This 69 y/o woman’s chief complaint was difficulty breathing while swimming and at bedtime. She thinks her palatal tori underwent rapid growth while on oral bisphosphonate therapy for osteoporosis. There is no recognized biologic basis for inducing exostosis growth, but she said after she discontinued the medication a few years ago that the rapid growth ceased. She requested that her palatal tori be removed.

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I agreed to her request, and explained that we could expect some improvement in her airway, but there is no way to know how much. I also explained that bisphosphonates remain bound in bone for years after the last dose and could sill create a risk of post-operative osteonecrosis. I recommended removing the lateral palatal exostoses first. I thought that getting rid of the lateral bulk would help her the most, and might be enough to open her airway. Also, I thought that including a midline incision for accessing the midline torus would potentially compromise the blood flow to the flaps that would be raised to get to the lateral tori. I decided to forgo a palatal stent appliance because I anticipated there would be a lot of redundant mucosa that would just get folded on itself and crushed if a stent was placed over it.

Here are photos of the intraoral exposure, and the bone that was removed from each side. I scored the bone with a fissure bur several millimeters from the teeth, and then carefully cleaved off the tori with a curved osteotome.

[image:60abc087597e4_Intra_op.jpg][image:60abc094d8f27_Removed_tori.jpg]

Dissecting the mucosa off the lobulated exostoses can be challenging, but fortunately the mucosa of the lateral palate is relatively thick. I keep electrocautery handy since the greater palatine artery can be in the field. I will make sure there is good hemostasis, either with electrocautery or Surgicell, to reduce the chances of a post-op hematoma. The redundant mucosa looks terrible post-operatively, but I explain that it will undergo a combination of contraction, necrosis, and adaptation to re-establish a smooth mucosal surface. I encourage saline rinses QID the first several weeks.

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At post-op week six she reports she feels she can breathe easier at night and while doing her laps in the pool. The mucosa has finally re-established itself to the new bony anatomy, and appears fine. She is going to hold off on removing the midline torus unless there is significant growth in the future.

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