1
Introduction
As new concepts have emerged in the medical literature for sleep apnea and also based on our own experience, lateral pharyngoplasty (LP) was developed and updated several times since we first published it in 2003 ( ; ; ; ; ; ; ; ).
The main factors that have led to the evolution of our technique described here and wider applicability to patients are the role of the retropalatal airway as the primary site of obstruction in sleep apnea, the physiologic integration of the upper airway (tongue–palate coupling), the role of the lateral wall as an extension (i.e. insertion of the soft palate), the lack of anteroposterior enlargement of the retropalatal area in our previous LPs, and residual supine obstructions in some of our patients who underwent prior versions of the procedure ( ; ; ; ; ; ; ).
The main changes in our technique were designed to avoid any stretching of the pharyngeal mucosa, to increase retropalatal enlargement, and to splint the upper lateral pharyngeal wall with a myomucosal palatopharyngeus flap.
2
Indications
We use LP to treat the spectrum of sleep-disordered breathing from habitual heavy primary snoring to obstructive sleep apnea (OSA) in adults, regardless of OSA severity. All patients are counseled about available nonsurgical treatments like mandibular repositioning devices and continuous positive airway pressure (CPAP). A nonsurgical therapy trial is not mandatory prior to a patient electing surgery for OSA in Brazil.
We recommend LP in a spectrum of patients, from those who have large tonsils to patients without tonsils, including cases with failed previous uvulopalatopharyngoplasties or even unsuccessful LPs. The soft palate–tongue position is not a factor for selection, nor is the thickness of the posterior tonsillar pillar. So far, we have found no reason to believe that the location or pattern of obstruction found in drug-induced sleep endoscopies would better indicate or contraindicate this technique.
3
Contraindications
As any technique designed to enlarge the retropalatal area, LP is contraindicated in patients with previous velopharyngeal insufficiency. Although we perform the surgery in obese patients routinely, we usually contraindicate it in patients with a body mass index above 35 kg/m 2 because of the increased perioperative anesthetic risk. Mild or moderate maxillary or mandible deformities are common in OSA patients and are not contraindications to the LP. Severe facial skeletal deformity is a contraindication. A very limited mouth opening is also an exclusionary criterion for the procedure.
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Surgical Technique
We use a mouth gag with a long tongue blade. The tongue blade is positioned over the endotracheal tube to give adequate exposure ( Fig. 40.1 ). We infiltrate the surgical site with Xylocaine 2% with adrenaline 1:200,000. LP starts with a bilateral tonsillectomy ( Fig. 40.2 ). Next, with an upside-down V-shape incision ( Fig. 40.3 ), using the monopolar cautery (with the needle tip), we remove a triangle of mucosa and muscle (palatoglossus) from the lateral oral free margin of the soft palate (supratonsillar tissue) and anterior pillar. The purpose of this removal is to provide wide exposure to the upper lateral pharyngeal wall—at least up to the height corresponding to the base of the uvula ( Fig. 40.4 ). In some cases with large tonsils, this exposure is already achieved after the tonsillectomy and no additional tissue removal is needed. In cases without tonsils, the V-shape incision is extended over the anterior tonsillar pillar, without removing any tissues, and we undermine the tonsillar fossa to achieve complete separation of the palatopharyngeus muscle from the lateral pharyngeal wall.
