| 1. BackgroundObstructive sleep apnea-hypopnea syndrome(OSAHS) refers to the apnea and hypopnea arising from the obstruction of the upper airway during sleep, accompanied by snoring and disrupted patterns of sleep. In case of OSAHS, there is frequently a decrease in oxyhemoglobin saturation, sleepiness during the day and a decline in memory. The three causes of OSAHS are currently believed to be the stricture of the respiratory tract, abnormal musculation of the airway dilator and abnormal regulation of the respiratory center caused by abnormal anatomy structure of the upper respiratory tract. However, what is most responsible for this syndrome is the obstruction of the upper airway during sleep. The stricture and obstruction of the upper airway involves the obstruction of the blockade of the nasal passage, palatal pharyngeal and tongue basis. A large number of clinical studies have confirmed that palatal pharyngeal is the most common and most important part of obstruction. collapse strictures in soft tissues are likely during sleep, which is directly linked to the abnormal anatomy structure of the soft palate and palatal pharyngeal. There were a lot of fatty tissue in the soft palate space (space veli palatine and anterior parts of the soft palate space). Surgery is the important method for the patient with serious palatal pharyngeal obstruction.The traditional approach to palatal pharyngeal obstruction was uvulopalatopharyngoplasty,(UPPP) first used by Fujita et al in1981. Redundant soft tissues in the side wall of the pharynx, such as the elongated soft palate and uvula, were removed to enlarge the pharynx cavity. However, this therapy was not widely used clinically because of the poor effect and frequent complications, such as incomplete platopharyngeal closure and cicatricial stricture of pharynx. Since then, many innovations have been introduced into this conventional therapy, such as H-UPPP, VPP, ZPP, and FEP. All these innovative therapies tend to remove the redundant tissues in the palatal pharyngeal cavity while preserving as much as possible the anatomy structure and functions of the pharyngeal cavity so as to reduce the chance of complications.However, it has been proved clinically that although the rear pharyngeal cavity can be enlarged, some patients continue to suffer from narrowing of soft palate during sleep, especially so for the middle-aged and elder patients. We assume that this problem might be associated with the post-operative failure to reduce the pressure on the soft palate. A surgery is currently unavailable that can alleviate the anatomy stricture in the pharyngeal cavity via micro invasive treatments while improving the functions of the soft palate.Over the past few years, we have been working hard to explore in surgical method of OSAHS. We have modified the incision of palatopharyngeal and coblation asisted surgery for OSAHS with palatopharyngeal obstruction.We intend to keep pharyngeal muscles intact, ablate the mucous membrane and the depository fat tissue inside the soft palate while exercising tension suturing on soft palate muscles and membrane so as to enhance the tension of the soft palate, enlarge the section size of the horizontal airway and solve the problem with palate obstruction caused by collapse.This study is based on the design concept of micro invasive removal of pharyngeal anatomy stricture and reconstruction of soft palate functions, with importance attached to the remodeling of the anatomy structure and function of the soft palate. Radiofrequency Ablation(RFA) is used in modified UPPP to treat mostly OSAHS patients with pharyngeal stricture and soft palate relaxation. 2. Objective2.1To establish an innovated surgical method of pharyngeal plasty intended for palatopharyngeal obstruction and soft palate relaxation. The purpose of this therapy is to carry out micro invasive removal of pharyngeal anatomy stricture while improving the tension of the soft palate via tension suturing.2.2To study the main indications of this innovative surgery2.3To analyze the treatment efficacy of this surgery.2.4To observe post-operative complications3. Research data and methods3.1Subjects of studyA total of55cases of OSAHS who had been hospitalized in the Department of Otolaryngology Head and Neck Surgery at the Beijing Army General Hospital between Dec2010and Dec2012were selected as subjects of this research. There were52males and3females of them, whose age ranged from23to67(the mean age was43.27±10.5). The BMI of these patients was20.5-38.3Kg/m2with an average of (28.78±4.18) Kg/m2.43of these cases were classified as severe while the rest mild according to the guidelines for the Sub-society of China ENTH Surgery. In55cases,16patients complicated with hypertension (including severe OSAHS10cases,6patients with moderate OSAHS),3cases of diabetes, hyperlipidemia in13cases.9cases of obvious nasal stenosis were treated with surgical treatment (before nasal surgery,9cases were severe cases, three months after nasal surgery,7cases become moderate cases by PSG data).Standards for inclusion(1) All the patients were adults and vulnerable to snoring during sleep, apnea and day-time sleepiness. They want to improve their symptoms by surgery.(2) Conventional examinations found the soft palate relaxed and drooping, accompanied by the enlarged tonsil and palatopharyngeal arch.(3) Surveillance by polysomnography(PSG) confirmed the symptom to be obstructive sleep apnea-hypopnea syndrome.(4) The electronic nasopharyngoscop and laryngopharynx3D-CT reconstruction showed that palatal pharyngeal stricture was the major plan.Standards for exclusion(1) Central apnea as confirmed by monitoring via polysomnography.(2) Patients who has a clear diagnosis of OSAHS caused by systemic diseases(3) Patients whose level of obstruction was confirmed to lie in the nasal cavity or tongue basis.(4) Patients who cleared suffered from nasal and tongue basis obstruction and needed concomitant surgery in the nasal cavity or the tongue.3.2Clinical characteristicsSubjective symptoms:The main symptoms of the patients were loud snoring and apnea during sleeping, dry throat in the morning, daytime sleepiness.Characteristics of pharyngeal cavity:according to Friedman palate position score(FPP). Of the55patients,grade Ⅱ5cases, gradeⅢ40cases, grade Ⅳ10cases. using Friedman tonsillar hypertrophy grading:tonsillar hypertrophy grade I4cases, grade Ⅱ42cases, gradeⅢ9casesElectronic nasopharyngolaryngoscope examination and Muller test:Of the55cases,45cases of simple obstruction soft palate plane, soft palate and tongue plane blocked10cases.Pharyngeal3D-CT measurement of the mean, the soft palate thickness was (10.23±1.75) mm, soft palate length was (38.5±5.5) mm, soft palate and the posterior pharyngeal wall shortest distance was (3.5±0.5) mm.According to the Polysomnography data, of the55cases,43cases of severe, moderate12cases.3.3Instrument and methods3.3.1The electronic nasopharyngoscop. Muller experiments were conducted.3.3.2CT three-dimensional reconstruction in the palatal pharyngeal. GE discovery HD750CT was used for scanning while the three-dimensional reconstruction of the throat was performed by AW4.5image post-processor. Observations were centered on the diameter of the pharyngeal cavity, the thickness of the soft palate, the shortest distance between the soft palate and the rear wall of the pharyngeal and that between the tongue basis and the rear wall of the pharyngeal, and finally the minimum section size of the pharyngeal.3.3.3Polysomnography. The Philip Alice Le polysomnography was used to monitor the sleep of patients for a minimum of seven hours a night. The waves and data obtained from the monitory were analyzed by a professional technician with priorities to such indexes as AHI and LSaO2.3.3.4Radiofrequency ablation(RFA) was used to surgery as tools3.4Surgical methods. All the patients received general anesthesia during operation3.4.1Treatment of the tonsil and the palate arch.EVac Xtra HP of coblation from Arthrocare of the United States was used for the bilateral tonsillectomy. Redundant mucous membrane tissues in the side wall of the pharyngeal were incised, with efforts devoted to protecting the pharyngeal arch. The mucous linkage between palatopharyngeus and uvula was cut open and the pharyngeal arch was pulled upward with3-0absorbable suture line used to suture the tonsillar fossa myometrium (mainly palate and pharyngeal muscles genioglossus), so pharyngeal tonsil surgery covered the palatal wound. The lateral pharyngeal mucosa was fattened lateraly. Upper palatal pharyngeal was temporarily left unsutured.3.4.2Treatment for the uvula and soft palateA plasma cutter was used on both sides of the soft palate toward the posterior maxillary molars and to the bottom edge of the triangular space in the velum palatinum where an incision was made. Hypertrophic mucosa and submucosal adipose tissue in this triangle were resected while protecting the deep muscles. The sides of the triangle edges and deep muscle mucosa (mainly elevator muscle of the horizontal portion) were sutured together. The soft palate was flattened laterallyincreasing the soft palate suture tension significantly. The pharyngeal arch was pulled outward and upper palatal pharyngeal mucosal hypertrophy was stip cut diagonally with the edge of the outer side of the soft palate mucosa sutured. The side of the uvula adipose tissue (do not hurt the uvula muscle tissue) was removed, and the uvula mucosa was sutured in situ. At the top of the uvula and soft palate junction, low temperature plasma cutter was used to incise a rectangular cross-cut in the uvula- soft palate mucosal flap and the localized fat tissue was removed (removal of the mucosal flap size depends on the extent of the uvula and soft palate length drooping), Great care was taken not to hurt the deep muscles. The edge of the mucosa was sutured together with the deep upper and lower muscles so that the uvula and soft palate obviously bent forward, and the retropalatal airway was expanded significantly.4. Evaluation of effect4.1Subjective assessmentEpworth sleepiness scale(ESS)was used to evaluate the sleepiness caused by OSAHS. Visual analogue scale (VAS) was used to evaluate before and after surgery disease on overall quality of life in patients with prejudice.4.2Objective assessmentPSG results were used to evaluate the therapeutic effect. AHI<5times/h was considered cured; AHI<20times/h and reducing the amplitude of greater than50%was regarded as quite effective; AHI reducing the amplitude of greater than50%was thought to be effective. Successful surgery was defined as being cured or being remarkably effective.5. Statistical analysisSPSS12.0statistical software was used for analysis. Mest was used for the comparisons before and after the surgery. Statistical significance was accepted when P<0.05.6. Results6.1Surgical effect:By PSG, six months after surgery found that8of the55cases were cured,41were treated quite effectively,3effectively and another3ineffectively. The success rate of surgery was89.1%. The LSaO2of34cases (61.82%) was above0.85, that of17cases(30.91%)0.65-0.85and that of4cases(7.27%)<0.656.2subjective and objective indicators of evaluation after surgeryObjective evaluation:The difference before and after surgery was significantly different in AHI, LSa02(P<0.01) Subjective evaluation:The difference before and after surgery was significantly different in ESS, VAS (P<0.01)6.3Post-operative morphologic observation of the pharyngeal cavity. Within one week following the operation, there was mucous edema in the soft palate and uvula, both of which tipped forward and were in vague contact with the tongue basis. Examinations after6months showed that the morphologic structure of the pharyngeal cavity among all the patients was stable, the soft palate was obviously pulled to the side and that the free edge of the soft palate and uvula were tipping forward.6.4Complications6.4.1Intraoperative bleeding. The average bleeding of the55cases was20ml. There was no post-operative bleeding or secondary bleeding.6.4.2Post-operative respiratory obstruction. There was mucous edema in the operated section of the pharyngeal during the week following surgery, but normal breathing was not affected. There was no post-operative acute obstruction of the respiratory tract that required tracheotomy6.4.3Nasal reflux. There was occasionally nasal reflux associated with water drinking among32cases within the week after surgery. Reflux lasted three days for3cases, five days for10cases and seven days for2cases. Nasal reflux stopped one week after surgery.6.4.4Post-operative pen rhinolania. All the patients had their pain of the pharyngeal cavity alleviated. None of them suffered from open rhinolania when they spoke.6.4.5Cicatricial stricture. The follow-up proved that there was no cicatricial stricture or adhesion in pharyneal and retropalatal.7. Conclusion7.1This surgery is a modified micro-invasive pharyngeal-remodeling surgery that can eliminate anatomy stricture of the palatal pharyngeal while reconstructing the functions of the soft palate. There are so many advantages to this modified surgery: the adipose tissue from two spaces was removed(space veli palatine and anterior parts of the soft palate space) by two incisions (oblique triangle incision in both sides of the soft palate and transverse rectangle incision in the soft palate central).This surgery was effective to our satisfaction and there were no complications.7.2The main indications of this modified surgery:(1) The patients with obstructive sleep apnea-hypopnea syndrome as confirmed by monitoring via polysomnography.(2) The palatal pharyngeal was the main obstructive level, with the soft palate relaxed and drooping, accompanied by the enlarged tonsil.(3) The patients with velopharyngeal obstruction were intolerance orreluctant to accept treatment of continuous positive airway pressure. |
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