Modified uvulopalatopharyngoplasty with uvula preservation

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Chapter 35 Modified uvulopalatopharyngoplasty with uvula preservation

Han Demin, Ye Jingying, Wang Jun

1 INTRODUCTION

A narrow upper airway is one of the main causes of obstructive sleep apnea/hypopnea syndrome (OSAHS). Uvulopalatopharyngoplasty (UPPP), which ablates both the two tonsils and part of the redundant soft palate to decrease the oropharyngeal obstruction, is still the most widely used surgery. Unfortunately there are about 50% non-responders to UPPP for unselected patients and the classic UPPP has complications such as palatopharyngeal incompetence 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 revised UPPP with uvula preservation was first introduced by Han Demin in 2000 and was named Han-UPPP (H-UPPP). H-UPPP is widely used in China and has been proved to be an effective surgical method, causing fewer complications compared with classic UPPP.

2 PATIENT SELECTION

2.1 INDICATIONS

1. OSAHS patients with the main collapsing sites at the level of oropharynx, which are induced by hypertrophic tonsils, long and enlarged soft palate, and redundant lateral pharyngeal mucosa. For severe OSAHS patients, continuous positive airway pressure (CPAP) should be used in the perioperative period to assure good ventilation.
2. Non-apneic snorers and patients with upper airway resistance syndrome who have oropharyngeal obstruction.

2.2 CONTRAINDICATIONS

1. Oropharynx is not the obstruction site.
2. Acute tonsillitis or acute upper airway infections within 2 weeks.
3. Evident risk factors of general anesthesia.
4. Tendency to developing scars.
5. Unstable cardiovascular status or severe cerebrovascular disease.
6. Severe chronic obstructive pulmonary disease.

2.2.1 RELATIVE CONTRAINDICATIONS

1. Severe hypoxemia.
2. Special demands on 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 polysomnogram (PSG) should be included to identify the OSAHS 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 responses to the surgery.
3. A detailed upper airway examination should be performed to identify the potential sites of upper airway obstruction. The regions of nose, palate and the tongue base should be highlighted. A computer-assisted fiberoptic pharyngoscopy can be used to evaluate the upper airway characteristics more accurately. Complete occlusion of the upper airway at Mueller’s maneuver is a criterion to determine obstruction site. If the obstruction sites are hard to identify by fiberoptic pharyngoscopy and radiographic evaluation, an overnight upper airway pressure monitoring and concurrent PSG could be considered to determine the obstruction sites.
4. For severe OSAHS patients (Apnea/Hypopnea Index (AHI)=40, or the lowest oxygen saturation=70%), CPAP should be used as early as possible to improve patients’ tolerance to anesthesia and surgery. Preoperative CPAP treatment can significantly reduce surgical risks and complications. For those with stubborn hypertension, combined treatment of CPAP and drugs may be effective.

4 TECHNIQUES

H-UPPP was carried out under general anesthesia with nasal intubation. The characteristics of H-UPPP are as follows.

• Anesthesia and tonsillectomy: Bilateral tonsillectomy is performed first and the redundant bilateral pharyngeal mucosa and submucosal tissue are trimmed or resected to enlarge the oropharyngeal lumen.
• CO2 laser incision: Two inverted ‘V’-shaped incisions are made on the ventral surface of the soft palate, along both sides of the uvula (see Fig. 35.1).
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Fig. 35.1 ‘V’-shaped incisions.

The upper border of incision and the length of soft palate that should be removed are determined as follows.

1. We found that there are two velum plati spatium along the two sides of palato-uvularis, and the velum plati spatium is between palato-uvularis and the lower margin of both tensor palatini and levator palatini. The spatium is filled with adipose tissue, which is evidently increased in OSAHS patients. The location of velum plati spatium and its adjacent structures is shown in Figures 35.2 and 35.3. On the ventral side of the soft palate, the casting of velum plati spatium borders are about 1–1.5 cm lower than the junction of the hard palate and soft palate, 0.8 cm lateral from the base of uvula.
2. The length of soft palate that should be removed is determined preoperatively according to the anatomy of the patients’ pharynx and the severity of sleep apnea (Fig. 35.4). For a moderate sleep apnea patient (AHI 20–40 times/h), the upper border should be as high as the second molar. The incision should be higher in severe patients and lower in mild ones.
3. Once the membrane of the soft palate ventral surface is incised by using the CO2 laser, blunt dissection is used to remove surplus submembranous adipose tissue (Fig. 35.5), i.e. adipose tissue in velum plati spatium. Therefore the tensor palati and palato-uvularis are not damaged.
4. The intact margins of the levator palatini and tensor palatini are preserved. The dorsal surface of the soft palate is incised and then trimmed along the uvula bilaterally (Fig. 35.6). The redundant adipose tissue and surplus mucous membrane along the uvularis are removed.
5. The dorsal and ventral margins of the preserved mucosal membrane of the uvula are closed with interrupted sutures, forming a long new uvula. The palato­glossal arch, the soft tissue of the tonsillar fossa and palatopharyngeal arch are also closed with interrupted sutures, so the oropharyngeal cavity is enlarged and the lateral pharyngeal wall is stabilized (Fig. 35.7).
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Fig. 35.2 Location of velum plati spatium.

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Fig. 35.3 Adjacent structures of velum plati spatium.

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Fig. 35.4 The upper border of incision in mild, moderate and severe patients.

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Fig. 35.5 Removal of surplus submembranous adipose tissue.

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Fig. 35.6 Incision of the dorsal surface of the soft palate.

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Fig. 35.7 Oropharyngeal cavity after suture.

5 POSTOPERATIVE MANAGEMENT

1. Medication: Antibiotics are needed to defend against infection; short-term use of corticosteroids during operation or postoperatively can reduce edema mucosal. Patients who have hypertension should receive anti-hypertension treatment postoperatively.
2. Postoperative upper airway obstruction: Postoperative air-way obstruction and asphyxia can be caused by airwayedema, bleeding and redundant secretion. The risk of decrease of arterial saturation in oxygen could be enhanced, especially in the first postoperative night. Appropriate monitoring should be employed including vital signs, arterial saturation in oxygen and airway. Secretions should be extracted regularly, and tracheotomy should be performed if needed. Considering their effect of inhibition of ventilatory control, narcotics should be used with caution after general anesthesia for OSAHS patients.
3. Patients expected to be monitored in the intensive care unit (ICU) postoperatively:

• Preoperative lowest oxygen saturation=70%.
• AHI=40 times/h.
• BMI=30.1 kg/m2.
• Tongue base obstruction approved by fiberoptic scope or cephalometry study preoperatively.
• History of hypertension grade 2 (systolic pressure higher than 150 mm Hg or diastolic pressure higher than 100 mm Hg), angina, or any disorders in hemaglutination.
• Preoperative electrocardiograph indicated arrhythmia, S-T segment or T wave changes.
• After 24 hours observation in ICU, patients could be transferred to the normal ward if there are no other risk factors. For those who have a severe airway edema or who bleed severely during the operation, the intensive monitoring period should be prolonged.

4. Postoperative CPAP: CPAP can improve oxygen saturation, reduce AHI, and reverse sleep debt in OSAHS patients. It also plays a role in expanding the pharynx. If CPAP can be tolerated, CPAP therapy should be started as early as possible and continue for 1–2 months after surgery.
5. Other measures: Behavior change has a major role in management and it also affects the long-term surgical outcomes. All obese patients with OSAHS should be counseled about weight loss and cutting down alcohol.

6 CLINICAL OUTCOMES AND COMPLICATIONS

6.1 THE CONCEPT OF VELUM PLATI SPATIUM

There are two velum plati spatium along the two sides of palato-uvularis, and the velum plati spatium is between palato-uvularis and the lower margin of both tensor palatini and levator palatini. The spatium is filled with adipose tissue, which is evidently increased in OSAHS patients. The clearance of the tissue in velum plati spatium is essential to the improvement of sleep apnea.

6.2 THE SIGNIFICANCE OF UVULA PRESERVATION

Fujita first reported the UPPP for treating OSAHS in 1981, and the UPPP has remained the main surgery for OSAHS. Velopharyngeal insufficiency and nasopharyngeal stenosis are two dreaded postoperative complications of UPPP. H-UPPP was designed to allow maintenance of the normal anatomy of the soft palate and the uvula’s functions when a larger portion of the soft palate is removed.

The long uvula becomes a ‘normal’ one through contraction of scar tissue of the soft palate and the bilateral sides of the palato-uvularis and the lower margin of the tensor pal­atini (Fig. 35.8 A&B). The uvula has important functions like deglutition, respiration, speech and pharyngeal airway dilation. Zakkar found that there is highly concentrated neutral endotryptase in the uvula of normal subjects, but decreased levels in the membrane of the uvula in OSAHS patients, and it is speculated that the uvula is where airflow receptors are distributed. The preservation of the uvula would seem to be very important to maintain the pharyngeal airway muscular tension and normal physiologic functions. To safeguard these important functions, the intact uvularis and its corresponding mucosal membrane (both dorsal and ventral) are preserved. The results show that H-UPPP effectively enlarges the oropharyngeal cavity and avoids some major postoperative complications of classic UPPP.

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Fig. 35.8 Comparison of the oropharyngeal cavity before and after H-UPPP. A, Before H-UPPP; B, 3 months after H-UPPP.

Velopharyngeal insufficiency can occur if too much tissue is removed. Since the tensor palatini has the function of enlarging the oral cavity, and the levator palatini’s function is to pull the soft palate upward and backward, closing the nasopharyngeal cavity during deglutition and phonation, it is important to identify the adipose tissue and muscle, and to keep the levator palatini and the tensor palatini intact. The results of our study show that the uvula’s preservation will effectively avoid many significant postoperative complications.

6.3 CLINICAL OUTCOMES AND FACTORS INFLUENCING SURGICAL EFFECTIVENESS

It has been reported that successful responders to UPPP amount to 33–77%, but the criteria for patient selection and successful surgical response definitions are not the same between studies. The response rate of H-UPPP was 51.9–69.12%, defined as a >50% reduction of the AHI or AHI < 20/h postoperatively. In patients who have been carefully selected for upper airway reconstruction and whose site of primary obstruction is at the oropharyngeal level, the surgical response rate is 68.57–90%.

Among the non-responders, most are severe OSAHS patients. Some anatomical features of the pharynx such as degree of the hypertrophic tonsil are relevant to the effectiveness of surgical treatment. Morbid obesity, older age, and tongue base obstruction may play important roles in the failure of H-UPPP. For patients with multilevel obstructive sites, an isolated procedure of H-UPPP may be insufficient. Other surgical techniques should be adopted, such as nasal reconstruction, temperature-controlled radio­frequency tongue base reduction, genioglossus advancement and maxillomandibular advancement.

FURTHER READING

Demin H, Jingying Y, Jun W, et al. Determining the site of airway obstruction in obstructive sleep apnea with airway pressure measurements during sleep. Laryngoscope. 2002;112(11):2081-2085.

Dickson RI, Mintz DR. One-stage laser assisted uvulopalatoplasty. J Otolaryngol. 1996;25:155-162.

Esclamado RM, Glenn MG, McCulloch TM, et al. Perioperative complications and risk factors in the surgical treatment of obstructive sleep apnea syndrome. Laryngoscope. 1989;99:1125-1129.

Fujita et al. Fujita S, Convey W, Zorick, F, et al. Surgical correction of anatomic abnormalities in obstructive sleep apnea syndrome: uvulopalatopharyngoplasty. Otolaryngol Head Neck Surg 181:89:923–34.

Han Demin, Ye Jingying, Lin Zhonghui, et al. Revised uvulopalatopharyngoplasty with uvula preservation and its clinical study. J Otorhinolaryngol Relat Spec. 2005;67(4):213-219.

Han DM, Ye JY, Li YR, et al. Preoperative overnight airway pressure measurement for predicting the outcome of revised uvulopalatopharyngoplasty. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2006;41(10):753-758.

Huang MH, Lee ST, Rajendran K. Structure of the musculus uvulae: functional and surgical implications of an anatomic study. Cleft Palate Craniofac J. 1997;34(6):466-474.

Isono S, Remmers JE. Anatomy and physiology of upper airway obstruction. In: Kryger MH, et al, editors. Principles and Practice of Sleep Medicine. 3rd edn. Philadelphia: WB Saunders; 2000:840-858.

Li YR, Han DM, Ye JY, et al. Sites of obstruction in obstructive sleep apnea patients and their influencing factors: an overnight study. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2006;41(6):437-442.

Loube DI. Uvulopalatopharyngoplasty may compromise nasal CPAP therapy in sleep apnea syndrome. Am J Respir Crit Care Med. 1996;154:1759-1762.

Meiljetaig H, Mataika S, Haight JS, et al. Subjective and objective assessment of uvulopalatopharyngoplasty for treatment of snoring and sleep apnea. Is J Respir Crit Care Med. 1994;150:1286-1290.

Mortimore IL, Bradley PA, Murray JAM. Uvulopalatopharyngoplasty may compromise nasal CPAP therapy in sleep apnea syndrome. Is J Respir Crit Care Med. 1996;154:1759-1762.

Powell N, Riley R, Guilleminault C, Troell R. A reversible uvulopalatal flap for snoring and sleep apnea syndrome. Sleep. 1996;19(7):593-599.

Rennotte MT, Baele P, Aubert G, et al. Nasal continuous positive airway pressure in the perioperative management of patients with obstructive sleep apnea submitted to surgery. Chest. 1995;107:367-374.

Riley RW, Powell NB, Li KK, et al. Surgical therapy for obstructive sleep apnea–hypopnea syndrome. In: Kryger MH, et al, editors. Principles and Practice of Sleep Medicine. 3rd edn. Philadelphia: WB Saunders; 2000:913-928.

Series F, Cote C, Simoneau JA, Gelinas Y, et al. Physiologic, metabolic, and muscle fiber type characteristics of musculus uvulae in sleep apnea hypopnea syndrome and in snorers. J Clin Invest. 1995;95(1):20-25.

Series F, Simoneau JA, St Pierre S. Muscle fiber area distribution of musculus uvulae in obstructive sleep apnea and non-apneic snorers. Int J Obes Relat Metab Disord. 2000;24(4):410-415.

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Wang J, Han D, Lin Z, et al. Clinical study of uvulopalatopharyngoplasty treatment for middle degree of obstructive sleep apnea syndromes. Lin Chuang Er Bi Yan Hou Ke Za Zhi. 2003;17(2):84-85.

Ye JY, Han DM, Wang J, et al. Computer assisted fiberoptic pharyngoscopy in obstructive sleep apnea syndrome. Chin Arch Otolaryngol Head Neck Surg. 2004;11:371-375.

Zakkar M, Sekosan M, Wenig B, et al. Decrease in immunoreactive neutral endopeptidase in uvula epithelium of patients with obstructive sleep apnea. Ann Otol Rhino Laryngol. 1997;106:474-477.

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