Uvulopalatopharyngoplasty: Prevention of complications with the imbrication technique.

Abstract

Uvulopalatopharyngoplasty is widely used to treat obstructive sleep apnea, and many techniques are described in the literature. However, complications and failures remain a problem. We describe a new imbrication technique that reduces pain, minimizes bleeding, and serves to realign muscle tension, thereby reducing palatal bulk. The imbrication technique has become the standard procedure at our clinic.

Introduction

Uvulopalatopharyngoplasty (UPPP), which was introduced by Fujita in 1981, remains the most frequently performed procedure for treating snoring and idiopathic obstructive sleep apnea (OSA). [1,2] Although continuous positive airway pressure (CPAP) is the preferred treatment for OSA, UPPP continues to be frequently requested by patients. The procedure is easy to perform, and it has dramatically improved the quality of life for many patients. [3] CPAP, on the other hand, is an inconvenient, uncomfortable, and, in severe sleep apneics, a lifelong treatment. Therefore, to many patients, CPAP is a less than desirable form of therapy, and compliance is poor. [4]

There has been much debate over the efficacy of UPPP, and reported success rates vary widely. The variability in success rates can be attributed to a lack of consistent pre-and postoperative polysomnography and to differences in patient selection, definitions of apnea and successful outcomes, surgical technique, and followup. [1] As a result, UPPP' s actual benefit to our patients is questionable. The availability of an alternate method of care is an important option for our patients.

Obstructive sleep apnea

OSA is a complex disorder that involves the neuromuscular, cardiopulmonary, and otolaryngeal systems. It is associated with potentially serious physiologic effects as well as obvious social consequences. OSA is characterized by frequent apneas, habitual heavy snoring, and daytime somnolence. The cessation of airflow lasting 10 seconds or more, on at least 30 occasions during 6 to 7 hours of nocturnal sleep, is diagnostic for OSA. Concomitant disorders, such as decreased arterial blood oxygen saturation, systemic and pulmonary hypertension, and severe cardiac arrhythmias, require the physician to inform the patient about the potential seriousness of this disorder and the need for medical or surgical intervention.

The syndrome is classified into three types: central, obstructive, and mixed. There might be several indicative findings on examination, including redundant soft palate mucosa, an elongated uvula, oropharyngeal narrowing, and glossal or oropharyngeal hypotonic muscular collapse. [5] Many of these patients are moderately to severely overweight. Again, there is controversy over the exact site and mechanism of the functional obstruction. Research shows that although a combination of obstructive sites can exist simultaneously, the most significant site is the palate. When surgery fails to correct OSA, the primary reason is the presence of an obstructive tongue base.

Several other methods of surgical intervention, each causing a degree of morbidity above and beyond that of UPPP, are outside the span of this paper. Tracheostomy and mandibular reconstruction have a place in OSA treatment, but they are usually reserved for more extreme cases.

Preoperative considerations

When a patient comes to the office exhibiting typical apneic symptoms, the physician's first steps are to perform a complete examination and obtain a full history. The examination should focus on noting any redundancy of the soft palate tissue, the length of the uvula, the size of the tongue, and the position of the jaw. Direct attention should also be given to the nose and sinuses. Any difficulties within the nasal airway should be corrected before palatal surgery. An important part of the history is to ask the patient as well as family members about the patient's snoring, apnea, any daytime difficulties with work or everyday chores, and the degree to which these factors affect their lives. Reports of a significant impact point to a diagnosis of OSA.

Sinusitis is usually managed medically, but when surgery is necessary, the sinuses and nasal septum should be addressed first, and the palate should be taken care of approximately 6 weeks later. All patients should be sent for polysomnography to determine the severity of the apnea and to identify the degree of central and obstructive causes. Patients should be encouraged to lose weight, with the help of their family physician if necessary. Patients with confirmed apnea should be placed on CPAP therapy initially. If that should fail, surgical options can be discussed. Patients then will frequently request UPPP.

The imbrication procedure

The patients at our clinic are taken to the operating room as they are being intravenously infused with 10 mg of dexamethasone and antibiotics. They receive general anesthesia and are intubated before they are turned over to the surgeon. A shoulder roll is put in place and a McIvor mouth retractor is inserted in the oropharynx, expanded, and suspended from a Mayo stand. A mixture of lidocaine, epinephrine, and hyaluronidase is used to locally anesthetize the soft palate, uvula, and tonsil beds for hemostasis.

At this point, the tonsils, if present, are removed. Next, attention is directed to the soft palate. Hemostats are used to clamp the palatopharyngeus muscle longitudinally on either side for hemostasis. The muscle is then incised with a scissor. With a 3-0 polydiaxanone suture (PDS), the palatopharyngeus muscle is attached to the palatoglossus muscle on either side at the incisional site. The uvula is then flipped upon itself to serve as a template for the mucosal incision.

The anterior soft palate mucosa is sharply incised in a triangular fashion, with the point inferior to the incisura and the base at the uvula. The incision is extended through the anterior aspect of the uvula. Once again, the uvula is flipped upon itself and sutured to the soft palate with 3-0 PDS in an interrupted fashion. Excess uvula is also removed. The tonsil beds are sutured together, and the repair is completed by squaring off the soft palate and creating a good airway. The patient is extubated and sent to the acute care unit for overnight airway observation and maintained on steroids and IV antibiotics. When the patient is able to tolerate fluids the next day, he is discharged and instructed to return for followup in 1 week.

Discussion

There are many advantages to the imbrication technique that have made it a successful procedure and the standard at our clinic. The most important aspect is that all sutures are placed anterior to the nasopharynx. Only the smooth, uncut mucosal surfaces face posteriorly, which facilitates healing without nasopharyngeal stenosis.

A moderate amount of postoperative pain is typical, less so when there are no tonsils to remove. Pain usually subsides significantly over the first 24 hours, although sometimes this can take up to 1 week. Patients are able to freely swallow immediately following surgery. Velopharyngeal dysfunction appears in a small percentage of patients, and it usually resolves completely. Bleeding is minimal, and cautery is usually not needed for the soft palate repair, which further lessens the potential for pain and tissue disruption. Also, only minimal amounts of tissue are removed, which helps maintain normal pharyngeal function.

The imbrication procedure can be performed even in severely obese patients whose airways are small and difficult to manage. Imbricating the muscle realigns the direction of tension upward to further treat palatal dysfunction. Finally, there is no uvular bulk to cause postoperative obstruction. In conclusion, we believe the imbrication technique is a consistently successful, easily performed procedure that yields a low rate of complications.

From Associates in Ear, Nose, Throat, and Facial Plastic Surgery, Woodbury, N.J.

Reprint requests: Howard J. Bresalier, DO, 620 N. Broad St., Woodbury, NJ 08043. Phone: [phone]; fax: [phone]; e-mail: [e-mail]

References

(1.) Miljeteig H, Mateika S, Haight JS, et al. Subjective and objective assessment of uvulopalatopharyngoplasty for treatment of snoring and obstructive sleep apnea. Am J Respir Crit Care Med 1994;150:1286-90.

(2.) Aboussouan LS, Golish JA, Wood BG, et al. Dynamic pharyngoscopy in predicting outcome of uvulopalatopharyngoplasty for moderate and severe obstructive sleep apnea. Chest 1995;107:946-51.

(3.) Larsson LH, Carlsson-Nordlander B, Svanborg E. Four-year follow-up after uvulopalatopharyngoplasty in 50 unselected patients with obstructive sleep apnea syndrome. Laryngoscope 1994;104:1362-8.

(4.) Doghramji K, Jabourian ZH, Pilla M, et al. Predictors of outcome for uvulopalatopharyngoplasty. Laryngoscope 1995;105:311-4.

(5.) Zohar Y, Finkelstein Y, Strauss M, Shvilli Y. Surgical treatment of obstructive sleep apnea: Technical variations. Arch Otolaryngol Head Neck Surg 1993;119:1023-9.