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   Submucous partial resection of the inferior turbinates (SPRIT). A simple surgical procedure that will practically double the success rate achieved with the traditional UPPP (Uvulopalatopharyngoplasty) operation. Long term relief of symptoms (85%) are superior to those achieved with the C-Pap (Respirator). And patient acceptance is much higher.

    Obstructive sleep apnea clinically presents as excessive daytime sleepiness, (EDS) early morning hangover, diminished intellectual function and in some cases, high blood pressure. These, mostly male, patients, between the ages of 25 and 65, snore very loudly and go to sleep while driving, at work, while sitting at stoplights and immediately after sitting down to watch television in the evening. Obstructive sleep apnea is more common in people of Northern European extraction, especially if they have long narrow faces (maxillary compression) and nasal obstruction. And especially if they are overweight. Women, especially if they are overweight, over 45 and nasally obstructed are also prone to have obstructive sleep apnea. Estrogen and Progesterone seem to have some protective effect as obstructive sleep apnea is relatively rare in women under age 45 (except during the last half of pregnancy when nasal obstruction and obstructive sleep apnea is a real problem for some women).

    Understanding why so many ENT surgeons report only 35% success rates in surgery for obstructive sleep apnea and understanding why so many ENT surgeons recommend nighttime breathing machines (C-Pap) rather than corrective upper airway surgery for obstructive sleep apnea:

• During sleep, the nasal airway is the preferred route of respiration. Conversely, in the awake patient, the oral route provides about 35% of the volume of air that we breathe in. Patients should know that during sleep, pharyngeal (throat) muscle tone is decreased and, thus, inspiratory (breathing in) pressure must increase to counteract this "flaccid" (floppy muscle) condition. Therefore, when the patient with a marginal nasal airway is recumbent (sleeping on back), further engorgement of the inferior turbinates (swelling of the nasal sidewall structures) occurs. This produces nasal obstruction. And, so, during sleep, an even greater inspiratory effort is required to counteract the obstructed nasal airway. When nasal obstruction is coupled with flaccid, redundant pharyngeal abductor and dilator muscles (muscles that open the airway in the throat), loud snoring and obstructive sleep apnea occurs.

    It has been my experience that most patients who snore loudly, who have clinically significant obstructive sleep apnea, and who have EDS (excessive daytime sleepiness), also have clinically significant nasal obstruction. If corrective inferior turbinate surgery is combined with the Uvulopalatopharyngoplasty, in this group of patients, the success rate for the correction of obstructive sleep apnea and excessive daytime sleepiness should be around 85%, rather than the 35% reported in most Uvulopalatopharyngoplasty series alone.

    Ironically, it should be noted that in 1973, Hunter Fry, M.D., took the courageous step, in the face of "conventional wisdom," and showed us (once again) how to partially resect offending inferior turbinates. One-third should be fine! Fry also showed how the chemical composition, the bacteriostatic activity, and the migratory pattern of the dynamic nasal mucous blanket was (favorably) changed after PRIT (partial resection of the inferior turbinates) in cases of long-standing nasal obstruction. And Courtiss presented two supporting series in 1978 and 1983. Courtiss often reminded us that Otolaryngologists, in the pre-antibiotic era, would frequently amputate the entire lateral nasal wall... the inferior turbinate, the middle turbinate, as well as the medial wall of the maxillary sinus (in cases where there was advanced, persistent [suppuration] infection of the contents of the maxillary sinuses and ethmoid sinuses) were often resected, in this pre-antibiotic era nasal surgery. Thus, the confusion about "turbinate surgery" and atrophic rhinitis (crusting of the nasal airway). I've done PRIT in well over 1,000 patients now and have yet to see atrophic rhinitis as a long-term (over six months) complication in any of these patients.

    Finally, two technical points. The Heavy Knight scissor, as noted by Sheen, is far too strong for partial resection of the inferior turbinate. Too much inferior turbinate is resected in some cases, when the Heavy Knight scissor is used. The Light Knight scissor is better. But the best is the #1 Gruenwald forcep. The Gruenwald forcep can be used to "manicure" the inferior turbinate to just the right size. The combination of Gruenwald trim and repeated infiltration of ½% Xylocaine with Epinephrine 1:200,000 (local anesthesia in a weak Adrenalin solution) into the remaining portion of the inferior turbinate, provides for excellent, yet safe, hemostasis (control of bleeding) and provides the operator with an accurate idea of what that turbinate's size will be months and years later. No freezing, no cautery and no lasers, please!

    With regard to postoperative nasal crusting, in the first few weeks postoperatively: the use of the Grossan Nasal irrigation tip, the WaterPik, and warm salt water provides significant relief from crusting in most postoperative patients. Two weeks later, the silastic sheeting is removed. Healing should be nearly complete. This technique will often reduce the "nasal toilet" required in the office by two sessions.

    Partial resection of the inferior turbinate is, in fact, superior to Electrofulguration in accurately reducing the size of offending inferior turbinates. Furthermore, snoring, and, especially, obstructive sleep apnea, are both improved in many patients following partial resection of the inferior turbinate.

    My clinical experience in over 300 cases of nasal obstruction, loud snoring, obstructive sleep apnea, excessive daytime sleepiness, early morning hangover and (sometimes) a decline in intellectual function... my clinical experience has shown that simultaneously correcting the nasal obstruction by partially resecting the inferior turbinate combined with the traditional palatal surgery (UPPP) increases the UPPP success rate from a maybe yes,... maybe no (35%),... to almost a sure thing (86%)!