1
Introduction
Uvulopalatopharyngoplasty (UPPP) is generally both safe and effective as a surgical treatment for nonobese patients who suffer with mild to moderate sleep apnea. This refinement in surgical technique employs strategies to avoid complications and improve efficacy. Palatal dysfunction is avoided by minimizing soft palate shortening in the midline (uvula) area. Nasopharyngeal stenosis is avoided by minimizing posterior pillar resection and avoiding pharyngeal undermining. Effectiveness of surgery is improved when emphasis is placed on opening the nasopharynx widely in the lateral port areas. Also, tissue removal deep in the inferior tonsillar poles (and hypopharynx) with mucosal advancement and suturing is emphasized.
1.1
Patient Selection
General indications for UPPP as an isolated procedure are discussed in Chapters 32 and 33 . This technique is particularly suited for patients with Friedman anatomic stage I oropharynx. This implies Friedman tongue position (FTP) I, IIa, or IIb and tonsil size 3 or 4 (see Chapter 15 ). For patients with Friedman anatomic stage II (FTP I, IIa, or IIb and tonsil size 1 or 2, or FTP III or IV and tonsil size 3 or 4) or stage III (FTP III or IV and tonsil size 0, 1, or 2), UPPP is usually combined with glossectomy or some form of hypopharyngeal procedure (see Chapter 15 ).
1.2
Objectives
The technique described here resembles the original descriptions of Ikematsu and Fujita et al. However, it is modified to achieve the following desirable objectives:
- 1.
Maximize the lateralization of the posterior pharyngeal pillars, including submucosal palatopharyngeal musculature, which will increase the lateral dimension of the oropharyngeal airway.
- 2.
Interrupt some of the sphincteric action of the palatonasopharyngeal musculature, which will increase the patency of the nasopharyngeal airway.
- 3.
Maximize shortening of the soft palate in the lateral ports while sparing midline musculature (resulting in a “squared off” soft palate appearance), which will prevent palatal tethering and nasopharyngeal stenosis, yet will preserve mobility and function of the palate for purposeful closure.
2
Surgical Procedure and Technique
Prophylactic antimicrobials with anaerobic activity are initiated 1 hour before surgery, with intravenous ampicillin/sulbactam (Unasyn 3 g) or clindamycin (900 mg). A preoperative corticosteroid intravenous injection is also given (Solu-Medrol 125 mg or dexamethasone 10–15 mg). Preoperative sedatives are avoided because obstructive sleep apnea patients are often overreactive to them and airway crisis may occur. Likewise, an anesthesiologist should be selected who is well aware of the compromised status of the airway in such patients. The orally intubated and anesthetized patient is placed in the head-extended supine position with the Crowe–Davis tonsillectomy mouth gag and the Ring tongue blade in place.
The areas to be surgically excised are injected with small amounts of epinephrine 1:100,000 solution (usually provided in 1% lidocaine). This is to promote hemostasis and is done by prior agreement with the anesthesiologist, who selects an appropriate inhalation agent.
The mucosa on either side of the uvula is clamped with hemostats and then incised in an oblique direction as in Fig. 34.1 . This severs the drooping mucosal web between the uvula and the posterior pillar, increases the mobility of the pillar, prevents soft palatal scar contraction (with “tethering”), and incises some of the lowermost fibers of the nasopharyngeal sphincter. Typically, the low-hanging soft palate of an apnea patient contains few muscular fibers of the nasopharyngeal sphincter.
The palatopharyngeal incision is designed as three sides of a rectangle, as in Fig. 34.2 . It begins at the base of the tongue lateral to the inferior tonsillar pole and extends cephalad in the sulcus or angle formed between the internal surface of the mandible and the anterior tonsillar pillar. At about 1 cm above the level of the trailing edge of the soft palate, the incision makes a 90-degree angle, transverses the soft palate horizontally, then angles 90 degrees downward again symmetrical to the opposite side. The ideal level for the horizontal palatal incision is at the location of the palatal “dimple” as described by Dickson and Blokmanis.
