Abstract
Purpose
The aim of this study has been to compare the Harmonic Scalpel (HS) and the “cold knife” dissection in the treatment of snoring by uvulopalatopharyngoplasty (UPPP).
Materials and methods
The investigation included 40 adult males with snoring. Patients were assigned to two homogeneous groups (A and B) and UPPP was performed using HS or “cold knife” dissection in groups A and B, respectively.
Before and 6 months after surgery, each patient was studied using the apnea-hypopnea index and a visual analogue scale of snore levels. Postoperative assessment of pain was evaluated on postoperative days 1 and 10.
All the patients underwent to a perioperative evaluation concerning the duration of surgical dissection, the amount of intraoperative blood loss and days of hospitalization.
Results
In group A, the HS provided excellent control without side effects on the adjacent structures and postoperative complications. Harmonic Scalpel’s group experienced shorter operation time, lesser blood loss, fewer days of hospitalization and lower postoperative pain.
Conclusions
The use of the HS in UPPP is safe and confers some advantages over conventional methods of UPPP: its use led to diminished bleeding, shorter operation time, lesser pain, and better wound healing in the postoperative period.
1
Introduction
Primary snoring is usually considered to be a consequence of soft palate vibration caused by a partial upper airway collapse during sleep .
Uvulopalatopharyngoplasty (UPPP) is a surgical treatment used to remove tissue in the throat for snoring and/or sleep apnea syndrome. Uvulopalatopharyngoplasty is still the most frequently used surgical treatment for snoring and/or sleep apnea syndrome .
Innovative advances have recently been introduced regarding instrumentation, energy sources, and devices aimed at facilitating surgical procedures in terms of efficient hemostasis, tissue legation and dissection, as well as reduction in surgical time: although curative for many patients, these procedures present side effects .
The Ultracision Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, Ohio) is an ultrasonic cutting and coagulating surgical device. The equipment consists of a generator, a hand-piece, and specific inserts .
The mechanism of the Harmonic Scalpel (HS) is based on transforming electrical energy into mechanical movement of 55.5 kHz frequency. The high-frequency ultrasonic vibrations produced by the HS cause an effect referred to as cavitation whereby the collagen and proteoglycans in the tissue become denatured and then combine with the tissue fluids to form a coagulum. The pressure exerted on the tissue by the blade surface collapses blood vessels and allows the coagulum to form a hemostatic seal. The HS controls bleeding by coaptive coagulation at low temperatures, ranging from 50°C to 100°C . By contrast, electrosurgery and laser coagulate by burning (obliterative coagulation) at higher temperatures (150–400°C) . The vibration frequency of HS is optimal for soft tissue and does not cut mineralized tissue (lower frequency waves need to be used) .
In our department, HS has been used successfully in head and neck surgery .
The aim of this study has been to test the efficacy and applicability of the HS in UPPP.
2
Materials and methods
The Regional Ethics Committee approved the study protocol. Informed written consent was obtained from all participants. 40 patients, between 19 and 68 years old (28 males and 12 females), affected by snoring, were enrolled in this no randomized study and divided into 2 numerically equal groups (group A and B) ( Tables 1 and 2 ).
| No | Sex | Age | AHI | SL | Pain | |||
|---|---|---|---|---|---|---|---|---|
| t =1 | t =2 | t =1 | t =2 | A | B | |||
| 1 | M | 38 | 23 | 9 | 9 | 3 | 2 | 0 |
| 2 | M | 44 | 26 | 8 | 8 | 2 | 3 | 1 |
| 3 | M | 68 | 19 | 10 | 8 | 2 | 3 | 1 |
| 4 | F | 41 | 25 | 9 | 7 | 1 | 2 | 0 |
| 5 | M | 44 | 21 | 8 | 8 | 2 | 3 | 1 |
| 6 | F | 35 | 18 | 10 | 7 | 1 | 3 | 1 |
| 7 | M | 56 | 23 | 9 | 8 | 2 | 2 | 1 |
| 8 | M | 44 | 24 | 10 | 9 | 2 | 2 | 1 |
| 9 | M | 48 | 21 | 10 | 7 | 1 | 3 | 0 |
| 10 | F | 53 | 22 | 9 | 7 | 1 | 3 | 0 |
| 11 | M | 19 | 20 | 10 | 8 | 1 | 3 | 1 |
| 12 | M | 59 | 24 | 8 | 8 | 1 | 2 | 1 |
| 13 | M | 43 | 23 | 9 | 7 | 1 | 3 | 0 |
| 14 | M | 54 | 17 | 8 | 8 | 2 | 3 | 1 |
| 15 | F | 35 | 26 | 9 | 9 | 2 | 2 | 1 |
| 16 | M | 44 | 24 | 9 | 7 | 1 | 3 | 0 |
| 17 | M | 29 | 18 | 8 | 8 | 1 | 2 | 0 |
| 18 | F | 44 | 25 | 10 | 8 | 1 | 3 | 1 |
| 19 | M | 56 | 19 | 8 | 8 | 1 | 3 | 1 |
| 20 | F | 39 | 21 | 9 | 9 | 2 | 3 | 1 |
| Mean | 44.65 | 21.95 | 9 | 7.9 | 1.5 | 2.65 | 0.65 | |
| P | P < .001 | P < .001 | P < .001 | |||||
| No | Sex | Age | AHI | SL | Pain | |||
|---|---|---|---|---|---|---|---|---|
| t =1 | t =2 | t =1 | t =2 | A | B | |||
| 1 | F | 39 | 21 | 10 | 8 | 2 | 7 | 5 |
| 2 | M | 44 | 22 | 9 | 9 | 3 | 7 | 5 |
| 3 | M | 68 | 23 | 9 | 8 | 2 | 8 | 4 |
| 4 | M | 43 | 25 | 11 | 8 | 2 | 7 | 4 |
| 5 | M | 20 | 22 | 11 | 8 | 2 | 7 | 4 |
| 6 | M | 39 | 19 | 9 | 7 | 1 | 8 | 5 |
| 7 | M | 57 | 23 | 8 | 7 | 1 | 7 | 4 |
| 8 | M | 42 | 20 | 10 | 9 | 3 | 6 | 3 |
| 9 | M | 40 | 25 | 9 | 7 | 1 | 7 | 4 |
| 10 | F | 54 | 23 | 8 | 8 | 1 | 8 | 5 |
| 11 | F | 49 | 19 | 8 | 8 | 1 | 7 | 4 |
| 12 | M | 66 | 21 | 9 | 7 | 1 | 7 | 4 |
| 13 | M | 51 | 24 | 10 | 9 | 2 | 8 | 5 |
| 14 | M | 44 | 25 | 11 | 9 | 1 | 7 | 4 |
| 15 | F | 38 | 19 | 9 | 7 | 1 | 7 | 3 |
| 16 | F | 40 | 19 | 8 | 8 | 2 | 7 | 1 |
| 17 | M | 28 | 25 | 9 | 7 | 1 | 8 | 5 |
| 18 | M | 37 | 24 | 8 | 9 | 2 | 7 | 4 |
| 19 | F | 54 | 23 | 9 | 8 | 1 | 7 | 4 |
| 20 | M | 38 | 20 | 11 | 8 | 1 | 8 | 4 |
| Mean | 44.55 | 22.1 | 9.3 | 7.95 | 1.55 | 7.25 | 4.05 | |
| P | P < .001 | P < .001 | P < .001 | |||||
The 2 groups presented a statistical similarity with respect to age, sex, and severity of the disease ( Table 3 ).
| Group | Sex | Age | AHI | SL | Pain | |||
|---|---|---|---|---|---|---|---|---|
| t =1 | t =2 | t =1 | t =2 | A | B | |||
| A | F | 44.65 | 21.950 ± 2.781 | 9.000 ± 0.795 | 7.900 ± 0.718 | 1.500 ± 0.607 | 2.650 ± 0.489 | 0.650 ± 0.489 |
| B | M | 44.55 | 22.100 ± 2.222 | 9.300 ± 1.081 | 7.950 ± 0.759 | 1.550 ± 0.686 | 7.250 ± 0.0550 | 4.050 ± 0.945 |
| P | P > .001 | P > .001 | P > .001 | P > .001 | P < .001 | P < .001 | ||
The indication for UPPP was made when prolonged (>1,5 cm) or hypertrophic uvula, redundant mucosa in the soft palate (distance from the posterior edge of the hard palate to the inferior edge of the hard palate >4 cm), or apnea-hypopnea index (AHI) above 15 were noticed .
We considered as exclusion criteria: age less than 18 years, previous tonsillectomy, and/or surgical treatment for snoring, other upper airway sites of obstruction besides the velopharynx, and AHI below 15.
Preoperative evaluation consisted of polysomnographic testing, fiberoptic examination with Müller’s manoeuvre at the velopharyngeal level and at the retrobasilingual level, and the Friedman staging system to asses patient selection criteria based on Friedman tongue position, tonsil size, body mass index . The patients enrolled presented a Friedman tongue position grade I, tonsil size 2–3 and a body mass index below 40 (kg/m 2 ).
Before and six months after the treatment, each patient studied was evaluated using: (1) AHI ; (2) snore levels (SL), recorded from the bed partners on a 10 cm visual analogue scale (VAS) from 0 (no snoring) to 10 (extremely disruptive snoring); (3) subjective assessment of the postoperative pain through a standard 10 cm VAS, ranging from 0 (no pain) to 10 (intolerable pain) on postoperative days 1 and 10.
All the patients underwent to a perioperative evaluation, this evaluation concerned the duration of surgical dissection (calculated in minutes), the amount of intraoperative blood loss (calculated in millilitres), and days of hospitalisation. Intraoperative blood loss was estimated by calculating the amount of fluid in the suction containers before and at the end of surgery.
The first step was to verify the efficacy and applicability of the hand-piece and the inserts used in the other surgical techniques: the results highlighted the adequacy of the hand-piece and the inserts.
Among the available hand pieces and inserts, a specific hand piece and insert was preferred: the insert, shaped like scissors, had a sharp inner beveled radius for cutting under tension, a blunt outer radius for coaptive coagulation, and a flat side for surface coagulation ( Fig. 1 ).
