Pillars Do Not Reduce CPAP Pressure or Increase CPAP compliance.

Patients with sleep apnea are frequently looking for an easy surgical procedure to treat their sleep apnea. Pillar surgery was intially considered to be a treatment for sleep apnea but has been relegated to a treatment for simple snoring coming from the soft palate.

PLACEMENT OF SOFT PALATE PILLARS SHOULD NOT BE CONSIDERED A PRIMARY TREATMENT FOR SLEEP APNEA!

A new study (PubMed abstract below)looked at Pillar Surgery to see if it increased compliance in CPAP users or decreased CPAP pressures. Sadly, this was not the case. The study published in Otolaryngology Head and Neck Surgery concluded that "Pillar implants do not significantly reduce CPAP pressure or increase CPAP compliance compared to sham controls but may subjectively improve CPAP satisfaction. These findings do not presently support the use of Pillar implants as an adjunctive treatment to improve CPAP compliance."

I advise patients who are looking for a surgical "cure" for sleep apnea avoid pillar surgery. Surgical interventions that can "cure sleep apnea" are available. The most successful is bimaxillary advancement. Base of tongue reduction is also successful but I strongly recommend doing it with the somnoplasty method to avoid adverse surgical consequences.

For the severely obese CPAP and tracheotomy are the most successful treatments. Mild to moderate sleep apnea is best treated with CPAP or Oral Appliances.

Otolaryngol Head Neck Surg. 2011 Feb;144(2):230-6. Epub 2010 Dec 29.
Effect of palatal implants on continuous positive airway pressure and compliance.
Gillespie MB, Wylie PE, Lee-Chiong T, Rapoport DM.
Source

Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina 29425-5500, USA. gillesmb@musc.edu
Abstract
OBJECTIVE:

Determine if the Pillar palatal implant system reduces continuous positive airway pressure (CPAP) pressure and improves patient compliance with CPAP therapy.
STUDY DESIGN:

Randomized, double-blind, placebo-controlled study.
SETTING:

Four geographically dispersed tertiary sleep disorder referral centers.
METHODS:

Subjects with mild to moderate sleep apnea dissatisfied with CPAP because of pressure-related complaints were randomized to receive Pillar implants or a sham procedure performed in double-blind fashion. Active and sham groups were compared for changes in therapeutic CPAP pressures (primary outcome) with a 90-day follow-up sleep study and CPAP compliance (secondary outcome) with a 90-day smart card report.
RESULTS:

Twenty-six subjects were randomized to Pillar implants and 25 to a sham implant procedure. There were no differences between groups with regard to demographics and baseline parameters. Both sham and active groups had reduced mean CPAP pressure (-1.1 vs -0.5 cm H(2)O) with no difference between groups (P = .32) at 90-day follow-up. In addition, there was no difference in average daily CPAP use between groups (P = .80). Both groups experienced improvements in Epworth sleepiness scores and Functional Outcome of Sleep Questionnaire scores at 90 days with no differences between groups. The active group reported significantly higher CPAP satisfaction scores than the sham group (P = .04).
CONCLUSION:

Pillar implants do not significantly reduce CPAP pressure or increase CPAP compliance compared to sham controls but may subjectively improve CPAP satisfaction. These findings do not presently support the use of Pillar implants as an adjunctive treatment to improve CPAP compliance.

PMID:
21493422
[PubMed - indexed for MEDLINE]

Sleep Apenea Surgery: Soft Palate Surgery is rarely, if ever a first line treatment for sleep apnea.

There are only two first line treatments for Sleep Apnea, CPAP and Oral Appliances. CPAP is extremely effective but the majority of patients abandon CPAP use due to comfort issues. Oral Appliances are a first line treatment for mild to moderate sleep apnea and an alternative to CPAP for the 60% of patients who abandon CPAP and those who use CPAP but just want to experience a more comfortable alternative to CPAP.

Note: For the morbidly obese CPAP is still the best treatment, for younger thinner and healthier patients oral appliances are effective and easy to fit into busy lifestyles.

Surgery, especiall soft palate surgery used to be considered a first line of treatment for sleep apnea but dismal results and high morbidity have relegated soft palate surery to a secondary proceedure, at best.

There were several types of soft palate surgery but the grandfather of all was the UP3, UPPP surgery or Uvulopalatopharyngoplasty. This surgery was excruciatingly painful, had a high morbidity and was usually unsuccessful in treating sleep apnea. According to Wikipedia the risks of UP3 surgery include:

"One of the risks is that by cutting the tissues, excess scar tissue can "tighten" the airway and make it even smaller than it was before UPPP. Some individuals who have undergone UPPP experienced a worsening of their breathing following UPPP.
Others have spoken of severe acid reflux.
After surgery, complications may include these:
Sleepiness and sleep apnea related to post-surgery medication
Swelling, infection and bleeding
A sore throat and/or difficulty swallowing
Drainage of secretions into the nose and a nasal quality to the voice. English language speech does not seem to be affected by this surgery.
Narrowing of the airway in the nose and throat (hence constricting breathing) snoring and even iatrogenically caused sleep apnea.
Patients who have had the uvula removed will become unable to correctly speak French or any other language that has a uvular 'r' phoneme."

All surgeries to the soft palate carry risk and are painful. The LAUP procedure or Laser Assisted Uvuloplasty was less painful than up3 but still very painful. There was less chance of scarrig that dangerously narrowed the airway as seen with UP3.

Somnoplasty of the soft palate was less painful but equally ineffective in treating sleep apnea. Somnoplasty is a procedure to consider in patients with soft palate snoring and no sleep apnea. Other surgical alternatives are snoreplasty and pillars which again are useful for snoring but minimally helpful for treating sleep apnea.

Tracheotomy is the grandfather of surgeries and allows patients to breathe thru their throats. It is very successful but most patients do not want a long term tracheotomy.

The majority of sleep apnea is caused by the base of the tongue obstructing the airway or pressing on the epiglottis that blocks the airway.

There are several procedures that can be done to either advance the tongue or make it smaller. Somnoplasty on the base of the tongue is probably the preferred surgery for most patients contemplating reducing tongue size.

MaxilloMandibular Advancement is probably the most successful sleep apnea surgery but is extensive surgery carring definite risks. I strongly recommentd that patients undergoing this rocedure avoid ENT's and Plastic Surgeons and utilize Oral Surgeons with extensive experience in this type of surgery. The dental background of Oral surgeons make themthe first choice. They frequently do these surgeries for orthodontic purposes and understand stomatognathic function.

PATIENTS CONTEMPLATING MAXILLOMANDIBULAR ADVANCEMENT SHOULD ALMOST ALWAYS GO THRU A TRIAL OF AN ORAL APPLIANCE TO DETERMINE THE BEST POSITION FOR THE JAWS AFTER THIS RADICAL SURGERY. THIS WILL PREVENT NEEDLESS SECONDARY SURGERIES.

Nasal surgery is frequently helpful but rarely is a cure for apnea when done alone. Correction of deviated septums and turbinate reduction offer greater comfort for most patients with obstructed breathing due to anatomical or allergic problems.

Nasal surgery is usually and ENT procedure but is frequently one by oral surgeons as well.

Pediatric patients with sleep apnea are usually candidates for removal of tonsils and adenoids. While effective at opening the pharyngeal airway newer research suggests that orthodontic widening of the hard palate should be done either before or after T&A procedures. Widening prior to surgery may reduce post-operative complications.

Sleep apnea is probably responsible for at least 80% of the cases ADD and ADHD in children. The earlier the airway obstructions are addressed the healthier it is for future development.