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Laser-assisted uvulopalatoplasty: post operative complications (NILES, preliminary experience)
Journal of Photochemistry and Photobiology B: Biology 62 (2001) 153–157 www.elsevier.com / locate / jphotobiol
Laser-assisted uvulopalatoplasty: post operative complications (NILES, preliminary experience) H. Negm, A. Elkharbotly* National Institute of Laser Enhanced Sciences, Cairo University, Cairo, Egypt Received 14 July 2000; accepted 13 July 2001
Abstract Laser (CO 2 ) assisted uvulopalatoplasty (LAUP) is an out-patient technique under local anesthesia, proposed for the treatment of snoring. The National Institute of Laser Enhanced Sciences, Cairo University, began to offer (LAUP) to patients since summer 1996. A patient survey was developed to evaluate the postoperative complications. A total of 60 post-treatment surveys were completed using a written questionnaire or telephone calls at intervals ranging between day 1 and 6 months. Complications ranged from allergy to local anesthesia to severe pain. No serious complications were recorded. Further long run study is necessary for full understanding and assessment. 2001 Elsevier Science B.V. All rights reserved. Keywords: Laser uvulopalatoplasty; Complications
1. Introduction Snoring is sonorous breathing due to nasal obstruction, velopharyngeal obstruction or obstruction at the base of the tongue [1]. Often the problem is caused by an elongated uvula and relaxed soft palate [2]. Physically, snoring may cause fatigue and irritability due to interrupted sleep [3] Habitual snoring may also be a social problem due to the noise. Selectively, however, daytime sleepiness is more often the reason to search for help. Car accidents, increased blood pressure, ischemic heart disease and cerebrovascular disorders are considered as complicating factors in snorers [1]. Over the years, various non-surgical methods have been employed to treat the problem of snoring. These treatments have met with varying degrees of success. Examples of non-surgical solutions include the use of chin straps, tennis balls sewn into the back of pyjamas, intraoral devices to maintain the airway during sleep, and electronic devices that shock the patient out of sleep should snoring occur [4]. Surgery is one way of treating snoring and sleep apnea. Several operative techniques have been published during the last decade, the uvulopalatopharyngoplasty (UPPP) has
*Corresponding author. E-mail address: [email protected] (A. Elkharbotly).
become a predominant surgical treatment modality [5]. In this technique, excision of the tonsils with trimming of the anterior and posterior pillars which are approximated and sutured together, and excision of the uvula and a small part of the free edge of the soft palate is performed. Some severe complications have been reported, mostly confined to the impact of general anesthesia, like difficulties in postoperative respiration and arousal. Even death due to postoperative asphyxia have been reported [6]. During the last few years, a laser technique has been introduced, making it possible to perform UPPP operation safely under local anesthesia in a day surgery unit. Laserassisted uvulopalatoplasty (LAUP) introduced by Kammami proved an advantage to patients who present major surgical and anesthetic risks for conventional UPPP, it was quick, convenient, simple bloodless and virtually painless in office procedure without side effects: regurgitation, and rhinolalia [2]. Performed in one or multistages, this procedure utilizes the CO 2 laser at a power setting between 10 and 25 W in continuous mode using the back stophand-piece to make bilateral incisions through the soft palate at the base of the uvula measuring about 1–1.5 cm. The uvula is then reduced to approximately 15 mm and reshaped in a curved fashion to resemble normal uvula [2]. The only complications were of a swallowing pain, like sore throat, for about 10 days, soothed by analgesic drugs, without any problem to speak or to work. In his series,
1011-1344 / 01 / $ – see front matter 2001 Elsevier Science B.V. All rights reserved. PII: S1011-1344( 01 )00174-9
154
H. Negm, A. Elkharbotly / Journal of Photochemistry and Photobiology B: Biology 62 (2001) 153 – 157
Fig. 1. Injection of local anaesthetic into the base of the uvula and the palatal arch.
Fig. 2. Through-and-through trenches of the soft palate arch performed with pharyngeal hand piece with a back-stop tip. Swiftlase is used to widen the trenches.
Fig. 3. Trimming of the uvula using CO 2 laser. The uvula is delivered anteriorly and a special tongue blade is used as a back stop.
Fig. 4. Palate and uvula healed 1 month after first session of LAUP.
H. Negm, A. Elkharbotly / Journal of Photochemistry and Photobiology B: Biology 62 (2001) 153 – 157
23% of patients had partial improvement and in 5% of patients, snoring remained a significant problem.
2. Aim of the work To assess the post-operative complications after LAUP as a preliminary experience in the National Institute of Laser Enhanced Sciences (NILES), Cairo University.
3. Patients and methods A total of 60 patients (48 men and 12 women; age range from 22 to 71 years; mean 45.5) complaining of habitual snoring by themselves or by their bed partners were involved in this study. No history of sleep apnea, no physical signs of morbid obesity, systemic hypertension or heart disease was present. LAUP operation under local anesthesia as an office based procedure was performed by the authors as described by Kammami [2] using CO 2 laser equipment (DEKKA) between the interval from 1 / 8 / 1996
155
and 31 / 4 / 1997 using one or multisessions, power ranged from 10 to 25 W, using a backstop pharyngeal hand piece (Figs. 1–4). A patient survey (in Arabic) was developed to evaluate the postoperative complications (Fig. 5).
4. Results The patients’ estimations for postoperative complications were scored using visual analog scale (VAS) for pain, where 0 means no pain and 10 means profound pain. Other complications were expressed using positive or negative along every day of the postoperative time (Table 1). Pain was the marked postoperative complications (100% of cases) stated by the patients as profound and persistent and was not relieved by any regular analgesics (Diclofenac sodium, 50-mg tablets; maximum four tablets daily). Fig. 6 summarizes the mean postoperative pain in the first 10 days and the 14th day using VAS. Pain was expressed to be increasing to reach its maximum on the seventh to the tenth days postoperatively, and
Fig. 5. Patients survey for postoperative complications.
H. Negm, A. Elkharbotly / Journal of Photochemistry and Photobiology B: Biology 62 (2001) 153 – 157
156
Table 1 Summary of postoperative complications Day
Pain Bleeding Fever Allergy Absence from work
1
2
3
4
5
6
7
8
9
10
14
Total
47 41 – 21 –
159 – 51 – –
179 – – – –
269 – – – 110
338 – – – 112
418 21 21 – 118
498 21 21 – 118
539 – – – 116
599 – – – 116
470 – – – 15
103 – – – –
60 61 71 21 181
Fig. 6. A curve shows the relation between pain and time.
it was described to be severe to profound and persistent. The effect of regular analgesics was minimal (Fig. 6). Bleeding was a minor symptom present in the first 24 h and reappeared again on the seventh day (four cases, 6.6%, and two cases, 3.3%, respectively). Again fever was a minor symptom that appeared on the first 2 days and on the seventh day postoperatively (8.3 and 3.3%, respectively). Allergic reactions were present in only two patients (3.3%) in the first 2 days postoperatively, most probably due to reactions to local anesthetics. It was in the form oedema to the new uvula and soft palate. Absence from work was marked in the interval between the fifth and the tenth days postoperatively (18 cases, 30%). Recurrence of snoring was estimated 6 months postoperatively using telephone calls asking the patients or their bed partners, it was partially present in eight cases (13.3%) and completely present in three cases (5%). The majority of cases (49 cases, 81.7%) reported total cure from snoring.
1990, it gained a great reputation in curing patients complaining of snoring; however, little was mentioned about the complications postoperatively apart from sore throat as described by Kammami [2]. The application of LAUP in the National Institute of Laser Enhanced Sciences, Cairo University, led to the need to assess the postoperative complications on a scale that can lead to giving postoperative instructions to overcome the complications. Pain was the major symptom which was described as severe to profound and persistent, and not modified by regular analgesics, this was proved by other centers [6]. Other complications ranged from bleeding to infection which were mild and transient. Recurrence of snoring was within the expected average (18.3%) and within the range of figures from other centers [4–6]. More long-term follow-up is mandatory to assess the percentage of recurrence, as it seems that it is the only complication that may increase with time.
References 5. Discussion LAUP seems to be an effective mode for operative treatment in patients with snoring. Since its introduction in
¨ Y. Tshushima, O. Polo, E. Laurkainen, J. [1] J. Antila, J. Sipila, ¨ ¨ The effect of laser uvulopalato-pharyngoplasty on the nasal Suorpaa, and nasopharyngeal volume measured by rhinometry, Acta Otolaryngol. (Stockholm) 529 (Suppl.) (1997) 202–205.
H. Negm, A. Elkharbotly / Journal of Photochemistry and Photobiology B: Biology 62 (2001) 153 – 157 [2] Y.V. Kammami, Laser CO 2 for snoring: preliminary results, Acta Oto-Rhino-Laryngol. 44 (1990) 451–456. [3] D.N.F. Fairbanks, Snoring surgical vs. non surgical management, Laryngoscope 24 (1984) 1188–1192. [4] L. Lynda, R.N. Schiebert, E. Joyce, R.N. Zeiler, R. Lynn, R.N. Bandaruk, E. Kathleen, R.N. Spagnola, Laser assisted uvulopalato-
157
plasty: evaluation of postoperative discomfort and the effectiveness of this procedure, Laser Surg. Med. 20 (1997) 157–163. [5] T. Ikemastu, Study of snoring 4th report, J. Jpn. Oto-RhinoLaryngol. 64 (1964) 434–435. [6] E.Q. Pelausa, L.M. Tarishis, Surgery for snoring, Laryngoscope 99 (1989) 1006–1010.
Laser-assisted uvulopalatoplasty: post operative complications (NILES, preliminary experience) H. Negm, A. Elkharbotly* National Institute of Laser Enhanced Sciences, Cairo University, Cairo, Egypt Received 14 July 2000; accepted 13 July 2001
Abstract Laser (CO 2 ) assisted uvulopalatoplasty (LAUP) is an out-patient technique under local anesthesia, proposed for the treatment of snoring. The National Institute of Laser Enhanced Sciences, Cairo University, began to offer (LAUP) to patients since summer 1996. A patient survey was developed to evaluate the postoperative complications. A total of 60 post-treatment surveys were completed using a written questionnaire or telephone calls at intervals ranging between day 1 and 6 months. Complications ranged from allergy to local anesthesia to severe pain. No serious complications were recorded. Further long run study is necessary for full understanding and assessment. 2001 Elsevier Science B.V. All rights reserved. Keywords: Laser uvulopalatoplasty; Complications
1. Introduction Snoring is sonorous breathing due to nasal obstruction, velopharyngeal obstruction or obstruction at the base of the tongue [1]. Often the problem is caused by an elongated uvula and relaxed soft palate [2]. Physically, snoring may cause fatigue and irritability due to interrupted sleep [3] Habitual snoring may also be a social problem due to the noise. Selectively, however, daytime sleepiness is more often the reason to search for help. Car accidents, increased blood pressure, ischemic heart disease and cerebrovascular disorders are considered as complicating factors in snorers [1]. Over the years, various non-surgical methods have been employed to treat the problem of snoring. These treatments have met with varying degrees of success. Examples of non-surgical solutions include the use of chin straps, tennis balls sewn into the back of pyjamas, intraoral devices to maintain the airway during sleep, and electronic devices that shock the patient out of sleep should snoring occur [4]. Surgery is one way of treating snoring and sleep apnea. Several operative techniques have been published during the last decade, the uvulopalatopharyngoplasty (UPPP) has
*Corresponding author. E-mail address: [email protected] (A. Elkharbotly).
become a predominant surgical treatment modality [5]. In this technique, excision of the tonsils with trimming of the anterior and posterior pillars which are approximated and sutured together, and excision of the uvula and a small part of the free edge of the soft palate is performed. Some severe complications have been reported, mostly confined to the impact of general anesthesia, like difficulties in postoperative respiration and arousal. Even death due to postoperative asphyxia have been reported [6]. During the last few years, a laser technique has been introduced, making it possible to perform UPPP operation safely under local anesthesia in a day surgery unit. Laserassisted uvulopalatoplasty (LAUP) introduced by Kammami proved an advantage to patients who present major surgical and anesthetic risks for conventional UPPP, it was quick, convenient, simple bloodless and virtually painless in office procedure without side effects: regurgitation, and rhinolalia [2]. Performed in one or multistages, this procedure utilizes the CO 2 laser at a power setting between 10 and 25 W in continuous mode using the back stophand-piece to make bilateral incisions through the soft palate at the base of the uvula measuring about 1–1.5 cm. The uvula is then reduced to approximately 15 mm and reshaped in a curved fashion to resemble normal uvula [2]. The only complications were of a swallowing pain, like sore throat, for about 10 days, soothed by analgesic drugs, without any problem to speak or to work. In his series,
1011-1344 / 01 / $ – see front matter 2001 Elsevier Science B.V. All rights reserved. PII: S1011-1344( 01 )00174-9
154
H. Negm, A. Elkharbotly / Journal of Photochemistry and Photobiology B: Biology 62 (2001) 153 – 157
Fig. 1. Injection of local anaesthetic into the base of the uvula and the palatal arch.
Fig. 2. Through-and-through trenches of the soft palate arch performed with pharyngeal hand piece with a back-stop tip. Swiftlase is used to widen the trenches.
Fig. 3. Trimming of the uvula using CO 2 laser. The uvula is delivered anteriorly and a special tongue blade is used as a back stop.
Fig. 4. Palate and uvula healed 1 month after first session of LAUP.
H. Negm, A. Elkharbotly / Journal of Photochemistry and Photobiology B: Biology 62 (2001) 153 – 157
23% of patients had partial improvement and in 5% of patients, snoring remained a significant problem.
2. Aim of the work To assess the post-operative complications after LAUP as a preliminary experience in the National Institute of Laser Enhanced Sciences (NILES), Cairo University.
3. Patients and methods A total of 60 patients (48 men and 12 women; age range from 22 to 71 years; mean 45.5) complaining of habitual snoring by themselves or by their bed partners were involved in this study. No history of sleep apnea, no physical signs of morbid obesity, systemic hypertension or heart disease was present. LAUP operation under local anesthesia as an office based procedure was performed by the authors as described by Kammami [2] using CO 2 laser equipment (DEKKA) between the interval from 1 / 8 / 1996
155
and 31 / 4 / 1997 using one or multisessions, power ranged from 10 to 25 W, using a backstop pharyngeal hand piece (Figs. 1–4). A patient survey (in Arabic) was developed to evaluate the postoperative complications (Fig. 5).
4. Results The patients’ estimations for postoperative complications were scored using visual analog scale (VAS) for pain, where 0 means no pain and 10 means profound pain. Other complications were expressed using positive or negative along every day of the postoperative time (Table 1). Pain was the marked postoperative complications (100% of cases) stated by the patients as profound and persistent and was not relieved by any regular analgesics (Diclofenac sodium, 50-mg tablets; maximum four tablets daily). Fig. 6 summarizes the mean postoperative pain in the first 10 days and the 14th day using VAS. Pain was expressed to be increasing to reach its maximum on the seventh to the tenth days postoperatively, and
Fig. 5. Patients survey for postoperative complications.
H. Negm, A. Elkharbotly / Journal of Photochemistry and Photobiology B: Biology 62 (2001) 153 – 157
156
Table 1 Summary of postoperative complications Day
Pain Bleeding Fever Allergy Absence from work
1
2
3
4
5
6
7
8
9
10
14
Total
47 41 – 21 –
159 – 51 – –
179 – – – –
269 – – – 110
338 – – – 112
418 21 21 – 118
498 21 21 – 118
539 – – – 116
599 – – – 116
470 – – – 15
103 – – – –
60 61 71 21 181
Fig. 6. A curve shows the relation between pain and time.
it was described to be severe to profound and persistent. The effect of regular analgesics was minimal (Fig. 6). Bleeding was a minor symptom present in the first 24 h and reappeared again on the seventh day (four cases, 6.6%, and two cases, 3.3%, respectively). Again fever was a minor symptom that appeared on the first 2 days and on the seventh day postoperatively (8.3 and 3.3%, respectively). Allergic reactions were present in only two patients (3.3%) in the first 2 days postoperatively, most probably due to reactions to local anesthetics. It was in the form oedema to the new uvula and soft palate. Absence from work was marked in the interval between the fifth and the tenth days postoperatively (18 cases, 30%). Recurrence of snoring was estimated 6 months postoperatively using telephone calls asking the patients or their bed partners, it was partially present in eight cases (13.3%) and completely present in three cases (5%). The majority of cases (49 cases, 81.7%) reported total cure from snoring.
1990, it gained a great reputation in curing patients complaining of snoring; however, little was mentioned about the complications postoperatively apart from sore throat as described by Kammami [2]. The application of LAUP in the National Institute of Laser Enhanced Sciences, Cairo University, led to the need to assess the postoperative complications on a scale that can lead to giving postoperative instructions to overcome the complications. Pain was the major symptom which was described as severe to profound and persistent, and not modified by regular analgesics, this was proved by other centers [6]. Other complications ranged from bleeding to infection which were mild and transient. Recurrence of snoring was within the expected average (18.3%) and within the range of figures from other centers [4–6]. More long-term follow-up is mandatory to assess the percentage of recurrence, as it seems that it is the only complication that may increase with time.
References 5. Discussion LAUP seems to be an effective mode for operative treatment in patients with snoring. Since its introduction in
¨ Y. Tshushima, O. Polo, E. Laurkainen, J. [1] J. Antila, J. Sipila, ¨ ¨ The effect of laser uvulopalato-pharyngoplasty on the nasal Suorpaa, and nasopharyngeal volume measured by rhinometry, Acta Otolaryngol. (Stockholm) 529 (Suppl.) (1997) 202–205.
H. Negm, A. Elkharbotly / Journal of Photochemistry and Photobiology B: Biology 62 (2001) 153 – 157 [2] Y.V. Kammami, Laser CO 2 for snoring: preliminary results, Acta Oto-Rhino-Laryngol. 44 (1990) 451–456. [3] D.N.F. Fairbanks, Snoring surgical vs. non surgical management, Laryngoscope 24 (1984) 1188–1192. [4] L. Lynda, R.N. Schiebert, E. Joyce, R.N. Zeiler, R. Lynn, R.N. Bandaruk, E. Kathleen, R.N. Spagnola, Laser assisted uvulopalato-
157
plasty: evaluation of postoperative discomfort and the effectiveness of this procedure, Laser Surg. Med. 20 (1997) 157–163. [5] T. Ikemastu, Study of snoring 4th report, J. Jpn. Oto-RhinoLaryngol. 64 (1964) 434–435. [6] E.Q. Pelausa, L.M. Tarishis, Surgery for snoring, Laryngoscope 99 (1989) 1006–1010.