1
Introduction
Laser-assisted uvulopalatoplasty (LAUP) is a surgical procedure for the treatment of snoring and mild obstructive sleep apnea/hypopnea syndrome. LAUP involves the use of a surgical laser to sequentially reduce and reshape the tissues of the uvula and soft palate. Initially described by Dr. Yves-Victor Kamami in 1986, LAUP has been widely performed in the United States since 1993 to remove excessive vibratory tissue of the velopharynx for sleep-disordered breathing. The benefits of LAUP include the ability to complete the procedure in the office under local anesthesia in one to four treatment stages. The staged procedure allows for minimal tissue excision matched to optimal benefits and low complication rates.
2
Patient Selection
Thorough preoperative assessment and appropriate patient selection are essential for maximizing success and meeting patient expectations with the LAUP procedure.
The medical history is best taken with the patient and the bed partner present. The sleep history should include discussion of sleep habits, daytime symptoms of fatigue, and observations of the bed partner. A detailed inventory of alcohol and caffeine consumption, as well as prescription and nonprescription medications, is also necessary. Validated questionnaires (e.g. Epworth Sleepiness Scale [ESS]) may be used as an adjunctive measure of sleep symptoms and daytime fatigue.
A complete head and neck physical examination includes calculation of the body mass index (BMI), measurement of the neck circumference, and full airway examination with flexible laryngoscopy. During an exam for all sleep-disordered breathing patients, it is important to identify the site or sites of potential obstruction. All patients considering surgery for sleep-disordered breathing should also undergo sleep apnea testing. As the ability to predict the presence of obstructive sleep apnea (OSA) is limited, our practice routinely obtains polysomnography or a home sleep study. Sleep testing provides the information necessary to counsel patients on risks, benefits, and expected outcomes from treatment.
Several key features help a practitioner identify the ideal patient for LAUP. First, polysomnography should demonstrate snoring without apnea or mild OSA. Although some studies have shown benefit in patients with moderate and severe obstructive sleep apnea syndrome, the long-term outcomes in the improvement of objective indices are controversial. Patients with OSA are counseled to trial noninvasive therapy with positive-pressure therapy before considering surgical options.
Physical examination findings for patients considering LAUP should be consistent with obstruction at the level of the velum. Patients with Friedman Tongue Position (FTP) I or II are ideal candidates. Patients with FTP III or IV may need additional treatment to address retrolingual obstruction. Stigmata for LAUP candidacy include an elongated or thickened uvula and soft palate and webbing of the posterior tonsil pillars to the soft palate ( Fig. 26.1 ). Caution should be exercised in patients with a narrow framework to the oropharyngeal inlet, as they may be at increased risk for stenosis after LAUP. Obstruction from septal deviation, hypertrophied tonsils or adenoids, base of tongue prolapse, or hypopharyngeal collapse will not be improved by reduction of uvula and soft palate tissues, and therefore obstruction in these areas will limit the potential success of LAUP.
A third important selection factor is the patient’s BMI. Rollheim and colleagues were able to demonstrate a statistically significant difference in snoring outcomes 3 months after surgery in patients with a BMI less than 28 kg/m 2 compared with those with a BMI greater than or equal to 28 kg/m 2 . This disparity is most likely related to a greater likelihood of multilevel obstruction in patients with a higher BMI, and thus persistent snoring from hypopharyngeal collapse.
There are also several more subtle patient factors to consider in patient selection. Patient cooperation is essential to success in an outpatient setting. A nervous patient or one with a heightened gag reflex may not be able to tolerate several or even one procedure. Trismus may limit the surgeon’s access to the oropharynx. Presence of cleft palate or preoperative palate insufficiency is a contraindication for surgery. Lastly, any medical condition, such as a bleeding disorder, that may affect the safety of the procedure should be considered a relative contraindication. In these circumstances, the procedure may be performed in the operating room under general anesthesia.
3
Procedure
The overall goal of LAUP surgery is to widen the retropalatal airspace and reinforce the free edge of the soft palate. When initially described by Kamami, and designated the French method, the LAUP procedure consisted of two paramedian vertical incisions extending superiorly from the free edge of the soft palate, and the uvula was largely resected up to the base. Woolford and Farrington modified this to create the British technique, which involves vaporization of a strip of mucosa from the uvula to the hard palate. This area is left bare to contract and scar, resulting in increased rigidity of the velum soft tissues. The authors prefer to utilize both techniques with modifications in a sequential, staged fashion. The following procedure is described with a CO 2 laser, but other lasers (KTP, Nd:YAG) and cutting/coagulating instruments can also be used, such as electrocautery.
The procedure is performed in an outpatient setting under local anesthesia without conscious sedation. Patients should limit their oral intake before the procedure to reduce the incidence of nausea and vomiting. The patient can be given an appropriate antibiotic to take the day of the procedure (optional); this may be especially important if that patient has heart valve disease. Also, if the patient desires, a small dose of an oral benzodiazepine (e.g. Valium) to reduce anxiety, but not enough to induce somnolence, can be administered before the procedure.
With the patient in the sitting position, a topical anesthetic spray (4% lidocaine) is applied to the oropharynx and palate. Next, lidocaine 1% with epinephrine (1 : 100,000) is infiltrated into the base of the uvula, medial and lateral portions of the soft palate, and the superior aspect of the tonsillar pillars ( Fig. 26.2 , black dots represent injection sites). The injected volume is limited (approximately 3 mL) to prevent soft tissue distortion, which may compromise the surgeon’s ability to precisely shape the palate. To minimize the painful burning associated with lidocaine infiltration, the solution may be mixed with bicarbonate solution (9 : 1 ratio) before injection. Further anesthetic may be readministered to alleviate any discomfort during the procedure.
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