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News in Sleep Disordered Breathing written by Dr. Richard R.J. Smyth
New Surgical Procedures for Snoring and Obstructive Sleep Apnea
Pillar Implant Procedure
This procedure involves the intramuscular placement in the soft palate of three polyester fibers under local anesthetic. It can be done in the office. It is a new addition to “palatal stiffening procedures” and has now received accreditation from Health Canada. In a double blind crossover randomized study (Level 1 evidence) it has been shown to have an approximately 33% success rate for mild and moderate obstructive sleep apnea, and a 88% success rate for snoring35. These figures are certainly comparable to those of our existing radiofrequency and laser treatments for snoring, and even to UPPP figures under general anaesthetic. However early studies are often on the optimistic side, and at this point we should retain some skepticism, particularly in regards to its effectiveness for obstructive sleep apnea. Although studies have not shown significant relapse, the longest follow-up studies are only about fifteen months at this point.
Currently, it would seem to be appropriate at this point for selected patients with snoring and mild obstructive sleep apnea, and is now available at the Sleep Surgery Centre.
Genioglossal Advancement
This surgery has been used for many years as an adjunctive procedure to UPPP in various centres throughout the USA. At Stanford University, Drs. Reilly and Powell have described this as part of their “phase 1” management of their obstructive sleep apnea, and it appears to raise the overall success rate of the surgery in mild and moderate OSA from about 50% to 75% when added to UPPP36. It involves making a window in the anterior mandible, and advancing the genioglossal tubercules by about 1 cms so that the genioglossal muscle and therefore the tongue are brought forward, thereby increasing the retrolingual airway space. This obviously is important in those sleep apneics who have significant retrolingual or hypopharyngeal airway narrowing. Such patients are selected on the basis of upper airway endoscopy. This form of surgery remains appropriate for patients who are unable to use CPAP and is now available through the Sleep Surgery Centre.
The “phase 2” surgery offered at Stanford University involves bimaxillary advancement, a major maxillofacial procedure. If the morbidly obese (BMI greater than 40) patients are excluded, it provides a 90% success rate in obstructive sleep apnea. It is hoped that in the near future the Sleep Surgery Centre will provide consultation and facilities for this procedure in the Lower Mainland.
Richard R.J. Smyth, M.B.B.S., F.R.C.S.
Director, Sleep Surgery Centre
Fall 2006
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