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Palatal Implants for Primary Snoring: Short- and Long-Term Results of a New, Minimally Invasive Surgical Technique
1
Introduction
Snoring is a widespread symptom affecting about 50% of the adult population. Primary snoring without sleep-disordered breathing is not harmful in itself. However, because snoring often causes social embarrassment and marital disharmony, affected patients apply to their physicians for treatment.
The primary therapeutic aim of all available therapies is a reduction in the duration and intensity of snoring to a tolerable degree without harming the patient. Apart from conservative treatments that require patient compliance to be successful, various kinds of surgical procedures exist, with techniques for the soft palate being the most widespread. All these procedures intend to reduce palatal flutter, the major cause of non-apneic snoring. Uvulopalatopharyngoplasty (UPPP) and laser-assisted uvulopalatoplasty (LAUP) are well known, but are associated with significant morbidity. Furthermore, these treatments are invasive, destructive, painful, and irreversible to a certain extent. UPPP even requires general anesthesia.
Therefore both patients and physicians prefer a minimally invasive and less painful procedure as a primary option for the treatment of snoring. Since its invention in 1998, interstitial radiofrequency (RF) treatment of the soft palate has gained increasing interest among the public because it was the first minimally invasive surgical treatment bearing a low morbidity as well as a remarkable success rate. However, it is not a single-step procedure, and treating the palate excessively may still impair the various functions of the soft palate in a very few cases. Furthermore, a considerable relapse of snoring 1 to 
years after the last RF treatment has to be considered. As a result of this relapse of snoring, alternative therapies with minimal morbidity and long-term efficacy are desired. Therefore a new procedure was developed in 2001 in which woven cylindrical implants are placed within the soft palate to stiffen the soft palate and thus reduce snoring. These implants are made of polyethylene terephthalate, a material that has been used in heart valve surgery for the last decades.
In this chapter, the patient selection criteria for the insertion of palatal implants in the treatment of snoring and its success rate, as well as its morbidity, are described according to the literature and to our own experience. The procedure is described in detail. It is performed identically in snorers and in sleep apnea patients. During the last few years the delivery tool has been modified three times. It became smaller and contains more safety precautions against unwanted or incorrect implant deployment ( Fig. 31.1 ).
2
Patient Selection
The Pillar procedure consists of inserting implants into the junction of the hard and soft palates to extend the hard palate, thus reducing the vibrating parts. The nature of the procedure where there is no resection or ablation of palatal tissue makes the patient selection criteria for this operation comprehensible. Patients with the following findings at the upper pharyngeal level should not receive palatal implants as a solitary intervention: nasal obstruction for whatever reason, distance between both tonsils less than 2 cm, excessive palatal and pharyngeal mucosa, and a uvula longer than 1 cm ( Fig. 31.2 ). Patients with signs of tongue base snoring or obstruction in the clinical examination such as Friedman tongue position 3 or 4 ( Fig. 31.3 ), tongue base hypertrophy, retrognathia, and floppy epiglottis are also not suitable candidates for this procedure. Obesity with a body mass index above 32 kg/m 2 is known to impair any surgical intervention at the upper pharyngeal level and therefore is considered to be an exclusion criterion. In brief, patients without any obvious morphologic anomaly in their nose and pharynx except a sufficiently long soft palate are suitable candidates for a solitary Pillar procedure ( Fig. 31.4 ). Keep in mind that in all publications concerning the efficacy of palatal implants themselves, only those patients who fulfilled the previously mentioned inclusion criteria were treated.
The impact of nasal obstruction on snoring can be easily detected by applying a nasal decongestant and/or a nasal dilator before bedtime for a period of 7 days. If the improvement of nasal breathing during the night does not lead to a decrease of snoring, a combined versus a stepwise operation of the nose and the Pillar procedure may be discussed with the patient. Of course, an adjunct conservative treatment with a mandibular advancement device, positional therapy, and/or weight reduction is possible at any time and vice versa. It is well documented in sleep apnea patients that palatal implants can be inserted synchronously to or as a second step after other soft palate procedures like UPPP. It is also possible in the case of a recurrence of symptoms after such operations. Future studies have to show whether this is also true for primary snorers. RF of the soft palate, injection snoreplasty, and cautery-assisted palatal stiffening operations are not recommended as additional surgeries by us because the tissue necrosis they induce is likely to increase the risk of implant extrusion and infection (see Complications section later). There are no data concerning the combination with tongue base procedures (i.e. RF, laser resection of the lingual tonsil, genioglossus advancement, hyoid suspension), but obviously there is no surgical contraindication, as different anatomic sites are addressed. However, tongue base procedures are rarely used in primary snoring anyway.
If palatal implants are used as additional surgery, one will lose the minimally invasive character of the intervention in most cases. Therefore it has to be investigated whether the indication for an isolated Pillar procedure may generally be extended to patients considered less suitable up to now to offer this minimally invasive procedure as a real alternative to more aggressive operations as mentioned earlier. Furthermore, it is not yet clear whether additional methods for the assessment of the site of snoring sound generation can improve the selection process toward a better outcome. Regarding this issue, sound analysis using the SNAP system did not increase the success rate. Multichannel pressure recordings during natural sleep and videoendoscopy during wakefulness as well as under sedation are still under investigation.
So far, there are no data concerning the treatment of children with palatal implants. Because children mainly have shorter palates than adults, the size of the implants would probably not fit for most children.
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