The Pillar® Procedure
The new minimally invasive snoring surgery
Not all snorers need help. Almost everyone snores at some point in their lives. Occasional snoring may occur when one is having a congested nose from a flu, experiencing severe physical exhaustion or having a drink too many before bed.Snorers who seek help are typically those who are habitual snorers (those whose bed partners’ lives are affected) or those who are showing symptoms of obstructive sleep apnea (OSA). Clinical indicators other than snoring which may suggest that one has OSA are: sleep disruption, breathing cessation during sleep, suddenly choking and gasping for air in the middle of sleeping, waking up in the morning wishing you have a few more hours (in spite of adequate number of hours of sleep) and increasing daytime tiredness. Hypertension, mental and mood alterations are also serious associated symptoms that may suggest that one may have OSA.
A multi-factorial problem
Snoring occurs when there is excessive tissue vibration in the upper airway during sleep. The soft palate and the lax pharyngeal tissue are the main regions of maximum tissue vibration. This process is initiated when a critical diameter of the pharynx is breached. Circumferential narrowing of the pharynx secondary to obesity, mouth breathing as a result of nasal blockage, an overly large tongue falling backwards to block the airway are all important contributing factors of snoring. The treatment of snoring therefore cannot be as straight-forward as what it is commonly made out to be.
A multi-modality treatment
While the soft palate is the most important generator of sound during snoring, other factors that set the stage for snoring must also be tackled and corrected. Weight correction remains the key to success in any surgical intervention for the treatment of snoring. A grossly overweight patient is a poor surgical candidate and more likely not to respond favourably to snoring surgery. The converse is true. A good sleep apnea surgeon will always incorporate weight management as an important part of his treatment protocol to ensure good treatment outcome whether surgery is intended or not. In an era of minimally invasive surgeries, the importance of total management of patients cannot be over-emphasized.
Minimally invasive snoring surgery
Over the past 10 years, the treatment for snoring has moved toward minimally invasive surgery. With the introduction of Laser Assisted Uvula Palatoplasty (LAUP), Radiofrequency Ablation Techniques targeted at nasal turbinates, soft palate and base of tongue tissue, more radical surgeries like Uvulopalatopharyngoplasty (UPPP) and nasal turbinectomies are seldom necessary. With the introduction of minimally invasive surgical techniques, patients can undergo procedures under local anesthesia in a clinic setting. With such techniques post-surgical morbidity and the time-off needed from work is significantly reduced. One of the latest innovative techniques that have been approved by the Food and Drug Administration (FDA) for the treatment of snoring is The Pillar® Procedure.
The Pillar® Procedure
The target of the Pillar Procedure is one of the important anatomical components of sleep apnea and snoring: the soft palate. In this procedure, three tiny woven inserts are introduced into the soft palate to help reduce the vibration that causes snoring. Once in place, the inserts add structural support to the soft palate. Over time, the body's natural tissue response to the inserts increases the structural integrity of the soft palate. The Pillar inserts are made of a polyester material, Polyethylene terephthalate (PET) which was first manufactured by Dupont in the late 1940s. Current medical applications of PET include surgical sutures, surgical mesh, heart valves cuffs and vascular grafts. Although the implanting the soft palate is a PET’s first the medical application of this material spans a 40-year period.The characteristic biological response to PET is a chronic inflammatory reaction, fibrous capsule formation and granulomatous tissue infiltrating the woven fabric.
The entire Pillar procedure takes about 10 minutes to execute and is done under local anesthesia. This is done in the ENT Clinic with the patient seated in an upright position. Three Pillar Implants each 18 mm in length are individually inserted with the aid of specially-designed implant-loaded hand pieces.
The post-operative morbidity of the Pillar Procedure is minimal, especially when compared with the traditional UPPP technique. The post-surgical pain can be managed easily with oral analgesics and rarely last longer than 72 hours. Foreign body sensation during swallowing is temporary and lasts only for a few weeks. The most significant complication of the Pillar Procedure is perhaps implant extrusion (reportedly about 5%) which commonly happen in the early post-operative period. The typical presentation of implant extrusion is increasing pain. Exposed implant in the oral cavity must be removed. Re-implantation can be undertaken a month after removal.The Pillar Procedure is a promising minimally invasive surgical procedure to treat snoring. The concept of reinforcing the soft palate instead of radically sacrificing soft palate tissue is perhaps Pillar’s edge over UPPP. The greatest challenge for the ENT Surgeon however is in choosing the most ideal patient for the Pillar Procedure. This technique works effectively as part of a multimodality protocol of weight reduction and nasal surgery. Trials are currently being conducted in several centres in the world to explore the use of a fourth and fifth Pillar Implant.
Dr Goh Yau Hong
FRCS, FAMS (ORL)
Consultant ENT Surgeon Dr Goh Yau Hong is a Consultant ENT Surgeon in Mount Elizabeth Medical Centre, Singapore. He is known for his pioneering work on jaw advancement surgery for the treatment of obstructive sleep apnea. Dr Goh also performed the first Pillar Implant Technique in SE Asia in 2005.