1 INTRODUCTION

Snoring is caused by the vibration of the structures in the oral cavity and oropharynx – namely the soft palate, uvula, tonsils, base of tongue, epiglottis and pharyngeal walls. Most authorities would concur that over 80% of snoring is due to palatal flutter, caused by vibration of the uvula and the soft palate. Hence, it would be conceivable that techniques to stiffen the palate would be beneficial in reducing snoring. Different techniques using various instruments (e.g. the laser, cautery and coblator) have been used to achieve the same outcome. The palatal stiffening operation was first introduced by Ellis in 1994¹ and improvised by Mair in 2000.² Both authors utilized cautery to stiffen the palate. The original cautery-assisted palatal stiffening operation (CAPSO) procedure was based on stripping a ‘diamond’ shaped area of mucosa off the soft palate and uvula, with the aid of cautery under local anesthesia (Figs 26.1 to 26.4). Although good results were reported, the procedure produced a stellate puckered scar on the soft palate that resulted in tenting of the lateral pharyngeal walls and therefore narrowing of the late­-ral distance between the tonsillar pillars (Fig. 26.5). These anatomic manifestations may explain why some patients did not have any clear benefit from the procedure.

Fig. 26.1 (CAPSO 1). The ‘diamond’ shaped mucosa is stripped off the uvula and the soft palate.

Fig. 26.2 (CAPSO 2). With the aid of an artery forceps and cautery, the mucosa is removed.

Fig. 26.3 (CAPSO 3). The uvulectomy is also performed with cautery.

Fig. 26.4 (CAPSO 4). The fibrotic scar starts to form as healing takes place.

Fig. 26.5 (CAPSO 5). A puckered stellate scar results that causes narrowing of the lateral pharyngeal pillars and tonsillar pillars medially, hence narrowing the oropharyngeal space.

Several of the newer methods involve the use of expensive implants or sophisticated equipment. The ideal technique would be an office-based procedure which would require no special equipment or implants, and which achieves effective results in a reliable and predictable fashion. We describe a modified palatal stiffening technique designed to create the palatal scar and fibrosis that is anatomically sounder and which results in retraction of the palate superiorly, avoiding the puckered scar and stenosis of the lateral pharyngeal walls.

2 PATIENT SELECTION

This modified CAPSO (Fig. 26.6) procedure is performed for patients with mild obstructive sleep apnea (OSA) (Apnea/Hypopnea Index (AHI) < 15) or patients who are primary snorers (AHI <5). The inclusion criteria include patients above 18 years of age, Body Mass Index (BMI) < 33, tonsil size grade 1 and 2, elongated uvula, all Mallampati grades, minimal base of tongue collapse (<25%) as seen on Mueller’s maneuver.

Fig. 26.6 (1 Oral cavity insert). Showing the uvulectomy, and bilateral vertical trenches. The horizontal strip of mucosa is removed down to muscle.

All patients undergo a thorough physical examination, nasoendoscopy, and a level I overnight attended poly-somnography (PSG). Patients also complete the Epworth Sleepiness Scale (ESS) and a visual analogue scale (VAS) for snoring before surgery and 7, 14, 30, 60 and 90 days after surgery. The sleep partner also completes a similar scale for snoring. Patients also complete a VAS for pain on postoperative days 1, 3, 7 and 14. Examination includes height, weight, neck circumference, BMI, and assessment of the nasal cavity, posterior nasal space, oropharyngeal area, soft palatal redundancy, uvula size and thickness, tonsillar size and Mallampati grade. Flexible nasoendoscopy is performed for all patients, and collapse during a Mueller’s maneuver is graded for the soft palate, lateral pharyngeal walls and base of tongue on a five-point scale.³

Outcome measures include subjective improvement in snoring based on the VAS and improvement in sleepiness as indicated by the Epworth scale. Objective changes are judged by the polysomnographic findings. The success criterion is a reduction of at least 50% of the pre-procedure AHI and post-procedure AHI below 15.