Introduction

Obstructive sleep apnea (OSA) is a dynamic collapse and obstruction of the upper airway occurring in sleep due to decreased upper airway neuromuscular activity. At least 13% of men and 6% of women aged 30 to 70 years in the United States have moderate-to-severe OSA (apnea-hypopnea index [AHI] ≥ 15/hour), and at least half of this population are likely to be intolerant of the first-line therapy, continuous positive airway pressure (CPAP).

The traditional uvulopalatopharyngoplasty (UPPP) was developed by Fujita in 1981. Despite numerous modifications, it remains the most commonly performed surgical intervention for snoring and OSA. Between 2000 and 2006 UPPP and its related modifications accounted for more than 80% of the surgeries performed for OSA in the United States. UPPP has been demonstrated to significantly improve subjective OSA outcome measures and AHI in appropriately selected CPAP-intolerant patients. Several UPPP modifications have been developed to target palatal anatomy variations and clinical scenarios, including the uvulopalatal flap (UPF) and anterior palatoplasty (AP). More advanced palatal surgery modifications are discussed separately in Chapter 54 .

Key Operative Learning Points

• •
  

  Careful patient selection and anatomic phenotyping are key to successful functional outcomes with UPPP, UPF, and AP.

  
  
• •
  

  The patients most likely to benefit from a UPPP as primary therapy are those with a type I or II Friedman clinical stage.

  
  
• •
  

  The UPF should be reserved for the patient with a thin and relatively atrophic soft palate.

  
  
• •
  

  AP may be performed under local or general anesthesia.

  
  
• •
  

  Transient velopharyngeal insufficiency is common and generally resolves spontaneously.

  
  
• •
  

  Consider drug-induced sleep endoscopy (DISE) to help to guide surgical decision making.

  
  
• •
  

  Many OSA patients benefit from a combination of surgical and medical therapies; upper airway surgery can improve CPAP treatment results and adherence.

Preoperative Period

Patients with sleep-disordered breathing may present to the otolaryngologist with a wide variety of subjective and objective concerns, including: loud, disruptive snoring; daytime hypersomnolence; poor sleep quality; impaired quality of life; increased risk of motor vehicle accidents; and cardiovascular disease. As part of the initial evaluation, OSA patients undergo overnight diagnostic sleep testing either in the home via home sleep test (HST) or via in-lab polysomnography (PSG) to document OSA severity and to differentiate OSA from central sleep apnea, sleep-related hypoventilation, nonapneic snoring, or other sleep medicine pathology.

Patients diagnosed with moderate-to-severe OSA should undergo a trial of CPAP before surgical management in considered. A large body of evidence has shown that CPAP is highly effective in reducing OSA-associated morbidity and mortality. However, approximately 50% of patients are unable to adhere to long-term therapy. Each patient’s experience with CPAP and the reasons for intolerance should be carefully reviewed for potential targeted intervention. Alternative positive pressure modalities may be helpful for patients having trouble tolerating CPAP. For others with complaints of nasal obstruction, nasal airway surgery may decrease the amount of positive airway pressure required, improving acceptance of CPAP.

Nonsurgical interventions for OSA include weight loss, behavioral modification, mandibular repositioning devices (MRDs) and other oral appliances, or positional therapy aids. Positional therapy aids assist patients with maintaining lateral positioning during sleep and are most effective for patients with a clinically significant reduction in AHI in the lateral position. An MRD can be an effective alternative to CPAP in select patients and is an acceptable initial alternative to trial in patients with mild OSA. However, approximately half of patients will have persistent subjective symptoms or residual OSA during repeat testing. Patients should also be counseled that MRDs may eventually cause undesired occlusal changes.

The heterogeneous clinical presentations of snoring and OSA are further complicated by the large variety of pharyngeal collapse patterns. Comprehensive awake physical examination remains the most used tool in the diagnostic workup. Patients with significant skeletal abnormalities may be best served by maxillomandibular interventions. The patients most likely to benefit from a UPPP are those with a type I Friedman clinical stage (3 to 4+ tonsils, modified Mallampati score I or II) and a body mass index (BMI) less than 40. Flexible nasopharyngoscopy should be used to visualize the base of the tongue and epiglottis. Because multilevel collapse is common and many patients do not have a clear site and pattern of pharyngeal obstruction during awake examination, DISE may provide a useful diagnostic tool to better characterize that anatomic location and pattern of obstruction and to better predict appropriate surgical therapy (see Chapter 52 ). CPAP-intolerant patients with multiple sites of upper airway obstruction may require combination medical and surgical therapy, multiple surgical procedures, or craniofacial modification.

UPPP is the most aggressive and excisional of the procedures described herein, followed by UPF and then AP. Although UPPP may benefit patients with more severe OSA, current evidence supports reserving UPF and AP for patients with mild-to-moderate OSA or nonapneic palatal snoring. UPF is most likely to be successful when used in patients with a thin, relatively atrophic soft palate with a significant vertical length. Folding the posterior, vertical component anteriorly alleviates airway obstruction. However, this maneuver can create significant anterior soft palate bulk that is bothersome to the patient with a more robust soft palate. AP advances the entire soft palate structure anteriorly and is likely most effective in the patient with a shorter vertical palatal length. It can be performed under local anesthesia in appropriate patients.

All patients undergoing UPPP, UPF, or AP should be counseled that transient hypernasal speech or nasal regurgitation due to velopharyngeal insufficiency is not uncommon in the immediate postoperative period and almost always resolves spontaneously. Patients with significant OSA should also be counseled that postoperative sleep testing is recommended to assess for residual OSA, regardless of residual snoring symptoms. Those with significant residual OSA may find that surgery has improved their results and adherence with CPAP or MRD therapy.