1
Introduction
Snoring is caused by the vibration of the structures in the oral cavity and oropharynx—namely the soft palate, uvula, tonsils, base of tongue, epiglottis, and pharyngeal walls. Most authorities would concur that over 80% of snoring is due to palatal flutter, caused by vibration of the uvula and the soft palate. Hence, it would be conceivable that techniques to stiffen the palate would be beneficial in reducing snoring. Different techniques utilizing various instruments (e.g. the laser, cautery, and radiofrequency ablation) have been used to achieve the same outcome. The palatal stiffening operation was first introduced by Ellis in 1994 and improvised by Mair and Day in 2000. Both authors utilized electrocautery to stiffen the palate. The original cautery-assisted palatal stiffening operation (CAPSO) procedure was based on stripping a diamond-shaped area of mucosa off the soft palate and uvula, with the aid of cautery under local anesthesia ( Figs. 27.1–27.5 ). Although good results were reported initially, the procedure produced a stellate puckered scar on the anterior surface of the soft palate that resulted in tenting of the lateral pharyngeal walls and therefore narrowing of the lateral distance between the tonsillar pillars. These anatomic manifestations may explain why some patients did not have any clear benefit from this CAPSO procedure.
Several of the newer methods involve the use of expensive implants or sophisticated equipment. The ideal technique would be an office-based procedure, which would require no special equipment or implants and which achieves effective results in a reliable and predictable fashion. Pang et al. modified the CAPSO technique by including a horizontal rectangular box of stripped mucosa and releasing incisions on the posterior soft palatal arches with a partial uvular trimming as needed, calling this procedure the anterior palatoplasty (modified CAPSO). The anterior palatoplasty palatal technique was designed to create the palatal scar and fibrosis that is anatomically sound and that results in retraction of the palate superiorly, avoiding the puckered scar and stenosis of the lateral pharyngeal walls.
2
Patient Selection
The anterior palatoplasty (see Fig. 27.1 ) procedure may be performed for patients who are primary snorers (Apnea/Hypopnea Index [AHI] <5) and/or patients with obstructive sleep apnea (OSA). The inclusion criteria include patients above 18 years of age, body mass index (BMI) <33, all tonsil size grades, elongated uvula, all Mallampati grades, and minimal base of tongue collapse (<25%) as seen on Mueller maneuver and/or drug-induced sleep endoscopy, or can be done as part of the multilevel surgery, but primarily patients with very narrow anterior and posterior velopharyngeal (retropalatal) diameter.
All patients should undergo a thorough physical examination, nasoendoscopy, and an overnight polysomnography (PSG). Patients should also complete the Epworth Sleepiness Scale (ESS), some form of quality-of-life scores, and a visual analog scale (VAS) for snoring before surgery and 7, 14, 30, 60, and 90 days after surgery. The sleep partner also completes a similar scale for snoring. Patients also completed a VAS for pain on postoperative days 1, 3, 7, and 14. Examination includes height, weight, neck circumference, BMI, and assessment of the nasal cavity, posterior nasal space, oropharyngeal area, soft palatal redundancy, uvula size and thickness, tonsillar size, and Mallampati grade. Flexible nasoendoscopy should be performed for all patients.
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