Diagnostic and Surgical Advances in Obstructive Sleep Apnea

Basic criteria for minimally invasive procedures include mild to moderate obstructive sleep apnea and anatomy that is easily correctable, Dr. Friedman said. We don’t use these procedures on patients with severe apnea. The choice of technique depends on the level of obstruction. The palate is easy to treat, the tongue base is a little more difficult, and if tonsils are blocking the airway, they need to be removed, he said.

Dr. Friedman pointed out that classic thinking was that only patients with mild sleep apnea could be helped. Now we know that if you choose the right technique for the individual patient depending on the sites of obstruction, you can help patients with mild and moderate sleep apnea using minimally invasive surgery, he stated.

In my experience, 75 percent of patients have some involvement of the palate and tongue base, and these include patients with mild and moderate sleep apnea. In these patients, I combine minimally invasive techniques to reduce the tongue base and to stiffen the palate, Dr. Friedman said.

Palatal Procedures

The Pillar implant is Dr. Friedman’s technique of choice for palatal obstruction. At the recent AAO-HNS meeting, he presented results of a randomized, double-blind study in 55 consecutive adults with a history of snoring, daytime sleepiness, and mild to moderate sleep apnea comparing the Pillar implant to a sham procedure. Objective cure rate was higher with the Pillar procedure (37.9% vs 0%), subjective improvement in symptoms was greater (62.1% vs 0%, respectively), and quality of life was improved compared with the control arm. This study provided level 1 evidence favoring the Pillar procedure for improvement of sleep apnea, quality of life, snoring intensity, and daytime sleepiness.

Dr. Friedman commented that at least eight studies to date have shown good outcomes with the Pillar implant at six months, and a recent study suggests that good results are maintained for at least one year.

Eric J. Kezirian, MD

Dr. Catalano agreed that the Pillar implant is an excellent procedure, with the caveat that that its success depends on appropriate patient selection. He said that success rates with the Pillar implant range from 70% to 75% in patients who are treated for snoring alone and for mild to moderate sleep apnea (respiratory disturbance index [RDI] ≤30).

FDA approval states that up to three Pillar implants can be used to treat snoring and obstructive sleep apnea. Every patient’s anatomy is different. We are not always hitting the threshold with three implants, he said.