Laser-Assisted Uvulopalatoplasty …: The Cart Before the Horse

Abstract

Laser-assisted uvulopalatoplasty (LAUP) was developed in France in the late 1980s1Kanami YV Laser CO2 for snoring: preliminary results.ACA Otorhinolaryngol Belg. 1990; 44: 451-456Google Scholar as an office-based laser procedure for snoring. Beginning in 1992, it was introduced into the United States2Krespi YP Pearlman SJ Keidar A Laser-assisted uvulopalatoplasty for snoring.J Otolaryngol. 1994; 23: 1-3Google Scholar, 3Krespi YP Keidar A Laser-assisted uvulopalatoplasty for snoring.Insights Otolaryngol. 1994; 9Google Scholar and has undergone a remarkable proliferation, which has preceded objective documentation of its efficacy. Resulting from a skillfully crafted promotional program including seminars, mass media interest, and news coverage, this technique has rapidly grown. It has been adopted by a large number of otolaryngologists and, more recently, by generalists and even dental professionals as an alledgedly simple and innocuous treatment for snoring. In conjunction with this promotion, it has subtly been expanded by many practitioners to treat obstructive sleep apnea (OSA) and upper airway resistance syndrome (UARS). The purpose of this editorial is to comment on this phenomenon and caution pulmonary and sleep practitioners regarding its potential misuse.Snoring and its perception as a nagging nuisance by bed partners and family members has, unfortunately, offered a unique opportunity for the LAUP and the rapid development of public interest and media attention. The public has come to request, and sometimes demand, laser treatment for snoring, and there is great potential for use in inappropriate clinical situations by health professionals with relatively little training in the field of sleep disorders and sleep disordered breathing.As a background, there appears to be an innocent misperception on the part of the general public and many nonsleep specialists as to the significance of snoring. Heavy snoring without overt daytime sleepiness need not only represent a trivial social issue. Numerous studies have shown that sleep questionnaires, self-reported by patients and family members as well as detailed histories by physicians, are notoriously inaccurate in assessing the true presence of sleep disordered breathing in patients with the primary complaint of snoring. Studies have shown that a high percentage of individuals believed to have simple snoring may well have a significant degree of OSA and UARS.4Hoffspein V Szalai JP Predicted value of clinical features in diagnosing obstructive sleep apnea.SLEEP. 1993; 16: 118-122Google Scholar, 5Hillerdale G Hetta J Lindholm CE et al.Symptoms in heavy snorers with and without obstructive sleep apnea.ACTA Otolaryngol. 1991; 111: 574-581Crossref Scopus (31) Google Scholar Many health professionals providing LAUP in their offices appear to be relying on such questionnaires and histories to exclude significant coexistent OSA and may be vastly underestimating the true incidence of obstructive apnea and then doing these patients a clear disservice.Furthermore, the recognition of the UARS as a point on the continuum between innocent snoring on the one extreme and OSA on the other extreme has increased the complexity and likelihood of inaccuracy in evaluating these patients by history alone. UARS has been shown to cause frequent arousals without clear-cut apneas or hypopneas, increased daytime fatigue, and unrefreshing sleep, and it may be a separate risk factor for cardiovascular complications from sleep disordered breathing. This is despite the absence of true apneas in these patients.6Guilleminault C Stoohs R Clerk A et al.A cause of excessive daytime sleepiness: the upper airway resistance syndrome.Chest. 1993; 104: 781-787Abstract Full Text Full Text PDF PubMed Scopus (848) Google ScholarSnoring is an extremely common disorder affecting at least one-third of the general population. About 10% of snoring adult men have sufficient OSA to constitute a health risk.7Young T Palta M Dempsey J et al.The occurrence of sleep-disordered breathing among middle-aged adults.New Engl J Med. 1993; 328: 1230-1235Crossref PubMed Scopus (8340) Google Scholar, 8Phillipson EA Sleep apnea: a major public health problem [editorial].New Engl J Med. 1993; 328: 1271-1273Crossref PubMed Scopus (332) Google Scholar Untreated OSA represents an independent risk factor for systemic hypertension, stroke, and other cardiovascular disorders.9Kliskenvuo M et al.Snoring as a risk factor for hypertension and angina pectoris.Lancet. 1965; 1: 893-896Google Scholar, 10Partinen M Palomaki H Snoring and cerebral infarction.Lancet. 1985; 2: 1325-1326Abstract PubMed Scopus (301) Google Scholar In addition, there is an increased risk for day and nighttime automobile and industrial accidents.11George CF Nikerman PW Hanly PJ et al.Sleep apnea patients have more automobile accidents.Lancet. 1987; 1: 447Abstract PubMed Scopus (243) Google Scholar, 12Findley LJ Unverzagt ME Suratt PM et al.Automobile accidents involving patients with obstructive sleep apnea.Am Rev Respir Dis. 1988; 138: 337-340Crossref PubMed Scopus (498) Google ScholarThe specialty of sleep medicine has developed rapidly in recent decades and numerous options for treatment of sleep disordered breathing have been determined to be effective. The use of nasal CPAP and nasal pressure support ventilator (BiPAP system) have become the standard for treatment of patients with sleep disordered breathing. Uvulopalatopharyngoplasty (UPPP) initially recommended in the early 1960s for snoring has subsequently been adopted for treatment of OSA. UPPP is effective in a high percentage of cases of snoring, but it is definitively curative in less than 50% of patients with apnea despite subjective improvement on the part of the patient.13Pelausa EO Tarhis LM Surgery for snoring.Laryngoscope. 1989; : 1006-1010Google Scholar, 14Maisel RH Maisel RH Antonelli PJ et al.Uvulopalatopharyngoplasty for obstructive sleep apnea: a community's experience.Laryngoscope. 1992; 102: 604-607Crossref PubMed Scopus (40) Google Scholar, 15Fujita S Conway WA Zorick PJ et al.Evaluation of the effectiveness of uvulopalatopharyngoplasty.Laryngoscope. 1985; 95: 70-74Crossref PubMed Scopus (203) Google Scholar Other more aggressive surgical approaches have resulted in a higher incidence of resolution of sleep disordered breathing, and these include various combinations of maxillofacial surgery, mandibular advancement procedures, and other more aggressive surgical approaches, all of which are less commonly used for the management of OSA.16Crampette L Carlander B Mondain M et al.Surgical alternatives to uvulopalatopharyngoplasty in sleep apnea.Sleep. 1992; 15: S63-S68PubMed Google Scholar, 17Riley RW Powell NB Guilleminault C Obstructive sleep apnea syndrome: a review of 306 consecutively treated surgical patients.Otolaryngol Head Neck Surg. 1993; 108: 117-125Crossref PubMed Scopus (484) Google Scholar, 18Johnson NT Chinn J Uvulopalatopharyngoplasty and inferior sagittal mandibular osteotomy with genioglossus advancement for treatment of obstructive sleep apnea.Chest. 1994; 105: 278-283Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar, 19Dierks E Geller M Roffwarg H et al.Obstructive sleep apnea syndrome: correction by mandibular advancement.South Med J. 1990; 93: 390-394Crossref Scopus (13) Google Scholar, 20Riley RW Powell NB Maxillofacial surgery and obstructive sleep apnea syndrome.Otolaryngol Clin North Am. 1990; 23 (August): 809-826PubMed Google ScholarThe LAUP procedure is an out-patient surgical procedure performed in the office setting with the patient under local anesthesia involving three to five laser sessions. Treatments provide a progressive enlargement of the oropharyngeal airway by trimming and reshaping the uvula and posterior soft palate. The sessions are performed 4 to 6 weeks apart, allowing healing between each session and retraction of the uvula and palate tissue secondary to scarring. The pain is controlled with local and oral analgesics. The results of LAUP procedures involve removal of significantly less tissue than UPPP.21Fairbanks DNF Fujita S Laser-assisted uvuloplasty.in: Snoring and obstructive sleep apnea. 2nd ed. Raven Press, New York1994: 136-145Google ScholarThe rapid proliferation of LAUP as a treatment for snoring, as well as more recently for sleep disordered breathing, has developed despite a lack of significant documentation as to its efficacy. An additional concern is the use of this by individuals with minimal knowledge in the area of sleep medicine. It appears that a large percentage of patients with snoring (and by implication sleep apnea) undergoing assessment and laser treatment are being treated without the involvement of the sleep specialist and without appropriate pre- and postoperative evaluation. The most recent expansion of this treatment into the nonotolaryngology community is especially a concern because snoring patients appear to represent a group of individuals with significant sleep disordered breathing as well as other medical problems.I would like to alert the pulmonary and sleep medical community of this unfolding diagnostic and therapeutic scenario. Fortunately, these developments have not gone unnoticed. Recent publications have confirmed that patients undergoing LAUP with significant sleep disordered breathing have unchanged apnea/hypopnea indexes when weight loss associated with surgical procedures is considered. This has resulted from analyses of pre- and post-LAUP polysomnography results.22Krespi YP Keidar A Khosh MM et al.The efficacy of laser-assisted uvulopalatoplasty (LAUP) in the management of obstructive sleep apnea syndrome (OSA) and upper airway resistance syndrome (UARS).Head Neck Surg. 1994; 5: 235-243Scopus (49) Google Scholar Recently, the American Sleep Disorders Association has issued guidelines for practice parameters for the use of LAUP. This includes that, because current data does not support the efficacy of LAUP in sleep-related breathing disorders, it not be recommended for treatment of these disorders. Patients undergoing LAUP should be preoperatively evaluated, including objective measurement of respiration during sleep to exclude coexistent sleep disordered breathing, and there are other precautions regarding the use of this new and undocumented treatment option.23American Sleep Disorders Association. Standards of Practice Committee. Practice parameters for the use of laser-assisted uvulopalatoplasty. Sleep 1994; in pressGoogle ScholarIn summary, a combination of public interest and media coverage of the topic of snoring and laser treatment has resulted in the establishment of numerous out-patient treatment facilities before adequate documentation of the role of this treatment regimen. The confusion between symptoms of snoring and the incidence of sleep disordered breathing has compounded this proliferation, and interested readers should be aware of the potential inappropriate applications of LAUP and be alerted to preserve the best medical interests of their patients. Laser-assisted uvulopalatoplasty (LAUP) was developed in France in the late 1980s1Kanami YV Laser CO2 for snoring: preliminary results.ACA Otorhinolaryngol Belg. 1990; 44: 451-456Google Scholar as an office-based laser procedure for snoring. Beginning in 1992, it was introduced into the United States2Krespi YP Pearlman SJ Keidar A Laser-assisted uvulopalatoplasty for snoring.J Otolaryngol. 1994; 23: 1-3Google Scholar, 3Krespi YP Keidar A Laser-assisted uvulopalatoplasty for snoring.Insights Otolaryngol. 1994; 9Google Scholar and has undergone a remarkable proliferation, which has preceded objective documentation of its efficacy. Resulting from a skillfully crafted promotional program including seminars, mass media interest, and news coverage, this technique has rapidly grown. It has been adopted by a large number of otolaryngologists and, more recently, by generalists and even dental professionals as an alledgedly simple and innocuous treatment for snoring. In conjunction with this promotion, it has subtly been expanded by many practitioners to treat obstructive sleep apnea (OSA) and upper airway resistance syndrome (UARS). The purpose of this editorial is to comment on this phenomenon and caution pulmonary and sleep practitioners regarding its potential misuse. Snoring and its perception as a nagging nuisance by bed partners and family members has, unfortunately, offered a unique opportunity for the LAUP and the rapid development of public interest and media attention. The public has come to request, and sometimes demand, laser treatment for snoring, and there is great potential for use in inappropriate clinical situations by health professionals with relatively little training in the field of sleep disorders and sleep disordered breathing. As a background, there appears to be an innocent misperception on the part of the general public and many nonsleep specialists as to the significance of snoring. Heavy snoring without overt daytime sleepiness need not only represent a trivial social issue. Numerous studies have shown that sleep questionnaires, self-reported by patients and family members as well as detailed histories by physicians, are notoriously inaccurate in assessing the true presence of sleep disordered breathing in patients with the primary complaint of snoring. Studies have shown that a high percentage of individuals believed to have simple snoring may well have a significant degree of OSA and UARS.4Hoffspein V Szalai JP Predicted value of clinical features in diagnosing obstructive sleep apnea.SLEEP. 1993; 16: 118-122Google Scholar, 5Hillerdale G Hetta J Lindholm CE et al.Symptoms in heavy snorers with and without obstructive sleep apnea.ACTA Otolaryngol. 1991; 111: 574-581Crossref Scopus (31) Google Scholar Many health professionals providing LAUP in their offices appear to be relying on such questionnaires and histories to exclude significant coexistent OSA and may be vastly underestimating the true incidence of obstructive apnea and then doing these patients a clear disservice. Furthermore, the recognition of the UARS as a point on the continuum between innocent snoring on the one extreme and OSA on the other extreme has increased the complexity and likelihood of inaccuracy in evaluating these patients by history alone. UARS has been shown to cause frequent arousals without clear-cut apneas or hypopneas, increased daytime fatigue, and unrefreshing sleep, and it may be a separate risk factor for cardiovascular complications from sleep disordered breathing. This is despite the absence of true apneas in these patients.6Guilleminault C Stoohs R Clerk A et al.A cause of excessive daytime sleepiness: the upper airway resistance syndrome.Chest. 1993; 104: 781-787Abstract Full Text Full Text PDF PubMed Scopus (848) Google Scholar Snoring is an extremely common disorder affecting at least one-third of the general population. About 10% of snoring adult men have sufficient OSA to constitute a health risk.7Young T Palta M Dempsey J et al.The occurrence of sleep-disordered breathing among middle-aged adults.New Engl J Med. 1993; 328: 1230-1235Crossref PubMed Scopus (8340) Google Scholar, 8Phillipson EA Sleep apnea: a major public health problem [editorial].New Engl J Med. 1993; 328: 1271-1273Crossref PubMed Scopus (332) Google Scholar Untreated OSA represents an independent risk factor for systemic hypertension, stroke, and other cardiovascular disorders.9Kliskenvuo M et al.Snoring as a risk factor for hypertension and angina pectoris.Lancet. 1965; 1: 893-896Google Scholar, 10Partinen M Palomaki H Snoring and cerebral infarction.Lancet. 1985; 2: 1325-1326Abstract PubMed Scopus (301) Google Scholar In addition, there is an increased risk for day and nighttime automobile and industrial accidents.11George CF Nikerman PW Hanly PJ et al.Sleep apnea patients have more automobile accidents.Lancet. 1987; 1: 447Abstract PubMed Scopus (243) Google Scholar, 12Findley LJ Unverzagt ME Suratt PM et al.Automobile accidents involving patients with obstructive sleep apnea.Am Rev Respir Dis. 1988; 138: 337-340Crossref PubMed Scopus (498) Google Scholar The specialty of sleep medicine has developed rapidly in recent decades and numerous options for treatment of sleep disordered breathing have been determined to be effective. The use of nasal CPAP and nasal pressure support ventilator (BiPAP system) have become the standard for treatment of patients with sleep disordered breathing. Uvulopalatopharyngoplasty (UPPP) initially recommended in the early 1960s for snoring has subsequently been adopted for treatment of OSA. UPPP is effective in a high percentage of cases of snoring, but it is definitively curative in less than 50% of patients with apnea despite subjective improvement on the part of the patient.13Pelausa EO Tarhis LM Surgery for snoring.Laryngoscope. 1989; : 1006-1010Google Scholar, 14Maisel RH Maisel RH Antonelli PJ et al.Uvulopalatopharyngoplasty for obstructive sleep apnea: a community's experience.Laryngoscope. 1992; 102: 604-607Crossref PubMed Scopus (40) Google Scholar, 15Fujita S Conway WA Zorick PJ et al.Evaluation of the effectiveness of uvulopalatopharyngoplasty.Laryngoscope. 1985; 95: 70-74Crossref PubMed Scopus (203) Google Scholar Other more aggressive surgical approaches have resulted in a higher incidence of resolution of sleep disordered breathing, and these include various combinations of maxillofacial surgery, mandibular advancement procedures, and other more aggressive surgical approaches, all of which are less commonly used for the management of OSA.16Crampette L Carlander B Mondain M et al.Surgical alternatives to uvulopalatopharyngoplasty in sleep apnea.Sleep. 1992; 15: S63-S68PubMed Google Scholar, 17Riley RW Powell NB Guilleminault C Obstructive sleep apnea syndrome: a review of 306 consecutively treated surgical patients.Otolaryngol Head Neck Surg. 1993; 108: 117-125Crossref PubMed Scopus (484) Google Scholar, 18Johnson NT Chinn J Uvulopalatopharyngoplasty and inferior sagittal mandibular osteotomy with genioglossus advancement for treatment of obstructive sleep apnea.Chest. 1994; 105: 278-283Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar, 19Dierks E Geller M Roffwarg H et al.Obstructive sleep apnea syndrome: correction by mandibular advancement.South Med J. 1990; 93: 390-394Crossref Scopus (13) Google Scholar, 20Riley RW Powell NB Maxillofacial surgery and obstructive sleep apnea syndrome.Otolaryngol Clin North Am. 1990; 23 (August): 809-826PubMed Google Scholar The LAUP procedure is an out-patient surgical procedure performed in the office setting with the patient under local anesthesia involving three to five laser sessions. Treatments provide a progressive enlargement of the oropharyngeal airway by trimming and reshaping the uvula and posterior soft palate. The sessions are performed 4 to 6 weeks apart, allowing healing between each session and retraction of the uvula and palate tissue secondary to scarring. The pain is controlled with local and oral analgesics. The results of LAUP procedures involve removal of significantly less tissue than UPPP.21Fairbanks DNF Fujita S Laser-assisted uvuloplasty.in: Snoring and obstructive sleep apnea. 2nd ed. Raven Press, New York1994: 136-145Google Scholar The rapid proliferation of LAUP as a treatment for snoring, as well as more recently for sleep disordered breathing, has developed despite a lack of significant documentation as to its efficacy. An additional concern is the use of this by individuals with minimal knowledge in the area of sleep medicine. It appears that a large percentage of patients with snoring (and by implication sleep apnea) undergoing assessment and laser treatment are being treated without the involvement of the sleep specialist and without appropriate pre- and postoperative evaluation. The most recent expansion of this treatment into the nonotolaryngology community is especially a concern because snoring patients appear to represent a group of individuals with significant sleep disordered breathing as well as other medical problems. I would like to alert the pulmonary and sleep medical community of this unfolding diagnostic and therapeutic scenario. Fortunately, these developments have not gone unnoticed. Recent publications have confirmed that patients undergoing LAUP with significant sleep disordered breathing have unchanged apnea/hypopnea indexes when weight loss associated with surgical procedures is considered. This has resulted from analyses of pre- and post-LAUP polysomnography results.22Krespi YP Keidar A Khosh MM et al.The efficacy of laser-assisted uvulopalatoplasty (LAUP) in the management of obstructive sleep apnea syndrome (OSA) and upper airway resistance syndrome (UARS).Head Neck Surg. 1994; 5: 235-243Scopus (49) Google Scholar Recently, the American Sleep Disorders Association has issued guidelines for practice parameters for the use of LAUP. This includes that, because current data does not support the efficacy of LAUP in sleep-related breathing disorders, it not be recommended for treatment of these disorders. Patients undergoing LAUP should be preoperatively evaluated, including objective measurement of respiration during sleep to exclude coexistent sleep disordered breathing, and there are other precautions regarding the use of this new and undocumented treatment option.23American Sleep Disorders Association. Standards of Practice Committee. Practice parameters for the use of laser-assisted uvulopalatoplasty. Sleep 1994; in pressGoogle Scholar In summary, a combination of public interest and media coverage of the topic of snoring and laser treatment has resulted in the establishment of numerous out-patient treatment facilities before adequate documentation of the role of this treatment regimen. The confusion between symptoms of snoring and the incidence of sleep disordered breathing has compounded this proliferation, and interested readers should be aware of the potential inappropriate applications of LAUP and be alerted to preserve the best medical interests of their patients.