1

Introduction

Surgical procedures designed to shorten or otherwise modify the palate may provide relief of upper airway collapse at the palatal level in patients with sleep-disordered breathing (SDB). For patients who fail to obtain relief or suffer a relapse after an initial surgical success, salvage surgical techniques may be appropriate. Although the principles of these salvage techniques are similar to the commonly performed primary surgical procedures, subtle modifications of the approach are sometimes required, and these are emphasized in this chapter.

The uvulopalatopharyngoplasty (UPPP) procedure has become a mainstay in the management of palatal collapse for patients with SDB. A review of the literature has shown that 40.7% of patients who have undergone this procedure have a favorable response. A favorable response is defined as an Apnea/Hypopnea Index (AHI) of less than 20 episodes per hour, as well as a 50% decrease in the AHI from the baseline. In addition, in an effort to decrease the morbidity of surgical treatment, several office-based surgical interventions have been developed and implemented for the treatment of obstruction at the palate level, including laser-assisted uvulopalatoplasty (LAUP) and radiofrequency ablation of the palate (RFAP). Although these procedures have proven effective in treating mild SDB in short-term analyses, the long-term evaluation of these procedures has revealed a substantial rate of recurrence of both the snoring and daytime sleepiness, and in some cases a steady trend toward recurrence has been shown over time.

There is a large number of publications and research on the possible cause of unsatisfactory response after palate procedures. The main culprit, most experts would agree, is the failure to recognize and treat obstruction at other levels of the airway such as the base of the tongue. Postoperative changes in upper airway dynamics, compliance, and site of collapse can also occur after prior palate surgery and result in relapse after initial surgical success. Finally, the inadequacy of addressing the soft palate obstruction at the initial palate surgery can result in surgical failure. In this chapter, we will focus our attention on addressing the persistent retropalatal obstruction after palate surgery, and we will assume that other levels of airway obstruction, if any, have been adequately addressed.

The salvage of patients who have undergone prior palatal procedures but failed to respond due to persistent retropalatal obstruction has received relatively little attention in the medical literature. Retreatment has been considered, and reports of successful series of patients have been documented. Li et al. showed that patients who have relapsed after successful RFAP treatment may be rescued with subsequent RFAP procedures with improvement in both snoring and sleepiness. The potential for long-term recidivism after UPPP, LAUP, and RFAP procedures with a second palate procedure emphasizes the need for technical knowledge in surgically managing patients who have failed initial palate surgery for SDB. It is important to note that to ensure the success of the reoperation, it is paramount to reevaluate the upper airway to confirm the persistent obstruction at the retropalatal level and the lack of obstruction at other levels of the airway.

We describe the implementation of well-known palatal interventions in patients who have been previously treated with a palatal procedure. We have found that many of these patients who have either failed initial treatment with prior palatal surgery or suffered a long-term recurrence may be successfully salvaged. We consider here the use of four basic palatal surgical interventions—UPPP, LAUP, RFAP, and palatal advancement—while recognizing that there are a number of other effective treatments, such as the Z-palatoplasty described in the next chapter. Although all these procedures are designed to enlarge the velopharyngeal isthmus and to decrease the vibration of the soft palate, they achieve this goal in different ways. We acknowledge that virtually any permutation of primary procedure and secondary salvage procedure can be considered. To illustrate the essential possibilities, however, we have focused on five typical circumstances that lend themselves, primarily because of the postsurgical anatomy, to one or other of the salvage strategies.

2

Patient Selection

Patients who have had their snoring successfully mitigated with LAUP but have experienced a relapse may be appropriate candidates for retreatment with LAUP. If they are reluctant to suffer the discomfort associated with this procedure, or if they are experiencing any type of dysphagia symptoms or occasional aspiration as a result of the prior treatment, it may be preferable to consider a trial of RFAP. Radiofrequency energy causes a low-temperature molecular disintegration, resulting in volumetric tissue removal with minimal collateral tissue damage.

3

Procedure

The treatment is performed as previously detailed with the patients seated in the office. After achieving local anesthesia, a commercially available RFAP handpiece connected to a 465-kHz radiofrequency device is introduced submucosally in a midline (600 J) and two lateral locations (300 J) for three separate sequences of energy, delivering a total of 1200 J at a target temperature of 85°C and 10 watts of power. The intended effect is the shrinkage of the soft tissues, resulting in tightening and modest shortening of the palate ( Fig. 66.1 ).

View of the palate of a patient who underwent laser-assisted uvulopalatopharyngoplasty (LAUP) previously (A), but has recurrence of symptoms. The patient elects to undergo rescue with radiofrequency ablation of the palate (RFAP), which is performed with multiple energy delivered sites as indicated (dotted lines). The intended effect is depicted in (B); note the modest shortening/tightening of the palate that results.

4

Complications

RFAP is not associated with any major complications. The salvage operation may involve the risks of attaining suboptimal results as in primary surgery. RFAP, although intended to be mucosa sparing, is nevertheless associated with a high incidence of mucosal injuries, many of which are occult. Mucosal edema, if it happens, settles by itself. Superficial ulceration of the soft palate has also been reported.