Transpalatal Advancement Pharyngoplasty

Successful surgical treatment of obstructive sleep apnea (OSA) continues to be a challenging goal. Maxillomandibular advancement (MMA) remains the gold standard of surgical care, but its use is limited due to its perceived morbidity, associated cosmetic changes, frequent requirements for additional orthodontic treatment, and cost. No other surgical procedure demonstrates similar success for a broad spectrum of patients. There is a need for more selective surgical procedures for OSA.

The retropalatal segment is the key location of airway collapse in OSA. Even in MMA, airway analysis demonstrates the retropalatal segment and lateral wall as critical. Many traditional palatopharyngoplasty techniques fail to adequately address the lateral wall. After failed uvulopalatopharyngoplasty, obstruction at this site often persists. Expansion sphincterplasty and lateral palatopharyngoplasty techniques alter the lateral wall but do not usually affect the more proximal retropalatal segment. Palatal advancement pharyngoplasty advances the soft palate proximally and alters the cross-sectional area, airway curvature, and lateral wall tension of both the lower and upper palatal airway.

The technique continues to evolve, both to improve effectiveness and to reduce morbidity. Major elements of the technique are similar to those described in prior articles.

1 Indications

Wake clinical examination and endoscopy, sedated endoscopy, cephalometric x-rays, computed tomography and magnetic resonance imaging scanning, and fluoroscopy are used to assess differences in patient airways. In sleep apnea the obstruction is not a “fixed obstruction” but is a dynamic obstruction where vulnerable anatomy contributes to collapse. Abnormalities may include cross-sectional airway size, shape, curvature, and compliance. These can be described by pharyngeal airway phenotypes. Mueller maneuver and other methods assess the airway at “chokepoints” (points of minimal cross-sectional size). These fail to measure other airway segments that are critical to determining airway collapse. In addition to the chokepoint, the shape is critical. Narrowing may be anteroposterior (coronal) or lateral to lateral (sagittal). Proximal anteroposterior or lateral to lateral collapse cannot be easily addressed by traditional UPPP techniques ( Fig. 38.1 ). A narrow anterior to posterior airway at this level indicates retromaxillary airway narrowing or proximal retropalatal anatomic stricture and may be considered for palatal advancement.