8 Surgery in Adults
Abstract
This chapter starts with minimally invasive surgery of the palate, palatal implants, and stiffening procedures. Then the various current invasive palatal procedures, including tonsils, are presented. Thereafter, current techniques for the base of tongue, including implants and transoral robotic surgery, are discussed. Subsequently, hyoid bone surgeries, genioglossal advancement, hypoglossal nerve stimulation, surgery for larynx and trachea, maxillofacial surgery, distraction osteogenesis maxillary expansion, and multilevel surgery are discussed in detail. Indications and contraindications, patient selection, diagnostic workup, risks, patient information, consent, anesthesia and positioning, surgical technique, complications, and postoperative care are discussed for each technique.
8.1 Minimally Invasive Surgery
8.1.1 Interstitial Radiofrequency in the Soft Palate
Definition and Principle
Interstitial radiofrequency is a minimally invasive technique that was introduced in sleep surgery by the Stanford team in 1996. Powell and Riley were looking for a safe technique to treat the tongue and possibly reduce the tongue volume. They met the CEO of a company that commercialized radiofrequency tissue ablation applied to other tissues than pharyngeal, in particular prostatic tissues. This meeting sets the point for radiofrequency development in sleep surgery. They first experienced radiofrequency ablation in vitro on a beef tongue then in vivo on porcine tongues. As the results were satisfactory in terms of safety and efficacy, experience went on humans quite fast thereafter.
Interstitial radiofrequency uses the same principle as electrocautery but with different frequency waves. It uses low-frequency waves, between 300 and 4,000 KHz delivered by a generator through an electrode. These waves induce two types of lesion, mainly thermal but also electrical.
Low-frequency waves produce a molecular agitation, responsible for a heating around the electrode. The heat is going to induce lesions at the level of the cellular membrane, the cytoskeleton, the cellular metabolism, and the nucleus. All these phenomenons create a coagulative necrotic lesion which has an elliptic circumscribed submucosal shape. This lesion leads to scar formation.
Several studies evaluated the effects of interstitial radiofrequency on pharyngeal tissue, especially the soft palate and the tongue.
The first study on the effects of radiofrequency was on porcine tongues which evaluated the treatment effects by piezoelectric sensors placed around the treatment area. The authors observed after 10 days a 26.3% reduction in tongue volume. 1 The effects of radiofrequency on human tissues remain controversial. The volume reduction is not always found in the studies. Stuck et al did not find any volume reduction 2 and Blumen et al did find a reduction but only in some patients. 3 Powell et al in the first study in mankind on soft palate showed that there was retraction of the uvula on lateral cephalometry. 4
The main action seems to be linked to the scaring process with rigidification and some kind of retraction of the treated tissue.
Radiofrequency to treat snoring or sleep apnea is used in different sites: soft palate, tongue base, inferior turbinates, and tonsils.
Indications, Contraindications, and Patient Selection
Indications are mainly as follows:
Simple snoring when the soft palate is believed to be the vibrating site.
Mild, and in some cases, moderate obstructive sleep apnea syndrome (OSAS) in case the soft palate is believed to be the obstruction site mostly due to excessive compliance.
There are no absolute contraindications. A pacemaker is a relative contraindication when the system uses a monopolar electrode.
In simple snoring, nasal obstruction or a long uvula may hinder good results.
In obstructive sleep apnea (OSA) vibration or obstruction of other sites than the ones treated, high body mass index (BMI) and high apnea–hypopnea index (AHI) (>30/h) are not good indications.
Diagnostic Workup
Radiofrequency does not need a specific preoperative workup.
In order to have good results in simple snoring, there is a need to carefully select the patient: evaluate the bed partner’s quality of sleep and the reality of the burden caused by the snoring, try to determine the site of vibration by awake clinical examination and eventually during a drug-induced sleep endoscopy (DISE), and rule out a nasal obstruction possibly responsible for the snoring. It is of course mandatory to have a sleep study to rule out severe OSA, quantify the amount of snoring and determine if it is positional.
Specific Risks, Patient Information, and Consent
There are no specific risks.
The patient needs to be informed of a slight discomfort during 4 to 5 days after the procedure. The level of discomfort is far less than the postlaser or postsurgery pains 5 applied on the soft palate. Snoring is more pronounced during approximatively 10 days, but the maximum level is during the 48 first hours after the procedure; this is linked to the edematous tissue response. A foreign body sensation could be felt by the patient during the following weeks, generally due to a long uvula touching the tongue base. Pharyngeal dryness can occur but is rare.
Anesthesia and Positioning
The procedure is performed under local anesthesia, generally in a sitting position.
Equipment
Radiofrequency waves are delivered by a radiofrequency generator. There are several radiofrequency generators that deliver waves at different wave lengths. A study compared four different radiofrequency generators, which did not show any significant differences in terms of efficacy on snoring. 6
The electrode through which the radiofrequency waves are delivered to the tissues can be either monopolar or bipolar. Some systems have a temperature retro control that controls the temperature at the tip of the electrode and the impedance in order to progressively deliver the energy, enabling the lesion to grow and widen as wished.
The electrode can be single use or resterilizable.
Operative Technique/Steps
The treatment is performed in a consultation room or in ambulatory operating room in a sitting position.
A local anesthesia is performed within the soft palate with norepinephrine and xylocaine 1%. Some practitioners ask their patients to gargle with contact anesthetics.
Doses injected depend on the soft palate thickness. It is recommended to blow up thin soft palate in order to increase the palate thickness to avoid heat diffusion at the surface of the soft palate, which induces mucosal lesions.
Local injections should be made first at the level of entry of the neurovascular bundles penetrating the soft palate (▶Fig. 8.1). After a couple of minutes, injections should be made to cover only the treated areas. There is no need to inject the uvula. The velar webs, if treated, should be injected at the top.
A tongue depressor should be used to isolate the soft palate from the tongue. It is preferable to have the patient breathe partially through his nose (if possible) in order to verticalize the soft palate.
The electrode is introduced perpendicularly to the surface of the soft palate, and then when the electrode is inside the soft palate, it should be tilted 45% to try to follow the soft palate curvature.
Before delivering the energy with a pedal, it is recommended to tilt back and forth the tip of the electrode to check it is still within the tissue.
If the tip is seen just underneath the mucosa, it is preferable to take it back a little and try to replace midway between the anterior and posterior surfaces of the soft palate. During energy delivery, if pain is felt in the neck, it means that the tip of the electrode has gone through the posterior surface of the soft palate into the posterior pharyngeal wall; this occurs when the posterior airway space (PAS) is small and when the patient is breathing through the mouth.
Several protocols have been described for the electrode placement. The original technique consists of three puncture deliveries: 4 one vertical and median and two high, slightly oblique laterally (▶Fig. 8.2). For each puncture, one lesion was created. The punctures are created high at the junction between the hard and soft palate. It is recommended not to make a puncture within the uvula (not make the tip of the electrode go further than 1 or 2 mm below the base of the uvula) because of a risk of major edema the following night and possible respiratory distress and/or uvula necrosis in the following weeks.
Other protocols were described using more punctures or more lesions per puncture (▶Fig. 8.3). Some articles describe higher energy levels per puncture to try to increase the size of the lesion, and thus the scaring area. It seems logical to create as much scarring as possible to cover the entire soft palate, or at least theoretically cover the areas that vibrate and/or obstruct. It is difficult to know in practice what these areas are on an awake clinical examination. These areas are probably better assessed during a DISE.
Snoring vibrations are most often generated at the level of the soft palate, especially at its inferior border. Obstructions seem to occur along a median and vertical width of tissue but can also involve the entire soft palate starting at the hard–soft palate junction down to the inferior border of the soft palate. Hence, it seems logical to cover this region with radiofrequency lesions. If these regions are not well determined, it seems compulsory to cover the entire soft palate. According to the soft palate anatomy (long/short/wide/narrow), the number of punctures and lesions per puncture can be more or less.
Most often, three to five punctures and several lesions per puncture are necessary, taking great care not to overlap the lesions to avoid mucosal lesions.
The delay between two sessions is generally 6 to 8 weeks. This is to enable the scaring to take place and obtain a stiffer tissue.
Shorter delays may induce overtreatment in some patients. Longer delays between sessions do not seem to be problematic.
The inferior part of the soft palate is involved in palatal flutter and sometimes low velopharyngeal obstruction, thus section of the velar webbing and a significant shortening of the uvula with radiofrequency in the cutting mode could be added to interstitial radiofrequency with better results than interstitial radiofrequency alone. 7
The number of treatment sessions is variable in the studies. In the earlier times, the authors would perform three or more sessions. With time, the surgeons tried to reduce the number of sessions. One study tried to determine the number of sessions required to reach a satisfactory result. A minimum of three sessions were needed. 8
Each puncture was followed by three lesions. The three sessions could probably cover the entire surface of the soft palate, but it could be covered in less than three sessions using more punctures or with a smaller soft palate.
One study 9 was published to determine if the results on snoring after the first session was predictive of the final results in two to three sessions with or without a uvula shortening, depending on the anatomy—after the first session, when the snoring volume reduced significantly, adding sessions enabled to satisfy 58% of the bed partners, whereas if the snoring volume did not decrease significantly only 38% of the bed partners were satisfied.
Risks, Tips, and Tricks
When the technique is not performed well, or in case of a thin soft palate, it is visible on follow-up superficial mucosal lesions (erosions) or deep lesions (ulcerations and even perforations).
In the earlier times, occurrence of mucosal lesions was high. Terris and Chen found an incidence of up to 60% of lesions. 10 More recently, these rates decreased drastically. Farrar etal, 11 in their meta-analysis, calculated a 2.4% of mucosal erosions, a 1.2% of perforations, and a 0.3% abscess occurrence—the local complication rate was 3.9%.
To avoid lesions, one can treat the entire surface of the soft palate in two or three sessions to avoid puncture overlapping.
Similarly, it is compulsory not to be too close to the anterior surface of the soft palate and to blow up the thickness of the soft palate, especially when it is thin, with local anesthetics.
When the surgeon delivers the energy to the tissues, he/she must look for the occurrence of mucosal blanchening. If this is the case, energy delivery should be stopped and the electrode should not be withdrawn and placed at the same level and deeper—the risk being to create a deeper lesion and increase the risk of perforation.
Superficial mucosal lesions heal in approximately 15 days and are associated with pain or great discomfort. Local care and analgesics can be given. Perforations on thick soft palate usually heal without a residual perforation, without having to put stiches. On thin soft palates, perforation can persist if nothing is done.
Complications
No persistent side effects regarding swallowing, voice, or speech were observed after performing interstitial radiofrequency. 12 No velar insufficiency, bleeding, or significant infections, 13 or pharyngeal stenosis were described.
Postoperative Care
Postoperative treatment is not compulsory. Analgesics can be prescribed. If a physician wants to make the patient comfortable, he/she could prescribe oral steroids on the first night.
Outcomes
Snoring
Radiofrequency of the soft palate was proven superior to placebo. 14 On a short-term basis (3 months), snoring intensity decreased significantly in all studies. 15 , 16 Adding UPP to radiofrequency increases the efficacy of radiofrequency 17 on snoring.
Radiofrequency efficacy decreases with time. Relapse occurs early: after 19 months, patients’ snoring increased by more than twofold. 18 After 3 years, snoring relapsed from a postoperative score of 3.6 at 6 months to 5.6 (preoperative score 8.1). Only 25% of the patients were satisfied. After 6 years, there was a 92% relapse of the snoring sound but with a level inferior to preoperative (8.1 ± 2.9 to 3.5 ± 2.2 cm on a short term then increased to 5.7 ± 2.9 cm). 19
Epworth score decreased significantly in 69% of the studies on radiofrequency on a short-term basis. 16
Radiofrequency on the soft palate alone can decrease RDI in some patients with mild to moderate OSA. 20 A meta-analysis 21 showed a nonsignificant trend toward improvement of short-term mean RDI (RoM 0.67, 95%, CI 0.43–1.03, p = 0.07, I2 = 83%).
BMI is the most important general factor that influences results of radiofrequency on snoring. 16 Best results are obtained in patients with BMI less than 25 kg/m2 and worst in those with BMI 30 kg/m2. 22 , 23 A large or long uvula is a negative factor to treat snoring with radiofrequency alone. 24 On a long-term basis, sectioning the uvula preserves to a certain degree relapse. 19
Among all factors studied (AHI, BMI, sex, age, snoring score, Epworth) that could influence results of radiofrequency on mild to moderate OSA, initial AHI is the one that could influence the greatest postoperative AHI in a normal weight population. 25
Key Points
Interstitial radiofrequency probably reduces tissue compliance but probably gives little volume reduction as well.
If the surgeon thinks that the factor that induces airway collapse is an excessive compliance (no retrovelar narrow space during wakefulness, not a long palate, no other obstacles), without obesity nor severe sleep apnea, radiofrequency can be indicated, especially since it has low morbidity.
Technically, there is a learning curve. One should pay attention to introduce the electrode at equal distance of the anterior and posterior surface of the soft palate. If the soft palate is thin, the surgeon should increase its thickness with infiltration. He/she should also be careful not to overlap the punctures to avoid mucosal lesions.
Results on snoring are good. Nevertheless, long-term follow-up should have a high rate of relapse, which needs to be explained to the patient beforehand. Adding an uvulectomy increases the success rate.
Results on mild and moderate OSA are acceptable if the patients are properly selected.
8.1.2 Palatal Implants and Other Stiffening Procedures
Introduction
As discussed in previous chapters of the book, in most patients, the main source of vibration of the upper airway, producing loud snoring, is the palate. This is why the idea of stiffening the palate, so it becomes more rigid and the vibration reduces, is so appealing. Nevertheless, one should always keep in mind that snoring could also originate at lateral pharyngeal walls (LPWs), tongue base, epiglottis, and even the posterior wall. 26 There are several procedures that aim at stiffening the palate, such as interstitial radiofrequency treatment (RFT) (see Section 8.1.1), but in this chapter we will cover various other options that have the same objective, so the reader can choose between them.
Along this chapter, injection snoreplasty (IS) and palatal implants (PIs) will be discussed. There is another technique called cautery-assisted palatal stiffening operation (CAPSO) that apparently has the same result. With CAPSO, a strip of palatal mucosa is removed and the palate is left to heal on secondary intention. 27 Nevertheless, the author believes that CAPSO is more painful and does not provide any benefit to PIs or IS, so CAPSO will not be discussed in detail in this section. In general, PIs and IS can help to reduce snoring but they are not as useful as conventional surgery in reducing AHI. Therefore, they should not be considered first-line therapy for patients with moderate to severe OSAS.
Injection Snoreplasty
Definition
IS means to inject, submucosally, a sclerosant agent that produces an aseptic inflammation with subsequent fibrosis, with the aim to stiffen the palate. It was first introduced by Brietzke and Mair in 2001 as an inexpensive and painless way to treat snoring. 28
Brietzke and Mair used 3% sodium tetradecyl sulfate as sclerosant agent. 28 This drug is not easily available in some European countries. Thus, other agents have also been used. The agents that have proven efficacy in animal studies were ethanol 50% (mixing 1 mL of ethanol 99% and 1 mL of lidocaine) 29 and polidocanol 3%. 30 Its injection produces a submucosal fibrosis similar to the one obtained by radiofrequency 28 , 30 or CAPSO. 31
Indications, Contraindications, and Patient Selection
This technique can be performed in patients with snoring, without OSAS, or in patients with mild OSAS, not obese, tonsil grade 0 or 1 with no evidence of tongue base obstruction in awake clinical exploration or DISE. Some authors have suggested to use IS as a treatment method previous to classical palatal surgery, arguing that if snoring is better after the injection, one can assume that the origin of the sound is the palate. 32
It should not be performed in patients with moderate to severe OSAS or in patients with big tongues (modified Mallampati index 4). If the patient has a strong gag reflex, it might be difficult to perform the procedure under local anesthesia.
Although it has not been described in the literature, probably it is not useful in patients with long and thick uvulas. In such patients, it makes more sense to opt for techniques that shorten the uvula.
Diagnostic Workup
Previous diagnostic workup to perform IS includes a complete history and awake examination of the patient, or DISE, as well as a diagnostic sleep study.
Specific Risks, Patient Information, and Consent
This technique is performed in an outpatient basis, in the consulting room.
The procedure itself is easy, quick, and with little discomfort.
The most common complication is an ulceration of the mucosa at the injection point that, as a rule, heals within a week.
Patients should be warned that during the first few days snoring will get worse due to the inflammation of the palate. After the first week, it should be better. If snoring improves but not enough to achieve patient and bed partner satisfaction, the treatment can be repeated after 4 to 6 weeks.
Although there are no publications reporting results longer than 18 months, snoring can be expected to deteriorate over time, as it happens with other techniques such as RFT. Patient should be informed about this potential relapse of snoring.
Anesthesia and Positioning
To perform IS at least a topical anesthesia of the palate is necessary. The author also suggests local anesthesia of the palate so the sclerosant agent does not cause pain during the injection. The patient is seated, similar to the usual upper airway exploration.
Equipment
The only equipment needed is an insulin or tuberculin syringe with its needle. ▶Fig. 8.4 shows the syringe used by the author; as the syringe is slim, it can reach the palate, allowing a proper visualization. Nevertheless, it can contain only 1 mL of the sclerosant agent, so it has to be charged twice. Brietzke and Mair used a syringe with bent ¾-inch 27-gauge needle.
Operative Technique/Steps
Topical anesthesia of the palate with lidocaine 10 or 14% benzocaine sprays.
Local anesthesia (lidocaine or mepivacaine) of the soft palate at the hard–soft palate junction, so it does not mix with the sclerosant agent. Usually 1.5 to 2 mL of anesthetic agent is used, divided in three injection points. The first one is at the center of the hard–soft palate junction, and two more laterally in order to block the palatine nerves (▶Fig. 8.5). Brietzke and Mair do not use local anesthesia instead they apply benzocaine gel (200 mg/gm) at the palate for 5 to 10 minutes.
Injection of 1 mL of the sclerosant agent at the center of the soft palate (submucosally), 1 cm above the uvula root (▶Fig. 8.6). The sclerosant agent must form a blister under the mucosa. Muscular injection should not be performed.
Injection of 0.5 mL of the sclerosant agent at the sides of the palate, also submucosally. These lateral injections were originally described as the injection points in a second step, but they can be performed in the first injection day as well.
Risks, Tips, and Tricks
This is a very simple technique. If the patient is correctly anesthetized and the injection is administered slowly, he/she will not move and the sclerosant agent will be injected correctly submucosally in the palate.
Complications
The most common complication is ulceration of the mucosa at the injection point that, if occurs, will heal without any specific care, in a short time. This ulceration can cause some pain and discomfort, but it is usually not a painful event (▶Fig. 8.7). 33
Although it is not a complication, the patient should be informed that, due to the infiltration and the inflammation that will follow, snoring might be worse during the first few days (usually for 2–4 days). The patient will encounter more swelling if the injection is started closer to the base of the uvula, as the sclerosant agent will reach it. It is therefore important to inject 1 cm above the base of the uvula. This edema of the palate can cause some discomfort, but it does not cause any breathing problems.
The occurrence of an asymptomatic palatal fistula has been described. It also heals spontaneously in less than 6 weeks. It mostly occurs in patients with thin palates, usually women, with a frequency of 2.6%. 33
Other possible secondary effects, due to the rigidity of the palate, can be a weird sensation when swallowing or pronouncing letters that elevate the palate. These effects are rare and more commonly observed if the procedure is performed in patients that had a previous palatal surgery to treat snoring or OSA.
Postoperative Care
The patient is advised to use painkillers such us ibuprofen, metamizol, or paracetamol in case of pain or discomfort. The level of pain is usually low, reaching a mean of 3.5 on a visual analog scale (VAS). 33 Antibiotics are not needed.
Outcomes
▶Fig. 8.8 shows outcome after IS. The fibrosis produced by the sclerosant agent can be seen over the uvula.
There are few articles published on IS; all of them are case series. One study compared IS with radiofrequency of the soft palate. 34 There are a few studies and it is not easy to merge them in a table because they use different objective and subjective scales. Therefore, the author will just comment on the main results.
The longest follow-up period was 19 months in 22 patients in the study by Brietzke and Mair. 33 There were no objective changes in mean AHI index (7.5/h pre to 8.5/h post). No data about effect on the ESS were provided. Subjective improvement of snoring was 75%.
Olszewska et al followed up 21 patients for 6 months. Mean AHI did not change (4.6/h to 3.6/h). Sleepiness (e.g., ESS) decreased from 9 to 5 and snoring time decreased from a mean of 110 to 22 minutes during the polysomnography (PSG). 35
Al-Jassim and Lesser found a subjective improvement on snoring in 62% of 60 patients after 1 year. 32
Labra et al achieved a decrease in mean AHI from 14.5 to 4.1. The snoring index improved as well (14.9 to 20.4), ESS changed significantly from 9.6 to 8.2, in 11 patients after 6 months. 36
Iseri and Balcioglu followed up 30 patients for 6 months; in VAS, snoring was reduced from 7.8 to 2.9. Subjective satisfaction with the procedure was 76.7%, comparable to radiofrequency. 34
Key Points
Injecting submucosally in the center of the palate can be considered in simple snorers or patients with mild OSA (AHI < 15), nonobese patients who had tonsillectomy previously, or small tonsils and low Mallampati index.
Palatal Implants
Definition
PIs were first described in 2004 by Nordgard et al. 37 The implant itself is a segment of braided, polyethylene terephthalate (PET) woven yarns around 18-mm long with an outer diameter of 1.5 mm. Notable biological characteristics of PET include biostability, promotion of tissue ingrowth, and a well-characterized fibrotic response with fibrous capsule formation typically being complete by 4 weeks. 37 PIs were presented as a minimally invasive single-stage treatment without any need of specific or expensive equipment. The commercial name is Pillar, distributed by Medtronic.
Indications, Contraindications, and Patient Selection
PIs can be offered to simple snorers and patients with mild OSAS. Some authors use it as a second surgery to improve palatal snoring after failed uvulopalatopharyngoplasty (UPPP). 38
There are anatomical factors to considerate before PIs. The soft palate length measured from the hard–soft palate junction to the base of the uvula is an important patient-selection criterion for implant insertion. A length of less than 24 mm is not recommended for 18-mm implant insertion, as more extrusions can be expected. Extrusion rate is higher in thin palates too. The uvular length, defined as the distance between the uvular base and tip, is another feature to consider, as the results in patients with a uvula longer than 15 mm are not as good compared to patients with shorter ones. 39 Tonsils should be grade 0, 1, or 2.
BMI is also important; patients should not be obese (BMI < 30).
Diagnostic Workup
As with IS, the previous diagnostic workup includes a complete history and awake examination of the patient (or DISE), as well as a diagnostic sleep study.
Specific Risks, Patient Information, and Consent
Although palatal infection has been described, the procedure is safe and the complication rate is low. The most frequent complication is partial extrusion of the implant(s) that forces to remove it. As in all procedures that address snoring, with time there is a relapse of snoring: the mean (standard deviation [SD]) preoperative score was 9.5 (0.5), mean week-52 score was 5.0 (1.6), and mean 4-year score was 7.0 (1.8). 40 Therefore, patients can expect relief from snoring, but it might recur over the years.
Although voice onset time for the letter “k” is shorter before implantation, no important changes on voice are to be expected. 41 Expected changes in patient’s compliance to continuous positive airway pressure (CPAP) or in the CPAP pressure 42 or in swallowing function are not longer than 1 week. 43
Pillar implantation induced changes in middle ear function up to 26.7% of the patients. Patients complained of otalgia or pressure feeling in the ear, however, the changes were temporary and not significant 1 week after surgery. 44
Anesthesia and Positioning
The procedure is usually performed under local anesthesia. It can be performed under general anesthesia in case it is combined with other upper airway procedures (e.g., nasal surgery). Local anesthesia of the palate will produce swelling that will facilitate the implant insertion. To reduce the risk of bleeding, a mix of lidocaine or bupivacaine with adrenaline is recommended. Palatal local infiltration with anesthesia will reduce discomfort if performed after the topical one.
Equipment
The implants are provided by the manufacturer with the instrument designed for its insertion (▶Fig. 8.9). It is recommended to use fiberscope in order to check the correct position of the implants and that they do not extrude at the posterior part of the palate.
Operative Technique/Steps
Rinse the mouth with an antiseptic solution such as chlorhexidine.
Use topical and local anesthesia.
The mucosa of the soft palate is perforated in the midline about 5 mm distal to the trailing edge of the hard palate.
The insertion of the cannula must be through the muscular layer toward the base of the uvula until the insertion depth marker on the delivery tool reaches the insertion point.
A thumb slider on the handle is pulled down to retract the needle tip while an obturator housed within the needle maintains the position of the implant, leaving it in place when the delivery device is withdrawn from the tissue.
Two more implants are inserted on each side of the first one, approximately 2 mm away in order to create fibrosis bridges between them in order to obtain the best results (▶Fig. 8.10).
Check the correct insertion of the implants with the fiberscope and adjust the implant if it is not completely inside the muscular layer of the palate, or extrudes at the posterior side of the palate.
Complications
The most frequent complication is extrusion, which occurs approximately in 9.3% of the patients (range 0–25%). 43 Once a Pillar implant is extruding, it should be removed and a new one should be implanted. Extrusion rate is the highest during the first year, but has also been described during the second year.
Pain and foreign body sensation disappear, usually within the first week, and these symptoms are self-limiting. Pain level is very low; patients can return to normal life the next day. Mucosal ulcerations, fistulas, or infections have been rarely reported. 43 If any infection occurs, the implant should be removed.
Approximately 25% of the patients complain of otalgia or pressure feeling in the ear after implantation but these symptoms typically do not last longer than 1 week. 44
Postoperative Care
Antibiotics are needed peri and postoperatively. Most of the authors recommend starting the same day as the surgery and continue for 4 more days (5 days of antibiotics).
Painkillers are prescribed in case of pain. Steroids are not needed and should be avoided to prevent infection.
Outcomes
Choi et al published a meta-analysis in which the articles published until March 2011 were reviewed. They included 363 OSA patients and 174 snorers. The meta-analysis showed that PIs reduced snoring, sleepiness, and AHI. Standardized mean difference (SMD) was −0.591 for snoring, −0.481 for sleepiness, and −0.378 for AHI. The common representation of the SMD is Cohen’s d, which suggests that bigger size is more effective in clinically meaningful terms. An effect size (SMD) between two means within a range closely encompassing 0.20± is considered small (possibly clinically nonsignificant), 0.50± is considered a medium effect, and 0.80± or greater is considered large (and clinically significant). All these SMD are closer to 0.5, which is a moderate effect, but statistically significant. Therefore, we should consider that patients might still have loud snoring, daytime sleepiness, or high AHI after receiving the Pillar implants. 43
Rotenberg and Luu reported subjective improvement, which deteriorated significantly over time, and was only minimally sustained at 4 years postoperatively. 40
The results of different studies are summarized in ▶Table 8.1.
Key Points
Select the patient properly—the patient should not be obese and should not have big uvula, large tonsils, short or thin palate, and moderate to severe OSA. Insert the implant 5 mm away from the junction of the hard–soft palate, in the middle of the palate, inside the muscular layer, and insert the instrument completely straight toward the uvula. The next two implants should be 2 mm apart on each side.
8.1.3 Uvulopalatoplasty
Definition
After its first description by Fujita in 1981, UPPP found its way in to the routine therapeutic arsenal of surgery for sleep disordered breathing. 45 Due to its widespread use and—at least in numerous case series—well-documented effect, further research was undertaken to help diminish the possible side effects like postoperative pain or swallowing problems.
Therefore, in 1986 Carenfelt introduced a technique called “laser uvulopalatoplasty” (LUPP). Contrary to UPPP, LUPP was a modification to the conventional technique as for the first time it used a laser to reshape the velum. 46 Briefly, in LUPP, the tonsils are removed and a palatal mucosal incision is made along the line of the crease created by gently lifting the uvula upward. Afterward, the reshaped pharynx is sutured much like in the original Fujita UPPP. According to the original publication, the use of a laser should help decrease the abovementioned side effects. Nevertheless, general anesthesia is mostly still needed for the LUPP procedure.
Another technique to treat the soft palate was introduced by Kamami in 1980 called “laser-assisted uvulopalatoplasty” (LAUP). LAUP consists of placing bilateral vertical incisions or trenches directly along both sides of the uvula followed by laser ablation of the uvula. 47 , 48 After publication, the procedure was widely used in Europe and by the end of 1990s, this became popular in the United States as well. 49 LAUP was carried out under local anesthesia and did not require conventional sutures for reshaping of the soft palate. Until now, more than 120 articles on LAUP have been published in peer-reviewed magazines. Due to the significant postoperative pain and the specific safety issues associated with LAUP, different methods for tissue cutting were sought after. The upcoming cutting devices based on radiofrequency energy seemed to be ideal for that purpose. Therefore, the term “radiofrequency-assisted uvulopalatoplasty” (RAUP) 50 , 51 was introduced for these types of procedures where parts of the soft palate were resected using radiofrequency-powered cutting devices. This resection of the soft palate was often combined with interstitial RFT and was then called RF-UPP. 52
Indications, Contraindications, and Patient Selection
With respect to RAUP, clear data related to indication, contraindication, and patient selection are missing, as consistency regarding the device for electrocautery is low. As the basic surgical concept is identical with LAUP, we also assume there is no difference regarding the abovementioned parameters.
As the effect regarding AHI-lowering is limited, and even increases in AHI have been described in case of LAUP, the only acceptable indication for these kinds of surgery is simple snoring. 53 With limited clinical efficacy of interstitial radiofrequency surgery of the soft palate in primary snoring in patients with excessive soft tissue at the palatal arches (webbing) and with uvula hyperplasia, these patients tend to be suitable for UPP. 52 The following conditions are known contraindications for LAUP and thereby for RAUP as well.
Overweight, arterial hypertension, mental irregularities or lack of cooperation, 54 and being a professional speaker, singer, or wind instrument player are known relative contraindications. 55 A solely retrolingual site of formation of snoring sounds, tonsillar hypertrophy, trismus, craniofacial malformation and cleft palate, macroglossia, prominent plication of the rear oropharyngeal wall, heavy retching, previously existing velopharyngeal incompetence, floppy epiglottis, and neuromuscular diseases of the pharynx are local factors that should lead to rejection of LAUP or RAUP. 54
Diagnostic Workup
In line with the “Standards of Practice Committee” of the AASM “[…] surgical candidates for LAUP as a treatment for snoring should undergo a preoperative clinical evaluation and a PSG or a cardiorespiratory study to determine if the candidate has a sleep-related breathing disorder (SRBD) including OSA (standard) […].” 47 Furthermore the patients complaints should be recorded pre- and postoperatively. A questionnaire regarding snoring using a VAS seems appropriate. 56
Specific Risks, Patient Information, and Consent
An informed consent should include severe postoperative pain, foreign body sensation (which is reported by 8–25% of the patients), voice changes (in 0–17.2%), and an increase in the incidence of dry mouth between 16 and 42%. 57 , 58 , 59 , 60 Additionlly, general risks of sedation and local anesthesia should be taken into account.
Anesthesia and Positioning
LAUP and RAUP are commonly performed under local anesthesia with the patient being seated comfortably in either a clinical chair or on a surgical table. As sedation is not ultimately needed for this procedure it depends on the patients’ needs and may be done by titration of midazolam or propofol intravenously up to the desired sedation level. Local anesthesia may be administered using 5 mL 2% prilocaine with 0.01% adrenaline directly at the site of surgery.
Equipment
For LAUP, the CO2 laser is used most often, yet some authors described successful procedures using a NdYAG or the KTP laser. 61 , 62 No comparative information pointing to differences between various laser types has been found in the literature yet. 63 For RAUP, a radiofrequency generator with an output frequency in the range of MHz, such as the Sutter Curis or Olympus Celon ProCut Series, is needed for minimizing thermal damages to the surrounding tissue, yet achieving adequate coagulation. As a cutting device, a coagulation needle electrode with a diameter between 0.2 and 0.4 mm should be used (▶Fig. 8.11). Argon shielding is not needed for this procedure.
Operative Technique/Steps
LAUP
After insertion of a suitable mouth gag (may not be needed, mostly depends on the sedation level) and the depression of the tongue, a backstop has to be inserted to protect the posterior pharyngeal wall from the laser beam. The CO2 laser is set to 8 W, continuous wave, and superpulse mode. To avoid velopharyngeal incompetence and increased postoperative complications, the original one-stage technique after Kamami should be modified in a way that by directing of the laser beam, an inverse V-shaped incision is made bilaterally to the uvula, cutting about only 5 mm into the anterior pillar of the soft palate (▶Fig. 8.12). Afterward, the uvula is pulled downward by grabbing the excessive tissue with a forceps. This way, the uvula muscle becomes apparent and should be preserved by any means. After removing redundant mucosa from the muscular tissue, special care is taken to coagulate any bleeding that might occur. This procedure may be repeated multiple times in a 6 to 8 weeks interval until the desired effect is achieved. ▶Fig. 8.13 shows a typical intraoperative setting with the lines to cut marked in yellow.
RAUP
In the case of using the Olympus Celon ProCut electrode, the radiofrequency generator is set to 20 W. For other devices, the wattage has to be adjusted accordingly. A triangular incision is then cut bilaterally through the uvula, only extending about 5 mm into the anterior pillar of the soft palate. Any hypertrophic mucosa of the posterior arch of soft palate and the uvula is thereupon also resected with the ProCut electrode (▶Fig. 8.14). The palatal muscles should be left intact in any case. Also, the RAUP procedure may be repeated multiple times until the desired effect is achieved.
Risks, Tips, and Tricks
UPP is an unsuitable treatment for OSA.
For treatment of snoring, RAUP should be preferred over LAUP because of its better safety profile.
Do not extend cuts deep into the muscular tissue of the soft palate.
Take small steps. It’s generally better to repeat surgery multiple times than to cause complications.
LAUP appears comparable to UPPP in relieving subjective snoring.
Complications
As written in the specific risk section, one of the most common complication of this type of surgery is foreign body sensation, which is also the hardest to treat and most annoying for the patient. 57 , 58 , 59 , 60 To prevent this type of complications, it’s most important not to extend the vertical velar incisions into muscle tissue of the soft palate and therefore treat the patient in repeated sessions. The same applies to nasopharyngeal stenosis, which most likely is also caused by extended circular resection of the soft palate. These complications are usually hard to treat with a huge impact on patient’s quality of life. Disturbed sensation and postnasal secretion most likely are of temporary nature. For patients using, or going to use, nasal CPAP there are some cases where extended surgery of the soft palate made it impossible to further use the CPAP device. Yet, according to the author’s own experience, if resection of the soft palate is taken with carefulness and in multiple sessions, this complication is likely never to appear.
Postoperative Care
After sedation with midazolam, the patient needs to be under supervision of a medical professional or a designated supervisor for at least 12 hours. During this time, the patient will not be able to drive in public road traffic. Surgical or postoperative antibiotic prophylaxis is usually not necessary. 64 Due to the high amount of postoperative pain the procedure is usually associated with adequate management of postoperative pain, which is crucial after soft palate surgery. In our experience, medication with ibuprofen (four times 400–600 mg) in addition with metamizole (four times 0.5–1 g) is sufficient for most of the patients. Opioids for pain management are only needed in rare occasions. For the judgment of an adequate healing process, ▶Fig. 8.15 shows a typical postsurgery state after 2 weeks and ▶Fig. 8.16 shows the same after 3 months.
Outcomes
Until now, two high-quality studies regarding LAUP are published. One of them was published by Ferguson in 2003. 65 Forty-six patients with an AHI between 10 and 27 were randomized in two groups. The active group was treated with LAUP; the control group did not receive any surgical intervention. After 7 months, the AHI in the active group dropped from 19 to 15; the AHI in the control group rose from 16 to 23. The second publication from Larrosa in 2004 randomized 28 patients with an AHI < 30/h in an active and a sham-surgery group. 66 There was no difference between the two groups. ▶Table 8.2 gives an overview regarding available studies. 53 The two aforementioned randomized controlled trials (RCTs) are listed at the top of the table. Beside these, studies like retrospective or prospective case series (RCS/PCS) only were published (see ▶Table 8.2).
Due to these indifferent outcome parameters in laser-assisted surgery of the soft palate, the American Academy of Sleep Medicine (AASM) Guidelines (2001) issued the following recommendations for patient selection 47 :
LAUP is not recommended for the treatment of the SRBDs including OSA.
LAUP is not recommended as a substitute for UPPP in the treatment of SRBDs including OSA.
LAUP appears comparable to UPPP in relieving subjective snoring.
These recommendations to not perform LAUP in OSA patients nowadays receives ample consensus between authors. 63 , 67
Nevertheless, LAUP seems to be an adequate treatment modality for simple snoring. In a recent meta-analysis, patients demonstrated decreased snoring intensity after LAUP, which, as the authors state, is likely secondary to scar tissue causing the soft palate to stiffen. 53 Snoring outcomes were quantified for 14 studies with 429 patients. There was significant heterogeneity in the manner in which the data were presented, with the highest number of studies reporting the VAS in which a 0 to 10 scale was used. The pre- and post-LAUP VAS for 158 patients was 8.4 ± 1.2 and 5.2 + 2.2, respectively. For most studies, snoring decreased. 53 The AASM’s practice parameters for LAUP, therefore, note that LAUP and UPPP are comparable with respect to relieving snoring. 47
Due to the slightly better long-term complications, for treatment of snoring, RAUP may be favorable. 58 , 68 Results for treatment of simple snoring for RAUP are depicted in ▶Table 8.3.
8.2 Invasive Procedures
8.2.1 Palate and Tonsils
Tonsillectomy and Tonsillotomy
Tonsillectomy
Definition
Tonsillectomy means the complete removal of all lymphatic tissue of the palatine tonsil. This surgery is often called “extracapsular tonsillectomy.” While performing this surgery, the bigger blood vessels at the outside of the tonsilar capsule need to be severed and closed by sutures or electrosurgery afterward. 69 “Hot tonsillectomy” means the use of lasers or radiofrequency instruments. The deapth of tissue damage and postoperative pain depend on the amount of energy applied to the tissue. “Cold tonsillectomy” disclaims the use of electrical or thermal energy for blood control.
Indications, Contraindications, and Patient Selection
In children with sleep disordered breathing and enlarged tonsils, we perform a tonsillotomy (see the next section). Partial tonsillectomy techniques that do not touch the tonsilar capsule with its bigger blood vessels are able to substantially reduce postoperative pain and hemorrhage in children. 70 , 71 , 72 , 73 , 74 Since postoperative hemorrhage is much more dangerous in children as compared to adults, we only perform tonsillectomies in children with frequently recurrent acute tonsillitis. To treat SRBDs we prefer tonsillotomies (synonym: partial tonsillectomy, intracapsular tonsillectomy).
In adults, we only perform tonsillectomy in patients with OSA. In case of adult simple snoring, there are less-invasive techniques that are also effective in reducing snoring. Interstitial RFTs of tonsils combined with treatments (RFT) of the soft palate and/or tongue base work well, at least in our hands. RFT treatments are less invasive and have much less complications. 13 , 75 In order to minimize complications as much as possible, we prefer less-invasive techniques instead of complete tonsillectomies in patients with simple snoring.
In contrast, the sleep apnea patient is at risk for several health impairments like stroke, heart attack, other vascular damages, systemic inflammation, metabolic dysregulation, and other health impairments. 76 , 77 , 78 , 79 Therefore, the pretreatment situation for sleep apnea patients is different from that of primary snorers (who are otherwise healthy) and this difference allows more invasive surgeries.
The complete removal of the tonsils results in bigger gain of airway volume than a partial tonsillectomy. This is why we always recommend a tonsillectomy to our sleep apnea patients, if the tonsils are still left within the pharynx, and secondly the site of obstruction is located at the oropharyngeal level, and thirdly a surgical treatment is desired by the patient.
UPPP surgeries in order to treat OSA should always be combined with tonsillectomies, as tonsillectomy has been shown to double the success rate of UPPP procedures. 80 Since an additional UPPP does not add much inconvenience to a patient that undergoes tonsillectomy we rarely perform isolated tonsillectomy, but mostly perform UPPP and tonsillectomy. Apart from the UPPP sutures, that might need to be taken out some days after surgery, the postoperative morbidity seems to be the same. Apparently, most sleep surgeons feel the same because the available data on isolated tonsillectomy to treat OSA are both rare and mostly a bit outdated (see ▶Table 8.4).
In our material, we were able to show a significant correlation between tonsil size (as measured in milliliter) and severity of OSA (unpublished own data). 94 In other words, the bigger the tonsils, the more likely they contribute to the severity of OSA, and the more likely a tonsillectomy will have a significant impact on the reduction of the AHI. The same correlation has been shown for UPPP surgery with tonsillectomy. 95 , 96 This makes us think that a complete tonsillectomy should provide superior results as compared to partial tonsillectomies. However, the superiority of tonsillectomy against partial tonsillectomy has not been presented so far in adults.
Naturally, the patients need to be able to open the mouth wide enough to insert the mouth gag and the surgical instruments. Sometimes dental pathologies exist that might interfere with the insertion of the mouth gag. Please check preoperatively and address this issue in the informed consent.
As in any sleep apnea case, severe comorbidities need to be excluded. The patient must be suitable for surgery under general anaesthesia.
As tonsillectomy is affected with the risk of postoperative hemorrhage in—depending on the definition used—up to 11% of the cases, 97 we do not perform surgery in patients with blood coagulation disorders, and in patients in need for anticoagulative medications that cannot be paused during the perioperative period. We recommend the preoperative use of a questionnaire asking for blood coagulation disturbances.
Like UPPP, tonsillectomy may affect the fundamental frequency of the voice. 98 Therefore, we are very cautious with the indication of tonsillectomies in professional singers and speakers. We remember a case of a radio moderator who had undergone tonsillectomy; after surgery some of his listeners were not able to recognize his voice again!
Rare complications of tonsillectomy are taste disturbances, in particular the persisting perception of a bitter taste. This issue needs to be discussed with professional chefs or ambitious cooks.
Diagnostic Workup
Any kind of sleep apnea surgery requires objective preoperative sleep studies. Without a preoperative sleep study, the effect of the surgery on the AHI cannot be determined after surgery. Apart from that subjective complaints need to be recorded pre- and postoperatively. Please refer to Chapter 5 to find the instruments that are available for this purpose.
We strongly recommend to use a standardized protocol to record and to document the clinical findings. Concerning the tonsils, we use the clinical staging system by Friedman 99 that provides five different tonsil sizes from 0 to 4 (▶Fig. 8.17).
To screen for blood coagulation disorders we use a specific questionnaire. In addition, we routinely test for olfactory and taste functions to identify preexisting taste disorders.
Specific Risks, Patient Information, and Consent
The general risks of surgery (i.e., pain, scarring, infection, wound healing problems, and postoperative hemorrhage) need to be addressed. Edema of the uvula occurs frequently and may induce globus sensation or even dyspnea. Such edema usually responds well to corticosteroids.
Apart from this, patients need to be informed that there will be a need for painkillers for 12 days in mean after surgery. Postoperative pain distinctively varies interindividually. Please check for intolerances prior to surgery. The intensity of postoperative pain depends on the amount of thermal energy used for blood control. 100 , 101 Please take a note of this during surgery.
Postoperative hemorrhage is the most common complication after tonsillectomy. The method of tonsillectomy used does not seem to have a substantial effect on the incidence of postoperative hemorrhage. 102 , 103 Please check for prior bleedings and/or affinity for bleedings in the patient’s history. Prebulged or pulsatile tonsils may indicate an aberrant course of one of the branches of the external carotic artery.
Please verify the patient’s ability to open his/her mouth and have a look at the teeth. Address damages of the teeth and hematoma within the tongue as potential complications induced by the mouth gag. Sometimes, even hypaesthesia of parts of the tongue may occur as a consequence of the pressure induced by the mouth gag. Fortunately, hypaesthesia is mostly temporary.
As mentioned above, the patients need to be informed about potential taste and voice disturbances.
Severe wound healing deficits or intense revision surgery for blood control of postoperative bleedings may rarely result in nasopharyngeal stenosis or velopharyngeal incompetence.
Anesthesia and Positioning
We routinely perform tonsillectomies under general anesthesia with the patient being orally intubated and lying in supine position with the head slightly extended. Most mouth gags have a gorge to hold the intubation tube. This is why the tube needs to be placed in midline.
Tonsillectomy under local anesthesia is still possible, but is associated with a lot of discomfort for the patient and much more sportive for the surgeon. Therefore, in my department, tonsillectomy is only performed under local anesthesia, if the patient is an adult and either does not want and/or cannot undergo tonsillectomy under general anesthesia.
Equipement
Standard surgical instruments for cold steel tonsillectomies are sufficient. Modern instruments can be used for dissection like lasers, bovies or other monopolar instruments, the coblator system, or others.
Operative Technique/Steps
Transoral Approach
Insert the mouth gag. Often, it is helpful to fully expose one tonsil by pushing the tongue to the opposite side. The tongue is held in that position by the adequate tongue blade (▶Fig. 8.18). Incision is made around the upper pole of the tonsil.
Exposure of the Tonsilar Capsule
After grasping the upper tonsilar pole with the surgical forceps or a clamp, the tonsil is pulled medially and dissected along its capsule while damaging the pharyngeal muscles as little as possible. In case of scarring, sharp instead of blunt dissection is recommended in order to save the peritonsilar tissue.
For blood control, we recommend compression with a swab for up to 5 minutes. Afterward, we carefully use cautery. Ligation sutures are only used in case of severe bleedings, as sutures intend to increase the level of postoperative pain.
Risks, Tips, and Tricks
Open the mouth wide enough. Separate exposition of each tonsil using the mouth gag maybe helpful.
Save as much mucosa and muscle tissue as possible.
Avoid intensive use of thermal energy in order to minimalize postoperative pain.
Use sharp instruments for the dissection in case of intensive scar tissue.
Long-lasting local anesthesia can help to reduce pain within the first 1 to 3 days after tonsillectomy.
Maybe intraoperative cooling of the wounds helps to reduce postoperative pain as well.
A very careful resection of mucosa at the tip of the uvula reduces uvular edema after surgery.
Edema of the uvula responds well to cortiocosteroids.
Hot tonsillectomy techniques can help to reduce intraoperative blood loss.
Complications
Postoperative Pain
According to our own data, postoperative need for analgetic drug intake is 12 days in mean. Under medication, patients should be free of pain unless during swallowing. Use VASs, separately for swallowing and no swallowing, to record treatment success. In childen, faces pain scales instead of numbered scales should be used to get the information. 104
Hot, spicy, and sour foods and drinks are not recommended during the first 1 to 2 weeks after surgery.
Hemorrhage
As stated earlier, postoperative hemorrhage is the most common and potentially dangerous complication. Patients should be advised to avoid physical effort, sauna, hot showering or baths, and other activities that potentially increase blood flow in the head and neck region.
Wound Infection
Although the mouth is always contaminated with various microorganisms, wound infections do not occur very frequently. This is why we do not subscribe antibiotics as a general role, but only in case of infection. We allow our patients to brush their front teeth. In addition, we provide a local antiseptic mouth solution to improve mouth hygiene.
Some surgeons reduce the fibrin films by carefully brushing the tonsilar wounds with myrrh solution or other agents.
Postoperative Care
As in any other sleep apnea surgery, the severity of OSA has a significant impact on postoperative care and monitoring. This is why sleep apnea patients undergoing surgery under general anesthesia or under sedation, in general, are at an increased risk for perioperative complications. 105 , 106 , 107
This perioperative risk is particularly increased if OSA is treated surgically, as postoperative bleeding and swellings within the pharynx need to be taken into account. According to a review, 108 postoperative complications are rare and occur within the first 4 hours after extubation. This result is in accordance to our own experience. As a result, we keep our sleep apnea patients in the recovery room for 4 hours after extubation. If there are no complications, the patients are regarded to be safe and will be discharged to the regular ward. In case of complications, the patients are monitored overnight. 109
The management of postoperative pain is crucial after tonsillectomy, but does not differ from tonsillectomies for other indications. A basic treatment with ibuprofen (four times 400–600 mg) in addition with metamizole (four times 0.5–1 g) works fine in adults. However, there are huge interindividual differences that require individual adaptations. If the basic treatment is not sufficient, we in time add opioids (e.g., three times 10 mg oxycodone). Please refer to Chapter 10.2 for further information about the postoperative care and medication.
Some authors recommend the intraoperative use of long-lasting local anaesthesia (like bupivacaine). We did not achieve a substantial benefit. Other authors recommend the use of ice cubes to cool the wound intraoperatively. 110 Unfortunately, this trick did not show us any significant effect in our patients. For this reason, we stopped intraoperative ice cooling.
Antibiotics are not mandatory for the perioperative period and perioperative antibiotic prophylaxis is not applied routinely.
Corticosteroids are used to protect airway compromise that may occur in the immediate postoperative phase, especially in OSA patients. At least in a pediatric population, the use of corticosteroids did not show an increase of postoperative bleedings. 111 Therefore, steroids can be used if necessary.
Outcomes
Tonsillectomies are rarely performed as isolated procedures to treat OSA. This is why objective outcome data are limited. There are 13 case series including 161 patients providing PSG data pre- and postoperatively (see ▶Table 8.4). Data about tonsil size are inconsistent, as there is no standard instrument to describe tonsilar size. Having read the articles, I can say that most but not all patients were chosen as they had enlarged tonsils prior to surgery. This means that there may be a bias in the patient population, as the patient might have had bigger tonsils as compared to the general population.
The follow-up varies from 1 to 43 months with mainly short-term follow-up periods. The AHI decreased in mean from 45.6 at baseline to 15.1 (–66.9%) after surgery. Surgical success rates a given between 40 and 100%. More recent studies used the Sher criteria (reduction of AHI by at least 50% below 20).
Only three series (69 patients) provide data about daytime sleepiness as measured with the ESS. The ESS score decreased from 11.9 (presurgery) to 6.1 (–48.7%) after surgery.
In conclusion, data are difficult to compare. The level of evidence is low, as the data were taken from case series only, and the total number of patients is limited. However, the data show a huge impact of tonsillectomy on AHI and ESS at least in the short-time run (see ▶Table 8.5).
In addition, there are some studies that show a superior effect of UPPP if combined with a tonsillectomy as compared to patients without a concomitant tonsillectomy, as they had undergone a tonsillectomy prior to UPPP. 80
Tonsillotomy
Definition
Tonsillotomy means the partial removal of lymphatic tissue of the palatine tonsils without touching the bigger blood vessels at the outside of the tonsilar capsule. Synonyma are: intracapsular tonsillectomy or partial tonsillectomy. Usually only minor bleedings are observed that do not need closure by sutures or electrosurgery.
Indications, Contraindications, and Patient Selection
As mentioned above, in children with sleep disordered breathing we always perform a tonsillotomy instead of a tonsillectomy due to the decreased risk for postoperative hemorrhage and pain. 70 , 71 , 72 , 73 , 74 As postoperative hemorrhage is much more dangerous in children as compared to adults, we only perform tonsillectomies in children with frequently recurrent acute tonsillitis.
In adults suffering from simple snoring we prefer less-invasive surgeries like interstitial RFTs of tonsils maybe combined with RFT of the soft palate and/or tongue base or UPPs. These surgeries can be done under local anaesthesia and on an outpatient basis. We do neither perform tonsillectomies nor tonsillotomies in adults with simple snoring.
In adults there is no sufficient data available so far to prove the efficiency of tonsillectomy in treating OSA. It can be estimated that the subtotal removal of the lymphatic tissue will have a similar effect as the complete removal. However, this has not been shown yet.
Therefore, tonsillotomy is a surgical procedure reserved for children only. Please refer to Chapter 6 for more detailed information about the treatment of pediatric OSA.
Key Points
In children (adeno)tonsillectomy still is the standard procedure to treat pediatric OSA. Due to the reduced risk for postoperative hemorrhage and significantly reduced postoperative pain, a subtotal tonsillectomy (tonsillotomy, intracapsular tonsillectomy) that does not touch the tonsilar capsule with its bigger blood vessels should be preferred. For further information concerning pediatric OSA, refer to Chapter 6.
In adults tonsillectomy is rarely performed as an isolated procedure. Therefore, scientific data are limited. However, the effect of tonsillectomy on AHI and on daytime sleepiness is significant with the bigger the tonsilar size the bigger the effect on AHI. In UPPP surgery a concomitant tonsillectomy doubles the success rate of palatal surgery.
Concerning the surgery itself, and its complications tonsillectomy in OSA patients does not differ from tonsillectomy for other indications apart from the generally increased risk for airway compromise in OSA patients. Due to this fact OSA patients undergoing surgery need a special perioperative management (refer to Chapter 10 for detailed information).
Uvulopalatopharyngoplasty
Definition
In all likelihood, the most commonly performed surgical procedure for OSA is UPPP in combination with tonsillectomy. It was first introduced in 1979 by Fujita et al and, apart from tracheostomy, it was the only available treatment option for adult OSA until the introduction of CPAP therapy. The technique was a modification of a similar procedure introduced by Ikematsu in 1963 to treat snoring and it is still the most commonly performed surgical procedure for OSA. 116 , 117 , 118 Aim of the procedure is to increase the retropalatal (RP) airway and reduce the collapsibility of the pharynx, by resection of excessive mucosa at the free edge of the uvula and soft palate followed by suturing of the anterior and posterior pillar after tonsillectomy. 119 , 120
The technique of UPPP was subject to change over time and still lacks standardization. In general, however, there is a tendency toward less-radical procedures with preservation of at least part of the uvula and the musculature of the anterior and posterior pillar. This development toward less-aggressive techniques was initiated as it became evident that complete soft-tissue resections at the soft palate performed in the 1980s and 1990s were associated with significant long-term morbidity and the outcome was not superior to muscle sparing techniques.
When referring to UPPP in general, it is performed with concomitant tonsillectomy. Nevertheless, UPPP can be performed without tonsillectomy, in particular in patients who have undergone tonsillectomy previously. Especially in the early literature, it often remains unclear whether UPPP was performed with our without tonsillectomy. In the more recent literature and in the subsequent chapter, however, UPPP is defined as UPPP with tonsillectomy unless otherwise specified.
Indications, Contraindications, and Patient Selection
UPPP can be considered in patients with OSA of any degree, as long as the individual anatomy appears suitable. In selected cases, UPPP may also be considered from snoring, although the invasiveness of the procedure should be weighed against the relative inoffensive nature of primary snoring.
UPPP has often been misused as the first-line surgical treatment for OSA, without adequate assessment of obstruction site(s) and regardless of predictive factors. 121 Assessment of the site(s) of obstruction, however, is paramount to surgical success. With regard to upper airway anatomy, a relevant obstruction at the velum and/or the oropharyngeal level should be present, which typically appears as a thickened uvula, excessive mucosa at the posterior pillar of the soft palate, and tonsillar hypertrophy (▶Fig. 8.19).
In the current literature, there is some evidence that the outcome of UPPP is related to tonsil size, leading to superior outcome in patients with larger tonsils. 95 , 96 , 100 , 122 , 124 , 125 As long as UPPP is considered as an isolated procedure, relevant obstruction at other levels of the upper airway should be ruled out, although UPPP can be combined with other surgical approaches and is an essential part of multilevel upper airway surgery.
As with other surgical approaches, surgical outcome is associated with the severity of the disease and individual BMI; patients with mild to moderate OSA and limited obesity being superior candidates. 126 , 127 , 128 In this regard, treatment effects are usually limited in patients with a BMI above 32. A maximum AHI, however, can hardly be defined in patients with very large tonsils, resulting in near total oropharyngeal obstruction; UPPP often leads to dramatic improvement regardless of baseline AHI.
UPPP should be indicated with care in professional speakers and singers, as voice changes may occur along with the procedure. In addition, potential changes in the sound of selected consonants have to be kept in mind. In addition, changes in taste perception may occur along with tonsillectomy, although this is usually temporary and resolves over time. 129 Nevertheless, professional “tasters” (chefs) should be consulted accordingly. Preexisting velopharyngeal dysfunction/insufficiency is a contraindication for UPPP. As with other surgical procedures, general contraindications for surgery need to be considered. With regard to bleeding being the major complication associated with tonsillectomy, special care should be taken to rule out relevant coagulation disorders with medical history and/or targeted coagulation tests.
As the anatomy at the level of the soft palate and the oropharynx can directly be assessed with clinical examination, several clinical staging systems have been suggested for treatment selection, mostly based on tonsil size and position of the soft palate. 95 , 96 , 100 , 122 , 127 , 125 Superior outcome was demonstrated in patients in whom upper airway obstruction was defined according to these clinical criteria. Furthermore, upper airway pressure measurements and DISE were suggested for upper airway assessment to identify patients with upper airway obstruction. 115 , 130 , 131 , 132 , 133 A superior outcome was described in patients with upper airway obstruction compared to mixed or lower airway obstruction as defined with pressure measurements or DISE. Whether these additional diagnostic measures are superior to clinical staging/clinical assessment, however, remains unclear.
Diagnostic Workup
For the assessment of the severity of OSA, PSG or out-of-center sleep testing (OCST) is required. Clinical assessment is essential for treatment selection and an obstruction at the level of the soft palate and the tonsils should be present. Standardized protocols for clinical assessment and staging systems (e.g., for tonsil size and tongue position) may be used for documentation purposes and to improve treatment selection. Further testing such as upper airway pressure measurements or DISE is not mandatory in cases of obvious obstruction at this level but may be considered in unclear cases or to rule out other relevant levels of obstruction. Medical history should identify professional voice users or tasters and patients with preexisting velopharyngeal dysfunction/insufficiency. BMI should be assessed to consult patients regarding the expected surgical outcome and the potential necessity for weight reduction.
With regard to the risk of transient postoperative changes in taste perception, preoperative testing of gustatory function (e.g., with the help of taste strips etc.) may be considered.
General medical history is important to identify perioperative risk factors and should include clinical signs of coagulopathy and current medication to identify potential medication interfering with blood coagulation. Coagulation tests should be performed, especially in patients with known or suspected coagulopathies or corresponding medication.
Specific Risks, Patient Information, and Consent
As with other surgical techniques, patients should be informed that surgical success cannot be guaranteed and that individual success is hard to predict. Velopharyngeal dysfunction including nasal regurgitation of fluids can occur in the early postoperative period, although with muscle-sparing, less-radical surgical techniques velopharyngeal function can be preserved in almost every case. Persisting velopharyngeal insufficiency (VPI) or postoperative velopharyngeal stenosis has been reported but is usually a result of aggressive surgery with muscle resection, which should be avoided. Patients have to be informed about the expected success rate of approximately 60 to 70%. 134
Postoperative pain is usually significant and exceeds typical post-tonsillectomy pain. Pain management is essential especially in the early postoperative period. The most relevant early postoperative complication, however, is bleeding at the site of tonsillectomy (see Complications under this section).
Patients need to be informed that, due to postoperative edema, snoring and obstructive events may persist in the early postoperative period and that the postoperative outcome cannot be assessed before 4 to 6 weeks. If patients are receiving CPAP treatment before surgery, the ongoing use of CPAP is recommended during this period, until control PSG or OCST has assessed surgical outcome.
Anesthesia and Positioning
UPPP requires general anesthesia. Head positioning is in slight hyperextension and is equivalent to standard tonsillectomy with midline position of the tube in a downward direction.
Equipment
A standard tonsillectomy set is sufficient for UPPP. For the resporbable palate sutures, Vicryl 2.0 or comparable material is used.
Procedural Steps
Surgery is performed in general anesthesia, with an oral endotracheally placed tube in the midline. The patient lies in supine position with the head slightly extended. A mouth gag with adequate tonsil blade is put in place for optimal exposure of the oropharynx. If no previous tonsillectomy has been performed, UPPP starts with tonsillectomy. There is no preferred surgical technique for tonsillectomy with regard to UPPP and the selection of the technique is at the surgeons’ discretion. Particular care however should be taken to achieve proper haemostasis at the end of tonsillectomy. If electrocautery is used, it should be applied with care to avoid major thermal damage to the surrounding tissue.
An incision at the free edge of the mucosa of the posterior pillar is done approximately 5 mm laterally to the uvula at both sides. The posterior pillar is then mobilized and pulled anteriorly and laterally for reconfiguration of the oropharynx with resorbable sutures. We recommend three to four sutures on both sides. For these sutures, the needle is passed through the anterior pillar and the tonsillar fossa and then through the posterior pillar (right side). Passing the suture two times through all the three structures helps to prevent loss of this suture during the postoperative period. Loss of sutures with unintended disintegration of the two pillars may occur in the postoperative period. To prevent suture loss, it should be ensured that enough soft tissue is included in the sutures (not only mucosal approximation, but also soft-tissue relocation). For the left side, starting with the posterior pillar is usually preferred (for right-handed surgeons). It is advised to avoid sutures that are too tight, due to risk of stenosis. After reconfiguration of the pillars, the uvula is shortened by excising excessive soft tissue. We recommend to not completely resect the uvula to preserve its paramount function in velopharyngeal closure. The stump of the uvula and the mucosa of the pillars at the parauvular area are closed with sutures. One may also start with the trimming of the uvula followed by reconfiguration of the pillars.
Pre- and postoperative views are provided in ▶Fig. 8.19 and ▶Fig. 8.20.
Risks, Tips, and Tricks
Use an appropriately sized mouth gag for optimal exposure.
Tonsillectomy should be performed with care to avoid damage to the surrounding structures.
Minimize the use of electrocautery.
Avoid resection or incision of palatine musculature.
For the incision of the mucosa of the posterior pillar, keep a distance of 2 to 3 mm from the uvula to avoid excessive swelling of the uvula.
Ensure to grab enough soft tissue when suturing the palate, otherwise the sutures will cut through the wound edges.
Be careful with suturing the pillars for approximation, the sutures will cut through the pillar if the knots are too tight.
Complications
The most relevant complication is postoperative bleeding associated with tonsillectomy and comparable complication rates with regard to postoperative hemorrhage have to be expected. Another relevant complication is velopharyngeal dysfunction that may occur in the early postoperative phase in up to 8% of patients, 114 , 116 although even persistent VPI has been reported. In addition, airway compromise has been described due to postoperative edema. In general, postoperative complication rates however are relatively low. In studies with larger sample sizes (>50), complication rates for postoperative bleeding, airway compromise, or velopharyngeal dysfunction of about 2% were reported. 124 , 135 , 136 In the largest sample of Kezirian et al including 1,570 patients with isolated UPPP, the overall postoperative complication rate was 1.3%. 137
In addition, complications related to the use of a mouth gag (teeth damage, numbness of the tongue, hematoma) should be mentioned (also see section on Tonsillectomy earlier in this chapter). Transient taste disturbances are not infrequent but usually disappear over time. Persistent taste changes however are a rarity.
Postoperative Care
Most patients can be discharged at the third postoperative day, although the duration of hospital stay varies significantly within different health care systems, especially for tonsillectomy. Resorbable sutures may be removed after some weeks, but are usually left in place until spontaneous resorption. Antibiotics are not mandatory for the perioperative period and perioperative antibiotic prophylaxis is not applied routinely. Corticosteroids may be administered during the early postoperative period in cases of significant edema. Sufficient pain medication is required and is usually based on oral anti-inflammatory drugs, such as ibuprofen or metamizol. According to individual needs, oral treatment with opioids may be necessary, but should be administered with caution in patients with severe OSA.
Outcomes
Being one of the earliest surgical techniques for OSA, an extensive body of literature regarding UPPP is available and it can be assumed that UPPP is one of the best studied surgical approaches in sleep medicine. With regard to the treatment of OSA, more than 1,000 articles on UPPP have been published. The assessment of surgical outcome however is compromised by the fact that the majority of these studies do not provide objective data on isolated UPPP for OSA. Especially in the early publications, patients with OSA were mixed with snoring subjects or combined surgical procedure were described, often lacking sufficient diagnostic measures for OSA. 134
The published literature contains retrospective case series and prospective studies, including a limited number of controlled and randomized controlled trials. Although the majority of trials reported short- and medium-term follow-up, studies with long-term follow-up of up to 10 years were published. Among the RCTs, three studies were presented comparing UPPP with an untreated control group, 138 , 139 , 140 two of them reported on the same cohort but with different outcome data. 138 , 139 In a most recent systematic review, two meta-analyses were performed using data of the available RCT (▶Fig. 8.21). 134
With regard to objective outcome measures (respiratory events/AHI), these meta-analyses demonstrate that UPPP was significantly more effective in reducing the AHI than no other treatment (large effect) 139 , 140 or compared to baseline (large effect). 139 , 140 , 141 Various studies provide success or response rates, although various definitions for success were used. Success/response rates range from 31.3 to 96.0%. Studies reporting on long-term outcome demonstrated a tendency toward a weakening of the initial effect over time, but the study results are conflicting.
In addition, UPPP has a significant effect on daytime sleepiness and daytime performance. Again, a meta-analysis was presented in the systematic review by Stuck et al, 134 which demonstrated that UPPP is significantly more effective in reducing the ESS in comparison to no treatment. Moreover, several other beneficial effects were described regarding UPPP. In the study of Santamaria et al 142 baseline testosterone levels could be increased with UPPP and Shin et al 143 were able to demonstrate a statistically significant improvement in the International Index of Erectile Function (FIEF 5). With regard to sleep stages, an improvement was demonstrated in selected trials. 126 , 144 Finally, the survival of 149 patients receiving UPPP was compared to 208 patients receiving CPAP in a retrospective study from 1994 145 with a mean follow-up of 43 ± 13 months. No difference in 5-year survival was detected between the two groups. In the study from Browaldh et al from Sweden with the longest follow-up period of about 15 years, 146 the standardized mortality rate of the study population was compared to the general Swedish population and no difference in the standardized mortality rate was described.
Key Points
In all likelihood, UPPP is still the most commonly performed surgical procedure for OSA. The technique of UPPP was subject to change over time and still lacks standardization; in this chapter, UPPP was defined as UPPP with tonsillectomy. UPPP can be combined with other surgical approaches and is an essential part of multilevel upper airway surgery. It can be considered in patients with OSA of any degree, as long as the individual anatomy appears suitable. The outcome of UPPP is related to tonsil size, severity of the disease, and BMI, patients with mild to moderate OSA and limited obesity being superior candidates. UPPP should be indicated with care in professional speakers and singers; it contraindicated in patients with preexisting velopharyngeal dysfunction. Several clinical staging systems were suggested for treatment selection, mostly based on tonsil size and position of the soft palate. Upper airway pressure measurements and DISE were also suggested for upper airway assessment to identify patients with upper airway obstruction, whether these additional diagnostic measures are superior to clinical staging/clinical assessment however remains unclear. The most relevant complications are postoperative bleeding associated with tonsillectomy and velopharyngeal dysfunction. In addition, airway compromise has been described due to postoperative edema. In general, postoperative complication rates however are relatively low; in studies with larger sample sizes they range about 2%. Regarding postoperative outcome, an extensive body of literature regarding UPPP is available, the published literature containing retrospective case series and prospective studies, including a limited number of controlled and RCTs. With regard to objective outcome measures (respiratory events/AHI), current meta-analyses demonstrate that UPPP is significantly more effective in reducing the AHI in comparison to no treatment. Success/response rates range from 31.3 to 96.0% with various definitions used for these criteria. In addition, UPPP has a significant effect on daytime sleepiness and various aspects of daytime performance.
Modifications of UPPP
Uvulopalatal Flap Techniques
Definition
The “uvulopalatal flap” (UPF) has first been described by Powell et al in 1996 as a reversible alternative to conventional UPPP. 147 The basic idea was to remove a rhomb of mucosa, fat, and salivatory glands only at the oral side of the palate without resecting the muscles. The lower edge of the rhomb is surged upward, and by folding the rhomb the defect is closed with sutures. This original version of the UPF was performed without a tonsillectomy. The authors claimed this surgery to be reversible; however, it turned out it was not.
Other authors refined the technique by adding a tonsillectomy. This new development was called extended uvulopalatal flap (EUPF) and was first described by Li et al in 2003. 148
All flap techniques do not leave a visible uvula, a fact that is associated with increased xerostomia after surgery.
Indications, Contraindications, and Patient Selection
The UPF is a technique that addresses soft palate obstruction (anterioposteriorly, and in combination with a tonsillectomy also laterally) in patients with simple snoring and OSA. UPF surgery can easily be done in patients who had undergone tonsillectomy earlier in their life. In this patient group we favored UPF over conventional UPPP, as in UPF surgery it is not necessary to reopen the tonsillar beds. In fact, it reduces surgery time and morbidity after surgery.
Naturally, the patients need to be able to open their mouth wide enough to insert the mouth gag and the surgical instruments. Sometimes dental pathologies exist that might interfere with insertion of the mouth gag. Please check preoperatively and address this issue in the informed consent.
As in any sleep apnea case, severe comorbidities need to be excluded. The patient must be suitable for surgery under general anesthesia.
As tonsillectomy is affected with the risk of postoperative hemorrhage in—depending on the definition used—up to 11% of the cases we do not perform surgery in patients with blood coagulation disorders, and in patients in need for anticoagulative medications that cannot be paused during the perioperative period. 97 We recommend the preoperative use of a questionnaire, asking for blood coagulation disturbances (refer to the section on Tonsillectomy and Tonsillotomy earlier in this chapter).
Like any kind of soft palate surgery, UPS may affect the fundamental frequency of the voice. Therefore, we are very cautious with the indication oftonsillectomy in professional singers and speakers.
Rare complications of tonsillectomy are taste disturbances, in particular the persisting perception of a bitter taste. This issue needs to be discussed with professional chefs or ambitious cooks.
In addition, neuromuscular diseases, neurological or psychiatric illnesses in need of treatment, cleft palates, chronic alcoholism, soporific drug abuse, severe bite misalignments, preexisting velopharyngeal stenosis or incompetences, and severe certain craniofacial deformities are regarded as contraindications.
Diagnostic Workup
As any kind of sleep apnea surgery, UPF requires objective preoperative sleep studies. Without a preoperative sleep study the effect of the surgery on the AHI and other objective parameters cannot be determined after surgery. Apart from this, subjective complaints need to be recorded pre- and postoperatively. Please refer to Chapter 5 to find the instruments that are available for this purpose.
Please screen for dysphagia and taste and speech disorders prior to surgery. To screen for blood coagulation disorders we use a specific questionnaire. In addition, we routinely test for olfactory and taste functions to identify preexisting taste disorders.
Specific Risks, Patient Information, and Consent
The general risks of surgery (i.e., pain, scarring, infection, wound healing problems, and postoperative hemorrhage) need to be addressed. Edema or hematoma of the soft palate may occur and may induce foreign body sensation or even dyspnea. Such an edema usually responds well to corticosteroids.
As mentioned earlier, xerostomia is a frequent problem after UPS surgery. As no visible uvula remains after the procedure, moisturing of the throat will be disturbed. This might be a significant impairment in patients who need to talk a lot or for a longer time. Please explain your patients that this might happen.
Apart from this, patients need to be informed that there will be a need for painkillers for up to 12 days in mean after surgery. Postoperative pain distinctively varies interindividually. Please check for intolerances prior to surgery. The intensity of postoperative pain depends on the amount of thermal energy used for blood control. 100 , 101 Please take a note of this during surgery.
Postoperative hemorrhage is the most common complication after tonsillectomy. In its original version without tonsillectomy we have hardly ever seen a relevant postoperative bleeding.
Please verify the patient’s ability to open his/her mouth and have a look at the teeth. Address damages of the teeth and hematoma within the tongue as potential complications induced by the mouth gag. Sometimes, even hypoesthesia of parts of the tongue may occur as a consequence of the pressure induced by the mouth gag. Fortunately, hypoesthesia is mostly temporary.
As mentioned above, the patient needs to be informed about potential swallowing, taste, and voice disturbances.
We use absorbable sutures. These sutures last a couple of weeks. In order to reduce discomfort, we remove these in 10 to 12 days after surgery.
Anesthesia and Positioning
We routinely perform UPS under general anesthesia with the patient being orally intubated and lying in supine position with the head slightly extended. Most mouth gags have a gorge to hold the intubation tube. This is why the tube needs to be placed in midline.
However, there are some reports in the literature that UPF surgery can be done under local anaesthesia. 149
Equipement
Standard surgical instruments for cold steel tonsillectomies are sufficient. Modern instruments can be used for dissection like lasers, bovies or other monopolar instruments, the coblator system, or others.
Operative Technique/Steps
Transoral Approach
Insert the mouth gag. We always start with topical disinfection of the oral mucosa by using a chlorhexidine solution (0.2%).
For original UPF resect the redundant mucosa at the tip of the uvula first. Then grasp the remaining tip of the uvula and pull it upward to determine the size of the rhomb, where the oral mucosa needs to be resected (▶Fig. 8.22). Sometimes a lateral incision through the webbing is necessary to rotate the UPF upward. We recommend marking the rhomb with a marker.
Using a bovie resect the mucosa and all fat and glands on the oral side of the rhomb without injuring the underlying mucosa. Careful blood control is strongly recommended to avoid postoperative infections and suture insufficiencies.
Now, rotate the inferior margin of the flap into the defect and close the wound with 2–0 resorbable sutures (▶Fig. 8.23).
In case of concomitant tonsillectomy, we recommend to perform the tonsillectomy first (for tonsillectomy, please refer to the section on Tonsillectomy and Tonsillotomy earlier in this chapter). This technique results in an opening of the velopharyngeal valve both anteriorly and laterally (▶Fig. 8.24).
Risks, Tips, and Tricks
Open the mouth wide enough.
Initially, resect the uvular tip carefully.
Use a pen to mark the amount of mucosa resected from the anterior soft palate.
Sometimes a lateral cut through the webbing is needed to sufficiently surge up the flap.
Use strong enough suture material (2–0) and enough sutures (≥ 7).
Remove sutures after 10 to 12 days.
See section on Tonsillectomy earlier in this chapter.
Complications
Postoperative Pain
As any kind of soft palate surgery, UPF can induce significant postoperative pain. According to our own data, postoperative need for analgetic drug intake is 12 days in mean with high interindividual variability. Under medication patients should be free of pain unless during swallowing. Use VASs separately for swallowing and no swallowing to record treatment success.
Hot, spicy, and sour foods and drinks are not recommended during the first 1 to 2 weeks after surgery.
Hemorrhage
As stated earlier, postoperative hemorrhage is not a frequent problem in UPF surgery as long as the tonsils are not removed within the same surgery.
In tonsillectomy, however, it is the most common and potential dangerous complication. Patients should be advised to avoid physical effort, sauna, hot showering or bathing, and other activities that potentially increase blood flow in the head and neck region.
Wound Infection
Although the mouth is always contaminated with various microorganisms wound infections do not occur very frequently. This is why we do not subscribe antibiotics as a general rule, but only in case of infection. We allow our patients to brush their front teeth. In addition, we provide a local antiseptic mouth solution (e.g., chlorhexidine solution) to improve patient’s mouth hygiene.
As we use absorbable, braided threads, we need to remove these in 10 to 12 days after surgery.
Postoperative Care
As in any other sleep apnea surgery the severity of OSA has a significant impact on postoperative care and monitoring. This is why sleep apnea patients undergoing surgery under general anaesthesia or under sedation are at an increased risk for perioperative complications. 105 , 106 , 107
This perioperative risk is particularly increased if OSA is treated surgically, as postoperative bleeding and swellings within the pharynx need to be taken into account. According to a review, postoperative complications are rare and occur within the first 4 hours after extubation. 108 This result is in accordance with our own experience. As a result, we keep our sleep apnea patients in the recovery room for 4 hours after extubation. If there are no complications, the patients are regarded to be safe and will be discharged to the regular ward. In case of complications, the patients are monitored overnight. 109
As stated earlier, management of postoperative pain is crucial after soft palate surgery. A basic treatment with ibuprofen (four times 400–600 mg) in addition with metamizole (four times 0.5–1 g) works fine in adults. However, there are huge interindividual differences that require individual adaptations. If the basic treatment is not sufficient in time add opioids might be added (e.g., three times 10 mg oxycodone). Please refer to Chapter 10.2 for further information about the postoperative care and medication.
Antibiotics are not mandatory for the perioperative period and perioperative antibiotic prophylaxis is not applied routinely.
Outcomes
So far, there are only two case series that published objective data about the isolated use of the UPF without tonsillectomies in OSA patients. 150 , 151 The prior study reports about 30 patients. The mean AHI significantly decreased in this group from 19.2 at baseline to 8.2 2 months after surgery. The more recent series included 83 OSA patients. 151 The follow-up period was 54 months in mean. The AHI decreased from 45.6 to 19.4. In both studies, patients benefitted in terms of daytime fatigue. The ESS score decreased from 5.5 to 3.0 in the study by Hörmann, and from 16.4 to 7.7 in the study by Nerunturat, respectively.
There is more data available for UPF plus tonsillectomy (e.g., EUPF). However, all but one study is published by the same working group. ▶Table 8.6 summarizes the latest available objective PSG data about the effectiveness of UPF and EUPF. 152 According to ▶Table 8.6, data about EUPF show very homogenous results with a success rate of more than 75%. This is much more as for any other kind of soft palate surgery. We were not able to reproduce these favorable results.
Key Points
The UPF is an easy and quick to perform technique to address palatal obstruction. We used this technique frequently in patient after prior tonsillectomy. However, frequent and disturbing postoperative xerostomia after UPF lead to decreasing numbers of patients that are treated with this technique.
In combination with tonsillectomy, the UPF enlarges the oropharynx both in anterioposterior and in lateral dimension.
Z-palatopharyngoplasty
Definition
Clinically, numerous amounts of OSA/hypopnea syndrome (HS) individuals who could not tolerate or were not willing to accept CPAP therapy as a long-term treatment will consider alternatives, including upper airway surgery. For this group of patients, the benefits of OSA surgery have been demonstrated. 159 The traditional method of UPPP remains the most common surgical procedure performed as treatment for OSA but has demonstrated frequent technical failure. Systematic review of reported success rate for UPPP was however around 40.7% in nonselected OSA patients. 160 In view of its limited success in treating OSA, many adjunctive or modified procedures have been proposed or performed concurrently or sequentially to alleviate upper airway obstructions. Several advances have been made in the surgical treatment of OSA, and considerable interest has increased with the recent refinements in the last decade. 147 , 161 , 162 , 163
The concept of Z-palatopharyngoplasty (ZPPP) was first introduced by Friedman et al as a modification of classic UPPP in 2004 and modified from the Z-palatoplasty procedure and pharyngoplasty. 3 The initial publication described its use for OSA patients without tonsils. The key of this technique is to not remove velopharyngeal musculature to widen the velopharyngeal space; instead, the zeta-flaps will create the necessary superoanterolateral tension to widen the pharynx and also ameliorate some of the possible complications of traditional UPPP. The theory behind ZPPP, which represents a double Z-plasty, is to change scar contraction tension lines to an anterior-transverse vector (as compared with an anterior-medial pull in classic UPPP). This change serves to widen the anteroposterior and lateral oropharyngeal air apace at the level of the velopharynx. The technique of ZPPP also has incorporated this concept by removing the bulky, LPWs and maintaining the adequate tension to prevent its collapse in selected OSA patients.
The results from the initial study showed more successes with acceptable morbidity for OSA patients using ZPPP rather than UPPP. Subsequential publications have discussed further modification for patients with OSA. 164 , 165 , 166 , 167 , 168 , 169 These articles described ZPPP as a relatively aggressive surgical procedure; however, it resulted in improved success rates for those patients studied.
Any new surgical technique must be performed by multiple surgeons, accumulating more experience, in order to validate its safety and efficacy. The safety and efficacy of ZPPP combined with tongue base tissue voulme reduction for treating moderate/severe OSA with unfavorable airway anatomy has been reported. 165 , 169 , 170
Indications, Contraindications, and Patient Selection
Indications include the following:
Age ≥ 20 years old.
Significant symptoms of habitual snoring and/or excessive daytime somnolence.
Moderate/Severe OSA.
Failure or refusal of attempts at conservative treatments, such as oral appliances or CPAP.
Friedman Tongue Position (FTP) ≥ III 96 , 99 .
RP and/or LPW obstructions identified by fibroscopic examination with/without Mueller’s maneuver or DISE.
Selected revision palate surgery.
BMI < 35 kg/m2.
Contraindications of ZPPP include the following:
No palatal obstruction during DISE.
Professional voice users and patients not willing to accept risk of VPI.
Previous palatal defect reconstruction surgery.
OSA patients with Friedman’s stage I disease.
Because ZPPP is a relatively aggressive soft palate procedure for OSA, it is usually applied to moderate/severe OSA patients who frequently had multilevel obstructions of the upper airway. Therefore, additional septoplasty or endoscopic sinus surgery without nasal packing and/or tongue base procedure, such as radiofrequency reduction of the tongue base (RFBOT) or transoral endoscopic Coblator open tongue base resection (Eco-TBR), can be simultaneously performed during the same-staged surgery to treat the additional obstruction site(s).
Diagnostic Workup
Overnight, attended comprehensive diagnostic sleep studies (e.g., PSG) should be performed in a temperature-controlled and sound attenuated room. The patient(s) should be evaluated for the risk of regular general anesthesia. The severity of upper airway collapse/obstruction(s) is examined based on Friedman’s OSA staging system and identified by fibroscopic examination with/without Mueller’s maneuver or DISE.
Specific Risks, Patient Information, and Consent
Patients have to be informed about the expected success rate (approximately 60%) and the possibility of a combination of other surgical procedures such as nasal and/or hypopharyngeal surgery. Swallowing problems may last for several days, most typically in the initial 3 to 5 days. Frequently drinking water may help speed up the recovery process. Voice changes may initially occur but usually will not persist. Taste disturbance and VPI might also occur initially.
Pain
In the case of ZPPP as the only procedure or combined with other procedures, pain must be anticipated. A combination of multiple oral and/or local narcotics may help reduce the severity of pain.
Anesthesia and Positioning
The author (H-C. L.) prefers that the procedure is performed under general anesthesia with regular orotracheal intubation. The neck should be in slight hyperextension (pillow under shoulders) with an armed tube diverted upward, exposure is obtained using a standard mouth retractor.
Equipment
Standard tonsillectomy/UPPP net.
Operative Technique/Steps
The surgical techniques (see ▶Fig. 8.25, ▶Fig. 8.26, ▶Fig. 8.27, ▶Fig. 8.28, ▶Fig. 8.29, ▶Fig. 8.30, ▶Fig. 8.31, ▶Fig. 8.32; Video 8.1) are as follows: (1) the procedure starts with a bilateral tonsillectomy preserving as much mucosa as possible; (2) after the tonsillectomy, a subtotal uvulectomy is done (if necessary); (3) two adjacent flaps are outlined on the palate; (4) only mucosa of the anterior aspect of the two zetaplasty (ZPP) flaps is removed; (5) the two flaps are separated from each other by splitting the palatal segment down the midline; (6) the palatoglossus muscle is cut, if necessary, to allow for lateral expansion of the air-space; (7) a very meticulous two-layer closure (with Vicryl suture 2–0 and 3–0) bringing the midline all the way to the anterolateral margin of the palate, and tonsillar fossa is accomplished. The goal is to increase the nasopharyngeal and oropharyngeal airway in both the anterior posterior dimension with minimum tissue resection, and to preserve the soft palate shape. In addition, the ZPPP procedure often corrects significant nasopharyngeal stenosis when present. On the basis of severity of disease and anatomy, tongue base tissue volume reduction or tongue base suspension procedure could also be performed at the same time.
Risks, Tips, and Tricks
Encourage oral hygiene before the surgery.
Select the adequate OSA patients for ZPPP, such as a wide open mouth and good dentition.
Use cold or low-temperature instruments during the surgery.
Avoid damaging too much palatal and oropharyngeal mucosa.
Achieve good hemostasis and ensure a very meticulous two-layer closure of the ZPPP wound.
Raise the systolic blood pressure of the patient to over 100 mm Hg to check the wound status before finalizing the procedure.
Prepare the surgical and anesthesia team to gently wake the patient in the operating room.
Complications
There were no perioperative complications or cases of immediate postoperative airway obstruction in our experience. The number of days of narcotic pain medication (ibuprofen 400 mg, qid) used ranged from 4 to 16 days. Difflam Spray (benzydamine hydrochloride, 3 mg/mL) could be used to spray two to four puffs directly to the sore area every 2 to 4 hours for local pain and inflammation. We did not have any patients who had serious postoperative bleeding from an oropharyngeal wound and needed to return to the operating room for hemostasis.
Temporary postoperative VPI was noted, in our experience, in around 40% of the patients. The VPI lasted between 3 days to 1 month and appeared to bother the patients most significantly during the first week after surgery. As per our patients’ reports, the severity of the VPI usually decreased after the first week and was thereafter only noted occasionally when drinking quickly or when attempting to swallow food or liquid while talking. None of the cases had permanent VPI, which bothered the patient’s daily life. Some patients, around 30%, reported temporary ear fullness or pressure postoperatively, but none had this discomfort for more than 2 weeks. The majority of minor complications encountered were related to postoperative throat discomfort such as sensation of a lump in the throat, dry throat, and frequent throat clearing. However, typical complaints included inability to clear phlegm, swallowing changes, and tightness in the throat. Patients must be willing to accept these possible changes while choosing this surgical treatment. None of the patients had palatal fistula or infection after ZPPP that required additional surgery.
Since ZPPP had created anterior and lateral forces to increase the oropharyngeal space, this might induce secondary tongue base collapse in some patients due to loss of some support from original soft palate or oropharyngeal framework in sleep. The patients should be well informed about this potential risk preoperatively.
Other complications and risks associated with surgery and anesthesia are presented as well.
Postoperative Care
The patients were extubated after fully recovering from the anesthesia in the operating room. We did not encounter the complication of immediate acute airway obstruction that needed to be reintubated or noticed any acute surgical wound bleeding after extubation.
The patient was in a head-up position with a back-rest elevation of around 30 to 45 degrees, especially in the first night after surgery. Intravenous antibiotics (cefazolin) were given postoperatively and oral antibiotics (cefadroxil) were used for 5 days after surgery. Low-dose steroids were prescribed for 5 days. Nonsteroidal anti-inflammatory drugs (NSAIDs, ibuprofen, 400 mg per 6 hours), proton-pump inhibitor or H2-receptor antagonists, and chlorhexidine-diluted povidone-iodine mouth rinses were prescribed for 1 week. A cool liquid or soft diet started 4 to 6 hours after surgery. Soft foods, such as ice cream, sherbet, yogurt, pudding, apple sauce, and Jell-O, should be encouraged. However, similar to most palatal surgeries, complaints of obviously postoperative pain in the throat and dysphagia are to be expected after ZPPP. Pain is often worse at night and may prompt the need for additional pain medication. An ice collar can also be helpful for postoperative sore throats. Oral narcotics are used after discharge for 5 to 14 days. Patients generally are able to return to a normal diet after 14 days.
Strenuous physical activity following surgery is not encouraged till 10 to 14 days after surgery.
Outcomes
So far, there is not much information about the effect of isolated ZPPP procedure in the literature. There were nine articles, 164 , 165 , 166 , 167 , 168 , 169 , 171 , 172 which reported the issue related to ZPP(P) and only seven case series 164 , 165 , 166 , 167 , 168 , 169 with a total of 203 patients could be identified to summarize the surgical outcomes (see ▶Table 8.7).
The follow-up periods were short and lasted not longer than 6 months. The objective and subjective data both show a significant improvement of OSA severity as well as its daytime symptoms. This should have an extended study to observe the possible long-term success rate after ZPPP and/or adding a tongue base procedure. Additionally, controlled trials are still missing.
There are two additional large reviews which overlap with the data in ▶Table 8.7. One is from Friedman et al 171 in 2015 and the other is our unpublished data. Friedman reported his 5 years experience and suggested that ZPP(P) might serve as a potential alternative to traditional UPPP in treating palatal-level obstruction in patients with and without tonsils. In our experience of 220 patients with OSA who underwent ZPPP and/or simultaneous nasal and tongue base surgery (unpublished data, up to December 2016), we did not have any cases of massive wound bleeding peri- and postoperatively, or severe permanent VPI after ZPPP.
Key Points
ZPPP is a reasonably effective alternative treatment for OSA patients with palatal obstruction who refuse of cannot tolerate CPAP therapy as a long-term treatment. It can be performed as a primary treatment in case of isolated RP obstruction, revised surgery for previous conservative UPPP or as part of multilevel surgery when nasal, RP, and/or retrolingual obstruction are present in OSA patients. Indications are AHI > 15/h, BMI < 35 kg/m2, and obvious obstruction on palatal level during DISE.
Success rates as part of multilevel surgery have been reported and vary between 46 and 68%. ZPPP has a low morbidity and literature shows it is one of the most effective treatment options for patients with OSA.
In conclusion, the reported literature shows reasonable surgical outcomes and relative safety of ZPPP combined with/without tongue base surgery in selected OSA patients with unfavorable upper airway anatomy. Our experience has been encouraging overall, and the procedure could be one of our surgical treatments of choice for OSA patients.
Declaration of Interest
The authors report no conflicts of interest. The authors are responsible for the content and writing of this section.
Relocation—UPPP
Definition
The “relocation pharyngoplasty (rPP)” has first been described in 2009 by Li and Lee. 173 It is a further development of Li’s “EUPF” described in 2003. 148 The latter technique is a palatopharyngeal flap combined with resection of the supratonsillar fat tissue, covering mucosa. The suturing is done in a double layer in order to achieve a widening of the velopharyngeal valve anteriorly but also laterally (▶Fig. 8.33; Video 8.2).
The rPP is a comparable technique that instead of a palatopharyngeal flap only gets along with a careful shortening of the uvula. As a result, the remaining uvula secures lumbrification of the throat after surgery. This is an important fact, as xerostomia is a frequent and severe problem after palatopharyngeal flap surgeries.
Indications, Contraindications, and Patient Selection
The rPP is a technique that addresses soft palate obstruction (anterioposteriorly and laterally) in patients with simple snoring and OSA. If tonsils are still in place, they should be removed within the same sitting. However, rPP can be performed in patients who have had undergone tonsillectomy earlier in their life.
Naturally, the patients need to be able to open their mouth wide enough to insert the mouth gag and the surgical instruments. Sometimes dental pathologies exist that might interfere with insertion of the mouth gag. Please check preoperatively and address this issue in the informed consent.
As in any sleep apnea case, severe comorbidities need to be excluded. The patient must be suitable for surgery under general anesthesia.
As tonsillectomy is affected with the risk of postoperative hemorrhage in—depending on the definition used—up to 11% of the cases we do not perform surgery in patients with blood coagulation disorders, and in patients in need for anticoagulative medications that cannot be paused during the perioperative period. 97 We recommend the preoperative use of a questionnaire asking for blood coagulation disturbances (refer to section on Tonsillectomy and Tonsillotomy earlier in this chapter).
Like any kind of soft palate surgery, rPP may affect the fundamental frequency of the voice. Therefore, we are very cautious with the indication oftonsillectomy in professional singers and speakers.
Rare complications of tonsillectomy are taste disturbances, in particular the persisting perception of a bitter taste. This issue needs to be discussed with professional chefs or ambitious cooks.
In addition, neuromuscular diseases, neurological or psychiatric illnesses in need of treatment, cleft palates, chronic alcoholism, soporific drug abuse, severe bite misalignments, preexisting velopharyngeal stenosis or incompetences, and certain severe craniofacial deformities are regarded as contraindications.
Diagnostic Workup
Any kind of sleep apnea surgery requires objective preoperative sleep studies. Without a preoperative sleep study the effect of the surgery on the AHI and other objective parameters cannot be determined after surgery. Apart from this, subjective complaints need to be recorded pre- and postoperatively. Please refer to Chapter 5 to find the instruments that are available for this purpose.
Please screen for dysphagia and taste and speech disorders prior to surgery. To screen for blood coagulation disorders we use a specific questionnaire. In addition, we routinely test for olfactory and taste functions to identify preexisting taste disorders.
Specific Risks, Patient Information, and Consent
The general risks of surgery (i.e., pain, scarring, infection, wound healing problems, and postoperative hemorrhage) need to be addressed. Edema of the uvula occurs frequently and may induce foreign body sensation or even dyspnea. Such an edema usually responds well to corticosteroids.
Apart from this, patients need to be informed that there will be a need for painkillers for up to 12 days in mean after surgery. Postoperative pain distinctively varies interindividually. Please check for intolerances prior to surgery. The intensity of postoperative pain depends on the amount of thermal energy used for blood control. 100 , 101 Please take a note of this during surgery.
Postoperative hemorrhage is the most common complication after tonsillectomy. The method of tonsillectomy used does not seem to have a substantial effect on the incidence of postoperative hemorrhage. 102 , 103 Please check for prior bleedings and/or affinity for bleedings in the patient’s history. Prebulged or pulsatile tonsils may indicate an aberrant course of one of the branches of the external carotid artery.
Please verify the patient’s ability to open his/her mouth and have a look on the teeth. Address damages of the teeth and hematoma within the tongue as potential complications induced by the mouth gag. Sometimes, even hypoesthesia of parts of the tongue may occur as a consequence of the pressure induced by the mouth gag. Fortunately, hypoesthesia is mostly temporary.
As mentioned earlier, the patient needs to be informed about potential swallowing, taste, and voice disturbances.
Severe wound healing deficits or intense revision surgery for blood control of postoperative bleedings may rarely result in nasopharyngeal stenosis or velopharyngeal incompetence.
We use absorbable sutures. These sutures last a couple of weeks. In order to reduce discomfort, we remove these in 10 to 12 days after surgery.
Anesthesia and Positioning
We routinely perform rPP under general anesthesia with the patient being orally intubated and lying in supine position with the head slightly extended. Most mouth gags have a gorge to hold the intubation tube. This is why the tube needs to be placed in midline.
Equipment
Standard surgical instruments for cold steel tonsillectomies are sufficient. Modern instruments can be used for dissection like lasers, bovies or other monopolar instruments, the coblator system, or others.
Operative Technique/Steps
Transoral Approach
Insert the mouth gag. Often, it is helpful to fully expose one tonsil by pushing the tongue to the opposite side. The tongue is held in that position by the adequate tongue blade.
We always start with topical disinfection of the oral mucosa by using a chlorhexidine solution (0.2%).
If still in place, remove the tonsils first. By doing this it is crucial to save the surrounding muscle tissue as carefully as possible.
Now, the posterior pillar is grasped with a forceps and pulled anteriorly, laterally, and cranially. While doing this we perform an incision very caudally through the posterior pillar (in contrast to the originally published technique by HY Li) in order to reduce the tension (▶Fig. 8.34). Now, the posterior pillar can easily be moved craniolaterally overlapping the anterior pillar. Mark this position of the posterior pillar with a sterile pen on the mucosa of the anterior pillar. Once the overlapping part of the anterior pillar is plotted, it can be resected. Include the underlying supratonsillar fat tissue in your resection. After careful blood control (use a little energy as possible to avoid postoperative pain) the posterior pillar is sutured into the newly created defect. We strongly recommend two layers of sutures. We use 2–0 Polysorb (company: Covidien) absorbable, braided material to suture the muscle tissue. Please use at least three sutures per side. Afterward, we close the mucosa with 3–0 absorbable, braided threads. Please use at least six mucosal sutures per side. ▶Fig. 8.35 shows the patient’s left side is done. As the right side has not been touched, the image nicely illustrates the opening of the velopharyngeal valve anterolaterally.
After having done the same steps to the other side, we carefully reduce the redundant mucosa of the uvula (▶Fig. 8.36). It is crucial to keep a clearly visible uvula to avoid postoperative xerostomia. Depending on the amount of mucosa taken out we close the wound with the same 3–0 absorbable, braided thread.
Risks, Tips, and Tricks
Open the mouth wide enough. Separate exposition of each side using the mouth gag maybe helpful.
While performing the tonsillectomy, save as much mucosa and muscle tissue as possible.
Avoid intensive use of thermal energy in order to minimalize postoperative pain.
Use sharp instruments for the dissection in case of intensive scar tissue.
The caudal incision through the posterior palatal pillar reduces the tension of the flap.
Use a pen to mark the amount of mucosa resected from the anterior pillar.
Use two layers of sutures (2–0 for muscle tissue, 3–0 for mucosa).
Remove sutures after 10 to 12 days.
A very careful resection of mucosa at the tip of the uvula reduces uvular edema after surgery.
Edema of the uvula responds well to corticosteroids.
Complications
Postoperative Pain
As any kind of soft palate surgery, rPP can induce significant postoperative pain. According to our own data, postoperative need for analgetic drug intake is 12 days in mean with high interindividual variability. Under medication patients should be free of pain unless during swallowing. Use VASs. separately for swallowing and no swallowing to record treatment success.
Hot, spicy, and sour foods and drinks are not recommended during the first 1 to 2 weeks after surgery.
Hemorrhage
As stated earlier, postoperative hemorrhage is the most common and potential dangerous complication. Patients should be advised to avoid physical effort, sauna, hot showering or bathing, and other activities that potentially increase blood flow in the head and neck region.
Wound Infection
Although the mouth is always contaminated with various microorganisms wound infections do not occur very frequently. This is why we do not subscribe antibiotics as a general rule, but only in case of infection. We allow our patients to brush their front teeth. In addition, we provide a local antiseptic mouth solution (e.g., chlorhexidine solution) to improve patient’s mouth hygiene.
As we use absorbable, braided threads, we need to remove these in 10 to 12 days after surgery.
Postoperative Care
As in any other sleep apnea surgery the severity of OSA has a significant impact on postoperative care and monitoring. This is why sleep apnea patients undergoing surgery under general anaesthesia or under sedation are at an increased risk for perioperative complications. 105 , 106 , 107
This perioperative risk is particularly increased if OSA is treated surgically, as postoperative bleeding and swellings within the pharynx need to be taken into account. According to a review, postoperative complications are rare and occur within the first 4 hours after extubation. 108 This result is in accordance with our own experience. As a result, we keep our sleep apnea patients in the recovery room for 4 hours after extubation. If there are no complications, the patients are regarded to be safe and will be discharged to the regular ward. In case of complications, the patients are monitored overnight. 109
As stated earlier, management of postoperative pain is crucial after soft palate surgery. A basic treatment with ibuprofen (four times 400–600 mg) in addition with metamizole (four times 0.5–1 g) works fine in adults. However, there are huge interindividual differences that require individual adaptations. If the basic treatment is not sufficient in time add opioids might be added (e.g., three times 10 mg oxycodone). Please refer to Chapter 10.2 for further information about the postoperative care and medication.
Some authors recommend the intraoperative use of long-lasting local anesthesia (like bupivacaine). We did not achieve any substantial benefit. Other authors recommend the use of ice cubes to cool the wound intraoperatively. 110 Unfortunately, this trick did also not show any significant effect in our own patients. For this reason, we stopped intraoperative ice cooling again.
Antibiotics are not mandatory for the perioperative period and perioperative antibiotic prophylaxis is not applied routinely.
Outcomes
So far, there are two case series that published objective data about the isolated use of rPP in OSA patients. 173 The prior study reports about 10 patients. The mean AHI significantly decreased in this group from 43.4 at baseline to 15.1 6 months after surgery. The more recent series included 47 OSA patients. 174 The follow-up period was 6 months as well. The AHI decreased from 59.5 to 22.6. Patients with positional obstructive sleep apnea (POSA) benefitted significantly better as compared to those patients without POSA.
▶Table 8.8 summarizes the latest available objective PSG data about the effectiveness of modern modifications of UPPP. 175 According to ▶Table 8.8, data about the different surgical techniques seem to be very similar. However, apart from lateral pharyngoplasty, data still need to be regarded as preliminary. This means, data are presently not sufficient to tell which technique might be superior. Probably this question will depend on the surgeon’s skills and preferences anyway.
By now, we performed more than 200 rPP surgeries in our department. We mostly combine it with hypopharyngeal surgeries. This is why we are not able to add substantial new data about the isolated use of rPP. Clinical experience is promising with no increased complication rates or postoperative discomfort so far as compared to conventional UPPP. Having tried most of the techniques summarized in ▶Table 8.8, we currently prefer the rPP, as it shows good results in out hands.
Key Points
The rPP nicely opens the velopharyngeal valve anterolaterally without the risk of velopharyngeal incompetence. We gained superior results as compared to conventional UPPP. Due to this fact rPP is our standard procedure to treat velopharyngeal collapse in OSA patients.
As compared to the original technique published by HY Li, 173 we perform an additional incision through the caudal part of the posterior pillar in order to reduce the tension of the posterior pillar while it is rotated superolaterally.
Two layers of absorbable, braided sutures work fine in our hands. However, the superficial mucosal sutures need to be taken out after 10 to 12 days.
Lateral Wall Addressing Pharyngoplasties
Introduction
Since the last century, generations of ear, nose, and throat (ENT) specialists have performed thousands of pharyngeal procedures removing tonsils and adenoids for recurrent infections or breathing problems. We may consider all of them as “not aware” sleep surgeons. In the area of simple snoring, Ikematsu (1964), as a real pioneer, designed the first surgical solution offering an anatomy-customized palate procedure. 183 In the area of sleep apnea a German team introduced tracheostomy as cure for severe obstructive disease, demonstrating at the same time the crucial role of upper airway collapse in producing OSA, and introducing us to a new treatment modality. 184 Deeply inspired by the previous work of Ikematsu, Fujita (1981) was the first surgeon who described an original palatal procedure in order to fix snoring and obstructive sleep apnea hypopnea syndrome (OSAHS) at the same time. 45 After its introduction in 1981, UPPP was intensively applied all over the world, receiving in all but a few countries a high degree of appreciation. UPPP was so frequently modified and adapted by so many different surgeons and opinions that a list of the entire span of individual versions is probably impossible to complete. In a very rough and schematic way, two different lines of development and improvement of UPPP may be described:
The first line of development includes all the techniques related to UPPP designed with the goal to increase the ratio between outcomes and costs/complications rate reducing the invasiveness and on the other hand improving efficacy, or both. It includes different geometries of section (parasagittal vs. circular), the use of reversible flaps, the application of manipulations of the bony palate plate, the introduction of many different minimally invasive technologies (lasers, radiofrequency, coblation, implants, sclerosant agents, conventional or barbed sutures, etc.).
The second line of development in the story of the sleep surgery was the attempt to address concurrent collapsing area(s) contributing to apnea but different from palate (e.g., tongue base, LPW), which includes tongue base surgery, facial bone framework procedures, multilevel procedures, etc.
In recent years, a special group of modifications has gained increasing diffusion and popularity. The common feature of this group of surgeries is the special attention to lateral displacement and splinting of the LPW. It means that this type of procedures fit to both the lines of development outlined above. Herein we will include all those techniques as lateral wall addressing pharyngoplasties (or simply LWAPs).
Definitions
It is somehow hard to give a precise and comprehensive definition of LWAP. First of all to some extent the most classic UP3s included some action in the area of the lateral walls inside the palatine tonsil bed. Tonsillectomy and sutures between anterior and posterior pillar had some effect in gaining space in the lateral pharyngeal area, and some tightening of the same wall was observed. In some conservative modifications of the classic UPPP the transversal enlarging effect was particularly evident. On the other hand, many common palate procedures for snoring and OSA are very clearly far from this LWAP philosophy: laser-assisted UPPPs (LAUPS) and UPFs, transpalatal advancement and interstitial procedures (snoreplasty, RFVR, Pillar) may be excluded. All the so called LWAPs share a common aim to be particularly in addressing the LPW, but basically all the LWAPs increase the anteroposterior diameters as well and at the same time.
The prototypic lateral pharyngoplasty by Cahali “consists of a microdissection of the superior pharyngeal constrictor muscle within the tonsillar fossa, sectioning of this muscle, and suturing of the created laterally based flap of that muscle to the same-side palatoglossus muscle. In addition, a palatopharyngeal ZPP is performed to prevent RP collapse. The created vector pulls the pharyngeal constrictor laterally toward the palatoglossus muscle.
In Woodson and Pang (2007) expansion sphincter pharyngoplasty (ESP), the tip of a posterior pillar/palatopharyngeal muscle superiorly based flap is pulled up and laterally toward the pterygoid hamulus (three-dimensional vector lateral, anterior, and superior; ▶Fig. 8.37; Video 8.3). 163
In Li and Lee’s rPP, an intact posterior pillar is laterally suspended to the anterior pillar/palatoglossus muscle (anterolateral vector). 173
In Vicini et al’s barbed reposition pharyngoplasty (BRP, 2015), an inferiorly weakened intact posterior pillar is superolateral suspended by a fan of superolateral pulling vectors created by means of a running barbed suture. 185
A very elegant application of the basic Z-plasty (technique to increase soft-tissue length along a selected axis) was introduced by Friedman (2004), sculpturing a couple of Z-flaps in the soft palate which produce a couple of superolateral directed enlarging vectors. 161
Finally, the best definition including all the published variations in LWAPs probably is a group of pharyngeal surgical procedure for sleep disordered breathing which share a common prevalent superolateral enlarging vector of force devised for enlarging the pharyngeal airway and, more important, for splinting lateral wall and prevent its inward collapse (see ▶Table 8.9).
Historical Perspective: The First Steps
The first series of 10 lateral pharyngoplasties was published by Michel Cahali, San Paolo (Brasil) in 2003 as a prospective randomized pilot study performed in an academic tertiary center as part of a doctoral thesis. 162 In a next study, the authors stated, “lateral pharyngoplasty produces better clinical and PSG outcomes in the treatment of OSAHS than does UPPP, without resultant differences in the cross-sectional measurements of the pharyngeal airway between these treatments.” 177 More recently, a new article introduced a more conservative modification of the original technique in preserving stylopharyngeal muscle, with very interesting results in reducing long-term dysphagia. 186
In 2014, in a small case series, the authors affirmed, “lateral pharyngoplasty proved to reduce the values obtained in the 24-hour ABPM due to a significant reduction of blood pressures during sleep in patients with OSA 6 months after surgery. 178 Although the patients presented with reductions in AHI, arousals, and desaturation time, this was not correlated with the improvement in arterial blood pressure.”
Lateral Wall Anatomy
The LPW anatomy is generally divided into two levels: RP and RG (retroglossal). This division has importance from an anatomical rather than physiological point of view as the LPW works as a single unit. Here the important structures are described from medial to lateral regarding the RP LPW: the lining mucous membrane, the palatine tonsils (a mass of lymphoid tissue incompletely surrounded by capsule) bounded by the palatoglossus muscle anteriorly, the palatopharyngeal muscle posteriorly and the superior constrictor pharyngeal muscle laterally, a group of small muscles including the tensor veli palatini, levator veli palatini, salpingopharyngeus, styloglossus, and stylopharyngeus muscles. The pterygomandibular raphe arising from the pterygoid hamulus, attached in the posterior end of the mylohyoid line of the mandible giving origin to the superior constrictor muscle of the pharynx. This raphe has a very important clinical importance in LPW surgeries.
The supratonsillar fossa is the region above the upper pole of the palatine tonsil occupied by a fat pad and Weber’s minor salivary glands. This area is of particular importance while performing different types of LPW addressing techniques.
Moving down to the RG level, the most important anatomical structure is the hyoid bone which consists of a body, two lesser horns, and two greater horns. It plays a central role in the upper aerodigestive tract as it is the only bone not articulating with other bones. The stylohyoid ligament has a stabilizing role to the hyoid bone, suspended through posterosuperior vector to the styloid process. The middle constrictor muscle of the pharynx makes the hyoid bone fixed to the pharynx. It arises from the greater horn of the hyoid bone and any movement causes tension in the LPW at the RG level.
The parapharyngeal fat pad is very important in the pathophysiology of the LPW collapse in patients with OSA. It is directly related to obesity, especially central. We have to realize that obesity is not the only determinant for the volume of the parapharyngeal fat, but other factors such as age, sex, craniofacial size, and ethnicity have to be considered as well.
Lateral Wall Pathophysiology
In the last few years, an increasing number of articles have emerged that define in a comprehensive way the central role of the LPW in the determination of the pharyngeal obstruction related to OSA.
The pathophysiological mechanisms for OSA are multifactorial by nature. The most important risk factors include increased anatomic compromise, increased pharyngeal dilator muscle dysfunction, lowered arousal threshold, increased ventilatory control instability, and/or reduced lung volume.
The two most important mechanisms with direct effect on LPW collapse include 1 anatomic theory: parapharyngeal fat deposition and thickening of soft tissue of pharyngeal wall and 2 a neural hypothesis: decreased neural output to pharyngeal dilator muscles during sleep, leading to muscle hypotonia. 187
Obesity is a direct risk factor for OSA and LPW collapse, as the parapharyngeal fat pads cause collapse and narrowing of upper airway during sleep. Larger neck circumference has been associated with greater severity of OSA. 188
Welch et al investigated fat tissue and upper airway volume in the neck during a weight-loss program and found that there is an increase in the upper airway volume in both the RP and RG regions after weight loss. Larger fat tissue volume in the RP area may be associated with positive segmental closing pressures. Also, fat tissues deposited in the lateral wall a the RG area may add to the volume of total collapsible soft tissues in the corresponding segment of airway, which predisposes to increased RG collapsibility. 189
Schwab et al (2003) were the first to use magnetic resonance imaging (MRI) to assess upper airway in OSA. 190 They found that the volume of the soft-tissue structures surrounding the upper airway is enlarged in patients with sleep apnea and that this enlargement is a significant risk factor for OSA, particularly at the LPW.
Huon et al (2016) used dynamic MRI in proving that increased LPW collapsibility is a major determinant of airway obstruction in (severe) OSA. 191 Increased collapsibility of the LPW may reflect inadequate neuromechanical response to airway obstruction in patients with severe OSA, while in the matched patients with mild OSA, coordinated airway dilation mechanism during sleep is preserved.
There is a strong association between LPW collapse and severity of oxygen desaturation during DISE. 192
Soares et al (2016) linked failure of surgery with the presence of severe LPW collapse in the preoperative DISE. 193
In 2015, Liu et al used static measures and dynamic sleep MRI to observe patterns of dynamic airway collapse in patients with mild and severe OSA. 194 They found that longer upper airway lengths and more inferior and posterior position of the hyoid are associated with severe OSA. They noticed the cut-off to be approximately between 8 and 9 cm for upper airway length, as measured from the level of the posterior nasal spine to the hyoid bone. They also linked the severity of the disease with the presence of LPW collapse.
In the same year, Liu et al also showed that maxillomandibular advancement (MMA) increases LPW stability, as based on VOTE scoring from DISE. 195 Based on the above mentioned information regarding the pathophysiology of LPW collapse, preoperative assessment using DISE is crucial in order to be able to know the pattern of pharyngeal collapse. In case of LPW collapse during DISE, the subsequent surgical technique has to address this specific collapse pattern.
Dynamic MRI might also be a tool, to add to the information obtained from DISE, and might be of use to assess soft-tissue thickness, either at pharyngeal or parapharyngeal level.
Lateral Wall Expanding/Stenting Mechanism
The various LWAP techniques work in a different way, but basically share the same goal: lateralizing and stenting the LPW. All techniques share a common biophysical background—to create an enlarging vector directed mainly laterally, and at the same time anteriorly and cranially in a different degree. For didactic purposes we will describe the main vector for each different technique, with special reference to the basic features of each vector: the tail, the head, the direction, and the force. In some techniques, additional effects must be considered.
In lateral pharyngoplasty as originally described by Cahali, the tail of the vector is located in a surgically developed, lateral based, superior constrictor flap and the head of the vector points to the adjacent palatoglossus muscle inside the anterior pillar. The anterolateral pulling force is produced by 3 to 4 separate sutures. It must be stressed that in the Cahali technique the combination of the superior constrictor lateral blunt dissection, the muscle interruption, and the possible posterior wall splitting in the midline allows an easy mobilization of the posterior pillar toward the anterior pillar, without significant tension. In addition, a palatopharyngeal elongating Z-plasty is performed to prevent RP collapse.
In Li’s technique the vectorial analysis is quite similar to the Cahali technique (tail in palatopharyngeal muscle, head in palatoglossus), as well the separate sutures array. In addiction, a careful supratonsillar fossa defatting is described. Due to the lack of manipulation in the posterior pillar area, the tensile strength of the separate sutures is slightly superior to lateral pharyngoplasty.
In ESP, the vectorial analysis is particularly interesting. A single, very effective vector connects the tail in the tip of a posterior pillar raised muscle flap to the head, located precisely at the ipsilateral hamulus. The required tension may differ according to the different oropharyngeal anatomy, but the complete transsection of the palatopharyngeal muscle makes a significant flap transposition possible with a limited amount of tension.
In BRP, the vector analysis may be summarized as a fan-like array of multiple small vectors connecting the palatopharyngeal muscle at different levels to the pterygomandibular raphe at different levels as well. The raphe is lateral, anterior, and superior to the posterior pillar, and this strategic location provides the lucky relationship that explains the efficacy of the technique.
In addition, the palatopharyngeal muscle is weakened in order to allow an easier lateralization and anteriorization, without high levels of tensile tension for the suture. Furthermore, the barbed running suture tends to distribute the overall required tension in a significant number of suture loops. Inside any loop the tension is not concentrated in the single knot, but widely dispersed in hundred of barbs, which implies a higher level of stability. It was experimentally measured an average tension for the main loops of the running barbed suture of 1.9 N.
Indications, Contraindications, and Patient Selection
By definition, a prevalent LPW collapse is the logic application for all the different options of LWATs. It is worth mentioning that all LWATs share a different degree of anterior palate displacement/stenting, which is an additional useful way of action.
Diagnostic Workup
The diagnostic workup is not different from the basic approach to any other sleep surgical procedure.
Specific Risks, Patient Information, and Consent
Any different LWATs may register a different percentage of common complications, including intra and postoperative bleeding, VPI, dysphagia, late scarring, as summarized in ▶Table 8.10. In LP, the risk of intrusion into the parapharyngeal space seems to be a little higher. In ESP, bleeding during the soft palate tunneling may be an issue. If this happens during surgery, in general, the bleeding can be stopped by applying local pressure. In BRP, a late suture extrusion may be encountered. Generally speaking, the reported rate of significant complications seems to be reasonably low.
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