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Dr. Powell and Dr. Riley Contributions Over Time to the Field of Obstructive Sleep Apnea Syndrome (OSAS) Early in 1983 Drs. Nelson Powell and Robert Riley began to develop methods and surgical procedures for the treatment of OSAS. At the time very few physicians believed in the significance of OSAS. The only surgical techniques available as treatment options were tracheotomy and palatopharyngoplasty (UPPP). Although tracheotomy was very successful in managing OSAS, with cure rates near 100%, it was not readily accepted by the patients The UPPP was originally developed as a technique to treat snoring. In some cases it was used to treat OSAS but seldom were cures attained. Drs. Powell and Riley experienced their share of treatment failures from the isolated UPPP even though the surgery does open the airway at this level. They came to believe that the tongue base, not previously identified as a potential area of obstruction, was at least partially responsible for UPPP failures. |
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A summary of their efforts to prove this finding will be chronologically listed below (presented from 1983 to present) as will subsequent treatment techniques for which they are responsible. Each technique was original and each procedure was performed first by Drs. Powell and Riley who also completed the appropriate investigational studies and published peer reviewed papers on the techniques. Cephalometric Analysis In 1983 we noted that the isolated treatment of OSAS using UPPP, with or without nasal reconstruction, was not significantly improving the majority of patients we were treating. We suspected that the tongue, which is below the palate level, could be a region of obstruction that had not previously been evaluated in OSAS. To evaluate this area a simple dental radiographic study called a cephalometric film was used to assess the soft tissues and bony anatomy of the face and neck. We found marked abnormalities of the upper airway in this study of subjects with OSAS. Most importantly, the analysis showed narrowing in the posterior airway space (PAS) accompanied with a low position of the hyoid bone. This new adaptation of the cepalometric film allowed us to evaluate this portion of the airway in a non-invasive manner both before and after treatment. Several important landmarks were used that had not have been previously described by others in our field. These we named as the PNS-P (posterior nasal spine to tip of uvula), the PAS (posterior airway space behind the tongue) and the MP-H (line from the inferior mandible to the hyoid bone below). We have used these measurements now for over 20 years to assess the anatomical configuration of the airway. About ten years ago we combined cephalometrics with fiber-optic technology using a tiny fiber-optic scope passed through the nose to give us a three dimensional view of the upper airway to confirm the two dimensional data from the cephalometrics. We consider this approach a necessary step for any patient with OSAS who is considering surgery.
First Mandibular Osteotomy with Objective Data
Cephaolmetrics helped identify a patient with OSAS who had a small jaw and a large tongue. The PAS was seriously compromised as the tongue was markedly collapsed. The symptoms and polysomnogram showed severe OSAS. The patient refused tracheotomy and due to his severe mandibular deficiency we elected to surgically treat his skeletal jaw deformity as the first step. This patient was our first case report of a mandibular advancement. A significant improvement was reported symptomatically (subjective) and by objective full night attended polysomnography. Several other surgeons had previously reported on mandibular advancement for OSAS but objective data was not presented. This index case was to be the beginning of skeletal surgery for OSAS. First Mandibular Osteotomy and Hyoid Advancement for OSAS First Inferior Sagittal Mandibular Osteotomy (Geioglossus Advancement-Hyoid) First Objective Report of Bi-Maxillary Advancement for OSAS First Reported Use of CPAP Postoperatively to Protect the Airway First Objective Comparison of Nasal CPAP and Maxillofacial Surgery for OSAS Largest Outcomes Study of Powell and Riley’s Phased Surgical Protocol Reversible Uvulopalatal Flap an Alternative to Traditional UPPP First Reported in 1996 Temperature Controlled Radiofrequency for OSAS (TCRF) In 1995 we were looking for an upper airway soft tissue treatment modality that would be minimally invasive, safe and could be done without hospitalization. The technology of radiofrequency had not been previously used on the delicate soft tissues of the upper airway but was used in many other fields of medicine and surgery e.g. cardiology, neurology and tumor reduction. It was approved for shrinking the tissues of the prostate in benign prostate hypertrophy (BPH) and could be performed as an outpatient procedure. There were no reports on the cellular changes associated with RF treatments thus we set out to examine this issue before using RF to shrink human soft tissues in the airway. We started this investigation in the hopes that RF could be used to treat the tongue base thus possibly bypassing the need for the more aggressive skeletal jaw surgery known as the Bi-Maxillary advancement. A four stage investigational protocol was developed to treat not only the tongue but also the nose and palate regions of the upper airway using RF. The original work was done at our center with Drs. Powell and Riley as the primary investigators for the entire project. The technique is now used in many countries and the literature is replete with peer-reviewed papers. After we were well into our investigations a company was formed to manufacture and sell the products developed as part of this investigation. We declined to own a part of the company, believing it was more important to remain objective and independent. First Powell and Riley Investigation of TCRF Include: Tongue, Palate and Turbinates TONGUE TCRF
PALATE TCRF TURBINATE TCRF For additional articles, see PubMed: http://www.ncbi.nlm.nih.gov/sites/entrez/. Or type “radiofrequency treatments for sleep apnea” in your browser. First Report of New Surgical Technique to Treat Nasal Alar Collapse It is common to see bilateral nasal alar collapse in subjects with OSAS. Hence, correction of this collapse is accomplished by placement of cartilage along the internal portion of the alar rim of the nasal opening thereby limiting such collapses. Medical Investigations in OSAS by Powell and Riley The majority of patients with OSAS present with Excessive Daytime Sleepiness (EDS) as their primary complaint. We felt it was important to better understand the relationship between EDS, whether secondary to OSAS or volitionally caused, and quality of life issues.
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