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).
image

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.
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