Advanced Surgical Techniques in Snoring and Obstructive Sleep Apnea

Review by L Flood
Middlesborough, UK

In the UK NHS system of rationing, operations deemed to be ‘of limited effectiveness’ are increasingly condemned, at least whilst our economy continues its prolonged slump. Few of us are allowed by the purchasers of healthcare to offer surgery for obstructive sleep apnoea (OSA), let alone ‘simple’ snoring. Such work is increasingly been driven into the commercial sector, and the Internet does more to drive the patient to an individual surgeon than does anyone in primary care, alas.There are those who argue that snoring is a physiological phenomenon and that surgery can only provide an anatomical answer. Obstructive sleep apnoea should be addressed by correction of body mass index and connecting a facemask at night; indeed, continuous positive airway pressure (CPAP) may be compromised by palatal resection. Evidence based medicine demands long term outcome results, and we must be honest: such results are sadly lacking for surgery of OSA and snoring.  I found this book fascinating and intend to reread the whole thing more slowly. As an otologist, I still cannot recall how I came to be so involved in such work. I suppose we had several expensive lasers, for which ‘The Boro’ has long been well known, and no tool is allowed to lie idle. Curiously, the laser features little in this book, nor does radio-frequency ablation (RFA), probably the two commonest UK procedures for palatal snoring. Cutting diathermy is favoured and RFA is used more on the tonsils and tongue base than on the soft palate. Indeed, both laser and RFA are reserved solely for failed uvulopalatopharyngoplasty (UPPP) in this book.  This is a multi-author work of over 360 pages and 33 chapters. Illustrations are monochrome (i.e. black and white!) and can be indistinct at times, especially for endoscopic views. Wait for the accompanying DVD, though, which more than compensates. The editors exploit personal experience from Singapore, Canada and the USA (although it is good to note that the senior editor holds an Irish FRCS in ORL). There are countless tips and techniques, even just minor modifications, which I am itching to try out. There is a nice comment in the preface, ‘A sleep surgeon is not a uvulectomist’, and later, ‘The traditional UPPP is not the cure-all surgery, every palate is different’.  As a result, there are various palatal and oropharyngeal flaps demonstrated, which certainly look convincing at the close of surgery, whatever subsequent scarring and contracture might do.  The book starts with the basic science and pathophysiology, concentrating on OSA. Airway evaluation, from sleep nasendoscopy to Muller, is of course fundamental to patient selection, now we suddenly have so many different ways to alter the anatomy. It is, naturally, the surgery we all want to read about, so we may just skip over mandibular appliances and CPAP.  Nasal surgery we know about: we want to be let loose in the oropharynx, the tongue base, the supraglottis, do we not?  The DVD is excellent. Operations are shown in real time and the image quality is remarkable. I feared for my disk as it seemed to have some sticky substances smeared across it, but in it went and it worked flawlessly. The chapters start with intranasal surgery and the detail is superb. Most procedures are described with subtitles, but accompanied by truly awful background music. If you have ever been held in a phone queue or heard the Xbox role-playing game Oblivion played by your offspring for hours on end, you’ll know it.  Rarely, there is a much better voice-over but, curiously, coinciding with the least sharp filming. The perils of live surgery we all know, and I was amused that the UPPP video freely admits to skipping a bit. We have all hit that vessel, as the delegates watch in the adjacent lecture theatre. As I grow in seniority or, in reality, countdown to retirement and part-time work (140 days to go today),I will not often open a book that seriously influences my practice. This one will, as no-one else wants to take on the snoring/OSA work and it is still pouring in! This book is an excellent manual, and there are lots of advances I have not mentioned, such as robots and neurostimulation, but they are for my successor.

Amazon Link: Advanced Surgical Techniques in Snoring and Obstructive Sleep Apnea
By purchasing books via this link you will help to fund the JLO