight
Obese
1.97 1.03 61
1.81 0.96 67
1.36 1.06 28
Ideal body weight, BMI <25 kg/m2; overweight, BMI between 25 and 30 kg/m2; obese, BMI >30 kg/m2.
weeks with 36 patients lost to follow-up. The mean BMI for the apneic group was 27.2 kg/m2 (SD 4.2) compared with a mean BMI for the nonapneic group of 25.8 kg/m2 (SD 3.7) (p < 0.05, Student’s t test). Table 2 shows that the patients with a postoperative good response had a mean BMI of 25.9 kg/m2, which was lower than that of patients with some response (27.0 kg/m2), which was statistically significantly lower than that of patients with no response (27.9 kg/m2) (p < 0.05, Student’s t test). On stratification by BMI as shown in Table 3, the patients with an ideal body weight (BMI <25 kg/m2 [Forse et al.5]) had a mean drop in AAS units of 1.97, which was better than that for patients who were overweight (1.81 units) and statistically significantly better than that for obese patients (1.36 units) (p < 0.01, Student’s t test). There was also a statistically significant difference (p < 0.05, Student’s t test) between the values for obese and overweight patients. The LAUP surgical treatment was performed alone without other procedures in 78.9% of the cases, whereas 3.5% of the procedures were accompanied by nasal septoplasty and laser treatment of the turbinate, 5.6% with nasal septoplasty and turbinectomy, 10.2% with tonsillectomy, 0.6% with laser treatment over lingular tonsils, and 5.9% with laser treatment over the nasal turbinate only (Table 2). Most patients (63%) reported no postoperative complications, whereas 2.1% reported temporary bleeding, 31% temporary dysphagia, 21% poor appetite, 3% temporary velopharyngeal insufficiency, and 5% temporary regurgitation. Postoperative pain was significant,6 and most patients (70%) had mild to severe pain or discomfort of the throat for 4 to 10 days after the LAUP procedures. DISCUSSION
Snoring affects approximately 50% of men and 30% of women in the adult population, and half of these are habitual snorers. In our series, 78.2% were male and only 21.8% female: approximately four times more men than women. In our series 87.3% were married and 12.7%
were single, for an approximately seven times greater number of married patients whose spouses prompted the bed partner to be treated for troublesome snoring. Patients’ spouses generally ranked the severity of snoring higher than the patients did, and many patients sought the procedure primarily at the request of their spouses. The mean age in our series was 42.6 years, which is a little younger than reported in the literature, which showed an average age of about 45 to 55 years. Only 15.6% of the patients in our series had LAUP done in more than one stage. Most of our patients who showed no response or some response refused to undergo the second or third sessions, which is different from findings in other series, many of which reported the need for multiple-stage operations for the treatment to be most effective. In Taiwan the willingness to undergo revision was limited because of severe postoperative pain or sore throat, surgical phobia, difficulty with hospitalization, and other cultural factors. Therefore we recommend scheduling a single-stage procedure rather than a multiple-stage procedure in patients who have some of these difficulties. Table 2 shows that the patients with a postoperative good response had a mean BMI of 25.9 kg/m2, which was lower than that of patients with some response, which was statistically significantly lower than that of patients with no response. This indicates that BMI may be a significant factor in the success of LAUP for snoring7; in other words, the heavier and stockier the patient, the less likelihood there is of a successful outcome after the operation. On stratification by BMI as shown in Table 3, the patients with an ideal body weight had an improvement in snoring of 1.97 AAS units, which was better than that for patients who were overweight and statistically significantly better than that for obese patients. This suggests that the patient’s BMI may be useful in predicting the outcome of the LAUP surgical procedure for snoring. In our series, 11 patients with hypertrophic tonsils had tonsillectomy combined with LAUP, done under general anesthesia. All 11 patients had a good response to the operation (Table 2). We recommend routine tonsillectomy with LAUP, done under general anesthesia, for patients with hypertrophic tonsils. There was a high success rate (97%) of combination nasal operations with LAUP (Table 2). This further stresses the importance of doing nasal operations, septoplasty, and turbinate reduction as necessary to open up the nasal passages for relief of snoring. In our series, when nasal pathologic conditions were present, nasal operation was an important factor in the successful outcome of the procedure for the patient.
Otolaryngology– Head and Neck Surgery Volume 118 Number 4
In conclusion, LAUP cured snoring in 87% of the patients in the present study. Because of many factors, some of the patients refused to complete a multiplestage procedure. The literature strongly suggests performance of a multiple-staged procedure, but the willingness to repeat LAUP operations is limited in Taiwan. Only 30 patients (15.6%) out of 192 in our series were willing to undergo more than one session. Nasal surgical procedures or tonsillectomies, or both, are important if nasal or tonsil pathologic conditions are present. In our series BMI seemed to be an important factor in the outcome of LAUP for snoring. We thank Tsuey-Ying Horng, RN, head of the Infection Control Department, Sin-Lau Christian Hospital, Tainan, Taiwan, for her kind assistance in preparing this article.
CHENG et al. 489
REFERENCES 1. Blythe WR, Henrich DE, Pillsbury HC. Outpatient uvuloplasty: an inexpensive, single-staged procedure for the relief of symptomatic snoring. Otolaryngol Head Neck Surg 1995;113:1-4. 2. Mickelson SA. Laser-assisted uvulopalatoplasty for obstructive sleep apnea. Laryngoscope 1996;106:10-3. 3. Krespi YP, Pearlman SJ, Keidar A. Laser-assisted uvula-palatoplasty for snoring. J Otolaryngol 1994;23:328-34. 4. Morar P, Nandapalan V, Lesser THJ. Mucosal-strip/uvulectomy by the CO2 laser as a method of treating simple snoring. Clin Otolaryngol 1995;20:308-11. 5. Forse A, Benotti PN, Blackburn GL. Morbid obesity: weighing the treatment options–surgical options. Nutr Today 1989;24:10-6. 6. Terris DJ, Clerk AA, Norbash AM, et al. Characterization of postoperative edema following laser-assisted uvulopalatoplasty using MRI and polysomnography: implications for the outpatient treatment of obstructive sleep apnea syndrome. Laryngoscope 1996;106:124-8. 7. Walker RP, Grigg-Damberger MM, Gopalsami C, et al. Laser assisted uvulopalatoplasty for snoring and obstructive sleep apnea: results in 170 patients. Laryngoscope 1995;105:938-43.
European Consensus Development Conference on Neonatal Hearing Screening
This conference will be held May 15-16, 1998, in Milan, Italy. Large neonatal hearing screening programs have started in several European countries over the last 2 to 3 years, but many who work in clinics may not be fully aware of the results achievable in this rapidly growing area. The European Project AHEAD from the Biomedical and Health Programme of the European Commission (1996-1999) is showing that there is an urgent need to evaluate effectiveness and to establish standards of best practice. This conference is an ideal forum for discussion of this important issue. Specialists in related fields will review the most up-to-date evidence in their own field, thus providing the evidence to a panel of leading experts in an open forum. Full deliberations of the panel will be published at a later date. For further information, contact Dr. F. Grandori, Center of Biomedical Engineering, Polytechnic of Milan, Piazza Leonardo da Vinci 32, 20133 Milan, Italy; fax 39-2-23993360; e-mail, [email protected].
Laser-assisted uvulopalatoplasty has been introduced as an alternative to uvulopalatopharyngoplasty for treatment of snoring and potentially of obstructive sleep apnea syndrome. Between July 1994 and June 1996, 192 patients underwent 227 laserassisted uvulopalatoplasty procedures. Loud habitual snoring was evaluated in 42 women (21.8%) and 150 men (78.2%), who were then treated with laser-assisted uvulopalatoplasty. Among the 192 patients (227 procedures), with ages from 18 to 81 years (mean 42.6 years), 15.6% (30 patients) had more than one laser-assisted uvulopalatoplasty treatment. In our series, 80 patients (42.1%) had a history of obstructive sleep apnea syndrome in addition to snoring. Laser-assisted uvulopalatoplasty treatment in patients with loud snoring resulted in elimination of snoring in 61%, partial improvement of snoring in 26%, and no improvement in 13%. The overall success rate was 87%. The mean body mass index was significantly higher in the patients with no response after the operation (27.9 kg/m2) compared with that in the patients with a good response (25.9 kg/m2). Obese (body mass index >30 kg/m2) patients were more likely to have no response to laser-assisted uvulopalatoplasty treatment of snoring than patients with an ideal body weight (body mass index <25 kg/m2) (p < 0.01). We conclude that the body mass index may be of significant value in the postoperative success rate of laser-assisted uvulopalatoplasty for the treatment of snoring. (Otolaryngol Head Neck Surg 1998;118:486-9.)
Snoring is a feature of upper airway obstruction that can be annoying to the snorer’s bed partner. Snoring can cause severe discord between the snorer and the bed partner, a great deal of tension, and even marital conflict. It is also a great embarrassment for the snorer. Habitual snoring affects 20% of the population, and its prevalence increases with age, with as many as 50% of men older than age 55 being affected.1 In 1990 Kamami introduced an approach to the treatment of snoring that combines the technology of the CO2 laser with the previously developed surgical approach of uvulopalatopharyngoplasty. This technique, termed laser-assisted uvulopalatoplasty (LAUP), allows progressive shortening and tightening of the uvula and palate to be done with the patient under general or local anesthesia.2 This approach has subsequently been popularized in the United States by Krespi et al.3 Its use has been expanded to include treatment of From Kaiser Hospital, Bellflower, Calif. (Dr. D. S.-T. Cheng), and Sin-Lau Christian Hospital, Tainan, Taiwan (Drs. Weng, Yang, and L.-H. S. Cheng). Reprint requests: David Shoou-Taw Cheng, MD, 9449 Imperial Highway, Building C, Suite 138, Downey, CA 90242. Copyright © 1998 by the American Academy of Otolaryngology– Head and Neck Surgery Foundation, Inc. 0194-5998/98/$5.00 + 0 23/1/83799 486
patients with obstructive sleep apnea syndrome. We conducted a prospective study in 192 patients with loud habitual snoring at Sin-Lau Christian Hospital in Tainan, Taiwan, between July 1994 and June 1996. METHODS AND MATERIAL
The patient’s parents or spouse is an invaluable resource in obtaining an accurate history of snoring, apnea, and sleeping habits. A thorough history was taken with emphasis on detecting nightly snoring, tiredness, awakening, gasping for breath, headache on awakening, nasal obstruction, observation of sleep apnea, weight gain, alcohol use, or drug use. At Sin-Lau Christian Hospital in Tainan, Taiwan, 192 consecutive patients were selected for participation in the study between July 1994 and June 1996. A complete history was obtained and thorough physical and otolaryngologic examinations were performed. The nasopharynx, hypopharynx, and larynx were visualized with the use of a fiberoptic flexible nasolaryngoscope, with Müller’s maneuver performed at the levels of the nose, the nasopharynx, the oropharynx, and the base of the tongue. A radiologic sinus or lateral skull x-ray film, or both, was routinely taken and medical or surgical treatment was requested first if the patient was found to have a nasal pathologic condition, such as hypertrophic
Otolaryngology– Head and Neck Surgery Volume 118 Number 4
CHENG et al. 487
Table 1. Preoperative classification of patients by AAS value AAS*
No. of patients % Mean BMI (kg/m2) *Values
0
1
2
3
4
0
0
17 9 24.9
27 14 26.6
42 22 25.1
5
106 55 26.8
Total
192 100 26.1
given from 1 to 5, where 0 = none; 1 = extremely soft; 2 = soft; 3 = moderately loud; 4 = loud; and 5 = extremely loud.
Table 2. Response rate Factor evaluated
Total patients BMI (kg/m2) Mean SD LAUP + nasal operation LAUP + tonsillectomy LAUP alone
Good response (drop more than 1 AAS unit)
Some response (drop 1 AAS unit)
Success rate (good response + some response)
95 (61%) 25.9 4.1 17 (59%) 11 (100%) 67 (58%)
41 (26%) 27.0 3.6 11 (38%) 0 (0%) 30 (26%)
136 (87%)
rhinitis, sinusitis, or septal deviation of the nose or hypertrophic adenoid that caused nasal obstruction. An overnight polysomnogram at the medical center was recommended if severe apnea was observed by the bed partner. All patients completed a questionnaire to assess the severity of snoring and sleep apnea on the basis of the acoustic auditory scale (AAS) (Table 1) and the sleep apnea scale.3 If the patient was scheduled for LAUP with tonsillectomy general anesthesia was used for the procedure. Otherwise most patients were placed in an upright or semi-Fowler position and the procedure was done with local anesthesia. Anesthetic treatment began with 8% lidocaine spray (Xylocaine) applied to the palate and the base of the tongue. This was followed by infiltration of the base of the uvula and soft palate with a mixture of lidocaine and epinephrine. The procedure was done with a CO2 laser that had pieces designed to protect the posterior pharyngeal wall. The laser power was set at 15 to 20 W and vertical transpalatal incisions, approximately 1 cm long, were made bilaterally, through the soft palate just lateral to the base of the uvula.4 This was followed by partial vaporization of one half or one third of the uvula. The procedure was done in stages, with at least 6 weeks between treatments. Some patients also required septal and turbinate surgical procedures because of nasal obstruction or tonsillectomy because of enlarged tonsils. A questionnaire was completed after the laser surgical treatment at each follow-up visit. Subjective reports of improvement in snoring were obtained from the bed partners, who were asked to estimate the severity of the snoring volume on the basis of the AAS scale (Table 1).
28 (97%) 11 (100%) 97 (84%)
No response
Total (N = 156)
20 (13%) 27.9 4.4 1 (3%) 0 (0%) 19 (16%)
156 26.1 29 11 116
The partner or patient completed the AAS for snoring at the first month of follow-up and at 3 and 6 months. Pain was recorded daily for 3 weeks after the operation. The patient’s need for analgesics was also noted, in addition to any bleeding, dysphagia, change in appetite, postoperative evaluation, nasal regurgitation, or change in body weight. Patients and bed partners were also asked whether there was subjective improvement in other symptoms such as respiratory disturbance or sleep apnea. Preoperative and postoperative data were compared with use of the AAS scale of snoring severity. Good response was defined as a drop of 2 or more AAS units; some response was defined as a drop of 1 AAS unit. The success rate included patients with good response plus those with some response (Table 2). RESULTS
Of the 192 patients 167 (87.3%) were married and 25 (12.7%) were single or divorced; 42 (21.8%) were female and 150 (78.2%) were male. The mean age of the patients was 42.6 years with a range of 13 to 82 years. Initial body weight and height were recorded and the body mass index (BMI; weight in kilograms divided by the square of the height in meters) was calculated. The mean BMI was 26.1 kg/m2 with a range of 18.4 to 41.9 kg/m2. Among 227 procedures performed, 203 (89.7%) were done with the use of local anesthesia and 24 (10.3%) were done with general anesthesia; 197 (86.7%) procedures were done on an inpatient basis and 30 (13.3%) on an outpatient basis. Among the 192 patients, 15.6% (30 patients) had more than one LAUP treatment. We had a minimum follow-up of at least 4
Otolaryngology– Head and Neck Surgery April 1998
488 CHENG et al.
Table 3. Postoperative reduction in AAS value
Mean drop in AAS SD No. of patients
Ideal body weight
Overweight
Obese
1.97 1.03 61
1.81 0.96 67
1.36 1.06 28
Ideal body weight, BMI <25 kg/m2; overweight, BMI between 25 and 30 kg/m2; obese, BMI >30 kg/m2.
weeks with 36 patients lost to follow-up. The mean BMI for the apneic group was 27.2 kg/m2 (SD 4.2) compared with a mean BMI for the nonapneic group of 25.8 kg/m2 (SD 3.7) (p < 0.05, Student’s t test). Table 2 shows that the patients with a postoperative good response had a mean BMI of 25.9 kg/m2, which was lower than that of patients with some response (27.0 kg/m2), which was statistically significantly lower than that of patients with no response (27.9 kg/m2) (p < 0.05, Student’s t test). On stratification by BMI as shown in Table 3, the patients with an ideal body weight (BMI <25 kg/m2 [Forse et al.5]) had a mean drop in AAS units of 1.97, which was better than that for patients who were overweight (1.81 units) and statistically significantly better than that for obese patients (1.36 units) (p < 0.01, Student’s t test). There was also a statistically significant difference (p < 0.05, Student’s t test) between the values for obese and overweight patients. The LAUP surgical treatment was performed alone without other procedures in 78.9% of the cases, whereas 3.5% of the procedures were accompanied by nasal septoplasty and laser treatment of the turbinate, 5.6% with nasal septoplasty and turbinectomy, 10.2% with tonsillectomy, 0.6% with laser treatment over lingular tonsils, and 5.9% with laser treatment over the nasal turbinate only (Table 2). Most patients (63%) reported no postoperative complications, whereas 2.1% reported temporary bleeding, 31% temporary dysphagia, 21% poor appetite, 3% temporary velopharyngeal insufficiency, and 5% temporary regurgitation. Postoperative pain was significant,6 and most patients (70%) had mild to severe pain or discomfort of the throat for 4 to 10 days after the LAUP procedures. DISCUSSION
Snoring affects approximately 50% of men and 30% of women in the adult population, and half of these are habitual snorers. In our series, 78.2% were male and only 21.8% female: approximately four times more men than women. In our series 87.3% were married and 12.7%
were single, for an approximately seven times greater number of married patients whose spouses prompted the bed partner to be treated for troublesome snoring. Patients’ spouses generally ranked the severity of snoring higher than the patients did, and many patients sought the procedure primarily at the request of their spouses. The mean age in our series was 42.6 years, which is a little younger than reported in the literature, which showed an average age of about 45 to 55 years. Only 15.6% of the patients in our series had LAUP done in more than one stage. Most of our patients who showed no response or some response refused to undergo the second or third sessions, which is different from findings in other series, many of which reported the need for multiple-stage operations for the treatment to be most effective. In Taiwan the willingness to undergo revision was limited because of severe postoperative pain or sore throat, surgical phobia, difficulty with hospitalization, and other cultural factors. Therefore we recommend scheduling a single-stage procedure rather than a multiple-stage procedure in patients who have some of these difficulties. Table 2 shows that the patients with a postoperative good response had a mean BMI of 25.9 kg/m2, which was lower than that of patients with some response, which was statistically significantly lower than that of patients with no response. This indicates that BMI may be a significant factor in the success of LAUP for snoring7; in other words, the heavier and stockier the patient, the less likelihood there is of a successful outcome after the operation. On stratification by BMI as shown in Table 3, the patients with an ideal body weight had an improvement in snoring of 1.97 AAS units, which was better than that for patients who were overweight and statistically significantly better than that for obese patients. This suggests that the patient’s BMI may be useful in predicting the outcome of the LAUP surgical procedure for snoring. In our series, 11 patients with hypertrophic tonsils had tonsillectomy combined with LAUP, done under general anesthesia. All 11 patients had a good response to the operation (Table 2). We recommend routine tonsillectomy with LAUP, done under general anesthesia, for patients with hypertrophic tonsils. There was a high success rate (97%) of combination nasal operations with LAUP (Table 2). This further stresses the importance of doing nasal operations, septoplasty, and turbinate reduction as necessary to open up the nasal passages for relief of snoring. In our series, when nasal pathologic conditions were present, nasal operation was an important factor in the successful outcome of the procedure for the patient.
Otolaryngology– Head and Neck Surgery Volume 118 Number 4
In conclusion, LAUP cured snoring in 87% of the patients in the present study. Because of many factors, some of the patients refused to complete a multiplestage procedure. The literature strongly suggests performance of a multiple-staged procedure, but the willingness to repeat LAUP operations is limited in Taiwan. Only 30 patients (15.6%) out of 192 in our series were willing to undergo more than one session. Nasal surgical procedures or tonsillectomies, or both, are important if nasal or tonsil pathologic conditions are present. In our series BMI seemed to be an important factor in the outcome of LAUP for snoring. We thank Tsuey-Ying Horng, RN, head of the Infection Control Department, Sin-Lau Christian Hospital, Tainan, Taiwan, for her kind assistance in preparing this article.
CHENG et al. 489
REFERENCES 1. Blythe WR, Henrich DE, Pillsbury HC. Outpatient uvuloplasty: an inexpensive, single-staged procedure for the relief of symptomatic snoring. Otolaryngol Head Neck Surg 1995;113:1-4. 2. Mickelson SA. Laser-assisted uvulopalatoplasty for obstructive sleep apnea. Laryngoscope 1996;106:10-3. 3. Krespi YP, Pearlman SJ, Keidar A. Laser-assisted uvula-palatoplasty for snoring. J Otolaryngol 1994;23:328-34. 4. Morar P, Nandapalan V, Lesser THJ. Mucosal-strip/uvulectomy by the CO2 laser as a method of treating simple snoring. Clin Otolaryngol 1995;20:308-11. 5. Forse A, Benotti PN, Blackburn GL. Morbid obesity: weighing the treatment options–surgical options. Nutr Today 1989;24:10-6. 6. Terris DJ, Clerk AA, Norbash AM, et al. Characterization of postoperative edema following laser-assisted uvulopalatoplasty using MRI and polysomnography: implications for the outpatient treatment of obstructive sleep apnea syndrome. Laryngoscope 1996;106:124-8. 7. Walker RP, Grigg-Damberger MM, Gopalsami C, et al. Laser assisted uvulopalatoplasty for snoring and obstructive sleep apnea: results in 170 patients. Laryngoscope 1995;105:938-43.
European Consensus Development Conference on Neonatal Hearing Screening
This conference will be held May 15-16, 1998, in Milan, Italy. Large neonatal hearing screening programs have started in several European countries over the last 2 to 3 years, but many who work in clinics may not be fully aware of the results achievable in this rapidly growing area. The European Project AHEAD from the Biomedical and Health Programme of the European Commission (1996-1999) is showing that there is an urgent need to evaluate effectiveness and to establish standards of best practice. This conference is an ideal forum for discussion of this important issue. Specialists in related fields will review the most up-to-date evidence in their own field, thus providing the evidence to a panel of leading experts in an open forum. Full deliberations of the panel will be published at a later date. For further information, contact Dr. F. Grandori, Center of Biomedical Engineering, Polytechnic of Milan, Piazza Leonardo da Vinci 32, 20133 Milan, Italy; fax 39-2-23993360; e-mail, [email protected].