- Email: [email protected]
Cautery-assisted palatal stiffening operation
CAUTERY-ASSISTED PALATAL STIFFENING OPERATION SUNGHUN CHO, MD, ERIC A. MAIR, MD, FAAP
Outpatient surgical therapy of habitual snoring and mild obstructive sleep apnea has evolved significantly in recent years. Cautery-assisted palatal stiffening operation (CAPSO) is a mucosal surgery that induces a midline palatal scar that stiffens the floppy palate. CAPSO has important advantages over uvulopalatopharyngoplasty, laser-assisted uvulopalatoplasty, and palatal radiofrequency ablation. CAPSO is a simple and safe office procedure that avoids the need for multiple-stage operations and does not rely on expensive laser systems or radiofrequency generators and hand pieces. The technique with "How I Do It" pearls is described in this article.
Cautery-assisted palatal stiffening operation (CAPSO) is a single, office-based surgery that treats both snoring and obstructive sleep apnea syndrome (OSAS) at the level of the soft palate. CAPSO uses standard electrocautery to remove the oral mucosa of the midline soft palate, inducing a scar that stiffens the floppy palate. It is a safe, simple, cost-effective procedure with comparable success rates with other palatal surgeries that treat primary palatal snoring or OSAS. 1-3
PATIENT SELECTION The patient who continues to have snoring at the level of the soft palate after nonsurgical methods have failed will benefit most from CAPSO. The patient is encouraged to bring his or her sleeping partner to the initial evaluation, in which a thorough interview and examination is performed. The nasal cavity, nasopharynx, oropharynx, hypopharynx, and larynx are viewed with fiberoptic nasopharyngolaryngoscopy (NPL) while the patient approximates the snoring sound in the presence of the sleeping partner or an audio tape of the snoring if no sleeping partner is available. Only patients with significant awake palatal flutter at the level of the soft palate as evidenced by NPL or acoustic polysomnography are considered for CAPSO. Exclusion criteria include uncontrolled hypothyroidism or considerable obstruction at other sites on NPL: 3-4+ tonsillar hypertrophy, notable nasal polyposis or septal deviation, or significant hypopharyngeal collapse without palatal flutter. Patients with documented OSAS are asked to quantify subjective symptoms of sleepiness via the Epworth Sleepiness Scale (ESS) before the procedure. 3 This is in addition to objective measures of OSAS via polysomnography.
From Wiiford Hall USAF Medical Center, Otolaryngology-Head and Neck Surgery, San Antonio, TX. Address reprint requests to: Eric A. Mair, MD, FAAP, Department of Otolaryngology, Wilford Hall USAF Medical Center, 2200 Bergquist Dr., Suite #1, San Antonio, TX 78236-6569. E-mail: [email protected] Copyright 2002, Elsevier Science (USA). All rights reserved. 1043-1810/02/1303-0006535.00/0
doi:10.1053/otot.2002.36439
188
PROCEDURAL TECHNIQUE CAPSO is a 10-minute surgical procedure performed in the otolaryngology clinic with the patient sitting in the examination chair. Topical anesthesia is first administered with 14% benzocaine (Cetylite Inc., Pennsauken, NJ) oral spray (gargle and spit) followed by a benzocaine gel "lollipop" (200 m g / g gel; Henry Schein, Port Washington, NY) applied on the end of a tongue depressor. The "lollipop" is held against the soft palate for 5 to 10 minutes. Next, a 27-gauge needle is used to inject 5 mL of 2% lidocaine with 1:100,000 units of epinephrine submucosally in the midline soft palate, extending I cm laterally on each side. The cautery is set to a blend of cut and coagulate ("Blend 3" on Valleylab electrosurgical generator, Boulder, CO). This mode provides optimal hemostasis while minimizing excessive postoperative pain and thermal injury. A tonsil suction evacuates cautery smoke. A sheathed needle-tip cautery outlines an inverted ~'U" on the soft palate (Fig 1). The outlined points are then connected with the cautery. A 2-cm strip of midline soft palate mucosa is developed staying 1 cm distal to the hard and soft palate junction (Fig 2). The mucosal strip is peeled off the palatopharyngeal muscle toward the uvula (Fig 3). The uvula is lifted (Fig 4) and the mucosal uvulae is dissected off of the muscular uvulae (Fig 5). The wound is left to heal by secondary intention (Fig 6). The patient is observed after the procedure for several minutes and then sent home. Resected palatal mucosa may be examined by means of routine histology.
SUBSEQUENT MANAGEMENT Pain is notable on postoperative days 3 through 10, peaking on days 5 to 7 after the surgery. Topical aspirin oral rinses (325 rag, 80-100 tablets dissolved in 1 L of water, 5-10 mL swish and spit every 30 minutes as necessary) provide significant relief without appreciable systemic absorption or bleeding. Additional pain management includes cool mist vaporizers to moisten the palate during nighttime, anesthetic lozenges, and acetaminophen with or without codeine. Prophylactic acyclovir (Zovirax 400 m g by mouth twice daily) is prescribed in patients with a history of oral aphthous ulcers. No steroids or antibiotics are given because these medications may diminish the desired palatal scarring. The patient follows up at 4 to 6 weeks after surgery, allowing sufficient time for
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 13, NO 3 (SEPT), 2002: PP 188-190
FIGURE 1. Outline of mucosa to be removed by cautery. An inverted "U" is mapped with cautery over the midline soft palate after injection with local anesthesia.
FIGURE 3. Removal of mucosal strip. The midline soft palatal mucosa is easily peeled down after identifying the mucosamuscle plane.
SUNGHUN ET AL
FIGURE 2. Connection of outline by cautery. The points are connected through the mucosa down to the level of the palatopharyngeal muscle.
FIGURE 4. Elevation of uvula. The uvula is elevated and prepared for dissection.
189
palatal stiffening to take place. In addition, the OSAS patient is given a postsurgical ESS and polysomnogram at 3-month follow-up to quantify the improvement of his or her OSAS. CAPSO is as effective as uvulopalatopharyngoplasty (UPPP) or laser-assisted uvulopalatoplasty in the shortand long-term treatment of palatal snoring and as effective as UPPP in the management of OSAS. a-3 Revisions are rare with CAPSO. In 4 years, less than 1% of more than 500 patients that we have treated with CAPSO required repeat surgery. 2
POSSIBLE COMPLICATIONS The great majority of the patients that we have treated at our institution have had no major complications. Most describe thickened mucus and "scratchy" palate during the first 3 weeks after the procedure. In a study of 206 people undergoing CAPSO for the treatment of primary
FIGURE 6. Soft palate 3 weeks after CAPSO. The surgical defect heals by secondary intention leaving a midline palatal scar that prevents palatal flutter snoring. The patient is also unable to voluntarily flutter the palate on postoperative clinic visit.
palatal snoring, 10% of patients experienced asymptomatic tiny vesicles at the surgical site for up to 2 months after the surgery. The vesicles were most likely minor salivary gland pseudocysts and resolved as the palatal scar matured. Four percent of patients had prolonged throat pain beyond 10 days. A total of 1.5% of patients reported temporary xerostomia and. taste changes. Less than 1% had temporary velopharyngeal incompetence. There were no reported cases of voice change, wound infection, or nasopharyngeal stenosis. 2
REFERENCES
FIGURE 5. Dissection of mucosa from uvula. Mucosa is dissected off the muscularis uvulae. A significant portion of the uvula may consist of mucosa. The muscle remains intact.
"190
1. LittlefieldPD, Mair EA: Snoringsurgery:whichone is best for you? Ear Nose Throat J 78:861-868, 1999 2. Mair EA, Day RH: Cautery-assistedpalatal stiffeningoperation. Otolaryngol Head Neck Surg 122:547-556, 2000 3. Wassmuth Z, Mair EA, Loube D, et al: Cautery-assisted palatal stiffening operation for the treatment of obstructive sleep apnea syndrome. OtolaryngolHead Neck Surg 123:55-60, 2000
OPERATIVE TECHNIQUESIN OTOLARYNGOLOGY--HEADAND NECK SURGERY
Outpatient surgical therapy of habitual snoring and mild obstructive sleep apnea has evolved significantly in recent years. Cautery-assisted palatal stiffening operation (CAPSO) is a mucosal surgery that induces a midline palatal scar that stiffens the floppy palate. CAPSO has important advantages over uvulopalatopharyngoplasty, laser-assisted uvulopalatoplasty, and palatal radiofrequency ablation. CAPSO is a simple and safe office procedure that avoids the need for multiple-stage operations and does not rely on expensive laser systems or radiofrequency generators and hand pieces. The technique with "How I Do It" pearls is described in this article.
Cautery-assisted palatal stiffening operation (CAPSO) is a single, office-based surgery that treats both snoring and obstructive sleep apnea syndrome (OSAS) at the level of the soft palate. CAPSO uses standard electrocautery to remove the oral mucosa of the midline soft palate, inducing a scar that stiffens the floppy palate. It is a safe, simple, cost-effective procedure with comparable success rates with other palatal surgeries that treat primary palatal snoring or OSAS. 1-3
PATIENT SELECTION The patient who continues to have snoring at the level of the soft palate after nonsurgical methods have failed will benefit most from CAPSO. The patient is encouraged to bring his or her sleeping partner to the initial evaluation, in which a thorough interview and examination is performed. The nasal cavity, nasopharynx, oropharynx, hypopharynx, and larynx are viewed with fiberoptic nasopharyngolaryngoscopy (NPL) while the patient approximates the snoring sound in the presence of the sleeping partner or an audio tape of the snoring if no sleeping partner is available. Only patients with significant awake palatal flutter at the level of the soft palate as evidenced by NPL or acoustic polysomnography are considered for CAPSO. Exclusion criteria include uncontrolled hypothyroidism or considerable obstruction at other sites on NPL: 3-4+ tonsillar hypertrophy, notable nasal polyposis or septal deviation, or significant hypopharyngeal collapse without palatal flutter. Patients with documented OSAS are asked to quantify subjective symptoms of sleepiness via the Epworth Sleepiness Scale (ESS) before the procedure. 3 This is in addition to objective measures of OSAS via polysomnography.
From Wiiford Hall USAF Medical Center, Otolaryngology-Head and Neck Surgery, San Antonio, TX. Address reprint requests to: Eric A. Mair, MD, FAAP, Department of Otolaryngology, Wilford Hall USAF Medical Center, 2200 Bergquist Dr., Suite #1, San Antonio, TX 78236-6569. E-mail: [email protected] Copyright 2002, Elsevier Science (USA). All rights reserved. 1043-1810/02/1303-0006535.00/0
doi:10.1053/otot.2002.36439
188
PROCEDURAL TECHNIQUE CAPSO is a 10-minute surgical procedure performed in the otolaryngology clinic with the patient sitting in the examination chair. Topical anesthesia is first administered with 14% benzocaine (Cetylite Inc., Pennsauken, NJ) oral spray (gargle and spit) followed by a benzocaine gel "lollipop" (200 m g / g gel; Henry Schein, Port Washington, NY) applied on the end of a tongue depressor. The "lollipop" is held against the soft palate for 5 to 10 minutes. Next, a 27-gauge needle is used to inject 5 mL of 2% lidocaine with 1:100,000 units of epinephrine submucosally in the midline soft palate, extending I cm laterally on each side. The cautery is set to a blend of cut and coagulate ("Blend 3" on Valleylab electrosurgical generator, Boulder, CO). This mode provides optimal hemostasis while minimizing excessive postoperative pain and thermal injury. A tonsil suction evacuates cautery smoke. A sheathed needle-tip cautery outlines an inverted ~'U" on the soft palate (Fig 1). The outlined points are then connected with the cautery. A 2-cm strip of midline soft palate mucosa is developed staying 1 cm distal to the hard and soft palate junction (Fig 2). The mucosal strip is peeled off the palatopharyngeal muscle toward the uvula (Fig 3). The uvula is lifted (Fig 4) and the mucosal uvulae is dissected off of the muscular uvulae (Fig 5). The wound is left to heal by secondary intention (Fig 6). The patient is observed after the procedure for several minutes and then sent home. Resected palatal mucosa may be examined by means of routine histology.
SUBSEQUENT MANAGEMENT Pain is notable on postoperative days 3 through 10, peaking on days 5 to 7 after the surgery. Topical aspirin oral rinses (325 rag, 80-100 tablets dissolved in 1 L of water, 5-10 mL swish and spit every 30 minutes as necessary) provide significant relief without appreciable systemic absorption or bleeding. Additional pain management includes cool mist vaporizers to moisten the palate during nighttime, anesthetic lozenges, and acetaminophen with or without codeine. Prophylactic acyclovir (Zovirax 400 m g by mouth twice daily) is prescribed in patients with a history of oral aphthous ulcers. No steroids or antibiotics are given because these medications may diminish the desired palatal scarring. The patient follows up at 4 to 6 weeks after surgery, allowing sufficient time for
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 13, NO 3 (SEPT), 2002: PP 188-190
FIGURE 1. Outline of mucosa to be removed by cautery. An inverted "U" is mapped with cautery over the midline soft palate after injection with local anesthesia.
FIGURE 3. Removal of mucosal strip. The midline soft palatal mucosa is easily peeled down after identifying the mucosamuscle plane.
SUNGHUN ET AL
FIGURE 2. Connection of outline by cautery. The points are connected through the mucosa down to the level of the palatopharyngeal muscle.
FIGURE 4. Elevation of uvula. The uvula is elevated and prepared for dissection.
189
palatal stiffening to take place. In addition, the OSAS patient is given a postsurgical ESS and polysomnogram at 3-month follow-up to quantify the improvement of his or her OSAS. CAPSO is as effective as uvulopalatopharyngoplasty (UPPP) or laser-assisted uvulopalatoplasty in the shortand long-term treatment of palatal snoring and as effective as UPPP in the management of OSAS. a-3 Revisions are rare with CAPSO. In 4 years, less than 1% of more than 500 patients that we have treated with CAPSO required repeat surgery. 2
POSSIBLE COMPLICATIONS The great majority of the patients that we have treated at our institution have had no major complications. Most describe thickened mucus and "scratchy" palate during the first 3 weeks after the procedure. In a study of 206 people undergoing CAPSO for the treatment of primary
FIGURE 6. Soft palate 3 weeks after CAPSO. The surgical defect heals by secondary intention leaving a midline palatal scar that prevents palatal flutter snoring. The patient is also unable to voluntarily flutter the palate on postoperative clinic visit.
palatal snoring, 10% of patients experienced asymptomatic tiny vesicles at the surgical site for up to 2 months after the surgery. The vesicles were most likely minor salivary gland pseudocysts and resolved as the palatal scar matured. Four percent of patients had prolonged throat pain beyond 10 days. A total of 1.5% of patients reported temporary xerostomia and. taste changes. Less than 1% had temporary velopharyngeal incompetence. There were no reported cases of voice change, wound infection, or nasopharyngeal stenosis. 2
REFERENCES
FIGURE 5. Dissection of mucosa from uvula. Mucosa is dissected off the muscularis uvulae. A significant portion of the uvula may consist of mucosa. The muscle remains intact.
"190
1. LittlefieldPD, Mair EA: Snoringsurgery:whichone is best for you? Ear Nose Throat J 78:861-868, 1999 2. Mair EA, Day RH: Cautery-assistedpalatal stiffeningoperation. Otolaryngol Head Neck Surg 122:547-556, 2000 3. Wassmuth Z, Mair EA, Loube D, et al: Cautery-assisted palatal stiffening operation for the treatment of obstructive sleep apnea syndrome. OtolaryngolHead Neck Surg 123:55-60, 2000
OPERATIVE TECHNIQUESIN OTOLARYNGOLOGY--HEADAND NECK SURGERY