1
Introduction
Uvulopalatopharyngoplasty (UPPP), first described by Fujita in 1981, was the first surgical procedure specifically designed to treat snoring and obstructive sleep apnea (OSA), and it is still the most commonly used surgical procedure for these conditions. The original procedures of UPPP include excision of the tonsils, trimming and relocating the tonsillar pillars, uvulectomy, and mucosal closure of the soft palate. Although UPPP can successfully reduce snoring and improve daytime sleepiness and quality of life, its success rate in treating OSA remains variable and unpredictable. Furthermore, UPPP is associated with severe postoperative pain and complications that may jeopardize normal pharyngeal function during the daytime. Therefore a number of modifications of UPPP have been described to improve surgical outcomes and reduce morbidity, including the Fairbanks technique, lateral pharyngoplasty, expansion sphincter pharyngoplasty, zetapalatopharyngoplasty (Z-palatoplasty [Z-PP]), and relocation pharyngoplasty. The main changes with these modifications are to enlarge the velopharynx by relocating the mucosal flap in an anterolateral direction instead of excision and avoiding lateral pharyngeal wall collapse. UPPP can be used alone or in conjunction with nasal or lingual surgery in multilevel surgery.
2
Patient Selection
Continuous positive airway pressure (CPAP) therapy is suggested for patients with moderate to severe OSA as first-line treatment. For the patients who are unwilling to undergo or have poor compliance with CPAP, surgery can be performed as an alternative or salvage treatment. UPPP is designed to improve upper airway obstruction in the velopharynx, and patients who have velopharyngeal obstruction should theoretically respond well to UPPP. However, it is difficult to precisely identify levels of airway obstruction using current examination techniques. Furthermore, complex aerodynamic changes of the airway during sleep accompanied with interactions of individual levels of obstruction can confound the clinical finding and surgical results.
The following preoperative examinations are widely accepted and used by the majority of otolaryngologists to select patients for UPPP:
- 1.
Physical examination : tonsil size, Friedman tongue position, length of uvula, webbing of posterior pillars, redundant pharyngeal folds, narrowing of the hard palate, overbite, overjet, craniofacial anomalies, and body mass index.
- 2.
Awake fiber-optic endoscopy with/without the Mueller maneuver : retropalatal space and shape (coronal, sagittal, circular), lateral pharyngeal wall position, retrodisplacement of the tongue, lingual tonsil hypertrophy, shape and position of the epiglottis.
- 3.
Cephalometry : posterior airway space, mandibular plane to hyoid, uvular length, and retrognathia.
Drug-induced sleep endoscopy, drug-induced sleep imaging : Velopharynx, Oropharyngeal lateral wall, Tongue, Epiglottis (VOTE) classification.
There are no standardized methods or algorithms to select patients for UPPP. However, UPPP is highly suggested in patients with large tonsils (tonsil size >1), elongated uvula (>1.5 cm), webbing of the posterior pillars, and redundant pharyngeal folds (“favorable” anatomic structure). UPPP is not advised as the only treatment in patients with Friedman tongue position III, circular shape of the retropalatal space, bulging of the lateral pharyngeal wall, lingual tonsil hypertrophy, retrodisplacement of the tongue, long and retrotilted epiglottis, obesity, and retrognathia. OSA patients with “favorable” anatomic structure for surgery were found to be less than one-fourth in clinical examination that emphasizes the necessity of a multilevel approach to their airway if surgical correction is suggested.
3
Technique
The UPPP procedure is performed while the patient is under general anesthesia with oral endotracheal intubation in the supine position. The patients have their heads extended and a mouth gag is used to adequately expose the oropharynx. The instruments used for the procedure include scalpel, electrocautery, plasma knife, and coblation. UPPP instruments are modified and tailored to address different types of obstruction, including anterior-posterior (A-P), lateral, and concentric obstructions of the velopharynx ( Fig. 33.1 ).
A-P obstruction due to collapse of the soft palate can be classified as the uvular type (collapse in uvula/posterior pillars) and the velar type (collapse in both uvula/posterior pillars and soft palate) ( Fig. 33.2 ). Anterior advancement of the soft palate can decrease the A-P obstruction.
For the uvular type, a surgical technique called supratonsilloplasty (a part of relocation pharyngoplasty) is suggested. The operation is initiated with a bilateral tonsillectomy. Two elliptical cuts are then made over the supratonsillar area, after which tissue in this semilunar area, including mucosa and submucosal adipose tissue, is dissected from the underlying muscles and removed. The posterior pillar flap is everted and sewn onto the residual anterior pillar in a mattress style. The mattress suture starts from low and inside to push the mucosal flap in an anterolateral direction, and the distal (nonmuscle) part of the uvula is excised ( Fig. 33.3 ).
The velar type of obstruction can be improved through combined surgery, including supratonsilloplasty with sliding palatal advancement (SPA) , a modified cautery-assisted palatal stiffing operation technique to improve the palatal collapse. SPA is initiated with a horizontal incision of the mucosa from the soft palate (4 cm in length). Submucosal adipose tissue is then dissected from the underlying muscles in an oblique style and removed. The edges are approximated anteriorly in a sliding model with 2-0 Vicryl mattress sutures ( Fig. 33.4 ). We recently performed a new technique called suspension palatoplasty (modified from barbed reposition pharyngoplasty), which submucosally suspends the palatopharyngeus muscle to the pterygomandibular raphe for OSA patients with A-P obstruction and small tonsils. The preliminary results of suspension palatoplasty have shown significant enlargement of the A-P dimensions of the velopharynx with improvements in OSA.
For a thick, soft palate (>1 cm in width) with an A-P obstruction, tissue volume reduction via radiofrequency or coblation is suggested. The technique is derived from coblation-assisted uvuloplasty, in which three channels are ablated on each side of the midline in a fan-shaped, upward direction into the soft palate to reduce the thickness of the soft palate ( Fig. 33.5 ).
