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Medical Research

A paper presented at the ASSOHNS ENT Conference in Perth in 2003.
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MEDICAL PRESENTATION

Original Article


Snoring cessation through radiofrequency treatment of the soft palate:
a preliminary analysis of 119 cases
A New Zealand experience

Neil A Hutchison, FRNZCGP and Andrew D Murley, FRNZCGP, Family Practitioners, Auckland, New Zealand
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Abstract

Aim

To assess the efficacy of radiofrequency tissue volume reduction (RTVR) treatment to the soft palate in reducing snoring (using “Surgitron” equipment) as a simple office procedure.

Methods

A non-randomised, prospective study, where 119 patients underwent some simple clinical
testing to best categorise them into:
1) sound originating from the soft palate
2) sound originating from the tongue
3) nasal obstruction as a contributory factor.
As seemed appropriate, the options for management were:
1) radiofrequency to the soft palate, and/or:
2) radiofrequency to the turbinates

Results

In line with other similar studies, our findings indicate a marked reduction in snoring volume with one procedure consisting RTVR to two sites in the soft palate. After the first procedure, 79.6 % of patients had improved, the mean improvement being 4.65 on the snoring scale. After the second procedure (n = 35), 62 % of patients had a further improvement, the mean improvement being 2.36 on the snoring scale. There was no improvement in 20.4% after the first treatment. There was a
marked reduction in the average scores of snoring disruptiveness across the full range of BMIs. A comparison of patients who received either palatal radiofrequency treatment alone, or combined palate/turbinate radiofrequency (when nasal obstruction due to very large turbinates was present) shows slightly improved scores in most BMI categories for the combined palate and turbinate patients.

Conclusions

These data suggest that the minor surgical procedure of radiofrequency is a valuable tool in the management of the snoring patient across the range of BMIs. There may be an advantage in treating severely congested turbinates concurrently. The success rates, minimal pain, and economy of the RFVTR to the palate make this office minor surgery an attractive alternative for the patient.

Snoring is a very common problem

There is a large industry developing with remedies for this problem. These include sprays for throat and nose, and nasal and mandibular advancement splints. However, there is now a minor treatment with an excellent chance of reducing snoring.

Radiofrequency tissue volume reduction (RTVR) has been shown to be tolerable, effective and safe option for treating snoring

RFVTR equipment is available from three sources: “Somnoplasty”, “Ellman Surgitron” , and "Coblation".  We have used all. These are similar in effect, the former being much more “hightech” (and much more expensive).  We prefer the Ellman equipment for ease of use, shorter burn time, and cost.

Previously trialled have been sclerosant injection methods (in 2003...note: this is not now in use in New Zealand in 2010). Another method is Palatal Pillars, where stiffening rods are place into the soft palate.  This is not generally available in New Zealand.

A Review of the Literature

A review of the literature (see below) shows papers extending back to about 1997. Numbers of patients in these trials tend to be quite low (averaging 34 patients, ranging from n = 12 to 113), and assess radiofrequency to the palate from a number of points of view. These include: The percentage satisfied after 3 treatments (Paper number 9) #9, single burn results compared with multiple burns, #10, comparing the effectiveness of laser-assisted uvulopalatoplasty (LAUP) with the radiofrequency technique #11, and assessing the value of objectivity vs subjectivity in assessing snoring #3. There is also studies of the longevity of the reduction #4, #12, #13, methods of evaluating pain scores #5, #8, #14, and assessment of the incidence of mucosal damage, seen and unseen #15.

Using RFVTR to successfully reduce turbinate volume has also been recorded #9#16-18.


Methods

One hundred and nineteen consecutive patients presented for radiofrequency treatment of the palate after the initial clinical assessment. They had been recruited through public advertising, and by referral from other family medical practitioners in our city. One had a previous laser-assisted uvulopalatoplasty (LAUP), which initially helped snoring, but had now “loosened”, and one had a previous uvulopalatoplasy (UPPP), which had not been successful.

Clinical Assessment

History taking involved questions on duration of snoring, snoring position, tiredness on waking and during the day, the presence of a very dry throat in the mornings, smoking, aggravating factors, and history of weight gain.


Questions about exercise levels, and what other methods tried so far were also asked and recorded.

At this assessment visit, a pre-operative snore-score sheet was completed, including a numeric comment from the bedmate. This seemed an effective way to quantify the snoring problem at the beginning and after treatment. (This scoring method was deficient for some who commented that the snoring was now not continuous, but occasional and the same loudness.). This scoring method has been employed in other
research #1, 3, 13.

The score sheet also included weight and height and BMI data.

 Informed consent was obtained.

The snoring examination

In the sitting position, examination of the patient included the production of a snore noise with the mouth open and closed, then with the jaw protracted. The palate was examined with “ah” and “ee” to assess for laxity. The uvula was observed for size, oedema, and inflammation. The nose was assessed for blockage from septal, turbinate or other causes. Fibre optic assessment of palatal vibration was not included. We
encouraged the patients to make a separate appointment for the actual procedure to allow them to read the details we provided.

The procedure

After topical then local anaesthetic (1 ml of Xylocaine 1% with adrenaline each side), the palate received two radiofrequency treatments in paramedian positions, with the probe tip (see photograph) carefully placed so as to be deep to avoid surface ulceration. The 20-second burns are not visible. They were placed in a tandem configuration (upper left and lower right) to allow a second procedure in new tissue if required later in the alternate position (see photograph). The radiofrequency apparatus used was the “Ellman Surgitron”. The settings used were “Partially Rectified”, and at power setting of 3.5 for palate use, for 20 seconds each.

Radiofrequency to the turbinates

Using topical xylocaine 4%, followed by the injection of 2% Xylocaine with adrenaline under direct vision into the inferior turbinate. The surgitron is set on “Partially Rectified” on a power setting of 2 for the turbinates. About twelve applications to each 
inferior turbinate produced a visible change in contour. Haemostasis was achieved by applying a burn on exiting.


Postoperative Pain Assessment

In our previous pilot study of 50 cases, post-operative pain was assessed on a visual analogue scale (V.A.S.). The mean pain rating on a scale of 0 to 10 (where 0 = no pain and 10 = maximum pain) was 2 (range: 0 – 4). One out of four patients required mild analgesia. Pain was not assessed in the current study.

Age Range and Sex

In this study of 119 cases, there were 97 males (81.5%) and 22 females (18.5%). The age range was 19 to 79 years of age. Mean improvement of males and females was similar, being 3.31 and 3.45 respectively (figure 1).

Scores for snoring have been quoted using the partner scores, not the patient scores, because often patients could not offer an opinion on their own scores. Partner scores were consistently higher than patient scores, as below.

Comparison of patient’s account of snoring compared with partner’s account

Mean scores Patient vs Partner
Pre-operative score 8.2 vs 9.0
Post-operative score first treatment 5.5 vs 5.8
Post-operative score second treatment 4.3 vs 4.7

Results of the snoring score after first and subsequent treatment

After the first procedure, 79.6 % of patients had improved, the mean improvement being 4.65 on thesnoring scale. After the second procedure (n = 35), 62 % of patients had a further improvement, the mean being 2.36 on the snoring scale. After the first treatment, 20.4% showed no improvement.

Based on age groupings

Reduction in snoring occurred over all ages with the first treatment. In the under 40-year-old group (n = 15), the mean improvement in snoring scale was 2.3. The mean improvement in snoring scale for the 40 to 49 year olds was 3.3 (n = 37). The mean for the 50 to 59 year olds was 3.5 (n = 43), and the 60 to 69 year olds was 3.1 (n = 18). Although the over 70’s group had the best improvement score at 4.45, the numbers were low (n = 5). (Figure 2)


Based on Body Mass Index

When grouping by Body Mass Index (BMI), all groups had average improvements of more than 3.

Categories were BMI of 20 to 25 regarded as "normal weight" (n = 26) where the mean improvement was 3.9 on the snoring score.

With a BMI of 25 to 30 regarded as "overweight" (n = 59), the improvement was 3.1.

With the BMI of 30 to 35 regarded as "obese" (n = 24), the mean improvement was 3.0.

With the BMI of 35-plus regarded as very "obese" (n = 6), the mean improvement was 3.8.

Comparing Palate only with Palate and Turbinates across the BMI ranges:

RFVTR application to the palate only, and RFVTR to both palate and turbinates in the different BMI groupings were compared. In most cases, the mean reduction in snoring score was greater where the combined procedure was done. With the BMI of 20 to 25, the mean score in the palate group was 5.34, and 5.23 for those receiving palate and turbinate radiofrequency. When the BMI range of 25 to 30 was compared, the mean postoperative scores were 5.21 and 4.74 respectively. With BMI 30 to35, the scores
were 4.67 and 4.88, and with the BMI over 35, scores were 4.5 and 4.0 (Table 2)

Table 2
BMI Preoperative score Postoperative Palate Palate & Turbinates
20-25 9.24 5.34 5.23
(n = 33)
25-30 9.23 5.21 4.74
(n = 39)
30-35 8.26 4.67 4.88
(n = 15)
35 plus 8.8 4.50 4.00

Adverse Reactions

The incidence of adverse reactions was considered low:
  •  Three patients felt faint, and needed to be reclined.
  • There were 11 mucosal burns, most of which were trivial, and not noticed by the patients. Two of these were considered moderate, and healed without problem by six weeks. There were no palate perforations in this series, and no one needed narcotic analgesia. Paracetamol sufficed when needed.

Used to "top up" after a UPPP or LAUP effect wears off

One patient who presented had LAUP several years ago had resumed snoring, and wanted to try RFTVRto reduce his snoring. One patient who had previously had UPPP without initial success, also presented.

The LAUP patient had what he considered a successful outcome to radiofrequency treatment to the palate, with an initial snoring score of 10, and a reduction to 8 with one procedure, and to 5 with a second one. The spacing was 8 weeks between these procedures.

The UPPP patient did not improve, scoring 10 preoperatively, and 10 at eight weeks, and 10 two months after a second attempt.


Discussion

Snoring is a distressing problem for the victims and the perpetrators, and is very prevalent. Thisprospective non-randomised preliminary study provides more data on some areas reported on previouslyby others in smaller samples, and offers some new data in some areas of radiofrequency tissue volumereduction (RFTVR). Our data differ from some other published studies, inviting discussion and furtherinvestigation.

Our snoring score scale has been used by many investigators (See below, papers #1-5, 8, 10, 13, 19, 20) and seems to be a reasonable method to quantitate preoperative disturbance levels. As patients improve, however, some develop intermittent snoring, and this scoring method is sometimes not adequate to accurately quantitate these reductions.

Embarrassed snorers are often quite reluctant or unable to put a score to their snoring volume. It is however a good, simple, and reproducible scoring system when scored by the spouse, #4.

Comment on result:

  A reduction in snoring, as scored by the partner, in 79.6% of patients after one treatment compares wellwith other studies #1-5 7 8 10 19 21, and the mean improvement of 4.65 on the snoring scale represents an excellent result. A second treatment, given when the patient wished for a further reduction, showed a
further reduction in 62% of these patients by a mean of 2.36 on the scale. Complete data is not yet available for recipients of a third procedure. The percentage having no significant improvement with the first treatment was 20.4%, and it remains to be seen whether this group would improve with further treatments.


Does Age Matter?

Response to treatment was evaluated looking at different age groups. All age groups responded with improvements in their mean snore scores. This varied from a mean reduction of 2.3 in the under 40 year olds (n = 14) to 4.4 in the over 70 year olds (n = 5). This may be an aberration because of the smaller numbers represented at either end of the graph, but does suggest that RFVTR treatment of snoring is worthwhile at all ages. This data has not been reported before in the literature.

Does Obesity affect the results of snoring surgery?

Previous data in a small series has suggested that response to RFTVR of the palate is closely related to the BMI  #2. Our results showed a consistent improvement over all ranges of BMI, including the very obese BMI of >35. This improvement suggests that this procedure is generally successful in the full range of body weights, and that one is not necessarily disadvantaged by being obese. Further trials of larger numbers are needed to resolve this question.

Nose and Palate surgery at the same time?

Using data from one operator, a comparison has been made between patients who have had RFVTR to soft palate alone, and to a combination of palate and turbinates, using the same apparatus at the same visit (Table 2). This data was further broken down into BMI groupings. Patients were selected on details of history and clinical impression as to whether the nasal obstruction was relevant to their snoring or not. In
the history, waking during the night to sip water, or waking with an excessively dry mouth suggested mouth breathing during the night. When not associated with a lot of sneezing, this was considered to be due to chronic turbinate congestion, rather than acute allergy. Clinically, when the above turbinates largely occlude the nasal airway, and they are accessible, treatment was offered with RFTVR. When reviewed at 6 weeks, tissue reduction is usually still obvious in the turbinate contours. We have observed
this phenomenon for as long as 2 years postoperatively. Utley et al #9, in their series of 10 cases, have quoted 100% success using similar methods for volume reduction of turbinates.

In a number of ways, Utley et al endeavoured to quantitate nasal patency. They concluded that: “submucosal ablation of the inferior turbinates with radiofrequency is effective in reducing nasal obstruction secondary to turbinate
hypertrophy”. A more efficient way of equating nasal patency would be helpful in evaluating this treatment.  (We have subsequently developed an accurate method at "SnoreOp"...Author)

Adverse reactions to RFTVR

Adverse reactions to RFVTR are minimal and well tolerated, though caution in cases of patients with cardiac pacemakers is advised. Pain is usually minimal, and this is an advantage when the inevitable loosening of tissues occurs perhaps one to 3 years later13, as is common in all mechanical tightening procedures. Acceptance of re-treatments is high #20.
Whether RFVTR can be appropriately used to augment a diminishing effect after LAUP and UPPP needs more research, as the much more minor operation of RFVTR has been shown to be equally effective and better tolerated when compared with LAUP for snoring reduction #11.


Final Conclusions

RFVTR is a safe and effective method for the reduction of snoring of all age groups, and all categories of BMI patients. It may also have a place in concomitantly reducing the volume of the turbinates in patients where this is relevant. We currently set the limit as less that 45 Litres per minute "Peak nasal inspiratory flow rate".




References as referred to above

1. Emery BE, Flexon PB. Radiofrequency volumetric tissue reduction of the soft palate: a new treatment
for snoring. Laryngoscope 2000;110(7):1092-8.
2. D'Souza A, Hassan S, Morgan D. Recent advances in surgery for snoring-somnoplasty (radiofrequency
palatoplasty) a pilot study: effectiveness and acceptability. Rev Laryngol Otol Rhinol
2000;121(2):111-5.
3. Hukins CA, Mitchell IC, Hillman DR. Radiofrequency tissue volume reduction of the soft palate in
simple snoring. Arch Otolaryngol Head Neck Surg 2000;126(5):602-6.
4. Blumen MB, Dahan S, de Dieuleveult T, Wagner I, Chabolle F. [Treatment of snoring with controlled
temperature radiofrequency: short- and mid-term tolerance and efficacy]. Ann Otolaryngol Chir
Cervicofac 2000;117(6):349-358.
5. Boudewyns A, Van De Heyning P. Temperature-controlled radiofrequency tissue volume reduction of
the soft palate (somnoplasty) in the treatment of habitual snoring: results of a European
multicenter trial. Acta Otolaryngol 2000;120(8):981-5.
6. Back L, Palomaki M, Piilonen A, Ylikoski J. Sleep-disordered breathing: radiofrequency thermal
ablation is a promising new treatment possibility. Laryngoscope 2001;111(3):464-71.
7. Taliaferro C. Submucosal radiosurgical uvulopalatoplasty for the treatment of snoring: Is the
monitoring of tissue impedance and temperature necessary? Otolaryngol Head Neck Surg
2001;124(1):46-50.
8. Sher AE, Flexon PB, Hillman D, Emery B, Swieca J, Smith TL, et al. Temperature-controlled
radiofrequency tissue volume reduction in the human soft palate. Otolaryngol Head Neck Surg
2001;125(4):312-8.
9. Utley DS, Goode RL, Hakim I. Radiofrequency energy tissue ablation for the treatment of nasal
obstruction secondary to turbinate hypertrophy. Laryngoscope 1999;109(5):683-6.
10. Ferguson M, Smith TL, Zanation AM, Yarbrough WG. Radiofrequency tissue volume reduction:
multilesion vs single-lesion treatments for snoring. Arch Otolaryngol Head Neck Surg
2001;127(9):1113-8.
11. Blumen MB, Dahan S, Wagner I, De Dieuleveult T, Chabolle F. Radiofrequency versus LAUP for the
treatment of snoring. Otolaryngol Head Neck Surg 2002;126(1):67-73.
12. Trotter MI, D'Souza AR, Morgan DW. Medium-term outcome of palatal surgery for snoring using the
Somnus unit. J Laryngol Otol 2002;116(2):116-8.
13. Li KK, Powell NB, Riley RW, Troell RJ, Guilleminault C. Radiofrequency volumetric reduction of
the palate: An extended follow- up study. Otolaryngol Head Neck Surg 2000;122(3):410-4.
14. Troell RJ, Powell NB, Riley RW, Li KK, Guilleminault C. Comparison of postoperative pain between
laser-assisted uvulopalatoplasty, uvulopalatopharyngoplasty, and radiofrequency volumetric tissue
reduction of the palate. Otolaryngol Head Neck Surg 2000;122(3):402-9.
15. Terris DJ, Chen V. Occult mucosal injuries with radiofrequency ablation of the palate. Otolaryngol
Head Neck Surg 2001;125(5):468-72.
16. Coste A, Yona L, Blumen M, Louis B, Zerah F, Rugina M, et al. Radiofrequency is a safe and
effective treatment of turbinate hypertrophy. Laryngoscope 2001;111(5):894-9.
17. Fischer Y, Gosepath J, Amedee RG, Mann WJ. Radiofrequency volumetric tissue reduction (RFVTR)
of inferior turbinates: a new method in the treatment of chronic nasal obstruction. Am J Rhinol
2000;14(6):355-60.
18. Rhee CS, Kim DY, Won TB, Lee HJ, Park SW, Kwon TY, et al. Changes of nasal function after
temperature-controlled radiofrequency tissue volume reduction for the turbinate. Laryngoscope
2001;111(1):153-8.
19. Boot H, van Wegen R, Poublon RM, Bogaard JM, Schmitz PI, van der Meche FG. Long-term results
of uvulopalatopharyngoplasty for obstructive sleep apnea syndrome. Laryngoscope 2000;110(3 Pt
1):469-75.
20. Li KK, Powell NB, Riley RW, Troell RJ, Guilleminault C. Radiofrequency volumetric tissue
reduction for treatment of turbinate hypertrophy: a pilot study. Otolaryngol Head Neck Surg
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21. Coleman SC, Smith TL. Midline radiofrequency tissue reduction of the palate for bothersome snoring
and sleep-disordered breathing: A clinical trial. Otolaryngol Head Neck Surg 2000;122(3):387-94.


Acknowledgements


The authors wish to acknowledge the expert assistance of Paul Prosée and Paul Hutchison in collating and interpreting data.

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