Operative techniques of uvulopalatopharyngoplasty.

Introduction

Uvulopalatopharyngoplasty--referred to variously as palatopharyngoplasty, uvuloveloplasty, and uvulopalatoplasty--is an operation that was introduced to Western physicians some 2 decades ago. Evolution of the operative technique has been driven by the need to achieve successful correction of pathological anatomy as well as to avoid complications. [1]

The technique I use resembles those originally described by Ikematsu and Fujita, [2-5] but is modified to achieve three desirable objectives:

1. To maximize the lateralization of the posterior pharyngeal pillars, including the submucosal musculature, in order to increase the lateral dimension of the oropharyngeal airway.

2. To interrupt some of the sphincteric action of the palatopharyngeal and nasopharyngeal musculature, in order to increase the patency of the nasopharyngeal airway.

3. To maximize shortening of the soft palate in the lateral ports, while sparing the midline musculature (resulting in a squared-off soft palate appearance), in order to prevent palatal tethering and nasopharyngeal stenosis and preserve mobility and function of the palate for purposeful closure.

Technique

Prophylactic antimicrobials--900 mg of clindamycin or 3 g of ampicillin/sulbactam intravenously--are initiated 1 hour before surgery. Preoperative sedatives are avoided because patients with obstructive sleep apnea often over-react to them, and airway crisis can 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 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 it is done by prior agreement with the anesthesiolgist, who selects an appropriate inhalation agent (e.g., not halothane).

The mucosa on either side on the uvula is clamped with hemostats and then incised in an oblique direction (figure 1). This severs the drooping mucosal web between the uvula and the posterior pillar, increases the mobility of the pillar, and prevents soft palatal scar contraction (with tethering). Typically, the low hanging soft palate of an apnea patient has few muscular fibers of the nasopharyngeal sphincter.

The palatopharyngeal incision forms three sides of a rectangle (figure 2). It begins at the base of the tongue lateral to the inferior tonsillar pole. Then it extends cephalad in the sulcus between the internal surface of the mandible and the anterior tonsillar pillar. At about 1 to 2 cm above the level of the trailing edge of the soft palate, the direction of the incision turns 90[degrees], transverses the soft palate horizontally, then angles 90[degrees] downward again in a symmetrical fashion. The ideal level for the horizontal palatal incision is at the location of the palatal dimple described by Dickson. [6]

The soft palatal mucosa and submucosa with glands and fat are then stripped away from the muscular layers, beginning at the horizontal palatal incision and moving downward toward the trailing edge of the soft palate and uvula. One or two brisk bleeders will often be encountered near the corners of the incision, and they must be suture-ligated with plain catgut (cautery is inadequate). The uvula is amputated at the level of the trailing edge of the soft palatal muscle fibers (figure 3). Traction on the uvula during its amputation should be avoided because this would result in excessive shortening of the uvula and interruption of the insertions of the levator palati muscles into the muscularis uvula. Loss of palatal sphincteric action (required for closure during speech and swallowing) has been attributed to excessive excision of the uvula and midline palatal tissue. A tiny bleeder on each side of the uvula requires electrocoagulation.

Tonsils (present in one-third of snoring and apneic patients) are excised, and other soft tissues between the posterior tonsillar pillars and the lateral incisions are all stripped out, down to the muscular layers. The plane of dissection is the peritonsillar space. If the patient had already undergone a tonsillectomy, dense fibrous scar tissue might be encountered, which will inhibit mobilization of the posterior pillars. This fibrous scar should be carefully stripped away from the muscle fibers of the tonsillar fossa (superior pharyngeal constrictor), and dissection should avoid damage to the underlying musculature or penetration of the muscle into the structures the carotid sheath.

Dissection should proceed as deep into the hypopharynx as the surgeon can safely reach in order to achieve fossa closure and to control bleeding should it occur. Bleeders are clamped and suture-ligated, which is less traumatic to the musculature than heavy electrocoagulation; good hemostasis is essential.

The posterior tonsillar pillar is then advanced in a lateral-cephalad direction toward the upper corner of the palatopharyngeal incision (figure 4). Contiguous submucosal muscle fibers should be included in this advancement, because this will increase the lateralizing effect and expand the lateral dimension of the pharyngeal airway. This maneuver should smooth and flatten the vertical fold redundancy of the posterior pharyngeal mucosa. [1] If this does not occur, then a little more mucosa could be trimmed, but it is always more advantageous to remove additional anterior tonsillar pillar than posterior pillar, because the act of surgical closure will advance the soft palate in a forward direction and increase the opening of the nasopharynx. (Conversely, if posterior tonsillar pillar is removed, then the surgical closure will pull the palate more posteriorly, decreasing the nasopharyngeal opening even further, which is the opposite of the surgical objective.) Furthermore, it is a grave mistake to cause any sur gical injury to the posterior pharyngeal surface (i.e., to undermine or cauterize), because this might cause nasopharyngeal stenosis.

The pillar is then advanced and fixated into its new lateralized position with multiple sutures of 3-0 polyglycolic acid. The sutures pass through the mucosa into the superficial muscular layers so as to lateralize the muscular elements of the pillar and the mucosa. This also eliminates dead space where hematoma might accumulate. I prefer to put in the second stitch before I tie the first so that the positioning is more visible (figure 5). Suturing then progresses downward to the tongue base, where a small opening is left unsutured to allow for spontaneous drainage. The dissection and closure on the opposite side are identical.

The palatal closure is accomplished as the nasal surface of the mucosa is advanced to meet the incision on the oral surface (figure 6). Redundant or flabby mucosa is trimmed, and the sutures are put in place, including a small amount of muscle fiber in the mucosal closure.

Postoperative management

During the postoperative period, a short course of steroids is given intravenously to prevent edema, and intravenous antimicrobial prophylaxis is maintained for 24 hours.

For patients with simple snoring, postoperative care is the same as it is for adult tonsillectomy patients. However, for patients with obstructive sleep apnea, pain medication is given more sparingly (i.e., low-dose parenteral morphine or oral elixir of acetaminophen with added codeine) in the recognition that apnea is aggravated by narcotics and that a life-threatening loss of airway can be precipitated, especially in the postanesthetic period or the period of postoperative edema of the airway.

Similarly, antiemetics, sleeping medications, and sedatives-tranquilizers can precipitate an apneic crisis; therefore, my nurses are instructed never to accept a telephone order for any of these medications by a physician who is not personally acquainted with my particular patient and his or her disease.

Any patient with severe apnea preoperatively will need vigilant postoperative monitoring of respirations. The intensive care unit is the ideal place for the first 24 hours after surgery.

Patients with severe apnea who are especially worrisome to the surgeon and anesthesiologist can be managed with 24 to 48 hours of endotracheal intubation. The oral endotracheal tube is simply left in place, with 60% oxygen and mist running over its opening (a bypass connector) and frequent suctioning of secretions. The cough reflex is obtunded with occasional instillations of 2 ml of 4% lidocaine into the tube as necessary. Fortunately, narcotics and hypnotics can be administered more liberally for pain relief in such an intubated patient.

From the Department of Otolaryngology--Head and Neck Surgery, George Washington University School of Medicine, Washington, D.C.

Reprint requests: David N.F. Fairbanks, MD, Ear, Nose, and Throat Medical Group P.C., 2021 K St. NW, Suite 210, Washington, DC 20006. Phone [phone]; fax: [phone].

Abstract

Uvulopalatopharyngoplasty is, for the most part, both safe and effective as a surgical treatment for obstructive sleep apnea and severe snoring. Most complications can be avoided with proper surgical technique. Palatal dysfunction can be avoided if the shortening of the soft palate in the midline (uvula) area is minimized. Nasopharyngeal stenosis can be avoided with minimization of the posterior pillar resection and by avoidance of pharyngeal undermining. The effectiveness of surgery can be improved by placing emphasis 1) on opening the nasopharynx widely in the lateral port areas and 2) on tissue removal deep in the inferior tonsillar poles (and hypopharynx) with mucosal advancement and suturing.

References

(1.) Fairbanks DN. Uvulopalatopharyngoplasty complications and avoidance strategies. Otolaryngol Head Neck Surg 1990;102:239-45.

(2.) Ikematsu T. Study of snoring,4th report: Therapy. NipponJibiinkoka Gakkai Kaiho 1964;64:434-5.

(3.) Fujita S, Conway W, Zorick F, Roth T. Surgical correction of anatomic abnormalities in obstructive sleep apnea syndrome: Uvulopalatopharyngoplasty. Otolaryngol Head Neck Surg 1981;89:923-34.

(4.) Ikematsu T. PPP and partial uvulectomy method of Ikematsu. In: Fairbanks DN, Fujita S, Ikematsu T, Simmons FB, eds. Snoring and Obstructive Sleep Apnea. New York: Raven Press, 1987:130-4.

(5.) Fujita S. Method of Fujita. In: Fairbanks DN, Fujita S, Ikematsu T, Simmons FB, eds. Snoring and Obstructive Sleep Apnea. New York: Raven Press, 1987:134-53.

(6.) Dickson RI. Determining how much palate to resect. In: Fairbanks DN, Fujita S, Ikematsu T, Simmons FB, eds. Snoring and Obstructive Sleep Apnea. New York: Raven Press, 1987:167-70.

(7.) Fairbanks DN. Method of Fairbanks. In: Fairbanks DN, Fujita S, Ikematsu T, Simmons FB, eds. Snoring and Obstructive Sleep Apnea. New York: Raven Press, 1987:160-7.