1
Introduction
A narrow upper airway is one of the main causes of obstructive sleep apnea (OSA). Uvulopalatopharyngoplasty (UPPP), which ablates both the two tonsils and part of the redundant soft palate to decrease the oropharyngeal obstruction, is used as an alternative treatment for OSA. Application of the classic UPPP is limited by variable effectiveness in unselected patients and a relative high rate of complications, such as palatopharyngeal incompetency and palatopharyngeal stenosis. To reduce the UPPP complication rate without compromising the surgical response, the first author designed a new method of UPPP in which the uvula is preserved, a larger portion of the soft palate is removed, and the basic structure of the oropharyngeal cavity is maintained. This modified UPPP with uvula preservation was first introduced by Han Demin in 2000 and was named Han-UPPP. Han-UPPP is widely used in China and has proved to be an effective surgery and causes fewer complications compared with classic UPPP.
2
Patient Selection
2.1
Indications
- 1.
OSA patients with the main collapsing sites at the retropalatal level, which are caused by hypertrophic tonsils, long and enlarged soft palate, and redundant lateral pharyngeal mucosa.
- 2.
Nonapneic snorers and patients with upper airway resistance syndrome who have oropharyngeal obstruction.
2.2
Contraindications
- 1.
Oropharynx is not the primary obstruction site
- 2.
Recent upper airway infection
- 3.
Evident risk factors of general anesthesia
- 4.
Tendency to developing scars
- 5.
Unstable cardiovascular or cerebrovascular conditions
- 6.
Severe chronic obstructive pulmonary disease
2.2.1
Relative Contraindications
- 1.
Severe hypoxemia
- 2.
Special demands in phonation or speech
- 3.
Morbid obesity
- 4.
Older than 65 or younger than 18 years old
3
Clinical Evaluation and Preoperative Management
- 1.
An overnight polysomnography (PSG) should be included to identify the OSA patients.
- 2.
Clinical evaluation should include routine vital signs, overall body habitus, facial skeletal pattern, and anatomy of the airway. Age, body mass index (BMI), PSG parameters, and anatomy of the pharynx should be documented to help predict the responses to surgery.
- 3.
A detailed upper airway examination should be performed to identify the potential sites of upper airway obstruction. The nose, palate, and tongue base should be highlighted. A computer-assisted fiber-optic pharyngoscopy can be used to evaluate the upper airway characteristics more accurately. Complete occlusion of the upper airway with Müller’s maneuver is a criterion to determine the obstruction site. If the obstruction sites are hard to identify by fiber-optic pharyngoscopy and radiographic evaluation, an overnight upper airway pressure monitoring or drug-induced sleep endoscopy could be considered to determine the obstruction sites.
- 4.
For severe OSA patients or the nadir oxygen saturation ≤70%, preoperative continuous positive airway pressure therapy (CPAP) is suggested to be used as early as possible to improve patients’ tolerance to anesthesia and surgery. CPAP may improve oxygen saturation and ventilatory control in OSA patients. Preoperative CPAP treatment can significantly reduce surgical risks and complications. For those with stubborn hypertension, a combined treatment of CPAP and medications may be effective.
4
Techniques
The steps of Han-UPPP are as follows:
- 1.
Han-UPPP is carried out under general anesthesia with nasal or oral intubation. Bilateral tonsillectomy is performed first and the redundant bilateral pharyngeal mucosa and submucosal tissue are trimmed or resected to enlarge the oropharyngeal lumen.
- 2.
CO 2 laser incision: Two inverted V-shaped incisions are made on the ventral surface of the soft palate along both sides of the uvula ( Fig. 37.1 ). The upper border of the incision and the length of the soft palate that should be removed are determined as follows:
FIG. 37.1
Incisions on soft palate using CO2 laser.
We found that there are two velum plati spatium along the two sides of the palatouvalaris, and the velum plati spatium are between the palatouvalaris and the lower margin of both the tensor palati and levator palati. The spatium is filled with adipose tissue, which is evidently increased in OSA patients. The location of the velum plati spatium and its adjacent structures are shown in Fig. 37.2 and Fig. 37.3 . On the ventral side of the soft palate, the casting of the velum plati spatium borders are about 1 cm to 1.5 cm lower than the connecting part of the hard palate and soft palate, 0.8 cm lateral from the base of the uvula.
FIG. 37.2
Location of the velum plati spatium.
FIG. 37.3
The adjacent structures of velum plati spatium.
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