Contemporary Treatment Alternatives For Pharyngeal Reconstruction Temperature Controlled Radiofrequency of the Palate

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Radiofrequency ablation (RF) of tissue has many applications in the medical and surgical fields. It has been used to treat benign prostatic hypertrophy and Wolfe-Parkinson-White syndrome (86,87). Powell and Riley adapted this modality to treat redundant tissue of the upper airway in patients with SDB. The initial investigation trial was performed in a porcine model. Histologic assessments revealed a well-circumscribed lesion with normally healing tissue without damage to peripheral nerves. Volumetric analysis noted an initial inflammatory response, which resolved within 48 hours. A 26.3% volumetric reduction of tissue was documented on the 10th postoperative day (88). Based upon the positive studies in animal models, RF was attempted on human palates to treat snoring and SDB. Subsequent trials were then applied to the nasal turbinates and tongue base.

Temperature-controlled radiofrequency (TCRF) has several advantages as compared to traditional techniques when treating SDB. This procedure is minimally invasive and can be performed on an outpatient basis. The mucosal layer of tissue is spared, thus resulting in less pain and complications. Lower temperatures allow for more precise treatment and reduce thermal injury to adjacent tissue. TCRF heats treated tissue from 47 to 90°C. Electrocautery and laser procedures can heat tissue from 750 to 900°C. More precise control of thermal energy and limited submucosal tissue injury results in less morbidity without sacrificing efficacy.

Treatment is administered by inserting an electrode probe into the submucosal layer of the tissue to be ablated. Low frequency (465 kHz), low heat electromagnetic energy is administered to denature tissue protein. This region of necrosis is resorbed by the body with resulting volumetric reduction and stiffening of the tissue.

TCRF treatment of the palate reduced subjective snoring scores by 77% and reduced EDS (89). Multiple studies have shown TCRF of the palate improves snoring as effectively as other treatment modalities (90-92). Relapse of snoring has been noted at rates similar to those obtained by other treatment protocols (93). However, patients are more likely to undergo repeat RF treatments than more invasive procedures. While outcomes may be similar for different treatment options for snoring, the main advantage RF offers is minimal postoperative pain. Typically, ibuprofen is used for analgesia after TCRF. Narcotics are not commonly needed to alleviate pain following TCRF, while they are needed in nearly all patients who undergo UPPP or laser-assisted palatoplasty (94). Although improvement in SDB has been documented following TCRF, it is unlikely to cure palatal obstruction as primary therapy. Blumen et al. (95) demonstrated a significant reduction in RDI following TCRF of the palate in patients with mild-to-moderate disease. It is our experience that, due to the bulk of tissue which needs to be reduced, TCRF is best utilized as an adjunctive technique to treat palatal obstruction.

TCRF is well-tolerated. The incidence of postoperative complications is exceedingly low. A study of the postoperative outcomes demonstrated no major complications and less than a 1% chance of minor complications (96). Mucosal ulceration or sloughing was defined as a minor complication. Airway obstruction, hemorrhage, palatal fistula, and severe dysphagia are potential serious negative outcomes.

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