Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder in the United States. OSA is characterized by recurrent upper airway collapse during sleep, leading to airway obstruction, hypercapnia, and hypoxemia. First-line treatments for OSA include lifestyle modifications and continuous positive airway pressure (CPAP). Despite CPAP’s well-documented efficacy in treating OSA, adherence rates are low and variable. Alternative treatment modalities include ablative surgical interventions tailored to target specific level(s) of upper airway obstruction. Upper airway obstruction can occur at various anatomical locations including the velum, oropharynx, tongue base, or epiglottis. Nasal obstruction can also worsen upper airway collapse and overall airway resistance by increasing the inspiratory pressure needed for airflow.

Physical examination is key to identifying target anatomical areas of intervention and should assess body mass index (BMI), neck circumference, nasal valve collapse, turbinate hypertrophy, uvula/palate/tongue size and length, and tonsil size. Awake flexible nasopharyngoscopy is also useful when evaluating deeper structures of the nasal cavity, nasopharynx and oropharynx including adenoid hypertrophy, retropalatal narrowing, lateral pharyngeal wall obstruction, tongue base size, lingual hypertrophy, and epiglottic malacia. Patients interested in surgery should also undergo drug-induced sleep endoscopy (DISE), a dynamic assessment of airway collapse during pharmacologically induced sleep.

Patient history, physical examination, and DISE findings are all integral when deciding which sleep surgical procedure is best. Although most procedures are performed in the operating room under general anesthesia, a proportion can be performed in the office setting. Most of these procedures can be performed under local anesthesia, bypassing the need for an operating room and general anesthesia. This chapter will highlight several in-office sleep procedures for treatment of snoring and select cases of OSA according to anatomic level of obstruction.

Indications: Interventions to open the nasal passages have been shown to improve CPAP tolerance and improve daytime sleepiness. Nasal obstruction leads to increased inspiratory pressure, resulting in increased upper airway collapse and reductions in nasally mediated afferent sensory stimulation, making CPAP less tolerable due to reduced airflow and upper airway muscle tone. ^, Radiofrequency (RF) ablation of the inferior turbinates can be performed as an in-office procedure. The goal is to reduce turbinate size in patients with OSA intolerant to CPAP despite use of conservative therapy like nasal steroids, nasal dilators, or nasal strips.

Technique: After informed consent is obtained, topical anesthesia is placed onto both nares, followed by submucosal injection of 1% lidocaine to both inferior turbinate heads. Care should be taken not to use epinephrine in patients prone to cardiogenic syncope since it can increase blood pressure or induce a vasovagal response. Both monopolar and bipolar devices can be used, with monopolar devices having the capability of being temperature controlled. Steward describes a technique using a temperature-controlled monopolar device (Gyrus ENT LLC).

Once the patient is adequately anesthetized, the needle electrode is advanced into the anterior inferior turbinate and 500 J are delivered bilaterally at a target temperature of 75°C. The posterior turbinate can be equally targeted after adequate local anesthesia. Postoperative care includes over-the-counter analgesics like acetaminophen or ibuprofen and nasal care with saline sprays and saline gel.

Outcomes: Compared to other traditional methods of turbinate reduction, there is less post-treatment pain associated with RF therapy. As previously noted, surgical intervention to increase nasal patency has been shown to improve CPAP tolerance and reduce daytime sleepiness using the Epworth Sleepiness Scale (ESS). A meta-analysis by Li et al. found that ESS significantly decreased from 10.6 ± 3.9 to 7.1 ± 3.7 after nasal surgery was performed. This meta-analysis, however, grouped all types of nasal surgery together and did not perform subgroup analysis according to the type of nasal surgery (e.g., RF ablation of inferior turbinates). Nasal surgery has not been shown to affect the postoperative apnea-hypopnea index (AHI). ^,

Complications: Li et al. reported the following complications in their meta-analysis: bleeding (10%), cacosmia (12%), and crusting over puncture area (43%). Notably, studies have shown that RF ablation of the turbinates does not affect mucociliary transport.

Other considerations (controversies, billing nuances, special equipment, etc.): A principal advantage to RF therapy is the ability to perform these procedures quickly and under local anesthesia in clinic. By decreasing nasal obstruction and negative pressure in the pharynx, these procedures can improve the opening to the airway. Additionally, these procedures have been shown to decrease overall costs upon evaluating 5-year, 10-year, and 15-year outcomes in a study by Kempfle et al. A sensitivity analysis showed that inferior turbinate reduction is cost-effective at increasing CPAP compliance when considering a range of variables including baseline CPAP compliance. Perioperative and postoperative surgical complications also did not unfavorably affect cost-effectiveness of surgery (assuming complication rates less than 60%).

Indications: The velum is one of the most well-studied anatom­ical locations of upper airway obstruction seen in OSA, with several landmark trials reporting the efficacy of palatal procedures in reducing OSA severity indices. Since the introduction of the uvulopalatopharyngoplasty (UPPP) by Fujita and colleagues in 1981, there have been significant variations on its original procedure that have reduced associated morbidity and mortality. One of these methods is RF ablation of the soft palate. Unlike conventional UPPP, this procedure does not affect the tonsillar or pharyngeal pillar anatomy. Patient selection is key to treatment success and this procedure should be avoided in patients with a strong gag reflex.

Techniques: After informed consent is obtained, topical Cetacaine (Cetylite, Pennsauken, NJ) is sprayed over the oropharynx. The oral cavity may be rinsed with an antiseptic, such as chlorhexidine mouthwash. Antibiotics are not used prophylactically. ^, The oropharynx is then topicalized with 1% lidocaine with 1:100,000 epinephrine. Steward recommends three injection points: one midline about 2 cm above the base of the uvula and two points laterally. Emery and Flexon report a single injection site between the uvula and junction of hard and soft palate. In the video, the injection is placed along the medial raphe and extended to involve the uvula.

Once the patient is adequately anesthetized, the palate RF handpiece (ArthroCare, Corp, Austin, TX) is inserted submucosally in the midline so that the tip of the needle sits above the base of the uvula. The tip of the RF handpiece can be bent to conform to the contour of the palate. A tongue depressor could be used for adequate visualization. RF ablation is then performed with 650 J with a target temperature of 85°C to a maximum power of 10 W. In the video, there are seven points of entry (one in the midline above uvula, four lateral to the uvula, and two along the posterior tonsillar pillars) with care to pull the handpiece and palate to oneself to prevent through-through penetration of the velum. RF ablation of the uvula is also performed. If uvular shortening with RF ablation is insufficient, the uvula is further shortened using cold resection (reflext Video 1). Hemostasis is achieved with silver nitrate (reflext Video 1).

Emery and Flexon similarly treat their single injection site with 700 J of energy with a target temperature of 85°C. Steward warns that seeing mucosal blanching means the needle was placed too superficially and can result in mucosal thermal injury and worsening postoperative pain.

Postoperative care includes use of over-the-counter analgesics or narcotics. Pain has been reported to last 2 to 3 days but can be reduced with Carafate (Axcan Pharma, Birmingham, AL) and/or amoxicillin elixir gargles. Use of postoperative steroids is per surgeon preference.

Outcomes: Steward reports that effects can be seen after 2 months but that repeat treatments can be performed 3 to 4 weeks apart in the absence of mucosal injury. Using the Sher criteria of sleep surgery success (AHI reduction ≥ 50% and AHI ≤ 20), Blumen et al. reported a 66% success rate while Brown et al. reported a 17% success rate.

Complications: Common complications include injury to oral mucosa (45%) and soft palate perforations. ^, As previously stated, mucosal thermal injury is one potential complication, which can result in uvular slough. Emery and Flexon reported two cases of uvular slough after a second treatment, but neither patient experienced any permanent voice changes or velopharyngeal insufficiency.

Other considerations (controversies, billing nuances, special equipment, etc.): Limited studies have shown that palatopharyngeal surgery is associated with decreased mortality when compared to untreated controls. This suggests that palatopharyngeal surgery may play a role in treating patients who are intolerant to CPAP. However, there is controversy regarding the overall success of this procedure (around 50%), as it is associated with modest postoperative morbidity and relatively high costs. Attempts to improve success rates of these surgeries have been made by combining these surgeries with other pharyngeal surgeries such as genioglossal advancement, hyoid suspension, tongue base reduction, septoplasty, and/or turbinoplasty. In terms of cost-effectiveness, a study by Tan et al. showed that palatopharyngeal surgery adds 0.265 quality-adjusted life-years (QALYs) for an increase of $2,767. The authors estimate that the CPAP and palatopharyngeal surgery treatment surgery is cost effective at $10,421/QALY, which is comparable to routine medical interventions such as a primary angioplasty for reperfusion after a myocardial infarction (incremental cost-effectiveness ratio of $12,000). Taken together, despite high upfront costs and unsubstantial cure rates, palatopharyngeal surgery appears to be cost-effective and may decrease mortality in patients with severe OSA who are intolerant to CPAP.

Indications: Laser-assisted uvulopalatopharyngoplasty (LAUP) was first described by Dr. Kamami in 1990 as an alternative to UPPP for treatment of snoring and OSA. This method can use laser, most commonly carbon dioxide (CO ₂ ) (wavelength 10,600 nm), Er:YAG (wavelength 2940 nm), or Nd:YAG (wavelength 1064 nm), to vaporize the uvula and portion of the soft palate during one or more sessions. Unlike conventional UPPP, this procedure does not affect the tonsillar or pharyngeal pillar anatomy.

The efficacy and use of LAUP for the treatment of snoring and OSA have been controversial, thus affecting patient selection. Wischhusen et al. reported that good candidates for the procedure have mild OSA, large tonsils, normal tongue, enlarged uvula, and a posteriorly displaced soft palate.

Techniques: LAUP uses CO ₂ laser to expand oropharynx by removing excess oropharyngeal tissue. It is performed in the office after injecting local anesthetic. Laser is used to make incisions in the palate and uvula, targeting the presumed excess tissue contributing to snoring and airway obstruction.

Indications: The Pillar palatal implant system (Xomed, Jacksonville, FL) is used for treatment in patients with snoring and mild to moderate OSA. ^, Palatal implants (PIs) stiffen the soft palate to prevent collapse of the retropalatal space and prevent palatal flutter. These implants are made from polyethylene terephthalate (PET), a compound that causes fibrosis and submucosal scarring to stiffen the palate. ^,

Techniques: After informed consent is obtained, topical lidocaine is sprayed in the oropharynx, followed by injection of 1% lidocaine with 1:100,000 epinephrine into each palatal site. As originally described by Romanow et al., the mucosa of the soft palate was perforated 5 mm distal to the trailing edge of the hard palate to insert the palatal implants. Three palatal implants are placed, one at the midline and the other two 2 mm to each side of midline. Patients are given 5 days of oral antibiotics with no need for perioperative steroids. ^,

Outcomes: In Romanow’s pilot study in 2006, change in snoring severity by bed partner using a visual analog scale (VAS) (0–10) significantly decreased at both 1 and 3 months ( P <0.001). Friedman et al. also found that PI significantly improved subjective symptoms of snoring, daytime sleepiness, and overall quality of life in UPPP patients. A follow-up study by Huang et al. tested the efficacy of PI alone and with concurrent microdebrider-assisted uvulopalatal flaps (UPFs) in reducing snoring and improving AHI. This study found that PI alone significantly reduced snoring VAS scores at both 1 and 6 months and AHI at 6 months.

Complications: Romanow et al. reported a partial implant extrusion rate of 2.7%. Huang et al. reported a partial implant extrusion rate of 5% but reported the lowest postoperative pain scores among patients undergoing PI alone compared to those who underwent concurrent UPF.

Other considerations (controversies, billing nuances, special equipment, etc.): The palatal implant procedure has several advantages over other office-based procedures. The technique is quick and takes approximately 2 minutes. Pain is minimal, and most patients do not require narcotic pain prescriptions. The procedure is technically simple and can easily be combined with other procedures for snoring or OSA. Each implant costs approximately $200. This price point should be viewed in comparison to the cumulative cost of other office-based procedures that may require more equipment.

Indications: Microdebrider-assisted UPFs were first described by Huang and Cheng in 2008 to correct retropalatal obstruction by shortening and tightening the soft palate as well as repositioning the uvula. The investigators included patients with significant retropalatal obstruction with respiratory disturbance index greater than 10 events per hour. They excluded patients with grade 4 palate position and grade 3 or 4 tonsil size using the Friedman classification scale. They originally described this method under general anesthesia but later published a similar technique under local anesthesia with similar inclusion criteria.

Techniques: After informed consent is obtained and the patient is placed in the supine position, the soft palate is infiltrated with lidocaine 1% with 1:100,000 epinephrine. The uvular tip is first retracted with forceps and then a straight-powered microdebrider (2.9-mm blade, Xomed, Jacksonville, FL) at a speed of up to 3000 rpm is used to remove the redundant mucosa between the uvula and pillars in an oblique direction. The tissue above the muscular layer of the uvula and the uvular tip are also removed. The microdebrider is also used to remove the soft palate mucosa and submucosa (including glands, fat, and fibrous tissue) without disturbing the muscular layer. Hemostasis is then obtained with bipolar cautery. Once hemostasis is obtained, the uvula is repositioned up on the soft palate and sutured into place with several 4-0 Monocryl sutures in an interrupted fashion.

Outcomes: Huang et al. reported that patients who underwent office-based microdebrider-assisted UPF had significant reductions in snoring VAS scores at both 1 month and 6 months as well as significant reductions in AHI at 6 months. They also found that patients who underwent concurrent PI and microdebrider-associated UPF had the highest AHI reduction rate and snoring 6 months after surgery and thus advocate for performing this joint procedure since it both stiffens the soft palate and widens the retropalatal space as a single-step procedure.

Complications: Complications include bleeding, VPI, and nasopharyngeal stenosis. ^, Unlike traditional UPPP, microdebrider-assisted UPF has lower rates of pain and bleeding, with the microdebrider providing precise means of resecting tissue that avoids violating deep musculature.

Other considerations (controversies, billing nuances, special equipment, etc.): There are several advantages to using a microdebrider in office-based sleep surgery. Notably, there is a drastic cost difference between setting up an office-based microdebrider ($4,000 to $5,000) to setting up an office-based CO ₂ laser system ($20,000 to $30,000). The cost per procedure is low at only $60 for the disposable microdebrider blade. Additionally, the microdebrider is user-friendly, safe to use, and does not require routine maintenance.