Snoring and obstructive sleep apnea (OSA) often result from anatomical and functional collapse of the upper airway, with palatal flutter accounting for over 80% of snoring cases. The Cautery-Assisted Palatal Stiffening Operation (CAPSO), introduced by Ellis in 1994, and its modified version, Anterior Palatoplasty by Pang et al., provide a minimally invasive solution for treating these conditions. These procedures aim to stiffen the soft palate and expand the retropalatal airway, offering promising outcomes for patients.
Patient Selection
Preoperative evaluation includes detailed history, physical examination, flexible nasoendoscopy, polysomnography (PSG), and quality-of-life assessments such as the Epworth Sleepiness Scale (ESS) and Visual Analog Scale (VAS) for snoring.
Anterior palatoplasty is recommended for:
- Patients with narrow retropalatal diameters.
- Primary snorers (AHI <5) and patients with mild OSA.
- Individuals above 18 years with BMI <33.
- Cases showing minimal base of tongue collapse (<25%) on drug-induced sleep endoscopy.
Surgical Technique
The procedure can be performed under local or general anesthesia. Key steps include:
- Preparation: The patient is positioned with their mouth open, and local anesthetic with adrenaline is administered.
- Excision: A horizontal rectangular strip of mucosa (approximately 50 mm x 7 mm) is excised from the central soft palate, ensuring the underlying muscles remain intact.
- Closure: The defect is closed in two layers using absorbable Vicryl sutures. The muscle-to-muscle approximation lifts the uvula and soft palate superiorly and anteriorly, enhancing the oropharyngeal airway. A second layer of mucosal sutures aids healing.
- Adjunct Procedures: In selected cases, partial uvulectomy or turbinate reduction may accompany the surgery.
How Anterior Palatoplasty Helps in OSA?
Healing after anterior palatoplasty leads to fibrosis of the palatal tissue, retracting it superiorly and reducing palatal flutter. This retraction widens the oropharyngeal airway and stabilizes the retropalatal space.
Postoperative Management
Post-surgical care includes monitoring vital signs, providing adequate analgesia, and advising a soft diet. Complications are rare but may include hemorrhage, velopharyngeal incompetence, or nasopharyngeal stenosis.
Outcomes and Success Rates of Anterior Palatoplasty
Studies report significant improvements in snoring intensity and AHI:
- Pang et al.: 75% success rate in mild OSA cases with a mean postoperative AHI reduction from 12.3 to 5.2 (p<0.05).
- Marzetti et al.: 86% success in selected mild-to-moderate OSA patients.
- Ugur et al.: Comparable results with innovative modifications.
Advantages include low cost, minimal invasiveness, and high patient satisfaction, making CAPSO an excellent option for carefully selected cases.
Cautery-Assisted Palatal Stiffening Operation and Anterior Palatoplasty provide effective, predictable, and minimally invasive solutions for snoring and OSA management. With proper patient selection and meticulous surgical technique, the procedure offers high success rates and improved quality of life for patients and their sleep partners.
References
- Ellis PD. Laser palatoplasty for snoring due to palatal flutter: a further report. Clin Otolaryngol Allied Sci. 1994;19(4):350-1.
- Mair EA, Day RH. Cautery-assisted palatal stiffening operation. Otolaryngol Head Neck Surg. 2000;122(4):547-56.
- Pang KP, Terris DJ. Modified cautery-assisted palatal stiffening operation: new method for treating snoring and mild obstructive sleep apnea. Otolaryngol Head Neck Surg. 2007;136(5):823-6.
- Pang KP, Tan R, Puraviappan P, et al. Anterior palatoplasty for the treatment of OSA: three-year results. Otolaryngol Head Neck Surg. 2009;141(2):253-6.
- Marzetti A, Tedaldi M, Passali FM. Preliminary findings from our experience in anterior palatoplasty for the treatment of obstructive sleep apnea. Clin Exp Otorhinolaryngol. 2013;6(1):18-22.
- Ugur KS, Kurtaran H, Ark N, et al. Comparing anterior palatoplasty and modified uvulopalatopharyngoplasty for primary snoring patients: preliminary results. B-ENT. 2013;9(4):285-91.