Combined Open Rhinoplasty With Spreader Grafts and Laser-Assisted Uvuloplasty for Sleep-Disordered Breathing: Long-Term Subjective Outcomes

J Oral Maxillofac Surg 64:1241-1247, 2006

Combined Open Rhinoplasty With Spreader Grafts and Laser-Assisted Uvuloplasty for Sleep-Disordered Breathing: Long-Term Subjective Outcomes Joseph E. Cillo, Jr, DMD,* Richard Finn, DDS,† and Richard M. Dasheiff, MD, DABSM‡ Purpose: To subjectively assess the long-term outcomes of combined functional open rhinoplasty with

spreader grafts and laser-assisted uvuloplasty (LAUP) for polysomnogram (PSG)-confirmed sleep-disordered breathing (SDB). Methods: Postoperative Epworth Sleepiness Scale (ESS) questionnaires were given to 30 patients and compared with preoperative ESS. Patients were also asked questions concerning postoperative improvement in upper airway breathing, nasal appearance, and snoring. Statistical analysis used 2-tailed parametric and nonparametric tests. Results: Thirty patients (average age 55 years) with an average (⫾ standard deviation) preoperative apnea-hypopnea index (AHI) of 37 ⫾ 27 and mean follow-up times of 21 months were evaluated. A statistically significant 50% (P ⬍ .001) postoperative decrease in average ESS was observed. Patients with severe (AHI ⬎ 30) and very severe obstructive sleep apnea (OSA) (AHI ⬎ 60) also had statistically significant (61% and 66%, respectively, P ⬍ .001) postoperative decreases in average ESS. In all patients, subjective upper airway breathing was statistically improved (P ⬍ .008), graded as significantly in 47% and moderately in 33% of patients. According to the patient’s bed partner, snoring was improved and/or decreased in 76% of patients (P ⫽ .008). All patients were satisfied with the postoperative cosmetic appearance of their nose (P ⬍ .0001). Finally, 90% of patients stated that they would have the procedure again (P ⫽ .009) and 90% stated that they would recommend the procedure to a friend or relative with the same condition (P ⫽ .009). Conclusion: Subjective assessment at long-term follow-up for combined open rhinoplasty with spreader grafts and LAUP for PSG-confirmed SDB produced a statistically significant decrease in excessive daytime sleepiness, even in patients with very high AHI, with high patient satisfaction. © 2006 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 64:1241-1247, 2006 Sleep-disordered breathing (SDB) is a common problem that has been associated with, among other things, cardiovascular morbidity1-3 and the occurrence of excessive daytime sleepiness (EDS).4 SDB refers to a wide spectrum of sleep-related breathing abnormalities including snoring, upper airway resistance syndrome (UARS), and obstructive sleep apnea (OSA). Snoring is initially the first sign in upper airway

obstruction and may progress to OSA. Obstructive sleep apnea syndrome (OSAS) is the physical manifestation of symptoms of OSA, such as EDS. EDS can have serious consequences in daily activity and may result in injury or death from accidents secondary to EDS.4 The Epworth Sleepiness Scale (ESS) has been internationally used to subjectively measure the level of EDS. Developed by Johns5 in 1991, the ESS subjec-

*Formerly, Resident, Oral and Maxillofacial Surgery, Parkland Memorial Hospital, University of Texas Southwestern Medical Center, Dallas, TX; Currently, Fellow, Maxillofacial Tumor and Reconstructive Surgery, University of Miami, Miami, FL. †Professor, Department of Surgery, Division of Oral and Maxillofacial Surgery and Department of Cell Biology, University of Texas Southwestern Medical Center, Dallas, TX; and Chief, Oral and Maxillofacial Surgery, Veterans Administration North Texas Health Care System, Dallas, TX. ‡Associate Professor, Department of Neurology, University of

Texas Southwestern Medical Center, Dallas, TX; and Director, Sleep Medicine Program, Veterans Administration North Texas Health Care System, Dallas, TX. Address correspondence and reprint requests to Dr Finn: Department of Oral and Maxillofacial Surgery, Parkland Memorial Hospital, University of Texas Southwestern Medical Center, 2526 Harry Hines Blvd, Dallas, TX 75201; e-mail: [email protected] © 2006 American Association of Oral and Maxillofacial Surgeons

0278-2391/06/6408-0012$32.00/0 doi:10.1016/j.joms.2006.04.020

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1242 tively measures the amount of daytime sleepiness by evaluating how likely an individual is to fall asleep while performing certain routine daily activities. Statistical analysis has shown that the ESS is a simple and reliable method for measuring persistent daytime sleepiness in adults.6 Surgical treatment for SDB has been classified into 2 phases. Phase I treatment involves a variety of upper airway surgeries and may include nasal reconstruction,7 and soft palate surgery, such as uvulopalatopharyngeal (UPPP) or laser-assisted uvuloplasty (LAUP).8-11 Phase I surgery has a documented success rate of about 70% to 80% in selected patients.12 Patients refractory to phase I surgery may undergo phase II surgery, which involves maxillomandibular advancement to open the posterior airway13,14 and has a documented success rate of 90% in selected patients.12 A combination of phase I surgical modalities may include nasal reconstruction such as septoplasty, turbinoplasty, internal and/or external nasal valve repair, etc, and soft palate surgery, such as UPPP or LAUP, has been reported to be safe and effective.15,16 This study was designed to subjectively evaluate the treatment outcome of patients having undergone combined functional open rhinoplasty with spreader grafts with LAUP for PSG-confirmed SDB.

SLEEP-DISORDERED BREATHING

FIGURE 1. Septal cartilage spreader grafts placed and sutured at the internal nasal angle between the upper lateral cartilages and the nasal septum via an open rhinoplasty approach. Cillo et al. Sleep-Disordered Breathing. J Oral Maxillofac Surg 2006.

Methods This was an analysis of 46 consecutive patients treated under general anesthesia with combined open rhinoplasty with spreader grafts and carbon dioxide LAUP by the Department of Oral and Maxillofacial Surgery at the Veterans Administration North Texas Health Care System in Dallas, TX, for preoperative PSG-confirmed OSA (apnea-hypopnea index [AHI] ⬎5) with a minimum of 8 months follow-up. All patients had either an all-night attended PSG with electroencephalogram and all physiologic monitors, or an unattended home-based sleep study using the StarDust System v1.0.28 (Respironics, Inc, Murrysville, PA). The StarDust technology was validated in our own Veterans Administration sleep lab, and all studies were reviewed by one of the authors who is a Diplomate of the American Board of Sleep Medicine. All patients had previously completed a preoperative ESS survey.5 A total of 39 patients (85%) could be contacted for follow-up exam and administration of a postoperative ESS survey. From these 39 patients, 9 were eliminated for either no preoperative PSG or an AHI ⬍5. A total of 30 patients (67%) were included in this study, with 28 patients being physically examined and 2 patients undergoing telephone interviews due to their inability to make a physical appearance. There was no statistically significant difference in gender, age, race, type of surgery, or AHI between those who

could and could not be contacted. All patients had preoperative bilateral internal nasal valve collapse clinically diagnosed by a positive Cottle test17 and clinically redundant uvulas with an average Mallimpatti score of 3 out of 4 and no tonsillar obstruction. All patients received open rhinoplasty with spreader grafts obtained from submucosal septoplasty (Fig 1), as previously described,18 and concomitant carbon dioxide LAUP (Fig 2) as previously described.11 Patients were clinically examined and had the ESS scale administered to them. Additional questions pertaining to the surgery were also asked of the patients. STATISTICAL ANALYSIS

Standard descriptive statistics were used. Statistical significance was set at P ⬍ .05, 2-tailed, for all analyses. The Student’s t test was used to compare the mean values of groups. Categorical and ordinal data were analyzed 2 ways. First, the nonparametric z test comparison of proportions with the Yates correction (SigmaStat 2.0; Jandel Scientific Software, San Rafael, CA); second, an exact test using a simple hypothesis based on the binomial distribution (SAS Version 8; SAS Institute Inc, Cary, NC). The more conservative (least significant) result between the z test and the frequency procedure was used. This study had approval of the local Institutional Review Board.

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CILLO ET AL

surgery, and 10% did use nCPAP prior to surgery but were able to discontinue its use after surgery, whereas 7% continued to use existing nCPAP after surgery (Table 3). Subjective clinical upper airway breathing was improved significantly in 47% and moderately in 33% of patients (P ⫽ .008). Slight improvement in upper airway breathing was subjectively improved in 7% of patients, whereas 13% of patients had no perceived improvement in upper airway breathing. According to the patient’s bed partner, snoring was eliminated or decreased in 76% of patients (P ⫽ .008). All patients were satisfied with the postoperative cosmetic appearance of their nose (P ⬍ .0001). Finally, 90% (P ⫽ .009) of patients stated that they would have the procedure again and 90% (P ⫽ .009) stated that they would recommend the procedure to a friend or relative with the same condition. All patients had healed well and without complications.

Discussion

FIGURE 2. A, Preoperative view of a patient’s uvula and soft palate prior to laser-assisted uvuloplasty. B, Immediate postoperative view of patient’s soft palate after laser-assisted uvuloplasty. Cillo et al. Sleep-Disordered Breathing. J Oral Maxillofac Surg 2006.

Results Thirty patients, 28 (93%) men and 2 (7%) women, with an average age of 56 ⫾ 8.3 years (range 41-71) and average follow-up of 21 ⫾ 8.5 months (range 8 –37), had a preoperative AHI of 37 ⫾ 27 (range 8 –110) (Table 1). There was a statistically significant (P ⬍ .001) 50% decrease in postoperative ESS (13.5 ⫾ 6.4 to 6.8 ⫾ 6.5) (Table 2). Sixteen patients (average age 55 ⫾ 8.4 years, range 44 –71) with severe OSA (AHI ⬎ 30) had an average AHI of 55 ⫾ 24 (range 30 –110) and an average of 19 months (range 8 –28) follow-up had a statistically significant (P ⬍ .001) 61% decrease in average ESS (15.6 ⫾ 6.1 to 6.1 ⫾ 6.4) (Table 2). Eight patients (average age 54 ⫾ 9.4 years, range 42– 66) with very severe OSA (AHI ⬎ 60) had an average AHI of 75 ⫾ 16 (range 60 –110) with an average follow-up of 20 months (range 12–24), had a statistically significant (P ⬍ .001) 66% decrease in average ESS (17.6 ⫾ 3.6 to 6.0 ⫾ 5.2) (Table 2). In all patients, 66% did not use nasal continuous positive airway pressure (nCPAP) either pre- or postoperative, 17% did not use nCPAP prior to surgery, but did after

Correction of upper airway obstruction, such as the nose and soft palate, has been a primary focus for the alleviation of SDB. The nose is the primary breathing route while awake and during sleep.19 Numerous investigators have shown that nasal obstruction can have an influence on SDB, causing increased incidences of loud habitual snoring, increased inspiratory effort, increased obstructive hypopnea and apnea episodes, disturbed sleep, and EDS.20-24 Nasal obstruction alters airflow dynamics and may lead to open mouth breathing during sleep, which has been shown to increase upper airway collapsibility, decreasing the pharyngeal airway diameter and resulting in obstructive SDB.25-27 During sleep, this can lead to loud snoring and irregular breathing, leading to SDB and its deleterious effects. Recently, we have employed radiofrequency-assisted uvuloplasty instead of traditional LAUP with similar results and low morbidity. There can be many causes of nasal airway obstruction, including deviation of the nasal septum, allergic rhinitis, chronic sinusitis, nasal polyps, and hypertrophic turbinates. Another cause of nasal airway obstruction is the incompetent internal nasal valve. The internal nasal valve is defined as the region of the nasal airway limited medially by the nasal septum and by the caudal end of the upper lateral cartilages (ULC). The angulation of the internal nasal valve between the septum and the ULC is generally 10 to 15 degrees and accounts for about 50% of total nasal resistance to respiratory airflow.28 The internal nasal valve works as a flow-limiting area and during inspiration this region may collapse, producing a marked increase in nasal airway resistance. It is estimated that as many as 13% of patients presenting with nasal obstruction have nasal valve incompetence.29 Etiolo-

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SLEEP-DISORDERED BREATHING

Table 1. PATIENT AGE, PREOPERATIVE AHI, LENGTH OF FOLLOW-UP, PRE- AND POSTOPERATIVE EPWORTH SLEEPINESS SCALE SCORE AND INCIDENCES OF PRE- AND POSTOPERATIVE NASAL CONTINUOUS AIRWAY PRESSURE USAGE

Pt

Age

AHI

F/U

Pre-ESS

Post-ESS

Pre-CPAP

Post-CPAP

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Avg SD

59ⴱ 44 57 62 65 51 66 70 41 66 71 42 60 62 43 55 55ⴱ 44 64 58 46 58 54 58 47 57 59 51 54 42 56 8.3

18 30 60 60 25 44 22 13 9 110 31 68 51 86 12 30 32 6 28 13 7 7 30 28 76 26 36 10 75 68 37 27

36 17 12 22 21 8 13 10 37 24 27 22 19 20 11 10 28 37 15 24 30 12 23 14 22 25 8 30 12 29 21 8.5

2 17 19 20 11 20 7 6 4 18 4 13 3 20 14 15 9 23 12 13 5 21 14 7 15 14 24 17 23 13 13.5 6.4

2 17 12 15 13 20 4 1 1 6 0 5 3 3 3 4 4 20 11 1 5 16 1 1 6 11 1 17 1 0 6.8 6.5

No Yes No No No Yes No No No Yes No No No Yes No No No No No No No No No No No No No No Yes Yes

No No No No No Yes No No No Yes No No Yes No No No Yes No No No Yes No No Yes No No No No No No

Pt, patient identification number (note, all patients were male except the 2 with asterisks). Abbreviations: Age, patient’s age in years; AHI, apnea hypopnea index; F/U, follow-up in months; pre-ESS, preoperative Epworth Sleepiness Scale score; Post-ESS, postoperative Epworth Sleepiness score; Pre-CPAP, whether patient used CPAP preoperatively; post-CPAP, whether patient used CPAP postoperatively. Cillo et al. Sleep-Disordered Breathing. J Oral Maxillofac Surg 2006.

gies for the incompetent internal nasal valve include congenital, such as deficiency of cartilage or cephalad rotation of lower lateral cartilage, and acquired, such as cartilage deficiency secondary to over-resection in primary rhinoplasty, trauma, and aging.30-32

Correction of nasal airway obstruction significantly affects some SDB symptoms, such as improving sleep quality, reducing snoring and decreasing EDS.33,34 The deviated nasal septum and hypertrophied turbinates have been the usual sites of attention for surgi-

Table 2. PRE- AND POSTOPERATIVE EPWORTH SLEEPINESS SCALE (ESS)

Epworth Sleepiness Scale (All AHIs) 30 patients Epworth Sleepiness Scale (AHI ⬎ 30, Severe OSA) 16 patients Epworth Sleepiness Scale (AHI ⬎ 60, Very Severe OSA) 8 patients

Preoperative

Postoperative

Change

P value

13.5 ⫾ 6.4

6.8 ⫾ 6.5

⫺50%

⬍ .001

15.6 ⫾ 6.1

6.5 ⫾ 6.4

⫺61%

⬍ .001

17.6 ⫾ 3.6

6.0 ⫾ 5.2

⫺66%

⬍ .001

Abbreviations: AHI, apnea hypopnea index; OSA, obstructive sleep apnea. Cillo et al. Sleep-Disordered Breathing. J Oral Maxillofac Surg 2006.

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CILLO ET AL

Table 3. POSTOPERATIVE SUBJECTIVE ASSESSMENT OF COMBINED OPEN RHINOPLASTY WITH SPREADER GRAFTS AND LAUP FOR SDB

Improvement in Nasal Breathing?* Significant Moderate Slight None Worse According to your bed partner, has there been a decrease/ improvement in your snoring?† Do you approve of the cosmetic appearance of your nose since your surgery?‡ Would you recommend this procedure to a friend or relative? Would you have this procedure again?§

Yes

No

N/A

47% 33% 7% 13% 0% 76%

18%

6%

100%

0%

90%

10%

90%

10%

*z ⫽ 2.641; P ⫽ .008. Power of performed test with alpha ⫽ .05: .803. †z ⫽ 2.641; P ⫽ .008. Power of performed test with alpha ⫽ .05: .803. ‡z ⫽ na; P ⬍ .0001. Power of performed test with alpha ⫽ .05: 1.000. §z ⫽ 2.630; P ⫽ .009. Power of performed test with alpha ⫽ .05: .804. Cillo et al. Sleep-Disordered Breathing. J Oral Maxillofac Surg 2006.

cal correction of nasal airway obstruction.30 However, treatment of septal deviations and turbinate hypertrophy without correction of the incompetent internal nasal valve is unlikely to completely correct nasal airway obstruction.35 In 1984, Sheen36 described a surgical procedure for the submucosal placement of strips of cartilage at the internal nasal valve to help increase the nasal valve angle and improve nasal airflow. Constantian and Clardy,37 in 1996, used anterior active mask rhinomanometry to show a 2-fold increase in postoperative nasal airflow after placement of spreader grafts. Numerous investigators have shown that surgical correction of the incompetent internal nasal valve alone is beneficial for relieving nasal airway obstruction and improving SDB.38,39 A variety of palatal surgeries have been proposed to increase the size of the oropharynx airway to remedy SDB. One procedure, the laser-assisted uvuloplasty (LAUP), had been initially performed to correct snoring and mild OSA. It has since evolved to be a procedure for the treatment of all phases of OSA. First described by Kamami40 in 1990, the technique is based on the progressive enlargement of the airspace in the oropharynx to eliminate or reduce obstructions that may occur during sleep by carbon dioxide laser ablation of the vibrating soft palate, posterior tonsil

pillars, and redundant posterior pharyngeal mucosa. In the report on 31 snorers treated with this procedure, all had been cured or had improvement of their snoring.40 Since that time, several retrospective and prospective studies have looked at the effect of LAUP on subjective and objective outcomes on snoring and obstructive sleep apnea. In 1995, Walker et al8 investigated the effect of LAUP alone on snoring and obstructive sleep apnea in 170 patients. In patients with PSG-diagnosed primary snoring, they succeeded in complete or near complete reduction in snoring in 60% of patients and partial snoring reduction in 29% of patients. Additionally, they found improvement in repeat PSG in patients treated for OSA in 48% of patients, but also found 21% with worse OSA and 15% that had no change. They concluded that the LAUP procedure was beneficial for primary snoring and mild OSA. Pribitikin et al41 postoperatively assessed 48 patients who had undergone LAUP alone for PSGconfirmed snoring and OSA. They reported a subjective improvement in snoring and EDS in all patients but had minimal effect in reducing respiratory distress index (RDI), which is the number of apneas-hypopneas per hour, in postsurgical PSG. In 1999, Walker et al10 reported on both objective and subjective results for 40 patients who had undergone LAUP alone for PSG-confirmed OSA with a mean follow-up time of 4 years. Postoperative PSG showed statistically significant decreases in RDI and apnea index, while subjectively they found that 75% of patients treated with LAUP alone had improvement in snoring and EDS. Mickelson and Ahuja42 found similar results in their analysis of 59 patients with improvements in mild, moderate and severe OSA. Similarly, Walker et al,43 reporting a prospective study of 38 patients undergoing LAUP for all stages of OSA, had a 40% response rate that they defined as a reduction of RDI by 50%. Data from this study show that the combination of procedures, open rhinoplasty with spreader grafts and LAUP, has a significant effect on the subjective assessments of OSA. Independently, open rhinoplasty with spreader grafts for incompetent internal nasal valve reconstruction and the LAUP procedure each have been shown to improve OSA symptoms. When these 2 procedures are combined for phase I surgery, they subjectively improve upper airway breathing and EDS as evidenced by the data in this study. A statistically significant decrease in average postoperative ESS was observed even in very severe OSA. While the decrease in average EDS was observed, this does not mean that every patient had an improvement. Some patients had no change (13%) or even a slight increase (3%) in their ESS score. However, 84% of patients did have an improvement in their ESS score and subsequent decreased EDS. Despite the conventional usage of these procedures for patients with only mild to

1246 moderate OSA, improved results were obtained in this study in both severe and very severe OSA patients. These procedures are now used at our institution to prepare patients for nasal continuous positive airway pressure (nCPAP) for the treatment of PSG-confirmed OSA. By removing upper airway restrictions, patients tend to be more compliant with nCPAP.44 Patients are either initially evaluated for upper airway obstruction, nasal valve incompetence and redundant uvula prior to the performance of a split-night PSG or after failed attempts at nCPAP due to upper airway obstruction. After combined open rhinoplasty with spreader grafts and LAUP and subsequent PSG, many patients have not had to use nCPAP because their OSAS was greatly diminished, as evidenced by decreased ESS scores. Seventy-two percent of patients who were evaluated for snoring and/or OSA were able to avoid the use of nCPAP after combined functional rhinoplasty with spreader grafts and LAUP. Additionally, 10% of patients who used nCPAP preoperatively were able to completely stop using their nCPAP postoperatively, while 22% of patients were able to either improve their compliance with or tolerate nCPAP. This study produced the same success rates as other types of phase I surgery for OSA, but no known study has yet examined the subjective outcome of this combination of treatments of upper airway obstruction for SDB. This study showed that open rhinoplasty with spreader grafts for reconstruction of the incompetent nasal valve combined with LAUP decreased EDS, as evidenced by a highly statistically significant decrease in the ESS survey. Additionally, it allowed people with snoring and/or varying degrees of OSA to forgo use of nCPAP and even allowed some to discontinue its use altogether. It subjectively improved upper airway breathing in patients, reduced snoring, and was a procedure that patients were willingly to undergo again for the postoperative benefits and would recommend to a friend or relative. Prospective studies to assess long-term objective data with postoperative PSG with this combination of procedures are needed.

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SLEEP-DISORDERED BREATHING 5. Johns MW: Daytime sleepiness, snoring, and obstructive sleep apnea. The Epworth Sleepiness Scale. Chest 103:30, 1991 6. Johns MW: Reliability and factor analysis of the Epworth Sleepiness Scale. Sleep 15:376, 1992 7. Kim ST, Choi JH, Jeon HG, et al: Polysomnographic effects of nasal surgery for snoring and obstructive sleep apnea. Acta Otolaryngol 124:297, 2004 8. Walker RP, Grigg-Damberger MM, Gopalsami C, et al: Laserassisted uvulopalatoplasty for snoring and obstructive sleep apnea: Results in 170 patients. Laryngoscope 105:938, 1995 9. Han S, Kern RC: Laser-assisted uvulopalatoplasty in the management of snoring and obstructive sleep apnea syndrome. Minerva Med 95:337, 2004 10. Walker RP, Garrity T, Gopalsami C: Early polysomnographic findings and longterm subjective results in sleep apnea patients treated with laser-assisted uvulopalatoplasty. Laryngoscope 109:1438, 1999 11. Herford AS, Finn R: Single-stage CO2 laser assisted uvuloplasty for treatment of snoring and mild obstructive sleep apnea. J Craniomaxillofac Surg 28:213, 2000 12. Aragon SB: Surgical management for snoring and sleep apnea. Dent Clin North Am 45:867, 2001 13. Guilleminault C, Li KK: Maxillomandibular expansion for the treatment of sleep-disordered breathing: Preliminary result. Laryngoscope 114:893, 2004 14. Li KK, Riley RW, Powell NB, et al: Maxillomandibular advancement for persistent obstructive sleep apnea after phase I surgery in patients without maxillomandibular deficiency. Laryngoscope 110:1684, 2000 15. Busaba NY: Same-stage nasal and palatopharyngeal surgery for obstructive sleep apnea: Is it safe? Otolaryngol Head Neck Surg 126:399, 2002 16. Kieff DA, Busaba NY: Same-day discharge for selected patients undergoing combined nasal and palatal surgery for obstructive sleep apnea. Ann Otol Rhinol Laryngol 113:128, 2004 17. Heinberg CE, Kern EB: The Cottle sign: An aid in the physical diagnosis of nasal airflow disturbance. Int Rhinol 11:89, 1973 18. Rohrich RJ, Hollier LH: Use of spreader grafts in the external approach to rhinoplasty. Clin Plast Surg 23:255, 1996 19. Nishimura T, Suzuki K: Anatomy of oral respiration: Morphology of the oral cavity and pharynx. Acta Laryngol Suppl 550:25, 2003 20. Taasan V, Wynne JW, Cassisi N, et al: The effect of nasal packing on sleep-disordered breathing and nocturnal oxygen desaturation. Laryngoscope 91:1163, 1981 21. Zwillich CW, Pickett C, Hanson FN, et al: Disturbed sleep and prolonged apnea during nasal obstruction in normal men. Am Rev Respir Dis 124:158, 1981 22. Lavie P, Fischel N, Zomer J, et al: The effects of partial and complete mechanical occlusion of the nasal passages on sleep structure and breathing in sleep. Acta Otolaryngol 95:161, 1983 23. Suratt PM, Turner BL, Wilhoit SC: Effect of intranasal obstruction on breathing during sleep. Chest 90:324,1986 24. Miljeteig H, Hoffstein V, Cole P: The effect of unilateral and bilateral nasal obstruction on snoring and sleep apnea. Laryngoscope 102:1150, 1992 25. Meurice JC, Marc I, Carrier MG, et al: Effects of mouth opening on upper airway collapsibility in normal sleeping subjects. Am J Respir Crit Care Med 153:255, 1996 26. Block AJ, Faulkner JA, Hughes RL, et al: Factors influencing airway closure. Chest 86:114, 1984 27. Kuna S, Remmers JE: Neural and anatomic factors related to upper airway occlusion during sleep. Med Clin North Am 69:1221, 1985 28. Bruintjes TD, van Olphen AF, Hillen B, et al: A functional anatomic study of the relationship of the nasal cartilages and the muscles of the nasal valve area. Laryngoscope 108:1025, 1998 29. Elwany S, Thabet H: Obstruction of the nasal valve. J Laryngol Otol 100:221, 1996 30. Beekhuis GJ: Nasal obstruction after rhinoplasty: Etiology, and techniques for correction. Laryngoscope 86:540, 1976

CILLO ET AL 31. Rohrich RJ, Hollier LH: Rhinoplasty with advancing age. Clin Plast Surg 23:281, 1996 32. McCaffrey TV, Kern EB: Clinical evaluation of nasal obstruction: A study of 1000 patients. Arch Otolaryngol 105:542, 1979 33. Hurst WB: Internal nasal implant to correct nasal valve obstruction. J Laryngol Otol 92:47, 1978 34. Verse T, Maurer JT, Pirsig W: Effect of nasal surgery on sleeprelated breathing disorders. Laryngoscope 112:64, 2002 35. Goode RL: Surgery of the incompetent nasal valve. Laryngoscope 95:546, 1985 36. Sheen JH: Spreader graft: A method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg 73:230, 1984 37. Constantian MB, Clardy RB: The relative importance of septal and nasal valvular surgery in correcting airway obstruction in primary and secondary rhinoplasty. Plast Reconstr Surg 98:38, 1996 38. Akcam T, Friedman O, Cook TA: The effect on snoring of structural nasal valve dilation with a butterfly graft. Arch Otolaryngol Head Neck Surg 130:131, 2004

1247 39. Ozturan O: Techniques for the improvement of the internal nasal valve in functional-cosmetic nasal surgery. Acta Otolaryngol 120:312, 2000 40. Kamami YV: Laser CO2 for snoring. Preliminary results. Acta Otorhinolaryngol Belg 44:451, 1990 41. Pribitikin EA, Schutte SL, Keane WM, et al: Efficacy of laserassisted uvulopalatoplasty in obstructive sleep apnea. Otolaryngol Head Neck Surg 119:643, 1998 42. Mickelson SA, Ahuja A: Short-term objective and long-term subjective results of laser-assisted uvulopalatoplasty for obstructive sleep apnea. Laryngoscope 109:362, 1999 43. Walker RP, Grigg-Damberger MM, Gopalsami C: Laserassisted uvulopalatoplasty for the treatment of mild, moderate, and severe obstructive sleep apnea. Laryngoscope 109: 79, 1999 44. Friedman M, Tanyeri H, Lim JW, et al: Effect of improved nasal breathing on obstructive sleep apnea. Otolaryngol Head Neck Surg 122:71, 2000