return to: Laser Surgery Protocols

Note: last updated before 2013

GENERAL CONSIDERATIONS

1. Indications
   1. Heroic and habitual snoring refractory to conservative measures (ie, weight loss, positional therapy, and elimination of sedatives and alcohol)
   2. Upper airway resistance syndrome
   3. Patient cooperative and capable of undergoing local anesthesia and procedure in a sitting position
2. Contraindications
   1. Patient with overly strong gag reflex
   2. Patients with more than very mild obstructive sleep apnea

PREOPERATIVE PREPARATION

1. History
   1. Obtain history from patient and patient's bed partner of snoring.
   2. Screen for obstructive sleep apnea symptoms.
   3. Review patient's medical history, medications (ie, sedatives, neuroleptics), alcohol use, and sleep habits.
2. Evaluation
   1. Complete head and neck examination
   2. Flexible fiberoptic examination (to include Mueller maneuver)
   3. Polysomnography in all cases to evaluate for obstructive sleep apnea
3. Consent
   1. Describe the anatomy of the upper airway and the etiology of snoring.
   2. Describe the steps of topical anesthesia, Xylocaine, Dyclone, atomized Pontocaine and Afrin.
   3. Describe the site and procedure for injecting local anesthetic into the soft palate and uvula.
   4. Describe the arrangement of the room. The patient is placed in a seated position, with goggles and wet towels over the face. The physician is standing to one side in front of him, holding the hand-held laser instrument. Explain the need for smoke evacuation and coordinating inspiration-expiration with periods of lasing.
   5. Describe the expected need for postoperative oral care and oral analgesics (ranging from Tylenol to Tylenol with Codeine, or Percocet).
   6. Describe complications:
      1. Bleeding, infection
      2. Vasovagal episodes
      3. 50% chance of completely eliminating snoring
   7. Explain the likely need for repeated procedures (3 to 4 on average) titrated to reported symptomatic response.

NURSING CONSIDERATIONS

1. Instrumentation
   1. General (see Nursing protocols; refer to ANCI standards for laser safety)
   2. Special Instrumentation
      1. CO2 laser fitted with articulating arm, handpiece, and backstop
      2. Burnished intra-oral instruments
         1. Weder tongue retractor
         2. Yankauer suction tip
2. Preoperative Medications
   1. Dyclone
   2. Hurricaine spray
   3. Neosynephrine
   4. 4% Pontocaine
   5. lidocaine with 1:100,000 epinephrine
   6. Marcaine
3. Intraoperative Medications
   1. None
4. Prep and Drape
   1. No prep needed
   2. Cover patient's eyes with laser-safe goggles
   3. Cover patient's head, neck, and shoulders with wet towels

ANESTHESIA CONSIDERATIONS

1. Procedure done under local anesthesia without sedation
   1. Initial gargle with Dyclone
   2. Hurricane spray to the tonsillar pillars and soft palate
   3. Atomized Neosynephrine spray to the nasal mucous membranes followed by atomized 4% Pontocaine (alternatively, 2 puffs of Afrin prior to going back to the operating room followed by the atomized 4% Pontocaine to the nasal cavity bilaterally)
   4. A 2:1 mixture of 2% lidocaine with 1:100,000 epinephrine and 0.5% Marcaine injected into the base of the uvula on either side; injection should follow the topical anesthetic by 2 to 3 minutes

OPERATIVE PROCEDURE

1. Operation
   1. Using a pharyngeal handpiece with the backstop attached to the articulating arm and the CO2 laser, 2 vertical troughs are made in the soft palate on either side of the uvula. These through-and-through trenches are approximately 1 to 1.5 cm in length. The laser setting is on 10 to 20 watts, continuous mode. After the vertical trenches have been created, swift-lase mode is used at 10 watts to ablate 50% of the length of the uvula.
   2. In cases where there are significant pharyngeal fold redundancy and large tonsils, swift-lase mode can also be utilized to ablate this tissue.
   3. Active laser firing should be performed during the patient's slow exhalation. A smoke evacuator should eliminate the plume. Lasing should be halted before the patient's inhalation.
   4. Take care to avoid excessive tissue removal, potentially resulting in velopharyngeal incompetence. It is better to have the patient without OSAS snoring than speaking and eating with nasal regurgitation.
   5. Avoid touching the posterior pharyngeal wall with the backstop, which can become quite hot during the procedure. Making contact would cause discomfort to the patient as well as potential thermal injury to mucosa, thus increasing the possibility for scar formation.

POSTOPERATIVE CARE

1. The patient should resume regular activities. If any sedatives have been administered IV, the patient should be observed in the usual fashion after a sedative anesthetic.
2. The patient should be instructed to maintain good hydration.
3. The patient should eat a soft, bland diet.
4. The patient should gargle with dilute peroxide or salt-and-soda washes, 4 to 5 times a day, for the first week. Analgesics should be prescribed, according to the patient's respective tolerance (Tylenol, Tylenol, with Codeine, or Percocet, etc).
5. Repeat procedures should be spaced by 4 to 6 weeks. These sessions can be repeated, titrating them to the elimination of snoring and to the patient's satisfaction.

REFERENCES

Krespi YP, Pearlman SJ, Keidar A. Laser-assisted uvula-palatoplasty for snoring. J Otolaryngol. 1994;23:328-334.

Wareing M, Mitchell D. Laser-assisted uvulopalatoplasty: an assessment of a technique. J Laryngol Otolayngol. 1996;110:232-236.