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Use of Laser in Sleep Disorders: A Review on Low Laser Uvulopalatoplasty
鐳射在睡眠障礙中的應用：低鐳射懸雍垂齶成形術的評價

Mayank Kakkar Shaima Malik, Bhumija Gupta, Nikhilesh Vaid, Robby George,
瑪雅克·卡卡爾 、沙伊瑪·馬利克、 普米亞·古普塔、 尼基萊什·維德、 羅比·喬治、 and Shilpa Singh
和希爾帕·辛格 Department of General Dentistry, Eastman Institute for Oral Health, University of Rochester, New York, USA
美國紐約羅切斯特大學伊士曼口腔健康研究所普通牙科系 Department of Orthodontics and Dentofacial Orthopedics, Eastman Institute for Oral Health, Rochester, New York, USA
美國紐約州羅切斯特市伊士曼口腔健康研究所正畸和牙頜面骨科 Private Dentist, Rochester, New York, USA
私人牙醫，羅切斯特，紐約，美國 Department of Orthodontics, European University College, Dubai, UAE
歐洲大學學院正畸學系，阿聯酋迪拜 Department of Orofacial Pain/TMD and Community Dentistry, Eastman Institute for Oral Health, Rochester, New York, USA
口面部疼痛/TMD 和社區牙科系，伊士曼口腔健康研究所，羅切斯特，紐約，美國

Correspondence should be addressed to Mayank Kakkar; mayankuever@gmail.com
信件應寄給 Mayank Kakkar;mayankuever@gmail.com
Received 14 September 2020; Revised 13 January 2021; Accepted 11 February 2021; Published 28 February 2021
收稿日期： 2020-09-14;2021年1月13日修訂;2021年2月11日接受;已發佈2021年2月28日
Academic Editor: Yuan-Yang Lai
學術編輯：Yuan-Yang Lai
Copyright Mayank Kakkar et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
版權所有 Mayank Kakkar等人。這是一篇根據知識共用署名許可分發的開放獲取文章，該許可允許在任何媒體上不受限制地使用、分發和複製，前提是正確引用了原始作品。

Abstract 抽象

Study Objective. The objective of this study is to find the effectiveness of the low laser therapy on uvulopalatoplasty/soft palate in sleep apnea patients and snoring. Also, this study aims to touch base on the effectiveness of the Er:YAG and combined use of Er:YAG and Nd:YAG lasers for the uvulopalatoplasty. Methods. A comprehensive and systematic literature review was conducted using PubMed, Google Scholar, Cochrane Central Register of Controlled Trials, Embase, Web of Science, the US National Institutes of Health Trials Registry, WHO Library, and Medline. The search strategies were developed to cover publications from January 2010 through March 2020. The past 10 years of the search were performed to report the data following systematic review and meta-analysis protocol (PRISMA-P) 2015 statement. Results. With the help of keywords, the total number of abstracts identified was 946 . These abstracts were further reviewed as per inclusion and exclusion criteria, and 106 abstracts were identified to match the selection criteria. Further review of full articles resulted in 12 articles that matched the inclusion criteria for the study. Conclusion. Er:YAG can be a good alternative and least invasive therapy for managing snoring and obstructive sleep apnea. Er:YAG therapy is considered to nonsurgical intervention with minimum side effects and can be performed chairside.
研究目標。本研究的目的是發現低激光治療對睡眠呼吸暫停患者和打鼾患者懸雍垂齶成形術/軟齶的有效性。此外，本研究旨在探討 Er：YAG 以及 Er：YAG 和 Nd：YAG 激光在懸雍垂腭成形術中的有效性。方法。使用 PubMed、Google Scholar、Cochrane 對照試驗中心註冊庫、Embase、Web of Science、美國國立衛生研究院試驗註冊庫、WHO 圖書館和 Medline 進行了全面系統的文獻綜述。檢索策略的制定涵蓋了2010年1月至2020年3月的出版物。根據系統評價和薈萃分析方案 （PRISMA-P） 2015 聲明，對過去 10 年的檢索進行報告。結果。在關鍵詞的説明下，識別出的摘要總數為946篇。根據納入和排除標準對這些摘要進行了進一步審查，確定了106篇符合納入標準的摘要。對完整文章的進一步審查產生了12篇文章符合該研究的納入標準。結論。Er：YAG是治療打鼾和阻塞性睡眠呼吸暫停的良好替代療法，也是侵入性最小的療法。Er：YAG 治療被認為是副作用最小的非手術干預，可以在椅旁進行。

1. Introduction 1. 引言

Sleep-disordered breathing (SDB) comprises a range of disorders with varying degrees of significance and severity including habitual snoring, upper airway resistance syndrome (UARS), and obstructive sleep apnea (OSA) [1]. Obstructive sleep apnea (OSA) is a sleep disorder in which breathing is compromised briefly during sleep . There is resistance of airflow during sleep due to partial or complete collapse of the upper airway mainly the oropharyngeal tract. It occurs due to failure of the muscle to keep the airway open or that supports the soft tissue in the throat such as tongue and soft palate . It is estimated that of men and of women meet the diagnosis criteria for obstructive sleep apnea in the United States with prevalence reported to be of men and of women. Prevalence is found to be higher in the Hispanic, Asian, and African American populations [5]. Snoring is a part of sleep-disordered breathing which may be a symptom of obstructive sleep apnea; however, not all patients who snore may have clinically evident obstructive sleep apnea [6]. Obesity, male gender, advancing age, and mandibular-maxillary insufficiency are wellcharacterized risk factors. Risk factors include snoring, male gender, middle age, menopause in women, obesity, and a variety of craniofacial and oropharyngeal features such as a large neck circumference, retro- or micrognazia, nasal obstruction, enlarged tonsils/adenoids, macroglossia, and low-lying soft palate (Guilleminault and Quo, 2001; Dempsey et al. 2010). Due to monotonous upper airway constriction during sleep, it may result in abnormally slow or
睡眠呼吸障礙（sleep-disordered breathed， SDB）包括一系列具有不同程度和嚴重程度的疾病，包括習慣性打鼾、上氣道阻力綜合征（upper airway resistance syndrome， UARS）和阻塞性睡眠呼吸暫停（obstructive sleep apnea， OSA）[1]。阻塞性睡眠呼吸暫停 （OSA） 是一種睡眠障礙，其中呼吸在睡眠 期間短暫受損。由於上氣道（主要是口咽道）部分或完全塌陷，睡眠期間氣流受阻。它是由於肌肉無法保持氣道暢通或支撐喉嚨中的軟組織（如舌頭和軟齶 ）而發生的。據估計， 在美國，男性和女性 符合阻塞性睡眠呼吸暫停的診斷標準，據報導，男性和女性的患病率為 男性和女性 。西班牙裔、亞洲裔和非裔美國人的患病率更高[5]。打鼾是睡眠呼吸障礙的一部分，可能是阻塞性睡眠呼吸暫停的癥狀;然而，並非所有打鼾患者都可能有臨床上明顯的阻塞性睡眠呼吸暫停[6]。肥胖、男性、年齡增長和下頜上頜骨功能不全是特徵性很強的危險因素。危險因素包括打鼾、男性、中年、女性更年期、肥胖以及各種頍面和口咽特徵，如頸圍大、后牙或小牙頜、鼻塞、扁桃體/腺樣體腫大、巨舌和低位軟腭（Guilleminault 和 Quo，2001 年;Dempsey 等人，2010 年）。由於睡眠期間單調的上氣道收縮，可能導致異常緩慢或
Table 1: Common symptoms associated with OSA.
表 1：OSA 相關常見癥狀。
Nocturnal Diurnal
Snoring Excessive sleepiness 過度嗜睡
Witnessed Apneas 目擊呼吸暫停 Morning headaches 晨起頭痛
Choking at night 晚上窒息 Depression/irritability 抑鬱/易怒
Nocturia Memory loss 記憶力減退
Insomnia Decreased libido 下降
shallowing breathing (hypopnea) and temporary cessation of breathing (apnea) which will deprive the adequate oxygen supply (hypoxia), excessive carbon dioxide (hypercapnia), and sleep fragmentation [1]. Consequently, this leads to OSA syndrome with subjective symptoms of daytime sleepiness, cognitive and neurobehavioral dysfunction, inability to concentrate, memory impairment, and mood changes such as irritability and depression , eventually affecting the quality of life. The most common symptoms during sleep are snoring, witnessed apneas, choking at night, nocturia, and insomnia. Chronicity of sleep apnea affects the function of different organs and systems most importantly the brain and cardiovascular system thereby altering body metabolic balance (Bradley et al. 2008). Uncontrolled medicationresistant hypertension may be one of the risks of sleep apneas too (Bradley et al. 2008). Other cardiovascular disorders may include ischemic heart diseases, cardiac arrhythmias, and stroke (Bradley et al. 2008). Sleep-related hypoxia is also known to induce low-grade systemic inflammation (Jordan et al. 2014), results in hyperalgesia effect, and enhances pain sensitivity [9]. Chronic pain conditions are few other comorbidities like fibromyalgia, temporomandibular disorders, and headaches [9-12]. The most common symptoms associated with OSA are illustrated in Table 1.
淺呼吸（低通氣）和暫時停止呼吸（呼吸暫停），這將剝奪足夠的氧氣供應（缺氧）、二氧化碳過多（高碳酸血症）和睡眠碎片化[1]。因此，這會導致OSA綜合征，其主觀癥狀包括白天嗜睡，認知和神經行為功能障礙，無法集中注意力，記憶障礙以及易怒和抑鬱 等情緒變化，最終影響生活品質。睡眠期間最常見的癥狀是打鼾、目擊呼吸暫停、夜間窒息、夜尿症和失眠。睡眠呼吸暫停的慢性影響不同器官和系統的功能，最重要的是大腦和心血管系統，從而改變身體代謝平衡（Bradley 等人，2008 年）。不受控制的耐藥性高血壓也可能是睡眠呼吸暫停的風險之一（Bradley 等人，2008 年）。其他心血管疾病可能包括缺血性心臟病、心律失常和中風（Bradley 等人，2008 年）。眾所周知，睡眠相關的缺氧會誘發低度全身炎症（Jordan et al. 2014），導致痛覺過敏效應，並增強疼痛敏感性[9]。慢性疼痛是纖維肌痛、顳下頜關節疾病和頭痛等少數其他合併症[9-12]。與OSA相關的最常見癥狀如表1所示。

2. Material and Methods
2. 材料與方法

This review and search were performed with the intention to report the data in accordance with systematic review and meta-analysis protocol (PRISMA-P) 2015 statement.
本綜述和檢索的目的是根據系統綜述和薈萃分析方案（PRISMA-P）2015年聲明報告數據。

2.1. Search Strategy. A comprehensive initial systematic liter-
2.1. 搜索策略。全面、初始、系統化、升

ature review was conducted using the PubMed databases and Google Scholar. This systematic search includes PubMed and Medline (2010-present), Cochrane Central Register of Controlled Trials, Embase, Web of Science, Google Scholar, the US National Institutes of Health Trials Registry, WHO Library, and Medline with no language filter. Additional dental organization websites were searched, including the American Dental Association, to identify articles and statistics that evaluated the effectiveness of the low laser on uvulopalatoplasty/soft palate in sleep apnea patients and compared the effectiveness of Er:YAG and Nd:YAG lasers in uvulopalatoplasty. The search strategies were developed to cover publications from January 2010 through March 2020. The past 10 years of search were selected as per investigator's decision and the use of laser-assisted uvulopalatoplasty as treatment for apnea/snoring.
2.2. Selection Criteria. The primary search objective was to identify all papers reporting the results of (1) randomized clinical trials (RCT) of laser-assisted uvulopalatoplasty in the treatment of adults with OSA or snoring or sleep apnea and (2) both randomized/nonrandomized clinical trials and case reports on the laser-assisted uvulopalatoplasty in OSA/sleep apnea adults. The first step was to identify and review all of the studies listed for analysis in three major literature reviews, a Cochrane Collaboration review [1] and a second systematic literature review published by the National Institutes of Health Research (NIHR) [2] on the use of CPAP for the treatment of OSA, and a second Cochrane Collaboration review on its surgical management [3]. The second step was an extensive search of the PubMed/Medline database, initiated using the following combined search terms: "Laser and obstructive sleep apnea" ( ); "Laser and snoring" ; and "Er:YAG and snoring" ; laser and sleep apnea ; Nd:YAG and sleep apnea ( ); Nd:YAG and snoring ; Nd:YAG and obstructive sleep apnea ; Nd:YAG and uvula . From these lists, studies were identified that (a) did not replicate studies already found and (b) were otherwise eligible for inclusion. The third and final step was a review of all reference lists and tables of other studies found within papers identified in the second step.
2.2. 選擇標準。主要檢索目的是確定所有報告（1）激光輔助懸雍垂齶成形術治療成人OSA或打鼾或睡眠呼吸暫停的隨機臨床試驗（RCT）結果的論文，以及（2）關於鐳射輔助懸雍垂齶成形術治療OSA/睡眠呼吸暫停成人的隨機/非隨機臨床試驗和病例報告。第一步是確定並評價三項主要文獻綜述中列出的所有分析研究，一項Cochrane協作網綜述[1]和第二篇由美國國立衛生研究院（National Institutes of Health Research， NIHR）發表的關於使用CPAP治療OSA的系統文獻綜述[2]，以及第二篇關於其手術管理的Cochrane協作網綜述[3]。第二步是對 PubMed/Medline 資料庫進行廣泛檢索，使用以下組合檢索詞啟動：“鐳射和阻塞性睡眠呼吸暫停”（ ）;“鐳射和打鼾” ;和“Er：YAG和打鼾” ;鐳射和睡眠呼吸暫停 ;Nd：YAG 和睡眠呼吸暫停 （ ）;Nd：YAG和打鼾; Nd：YAG和阻塞性睡眠呼吸暫停 ;Nd：YAG和懸雍垂 。從這些清單中，確定了（a）沒有重複已經發現的研究，（b）在其他方面符合納入條件的研究。第三步也是最後一步是審查第二步確定的論文中發現的所有參考文獻清單和其他研究的表格。
Articles were considered for inclusion into the study by reviewing the titles and abstracts of all retrieved studies. The senior study authors SS, BG, and MK did this, and results were compiled to ensure no studies were missed. The full text of selected studies was then analyzed to ensure that the following inclusion criteria were met: diagnosis of obstructive sleep apnea, no confounding data for central sleep apnea, and the paper referred to laser-assisted uvulopalatoplasty in OSA or snoring.
通過審查所有檢索到的研究的標題和摘要，考慮將文章納入研究。高級研究作者SS、BG和MK這樣做了，結果被匯總以確保沒有遺漏任何研究。然後對所選研究的全文進行分析，以確保滿足以下納入標準：阻塞性睡眠呼吸暫停的診斷，中樞性睡眠呼吸暫停的混雜數據，並且該論文提到了激光輔助懸雍垂齶成形術治療OSA或打鼾。
2.3. Search Terms/Keywords. Laser, sleep apnea, Nd:YAG, snoring, obstructive sleep apnea, uvula, and uvulopalatoplasty.
2.3. 搜索詞/關鍵字。鐳射、睡眠呼吸暫停、Nd：YAG、打鼾、阻塞性睡眠呼吸暫停、懸雍垂和懸雍垂齶成形術。
2.4. Inclusion Criteria. The literature included in this study was based on the following inclusion criteria:
2.4. 納入標準。本研究納入的文獻基於以下納入標準：
(1) Studies/case reports on laser-assisted uvulopalatoplasty as management for snoring or sleep apnea
（1） 激光輔助懸雍垂齶成形術治療打鼾或睡眠呼吸暫停的研究/病例報告
(2) Randomized clinical trials on laser-assisted uvulopalatoplasty for management of sleep apnea or snoring
（2）激光輔助懸雍垂腭成形術治療睡眠呼吸暫停或打鼾的隨機臨床試驗
(3) Studies/literatures or case reports for management of sleep apnea by laser in the soft palate
（3）軟腭激光治療睡眠呼吸暫停的研究/文獻或病例報告
2.5. Exclusion Criteria. The literature eligible for inclusion in this study was based on the following exclusion criteria:
2.5. 排除標準。符合本研究納入條件的文獻基於以下排除標準：
(1) Literature/studies or case reports on conventional surgical management of sleep apnea
（1）關於睡眠呼吸暫停常規手術治療的文獻/研究或病例報告
(2) Literatures/studies reporting the laser-assisted surgical management strategies in combination including trachea, soft palate, or uvulopalatoplasty
（2） 報導鐳射輔助手術治療策略的文獻/研究，包括氣管、軟腭或懸雍垂齶成形術
FIGURE 1: Risk of bias.
圖1：偏倚風險。
(3) Literature on previous history of wisdom teeth extraction
（3）關於智齒拔除既往史的文獻
2.6. Selection of Studies and Data Extraction. The articles were evaluated for their relevance based on the titles and abstracts. Further validation of the articles was done by obtaining the full text of the possible relevant studies that met the inclusion criteria. All the articles were reviewed by three reviewers (SS, BG, and MK). The studies assessed by SS and deemed eligible were checked by MK and BG for methodological quality and inclusion criteria. All disagreements were resolved verbally, with strict adherence to the predetermined inclusion criteria. Risk of bias analysis has been done in Figure 1 [13].
2.6. 研究選擇和數據提取。根據標題和摘要對文章的相關性進行評估。通過獲取符合納入標準的可能相關研究的全文，對文章進行了進一步的驗證。所有文章均由三位審稿人（SS、BG和MK）審稿。由SS評估並被認為符合條件的研究由MK和BG檢查方法學品質和納入標準。所有分歧均通過口頭解決，嚴格遵守預定的納入標準。偏倚風險分析如圖1所示[13]。
2.7. Diagnosis. An appropriate diagnosis of sleep disorders starts with comprehensive examination that includes complete medical history and physical examination. Usually, the diagnosis of sleep disorders happens in either of the three settings: first, usually routine physical examination or dental examination; second, as part of an evaluation of symptoms of snoring or apneas; third, as part of the comprehensive evaluation of patients at high risk for OSA.
2.7. 診斷。睡眠障礙的正確診斷始於全面檢查，包括完整的病史和體格檢查。通常，睡眠障礙的診斷發生在以下三種情況中的任何一種：首先，通常是常規體格檢查或牙科檢查;其次，作為評估打鼾或呼吸暫停癥狀的一部分;第三，作為對OSA高危患者進行全面評估的一部分。
Routine examination includes comprehensive sleep history, Epworth sleepiness scale questionnaire, and intraoral, extraoral, and physical examination. Sleep history and ESS will provide details for the sleep quality and subjective symptoms. Physical, intraoral, and extraoral examination will suggest respiratory, cardiovascular, and neurologic symptoms.
常規檢查包括全面的睡眠史、Epworth 嗜睡量表問卷以及口內、口外和體格檢查。睡眠史和 ESS 將提供有關睡眠品質和主觀癥狀的詳細資訊。體格檢查、口內檢查和口外檢查可提示呼吸系統、心血管和神經系統癥狀。
Table 2: Based on the Apnea-hypopnea index (AHI), and oxygen saturation category for the sleep apnea can be categorized into 3 groups.
表2：根據呼吸暫停低通氣指數（AHI），睡眠呼吸暫停的氧飽和度類別可分為3組。
Mild Moderate Severe
AHI
Oxygen saturation 血氧飽和度 At least  至少 to
Narrowing of upper respiratory symptoms can be evaluated by obtaining neck circumference ( inches in men and inches in women), body mass index (BMI) , a modified Mallampati score of 3 or 4,7 the presence of retrognathia, lateral peritonsillar narrowing, macroglossia, tonsillar hypertrophy, elongated/enlarged uvula, high arche narrow hard palate, nasal abnormalities (polyps, deviation, valve abnormalities, and turbinate hypertrophy), and/or overjet.
上呼吸道癥狀變窄可以通過獲得頸圍（男性 英寸和 女性英寸）、體重指數 （BMI）、 改良的 Mallampati 評分 3 或 4,7 存在頜后、扁桃體外側周圍狹窄、巨舌、扁桃體肥大、懸雍垂拉長/擴大、高弓 狹窄硬腭、鼻畸形（息肉、偏斜、瓣膜異常和鼻甲肥大）來評估， 和/或溢流。
Comprehensive examination can help to identify the risk of OSA. High-risk patients need objective testing to further confirm the severity of the OSA. OSA is diagnosed by performing a sleep study using polysomnography, in which the patient is attached to equipment while sleeping which monitors the oxygen saturation level, oral and nasal airflow, electrocardiographic measurements, and body movements [6]. Based on the apnea-hypopnea index (AHI), and oxygen saturation, sleep apnea can be categorized into 3 groups (refer to Table 2).
全面檢查有助於識別OSA的風險。高危患者需要客觀檢測，以進一步確認OSA的嚴重程度。OSA的診斷方法是使用多導睡眠圖進行睡眠研究，即患者在睡眠時連接到監測氧飽和度水準、口腔和鼻腔氣流、心電圖測量和身體運動的設備[6]。根據呼吸暫停低通氣指數（AHI）和血氧飽和度，睡眠呼吸暫停可分為3組（見表2）。
2.8. Treatment Modalities. OSA should be considered as a chronic condition that requires long-term multidisciplinary management. This includes medical, behavioral, and surgical options to manage OSA. At times, adjunctive therapies can be incorporated to supplement the treatment options. CPAP (continuous positive airway pressure) is considered the gold standard choice of treatment for mild, moderate to severe patients. Alternative therapies are provided based on risk factors and preferences.
2.8. 治療方式。OSA應被視為一種需要長期多學科治療的慢性疾病。這包括治療OSA的藥物、行為和手術選擇。有時，可以結合輔助療法來補充治療方案。CPAP（持續氣道正壓通氣）被認為是輕度、中度至重度患者治療的金標準選擇。根據風險因素和偏好提供替代療法。
Alternative therapies include oral appliances that can be used as adjunctive therapy or in cases of noncompliance to other treatment options. Surgical options include a variety of upper airway reconstructive or bypass procedures, often site-directed and/or staged (LJ Epstein, D Kristo, PJ Strollo et al. 2009) [14]. Evaluation for primary surgical treatment can be considered in patients with mild OSA who have severe obstructing anatomy that is surgically correctible (e.g., tonsillar hypertrophy obstructing the pharyngeal airway) (LJ Epstein, D Kristo, PJ Strollo et al. 2009) [14]. Surgical procedures may be considered as a secondary treatment for OSA when the outcome of PAP therapy is inadequate, such as when the patient is intolerant of PAP, or PAP therapy is unable to eliminate OSA (LJ Epstein, D Kristo, PJ Strollo et al. 2009) [14]. Surgery may also be considered as a secondary therapy when there is an inadequate treatment outcome with an OA, when the patient is intolerant of the , or the OA therapy provides unacceptable improvement of clinical outcomes of OSA (LJ Epstein, D Kristo, PJ Strollo et al. 2009) [14]. Surgery may also be considered as an adjunct therapy when obstructive anatomy or functional deficiencies compromise other therapies or to improve tolerance of other
替代療法包括口腔矯治器，可用作輔助治療或不依從其他治療方案。手術選擇包括各種上氣道重建或搭橋手術，通常定向和/或分期（LJ Epstein、D Kristo、PJ Strollo等，2009）[14]。對於有嚴重梗阻解剖結構且可手術矯正（例如，扁桃體肥大阻塞咽氣道）的輕度OSA患者，可考慮評估初次手術治療（LJ Epstein、D Kristo、PJ Strollo等，2009）[14]。當PAP治療結果不充分時，例如當患者對PAP不耐受，或PAP治療無法消除OSA時，可考慮將外科手術作為OSA的輔助治療（LJ Epstein， D Kristo， PJ Strollo et al. 2009）[14]。當OA治療結果不充分時，當患者不 耐受時，或者OA治療對OSA的臨床結局有不可接受的改善時，手術也可被視為輔助治療（LJ Epstein， D Kristo， PJ Strollo et al. 2009）[14]。當阻塞性解剖結構或功能缺陷損害其他治療或提高對其他治療的耐受性時，手術也可被視為輔助治療
OSA treatments (LJ Epstein, D Kristo, PJ Strollo et al. 2009) [9].
OSA治療（LJ Epstein、D Kristo、PJ Strollo等人，2009）[9]。
Laser-assisted uvulopalatoplasty (LAUP) has been reported as one of the treatment modalities for snoring and OSA. Dr. Kamami in the year 1990 reported the use of a carbon dioxide laser on 31 patients. She used the laser to erode the soft palate as a treatment for snoring [10]. The LAUP technique eliminates or diminishes the oropharynx obstructions by successfully stripping the colonization of vibrating soft palate, wide posterior tonsil pillars, and excessive posterior mucosa [14]. LAUP was originally carried out with the patient placed in a seated position as clinic procedure under the local anesthesia, with laser vaporization of the "wide lateral pharyngeal walls and low arched soft palate, on both sides of the uvula, sparing the uvula" [14]. In 1994, Dr. Kamami published another research paper with emphasis on the indication of LAUP for OSA patients with 40 of 46 patients being classified as responders .
據報導，激光輔助懸雍垂齶成形術 （LAUP） 是打鼾和 OSA 的治療方式之一。Kamami 博士在 1990 年報告了對 31 名患者使用二氧化碳 激光的情況。她使用 鐳射侵蝕軟腭作為打鼾的治療方法[10]。LAUP技術通過成功剝離振動的軟齶、寬扁桃體後柱和過多的後黏膜的定植，消除或減少口咽梗阻[14]。LAUP最初是在局部麻醉下將患者置於坐姿作為門診手術， 激光蒸發“懸雍垂兩側寬闊的咽外側壁和低拱形軟齶，從而保留懸雍垂”[14]。1994年，Kamami 博士發表了另一篇研究論文，重點是 OSA 患者的 LAUP 適應症，46 名患者中有 40 名被歸類為應答者 。
In 2000, the American Academy of Sleep Medicine's Standards of Practice Committee published updated parameters for the use of LAUP (AASM's Practice Parameters for LAUP) and stated that "LAUP is not recommended for the treatment of sleep-disordered breathing" [12]. In this review, we aim to find the effectiveness of the low laser on uvulopalatoplasty/soft palate in sleep apnea patients and snoring. Also, this study aims to touch base on the effectiveness of the Er:YAG and combined use of Er:YAG and Nd:YAG lasers for the uvulopalatoplasty.
2000年，美國睡眠醫學會（American Academy of Sleep Medicine）的實踐標準委員會（Standards of Practice Committee）發佈了LAUP使用的最新參數（AASM的LAUP實踐參數），並指出“不推薦將LAUP用於治療睡眠呼吸障礙”[12]。在這篇綜述中，我們旨在發現低鐳射對睡眠呼吸暫停患者和打鼾患者懸雍垂齶成形術/軟齶的有效性。此外，本研究旨在探討 Er：YAG 以及 Er：YAG 和 Nd：YAG 激光在懸雍垂腭成形術中的有效性。

3. Results 3. 結果

With the help of keywords, the total number of abstracts identified was 946 . These abstracts were further reviewed as per inclusion and exclusion criteria, and 106 abstracts were identified to match the selection criteria. Further review of full articles resulted in 12 articles that matched our inclusion criteria. 91 articles were excluded. There were no articles identified in our manual search. The flow chart in Figure 2 depicts the search strategy for this study. All the included studies and demographics are depicted in Table 3.
在關鍵詞的説明下，識別出的摘要總數為946篇。根據納入和排除標準對這些摘要進行了進一步審查，確定了106篇符合納入標準的摘要。對完整文章的進一步審查產生了12篇文章符合我們的納入標準。91篇文章被排除在外。在我們的手動檢索中沒有發現任何文章。圖 2 中的流程圖描述了本研究的檢索策略。所有納入的研究和人口統計學都列在表3中。

4. Discussion 4. 討論

Camargo et al. have ongoing research in the recruitment stage. This research has proposed for low laser therapy (LLT/biomodulation) as a therapeutic option for the treatment of snoring and OSA. According to Camargo et al., it can be proved to be efficient, cost effective, and adjuvant therapy to conventional treatments with CPAP. In this study, (mill watts) of laser will be used and a continuous wavelength of will be administered on the soft palate, palatine tonsils, pharyngeal walls, uvula, and the base of the tongue. This study hypothesizes that when LLT is applied to the soft palate, it can decrease the phallus collapsibility and snoring and thereby improves the AHI (apnea/hypopnea) index .
Camargo等人正在進行招募階段的研究。這項研究提出了低鐳射療法（LLT/生物調節）作為治療打鼾和 OSA 的治療選擇。根據 Camargo 等人的說法，它可以被證明是有效、具有成本效益的，並且是常規 CPAP 治療的輔助療法。在這項研究中， 將使用（磨瓦）鐳射，並在軟齶、腭扁桃體、咽壁、懸雍垂和舌根上施用連續波長 。本研究假設，當 LLT 應用於軟腭時，它可以降低塌陷和打鼾，從而改善 AHI（呼吸暫停/低通氣）指數 。
A prospective study was conducted on 40 patients by Storchi et al. in 2018, where patients with snoring and sleep
Storchi 等人於 2018 年對 40 名患者進行了一項前瞻性研究，其中打鼾和睡眠的患者
FIGURe 2: PRISMA 2009 flow diagram.
圖 2：PRISMA 2009 流程圖。
disorders were evaluated for the effectiveness of Er:YAG laser treatment sessions. After the three laser sessions, of the patients self-reported to be satisfied after the treatment . The results demonstrated that change in patient's quality of sleep is significantly increased ( ), snoring severity is significantly improved ( ), and immediate sensation of breathing improvement is reported in pre- and postlaser treatment [10]. In addition to this, when applied on the soft palate, uvula, palatine tonsils, and the base of the tongue, the rate of apnea and hypoxia is improved. The mechanism of action of the erbium:YAG laser is a photothermal effect that creates depletion of the collagen fibers in the treated oral mucosa and stimulates a neocollagenase via heat shock protein (HSP) action .
評估了 Er：YAG 激光治療療程的有效性。在三次激光治療后， 患者自我報告對治療 感到滿意。結果顯示，在激光治療前後，患者睡眠質量的變化顯著增加（ ），打鼾嚴重程度顯著改善（ ），並立即改善呼吸 感[10]。除此之外，當應用於軟齶，懸雍垂，齶扁桃體和舌根時，呼吸暫停和缺氧的發生率得到改善。鉺：YAG鐳射的作用機制是一種光熱效應，它會導致治療口腔粘膜中的膠原纖維耗盡，並通過熱休克蛋白（HSP）作用 刺激新膠原酶。
In the pilot study conducted by Lee et al. (2015), seven patients were recruited for the study, out of which 5 were diagnosed with OSA and 2 were documented as snorers. Each patient was laser-treated on the palatoglossal arch, palatopharyngeal arch, and uvula using the Er:YAG laser (LightWalker laser, Technology4Medicine, Irvine, CA) having an infrared of wavelength . Prelaser and postlaser CBCT scans were compared, and it was found that laser procedure increased the mean total airway volume from 10.23 to , and the minimum cross-sectional area from to 142.4 . The study concluded that lowlevel laser therapy significantly increases the oropharyngeal airway volume which may serve as an alternative or adjunctive treatment option for sleep-disordered breathing especially CPAP intolerant individuals .
在 Lee 等人（2015 年）進行的初步研究中，招募了 7 名患者進行研究，其中 5 名被診斷為 OSA，2 名被記錄為打鼾者。每位患者都使用具有波長紅外線的 Er：YAG 鐳射（LightWalker 鐳射，Technology4Medicine，Irvine，CA）對齶舌弓、腭咽弓和懸雍垂進行激光治療 。比較了鐳射前和鐳射后 CBCT 掃描，發現鐳射手術將平均總氣道容積從 10.23 增加到 ，最小橫截面積從 142.4 增加到 142.4。該研究得出的結論是，低水準激光治療顯著增加了口咽氣道容積，這可以作為睡眠呼吸障礙的替代或輔助治療選擇，尤其是 CPAP 不耐受者 。
Sleep disorder breathing is a broader term which includes OSA and snoring, and there are different studies that have included either one of the diagnoses or both for the study purpose (refer to Table 4).
睡眠呼吸障礙是一個更廣泛的術語，包括 OSA 和打鼾，並且有不同的研究出於研究目的包括其中一種診斷或兩者兼而有之（參見表 4）。
CPAP remains a treatment option for sleep apnea; however, many patients have reported difficulty adapting to the CPAP machine. CPAP therapy is expensive, and noncompliance rate is higher. Nasal or throat dryness, noise of machine, and size of machine are few of the reasons for which patients tend not to be regular with CPAP use. Due to the physical impairment, CPAP machine may not be an effective option and thus low-level laser therapy (LLLT) can play an important adjunct treatment modality for these populations. Additionally, LLLT is a safe, easy to perform, and inexpensive treatment when compared to CPAP therapy. There has been no serious complication reported to this therapy. LLLT is a simple, minimally invasive, reliable, and painless procedure
CPAP仍然是睡眠呼吸暫停的治療選擇;然而，許多患者報告說難以適應 CPAP 機器。CPAP治療費用昂貴，不依從率更高。鼻腔或喉嚨乾燥、機器噪音和機器大小是患者不經常使用 CPAP 的幾個原因。由於身體損傷，CPAP機器可能不是一個有效的選擇，因此低水準激光治療（LLLT）可以為這些人群發揮重要的輔助治療方式。此外，與 CPAP 療法相比，LLLT 是一種安全、易於執行且價格低廉的治療方法。該療法沒有嚴重的併發症報告。LLLT 是一種簡單、微創、可靠且無痛的手術
Table 3: Study subject demographics.
表3：研究物件人口統計學。
S.No Author
 出版年份
Publication
year
Study type 研究類型
 受試者數量
Number of
subjects
 平均年齡/範圍
Average
age/range
Gender
1. Usumez et al. Usumez等人。 2016 Animal model 動物模型 20 N/A Female
2. Camacho et al. 卡馬喬等人。 2017 Systematic review 系統評價 717 NA
3. Lee et al. Lee等人。 2015 Prospective pilot 准飛行員 7 59.5 5 male, 2 female
5 男，2 女
4. Camargo et al. Camargo等人。 2020

隨機臨床研究方案試驗
Randomized clinical study protocol
trial
36 NA
5. Karaman et al. 卡拉曼等人。 2017

前瞻性非隨機臨床研究
Prospective nonrandomized clinical
study
20 16 male, 4 female
16 男，4 女
6. Yaremchuk 2016 Literature review 文獻綜述 NA NA NA
7. Miracki et al. Miracki等人。 2013 Randomized clinical trial
隨機臨床試驗		 57 NA NA
8. Neruntarat et al. Neruntarat 等人。 2020 Systematic review 系統評價 247 NA
9. Shiffman et al. Shiffman等人。 2018 Literature review 文獻綜述 NA NA NA
10. Sippus 2015 Case report 病例報告 5 3 male, 2 female
3男2女
11. Storchi et al. Storchi 等人。 2018 Prospective cohort study
前瞻性佇列研究		 40 53

男29，女11
29 male, 11
female
12.

Wischhusen 等人。
Wischhusen
et al.
2019 Systematic review 系統評價 3093 NA
Table 4: Study based on OSA and snoring with their result measurement variables.
表 4：基於 OSA 和打鼾及其結果測量變數的研究。
S.No Author
 出版年份
Publication
year
Snoring OSA Study variables 研究變數
1.
 Usumez等人。
Usumez
et al.
2016 Histological effect 組織學效應
2.
 卡馬喬等人。
Camacho
et al.
2017 Apnea-hypopnea index (AHI), respiratory disturbance index
呼吸暫停低通氣指數（AHI）、呼吸紊亂指數
3. Lee et al.  Lee等人。 2015 Total airway volume 總氣道容積
4.
 Camargo等人。
Camargo
et al.
2020 Apnea-hypopnea index 呼吸暫停低通氣指數
5.
 卡拉曼等人。
Karaman
et al.
2017 Apnea-hypopnea index 呼吸暫停低通氣指數
6. Yaremchuk 2016 Apnea-hypopnea index 呼吸暫停低通氣指數
7. Miracki et al. Miracki等人。 2013 NightLase questionnaire and sleep-disordered breathing score
NightLase 問卷和睡眠呼吸障礙評分
8.
 Neruntarat 等人。
Neruntarat
et al.
2020

打鼾評分、患者滿意度、AHI、呼吸紊亂指數 （RDI）、Mallampati 分類、Epworth 嗜睡量表
Snoring scores, patient satisfaction, AHI, respiratory disturbance index (RDI),
Mallampati classification, Epworth sleepiness scale
9.
 Shiffman等人。
Shiffman
et al.
2018 SnoreLab iPhone application, CBCT
SnoreLab iPhone 應用程式，CBCT
10. Sippus 2015 Mallampati classification
Mallampati 分類
11. Storchi et al. Storchi 等人。 2018 Epworth sleepiness scale, AHI, Mallampati classification
Epworth 嗜睡量表、AHI、Mallampati 分類
12.
 Wischhusen等人。
Wischhusen
et al.
2019 Complications and side effect
併發症和副作用
that can be performed without hospital admission. Application of LLLT use in the soft palate region can act as adjunctive therapy to CPAP. Most of the studies have used a LightWalker AT laser manufactured by Fontana which has a dual-wavelength capacity and can operate with Er:YAG (wavelength ) and Nd:YAG (wavelength ). Most of the studies have suggested that there are no to minimal complications; however, a systematic review conducted by Wischhusen et al. in 2019 has suggested that there may be some transient complications such as bleeding, dryness, candidiasis, dehiscence, and surgical site infections. The major limitation of this study is that it did not mention about the kind of laser that was used and thus it is hard to comment that these complications are associated with which type of laser or the wavelength. Also, the location where LLLT is applied also is another factor for post complications. The study also suggests that collecting and gathering information such as timing, duration of the surgery, surgical technique,
可以在不入院的情況下進行。LLLT在軟齶區域的應用可以作為CPAP的輔助治療。大多數研究都使用了由Fontana製造的LightWalker AT鐳射器，該鐳射器具有雙波長容量，可以使用Er：YAG（波長 ）。大多數研究表明，沒有併發症或併發症很少;然而，Wischhusen 等人在 2019 年進行的一項系統評價表明，可能存在一些短暫的併發症，例如出血、乾燥、念珠菌病、裂開和手術部位感染。這項研究的主要局限性在於它沒有提到所使用的鐳射類型，因此很難評論這些併發症與哪種類型的鐳射或波長有關。此外，應用LLLT的位置也是后併發症的另一個因素。該研究還建議收集和收集資訊，例如時間、手術持續時間、手術技術、
Table 5: Type of laser, location, and wavelength.
表 5：雷射器的類型、位置和波長。
S.No Author
 出版年份
Publication
year
Laser type 激光類型 Location Wavelength
1.
 Usumez等人。
Usumez
et al.
2016 Er:YAG laser Er：YAG雷射器 Soft palate 軟齶
2.
 卡馬喬等人。
Camacho
et al.
2017 NA Uvula NA
3. Lee et al. Lee等人。 2015

非燒蝕性Er：YAG鐳射
Nonablative Er:YAG
laser
Palatoglossal arch, palatopharyngeal arch, and uvula
齶舌弓、腭咽弓和懸雍垂
4.
 Camargo等人。
Camargo
et al.
2020 Diode laser 二極管雷射器

軟齶、懸雍垂、咽壁、腭扁桃體和舌根部
Soft palate, uvula, pharyngeal walls, palatine tonsils, and on
the tongue base
5.
 卡拉曼等人。
Karaman
et al.
2017 laser Tongue base 舌根
6. Yaremchuk 2016 NA NA NA
7. Miracki et al. .
Miracki等人。 		2013 Nonablative Er:YAG 非燒蝕性 Er：YAG

上顎，懸雍垂與硬腭下部，後柱和扁桃體，舌頭的外側和下側
Palate, uvula with the lower part of hard palate, posterior
pillars and tonsils, the lateral and bottom sides of the tongue
8.
 Neruntarat 等人。
Neruntarat
et al.
2020 Nonablative Er:YAG 非燒蝕性 Er：YAG Oropharyngeal mucosa, the soft plate, and the tongue
口咽黏膜、軟板和舌
9.
 Shiffman等人。
Shiffman
et al.
2018

亞燒蝕組合 Nd：YAG 和 Er：YAG
Subablative combined
Nd:YAG and Er:YAG
Soft palate and uvula
軟齶和懸雍垂
,
10. Sippus 2015 Er:YAG laser Er：YAG雷射器 Soft intraoral tissue 軟口內組織
and
11. Storchi et al. Storchi 等人。 2018 Er.YAG Soft palate, uvula, tonsillary regions, and base of the tongue
軟齶、懸雍垂、扁桃體區域和舌根
12.
 Wischhusen等人。
Wischhusen
et al.
2019 NA NA NA
and extend of the surgery can better assess risk and cautions can take while doing the procedures [20].
延長手術時間可以更好地評估風險，並在手術時採取謹慎措施[20]。
The study conducted by Shiffman et al. in 2018 aimed at providing the clinical experience with the combined Er:YAG and Nd:YAG laser for the LAUP procedure in the SDB (sleeping disorder breathing) patients. In this study, they have described the LAUP procedure with first using the :YAG laser which acts as an effective coagulator and after that, they have used the Er YAG laser on the same site to further enhance the shrinkage of collagen and neocollagenase resulting in tightening of the soft palate and surrounding tissues. This combined approach of two lasers has been described as NightLase LAUP protocol [21]. Type of lasers, target location, and wavelength used in the studies are included in Table 5.
Shiffman 等人於 2018 年進行的研究旨在為 SDB（睡眠呼吸障礙）患者的 LAUP 手術提供聯合 Er：YAG 和 Nd：YAG 鐳射的臨床經驗。在這項研究中，他們描述了LAUP程式，首先使用作為有效凝固劑的 ：YAG激光，然後，他們在同一部位使用Er YAG鐳射進一步增強膠原蛋白和新膠原酶的收縮，從而收緊軟腭和周圍組織。這種由兩種雷射器組成的組合方法被描述為NightLase LAUP協定[21]。表5包括研究中使用的鐳射類型、目標位置和波長。
Üsümez et al. 2016 performed LLLT Er:YAG on the soft palate of Wistar albino rats with successful contraction of the soft palate. The finding of this study suggests that there is contraction of soft palate tissue but relapse is noticed in the week. This study concluded that Er:YAG application on the soft palate for snoring can be considered to be a safe treatment due to the absence of any carbonization, necrosis, or hemorrhage. Similarly, Dovsak et al. conducted a pilot study and showed that Er:YAG laser treatment is a safe method and is easily tolerated by patients [11].
Üsümez 等人 2016 年對 Wistar 白化大鼠的軟腭進行了 LLLT Er：YAG，軟腭成功收縮。這項研究的結果表明，軟腭組織有收縮，但在 一周內注意到復發。本研究得出的結論是，Er：YAG在軟齶上的應用可以被認為是一種安全的治療方法，因為沒有任何碳化、壞死或出血。同樣，Dovsak等人進行了一項初步研究，結果表明Er：YAG激光治療是一種安全的方法，患者容易耐受[11]。
Sippus et al. 2015 study used Er:YAG laser with HP PS04 handpiece with minimal invasive settings. In these case reports, the laser beam of in LP mode was fired on the soft tissue horizontally or vertically repeatedly in short intervals with obvious shrinkage of soft tissue in the palatal region. Total delivered pulses vary per patient from between 10,000 and 15,000. According to this study, Er:YAG application is a safe and successful treatment in reducing snoring. Its easy application and no anesthesia use make this treatment very well accepted by the patients as well.
Sippus 等人 2015 年的研究將 Er：YAG 雷射器與 HP PS04 手機配合使用，具有微創設置。在這些病例報告中，LP模式下的 鐳射束在短時間內水準或垂直反覆發射到軟組織上，腭部軟組織明顯收縮。每位患者的總輸送脈衝數在 10,000 到 15,000 之間。根據這項研究，Er：YAG應用是減少打鼾的一種安全且成功的治療方法。它易於應用且無需麻醉，因此患者也非常接受這種治療方法。

5. Conclusion 5. 結論

Based on the finding of this systematic review, it is recommended that low-level laser therapy (LLLT) such as Er:YAG lasers can be performed as a treatment modality for sleepdisordered breathing, especially obstructive sleep apnea and snoring. Laser-assisted uvulopalatoplasty (LAUP) can be performed on the pharyngeal and palatal soft tissues to diminish or eliminate the obstructions. This nonsurgical therapy is revolutionary development in treating obstructive sleep apnea patients, especially those who have difficulty in using the CPAP machine. The long-term efficacy, quality of life, and painless laser procedure can be performed with successful outcomes on sleep apnea patients. Based on the research, there have not been any serious complications that were reported that make this procedure an effective treatment modality for sleep apnea patients. Another important outcome of this research is that there needs to a patient selection and inclusion criteria for the LAUP procedure as it may not be suitable for all the patients. It is recommended that there should be more randomized clinical controlled trials in the future with long-term follow-up to check for the LAUP when used in conjunct and adjunct to CPAP machine.
根據本系統評價的結果，建議將低水平激光治療 （LLLT） （如 Er：YAG 鐳射）作為睡眠呼吸障礙，尤其是阻塞性睡眠呼吸暫停和打鼾的治療方式。激光輔助懸雍垂齶成形術 （LAUP） 可以在咽部和齶部軟組織上進行，以減少或消除阻塞。這種非手術療法是治療阻塞性睡眠呼吸暫停患者的革命性發展，尤其是那些難以使用 CPAP 機器的患者。長期療效、生活品質和無痛激光手術可以在睡眠呼吸暫停患者身上取得成功。根據這項研究，目前還沒有報告任何嚴重的併發症，使該手術成為睡眠呼吸暫停患者的有效治療方式。這項研究的另一個重要結果是，LAUP 程式需要患者選擇和納入標準，因為它可能不適合所有患者。建議未來應進行更多隨機臨床對照試驗，並進行長期隨訪，以檢查與 CPAP 機器聯合使用和輔助使用時的 LAUP。
Based on current evidence, Er:YAG can be a good alternative and least invasive therapy for managing snoring. This therapy can also be beneficial as nonsurgical management for sleep-disordered breathing and more importantly in noncompliant CPAP individuals. Er:YAG therapy is considered to nonsurgical intervention with minimum side effects and can be performed chairside. This treatment involved no che harmacotherapy and no anesthesia or at the most topical or local anesthesia. The Er:YAG laser application causes the shrinkage of mucosa. And there is no production of carbonization, necrosis, or hemorrhage posttherapy. This makes the treatment to be cost effective, fast, and easy with positive results and patient satisfaction.
根據目前的證據，Er：YAG可以成為控制打鼾的良好替代療法和侵入性最小的療法。這種療法也可以作為睡眠呼吸障礙的非手術治療，更重要的是，對於不依從的CPAP個體。Er：YAG 治療被認為是副作用最小的非手術干預，可以在椅旁進行。這種治療不涉及 che harmacotherapy 和麻醉，也不涉及大多數局部或局部麻醉。Er：YAG激光應用會導致粘膜收縮。治療後不會產生碳化、壞死或出血。這使得治療具有成本效益、快速和簡單，具有積極的結果和患者滿意度。
These findings suggest that the contact Nd:YAG laser might be more effective for soft palate stiffening operations.
這些發現表明，接觸式Nd：YAG鐳射可能對軟齶硬化手術更有效。
There was no animal or human participants involved in this research and thus informed consent was not required.
這項研究沒有動物或人類參與者參與，因此不需要知情同意。

Conflicts of Interest 利益衝突

The authors declare no conflict of interest. Additionally, the authors have no financial interest in this project.
作者聲明沒有利益衝突。此外，作者在這個專案中沒有經濟利益。

Authors' Contributions 作者的貢獻

All the articles were reviewed by three authors (SS, BG, and MK). The studies assessed by SS and deemed eligible were checked by MK and BG for methodological quality and inclusion criteria. All disagreements were resolved verbally, with strict adherence to the predetermined inclusion criteria.
所有文章均由三位作者（SS、BG和MK）審稿。由SS評估並被認為符合條件的研究由MK和BG檢查方法學品質和納入標準。所有分歧均通過口頭解決，嚴格遵守預定的納入標準。

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