Sleep. 15:S56-S62 © 1992 American Sleep Disorders Association and Sleep Research Society

Assessment of Uvulopallatopharyngoplasty for the Treatment of Sleep Apnea Syndrome Daniel O. Rodenstein

Summary: Uvulopalatopharyngoplasty (UPPP) consis.ts in the surgical removal ofthe uvula, part ofthe muscular portion of the soft palate and redundant palatal and pillar mucosa, and the tonsils. Since 1981, UPPP has been proposed for the treatment of sleep apnea syndrome. Polysomnographic studies have shown that in about half of the patients submitted to UPPP there is a 50% or greater reduction in apnea index. Attempts to identify presurgically those patients more likely to benefit from UPPP have yielded inconsistent results. Limited retrospective follow-up data suggest that UPPP does not modify the increased mortality associated with moderate and severe sleep apnea syndrome. Patients submitted to UPPP report subjective improvement, irrespective of the objective polysomnographic postsurgical results. It is suggested that polysomnographic evaluation ofUPPP results should be mandatory; that any patient with 20 or more apnea/hypopneas per hour of sleep or sleep fragmentation after UPPP should be considered a treatment failure and be offered alternative therapy; and that UPPP should be performed only as part of prospective clinical trials including long-term follow-up. Key Words: Uvulopalatopharyngoplasty-Sleep apnea syndrome - Polysomnography - Sleep fragmentation.

Palatopharyngoplasty with partial uvulectomy, later known as uvulopalatopharyngoplasty (UPPP), was in·troduced by Ikematsu in 1952 as a bold (and successful) attempt to treat loud snoring in a 23-year-old Japanes(: woman. The technique was fully reported in 1964 (1). Seventeen years later, Fujita et al. performed a mod·· ified version of this surgical technique to treat obstruc.. tive sleep apnea syndrome (OSAS) patients (2). At that time, the only available effective treatment for this socially devastating disease (the mortality and mor.. bidity of OS AS had not yet been fully appreciated) was tracheostomy (3). Effective as it was, tracheostomy re .. mained an aggressive therapy with a handful of com .. plications, including hemorrhage, granulation tissue formation, repetitive infectious episodes with chronic cough and expectoration and serious aesthetic impli .. cations. This was undesirable in relatively young peo .. pIe with no respiratory problems when awake. Thus, the introduction of UPPP was a welcome and well .. needed alternative to mutilating tracheostomy. Problems arose when doctors tried to evaluate the: untoward effects and complications of this new treat.. Accepted for publication May 1992. Address correspondence and reprint requests to Dr. Daniel O. Rodenstein, C1iniques Saint Luc, Av. Hippocrate 10, 1200 Brussels, Belgium.

ment and to predict preoperatively for which patients surgery was likely to be successful. As with any surgical technique, matters are further complicated by the fact that many surgical teams introduced their own modifications to the original method, which may have affected surgical outcome. In the last 3 years, the first long-term data on mortality of treated and untreated OSAS patients have become available, including the assessment of tracheostomy, UPPP and nasal continuous positive airway pressure (nCPAP), introduced also in 1981 (4). Since then, we have learned a number of facts concerning the morbidity associated with OSAS, its prevalence and the relative importance of the respiratory, cardiovascular and sleep components of OSAS that underlie the multiple symptoms of this entity. It is with this framework in mind that we have undertaken the difficult task of evaluating UPPP in OSAS and reaching a meaningful conclusion of its value. We will not specifically address the issue of UPPP in pure snoring without OSAS. We have critically evaluated a representative part (thOUgh by no means all) of the literature on UPPP published as full papers in peerreviewed journals and compared this data with that available for other treatments and with the known facts of the natural history of OS AS. We have no doubt that our own prejudices have influenced the conclusions reached, and that many will not agree with them. We

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Service de Pneumologie. Cliniques Universitaires Saint Luc, Universite Catholique de Louvain, 1200 Brussels. Belgium

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UVULOPALA TOPHAR YNGOPLASTY IN SLEEP APNEA hope to provoke stimulating and fruitful discussion, leading to better therapeutic results. TECHNIQUE

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RESULTS Analysis of the results of UPPP in OSAS involves several different aspects. Among them are short- and long-term results of surgery on breathing during sleep and on sleep structure, effect of UPPP on long-term morbidity and mortality due to OSAS and morbidity and mortality of the surgical procedure itself. We will first review the published literature concerning the short- and long-term results of UPPP on breathing during sleep and sleep quality. In their original report, Fujita et al. (2) defined improvement due to UPPP as a 50% decrease in the apnea index (number of apneas per hour of sleep) on polysomnography 6 weeks after surgery. According to this definition, results ofUPPP were good in eight of their 12 original patients. In 1983, the same group reported results on 31 patients studied 6 weeks after surgery (5). In 16 patients (responders), the apnea index had decreased by more than 50% (64 ± 19 to 12 ± 13), whereas in the rest ofthe patients (nonresponders), the decrease was slight (59 ± 29 to 49 ± 23). Nocturnal oxygenation, assessed through transcutaneous monitoring of Sa02 , was better after surgery in both groups of patients. Sleep quality improved only in the responder group (reduction in stage 1, increase in stage 2 and normalization of the mean sleep latency test). The arousals associated with respiratory events, which are related not only to apneas but also to hypopneas, decreased in the responder group from 68 ± 24 before

to 34 ± 34 after surgery. The authors stressed that subjectively, nonresponders had benefited from UPPP as much as responders (5). On a subsequent report, Conway et al. (6) evaluated, after 1 year follow-up, 20 of 33 patients originally defined as responders on the sixth week postsurgical polysomnography. No significant difference was found between respiratory or sleep structure data between 6 weeks and 1 year after UPPP. The authors concluded, from a previous report on the same group of patients (7), that UPPP should be reserved for patients with no less than 25% excess body weight and that increases in body weight after surgery could jeopardize the good surgical results. Indeed, in three of the original 13 responders not evaluated after 1 year, OSAS recurred after 2 years to or above presurgical levels. In these three patients, contrary to the patients assessed after 1 year, body weight had increased in the meantime (6). It should also be noted that four of the 13 responders not evaluated after 1 year had sought additional treatment (permanent tracheostomy or mandibular advancement) and that another one had died of myocardial infarction (6), a condition later shown to be associated with OSAS (8). De Berry Borowiecki and Sassin (9) were less successful in treating OSAS with UPPP, which they called pharyngoplasty, although the uvula was also resected. In 1983, they reported on 10 patients undergoing tracheostomy and UPPP. On repeat polysomnography with the tracheostomy occluded, alII 0 patients showed persistence of OS AS (9). In a later 1985 paper, de Berry Borowiecki et al. (10) reported on results of UPPP in 30 patients. In the more severe cases, a tracheostomy was performed simultaneously with UPPP. On the basis of polysomnography performed after at least 3 months, they divided the patients into three groups: major improvement-seven patients, or 22% showing 7 ± 5 apneas per hour of sleep after UPPP; partial improvement-seven patients, or 22% with> 50% decrease in apnea index after UPPP, but showing a mean of 21 ± 7 apneas per hour of sleep, and failure-16 patients, or 54% with 59 ± 24 apneas per hour of sleep. Overall, 25 patients (83%) had an apnea index> 10 and 18 patients (60%) had an apnea index >20 after UPPP. Only four patients achieved an apnea index ::::;5. These authors (10) concluded that UPPP is of limited value in OSAS and should be reserved for patients with moderate OSAS, with sleep-related pharyngeal obstruction limited to the velopharyngeal sphincter and with normal hypopharynx as assessed from presurgical cephalometric and endoscopic studies (see further). They also stressed that objective followup monitoring (polysomnography) was mandatory because subjective improvement was seldom confirmed by objective evaluation (10). Guilleminault and coworkers have accumulated a Sleep. Vol. 15. No.6. 1992

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The technique ofIkematsu (1) involves a wedge section in the posterior pillar mucosa adjacent to the root of the uvula, removal of the pillar mucosa between the palatal arches and interrupted sutures of the anterior and posterior palatal arches. Later modifications of the technique have included section and removal of the entire uvula, removal of some muscle (the more dorsal part of the levator, and part of the palatoglossus and/ or palatopharyngeus), removal of the redundant palate and tonsillar fossae mucosa and removal of the tonsils when they are present. The upper limit of the resection of the palate is subject to debate, but many authors recommend resecting about 1.5 cm of the free palate, stopping just short of its thick muscular part. Posterior and anterior tonsillar pillars are then brought together and sutured, as are the anterior and posterior edges of the remaining palate. Surgery is performed under general anesthesia, although local anesthesia has sometimes been used.

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when OSAS symptoms reappeared. Thus, the nine patients studied may represent the group with the more favorable results. The authors state that of all patients undergoing UPPP with tracheostomy, none could be decannulated. They also stress the great subjective symptomatic improvement felt by most patients, irrespective of the poor postsurgical polysomnographic findings. Blakley et a1. (14) concluded that UPPP is unlikely to provide satisfactory objective improvement in OSAS. A similar discrepancy between subjective improvement and absence of objective favorable changes was reported by Regestein et a1. (15). Out of 40 patients, they evaluated 18 pre- and postoperatively. Neither respiratory nor sleep structure indices changed after surgery. For instance, obstructive respiratory events increased from 34 ± 30 before to 47 ± 28 after UPPP. In nine patients, a continuous performance test-particularly impaired by sleep deprivation-was performed, and showed no significant difference after surgery. Nevertheless, results assessed by questionnaire were good or better in 71 % of patients. Regestein et a1. (15) concluded that objective postoperative monitoring should be mandatory, regardless of subjective improvement. Ofthe 34 patients studied by Gislason et a1. (16), 22 (65%) were defined by these authors as "responders" (50% or greater decrease in the apnealhypopnea index 6 months after surgery) and 12 (35%) as "nonresponders". The former were less obese, had fewer obstructive events before surgery and had a smaller tongue width on computed tomography. From the results of this paper, it can be seen that 18 patients had > 10; 15 patients> 15 and 12 patients >20 apnea/hypopneas per hour of sleep after surgery. Postoperative sleep data were not provided. In a study assessing the acute (within 5 days) effects of UPPP in nine patients, Sanders et a1. (17) found, with respect to the diagnostic polysomnography, no significant change after UPPP in the apnea/hypopnea or oxygen saturation indices. Sleep structure did not change after UPPP, except for a decrease in rapid eye movement (REM) sleep. Sanders et a1. concluded that a tracheostomy should not be systematically associated with UPPP but that patients have to be closely monitored postoperatively (17). The same group later compared early (within 5 days) and late (>6 weeks) postsurgical polysomnographies in 15 patients (18). They found that late results were generally better than early ones (less apnea and hypopnea, less de saturation episodes, more REM sleep). Their late results show six patients with < 10 and nine with 20 apnea/ hypopneas per hour of sleep. Sleep structure was not modified after UPPP for the group as a whole, but data were not provided in this study. A subjective good result was noted in 31 patients, independent of objec·· tive data. The conclusion of this study was that patients most likely to benefit from UPPP were those with mod·· erate OSAS (apnea/hypopnea index < 30) who were no more than 30% overweight. Weight increase after sur,· gery was associated with poor objective results (11). In a i 984 report (12), patients were classified in four groups [simple snorers, mild (apnea index between 11-30 per hour of sleep), moderate and severe (apnea index> 30 OSAS)]. Of 39 moderate arid severe patients, 54% re'rriained in these two categories after surgery. Of nine mild patients, five were considered mild or moderat{~ after surgery. Overall, the success rate was 46%, Out of 21 patients severe enough to have tracheostomy performed at the same time as UPPP, six (29%) had been successfully decannulated. This report contains no sleep data, but the authors note the striking differ·· ence between subjective and objective postsurgical re·· sults, with the latter being generally worse than the former, stating that patients' and bed partners' histo·· ries are not reliable (12). Finally, Simmons et a1. (12) insist on formally evaluating every patient by poly·· somnography before surgery, since many snorers with· out any other symptoms suggestive of OS AS do indeed have OSAS. In a more recent report on maxillofacial surgery for OSAS, the same group (13) provides data after UPPP performed as a first-step operation in patients deemed to have both oro- and hypopharyngeal obstruction during sleep, as assessed preoperatively through cephalometric and endoscopic examination. Of 25 such patients undergoing UPPP, none benefited from surgery (mean respiratory disturbance index, which is similar to the apnealhypopnea index, declined from 72 before to 69 after UPPP). Blakley et a1. (14) reported on nine patients undergoing UPPP for OSAS. The best apnea index after surgery was 20 apneas per hour of sleep. Mean apnea index decreased from 64 to 53. It should be noted that the protocol called for tracheostomy to be performed simultaneously with UPPP if OSAS was moderate to severe (not defined). Postsurgical polysomnography was performed 8 weeks after surgery, and patients were asked to occlude their tracheostomies for 7 days prior to polysomnography. Many patients could not be studied because they were unable to keep the tubes plugged

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UVULOPALATOPHARYNGOPLASTY IN SLEEP APNEA

in percentage of total sleep time, decreased in the complete responders from 70 to 7% and from 81 to 23% in the partial responders. Similar improvements were found in the oxygen saturation indices. As reported by others, Fleury et al. also found a clearcut decrease in subjective daytime somnolence in most of the 30 patients, regardless of objective polysomnographic results (23). COMMENTS Definition of surgical success or failure is one of the main problems in assessing UPPP. Most authors follow the arbitrary definition of Fujita et al. (2): 50% or more decrease in the apnea (or apnea/hypopnea) index defines success. Although this definition could be considered valid when first proposed, it can no longer. He et al. (24) showed that mortality was significantly increased in untreated OSAS patients when the apnea index (excluding hypopnea) was> 20. Thus, a decrease of more than 50% in the apnea index following UPPP cannot be considered a success if the patient is left with > 20 apnea/hypopneas per hour of sleep. Since the physiologic significance of hypopnea is similar to that of apnea (25), it is sound to include hypopnea episodes in the definition of success or failure. Unfortunately, most reports do not allow the reader to recalculate the success (or failure) rate ofUPPP taking this limit into account, but when this is possible, the failure rate generally increases above that calculated from the 50% reduction in the apnea index. Partinen et al. (26) have shown that overall mortality is increased in OSAS patients in whom weight loss is the only advised treatment. Their group with increased mortality comprised 127 patients and had an initial average apnea index of 31 ± 8. The lowest apnea index at entry into the study in the eight patients dying from a vascular cause (most probably linked causally to OSAS) was 19.6, confirming that an apnea/hypopnea index of20 may be a useful cutoff point in determining outcome of any treatment for OSAS. However, a more conservative approach might be wiser. Hung et al. (8) found that an apnea index (hypopnea excluded) > 5.3 was an independent predictor of myocardial infarction, with an odds ratio of23.3 (95% confidence interval 3.9-139.9). This paper is important because the myocardial infarction population studied was large (101 patients), their mean body mass index was lower than a typical OSAS sample (27.3, SEM 0.4 kg·m- 2) and their mean apnea/hypopnea index was unimpressive (12.7, SEM l.6), with modest levels of desaturation (lowest Sa0 2 86.1, SEM 0.6%) (8). Thus, if one takes into account morbidity as well as mortality, an apnea index of 10 (or 5, which is the original definition of OSAS) might be a more adequate figure to determine success or failure of a Sleep. Vol. 15. No.6. 1992

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sillar enlargement and who was cured by surgery, all patients had an apnea index of >47 after UPPP. Four patients later developed cardiac failure and one, among those who declined further therapy, died in his sleep. It is to be noted that nine patients had been examined by computed tomography. In all of them, narrowing was confined to the oropharynx. In all 11 patients, trials ofnCPAP had proved effective in reversing OSAS (19). Shepard and Thawley (20) performed a thorough computed tomographic study of 23 OSAS patients undergoing UPPP. Eight (35%) were classified as good responders, with a mean 65% decrease in the apnea/ hypopnea index 7 weeks after surgery (from 57 ± 9 per hour before to 20 ± 5 after UPPP), whereas 15 patients were classified as poor responders with no change in mean apnea/hypopnea index despite significant improvements in oxygen saturation indices. Only scant data on sleep structure were provided and showed no change in either group after UPPP. They concluded that the patients more likely to improve after UPPP were those with a minimum pharyngeal area < 1 cm 2 located 20 mm below the hard palate (20). However, in a subsequent study on a small group of six patients in whom the site of airway collapse was determined during sleep using the multiple catheter pressure technique, only one patient showed more than 50% decrease in the apnea/hypopnea index (to 23 per hour). He had collapse in the velo- and hypopharynx. The three patients with collapse confined to the velopharynx before surgery showed a persistent collapse in the same region after surgery (21). A related finding was recently reported by Hudgel et al. (22). Out of the 14 patients they studied preoperatively with the multiple pharyngeal catheter technique during sleep, seven had transpalatal and seven had hypopharyngeal obstruction. After UPPP (1-9 months after surgery), three patients in the transpalatal obstruction group and five in the hypo pharyngeal obstruction group still had more than 20 apnea/hypopneas per hour of sleep. Postoperatively, all these patients showed pharyngeal obstruction at the transpalatal level. Hudgel et al. also found that patients with transpalatal obstruction improved in the apnea, but not the hypopnea, component of their sleep-related breathing disorder, whereas the opposite was true in patients with hypopharyngeal obstruction (22). Fleury et al. (23) have divided their 30 patients into three groups: complete responders (14 patients, or 47%) with < 10 apneas per hour of sleep 3 months after surgery, partial responders (6 patients, or 20%) with > 50% decrease in the apnea index but> 10 apneas per hour of sleep (mean postoperative index in this group 19 ± 4) and nonresponders (10 patients, or 33%) (23). Sleep fragmentation, defined as the time with arousals

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EFFECTS OF UPPP ON LONG-TERM EVOLUTION OF OSAS In the only study dealing with the effects of UPPP on long-term mortality from OSAS, He et al. (24) found that the increased mortality due to OSAS with an apnea Sleep, Vol. 15, No.6, 1992

index> 20 was not modified by UPPP. In their group of 60 patients, eight died in the first 8 years after surgery. Two of them had had postoperative polysomnographic studies showing failure of UPPP (less than 50% decrease in the apnea index) and had received no further therapy. The six other patients who died after UPPP had not been restudied and we do not know whether they were responders or nonresponders (24). This piece of information cannot be neglected, however, until proven otherwise, particularly because none of the patients with similar characteristics treated by tracheostomy (33 patients, 8-year follow-up) or nasal continuous positive airway pressure (25 patients, 5-year follow-up) had died (24). The same authors (6) reported the death of one patient after a successful UPPP, who is probably not included in these series. UPPP: MORBIDITY AND MORTALITY UPPP has its own morbidity and mortality. Many patients with OSAS carry an increased risk for surgery, due to obesity (30), arterial hypertension (31) or previous cardiovascular morbidity (32). Moreover, the intraoperative management may be complicated by the particular neck anatomy of some of these patients, making intubation difficult for the anesthesiologist. Finally, anesthetic drugs are known to impair pharyngeal muscle function (33), and postoperative edema and swelling of pharyngeal structures after UPPP may further compromise airflow in the immediate postoperative period (17). Harmon et al. reviewed evidence on morbidity and mortality of UPPP in their own series of 126 patients (UPPP alone or associated with septoplasty, tracheostomy or adenoidectomy) and in the literature (34). The most common complications were hemorrhage (7 patients, 2 of whom had a second surgical procedure to control the bleeding, failing in one and requiring Gelfoam embolization of the external carotid artery), rhinolalia (2 patients) and transient nasopharyngeal reflux. Two patients had pneumonia, two other patients had emergency tracheostomies and six needed prolonged intubation or reintubation. Two patients died, one probably of pulmonary embolism 21 days after combined UPPP and tracheostomy, and one of a cerebral infarction after embolization of the external carotid artery for bleeding after UPPP (34). Harmon et al. (34) noticed in the literature a reported incidence of about 10% for rhinolalia and nasal regurgitation (both are usually self-limited and regress in 4 to 8 weeks), 5 to 10% for pharyngeal infection and 1 to 4% for palatal stenosis after UPPP. Gislason et al. (16) mention one patient with ventricular fibrillation, four needing a temporary tracheostomy and one patient requiring suture ligation for bleeding. Sanders et al. (17) report one patient with pharyngeal stricture

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given therapy for OSAS. This issue must be clarified in the future, with more long-term follow-up studies. However, lowering the apnea (or apnea/hypopnea) index considered as safe after UPPP from 20 to 10 or 5 would tip the balance against UPPP as a valuable allternative to tracheostomy or nCPAP. Another point merits comment. The great majority of the published studies offer serious limitations in the data provided to the reader. Only a few papers give detailed sleep structure results, including some quantification of sleep fragmentation or excessive daytime sleepiness (5). Most information on sleep structure is limited to total sleep time and percent REM or delta sleep, and the bulk of the literature simply does not mention sleep structure. Considering that sleep fragmentation is probably the best explanatory factor for daytime sleepiness (27), this absence of hard data is regrettable. Similarly, normalization of sleep stages 3 and 4 and decreases in stages 1 and 2 are an indirect indication that breathing during sleep is adequate. Unfortunately, the reader cannot judge in most cases whether sleep structure is normalized after UPPP. Similarly, several papers give data on apnea but not on hypopnea. Since the physiopathologic and clinical implications of hypopnea are similar to those of apnea, the reader does not know if there were no hypopnea episodes or if they simply were not counted. For instance, Ryan et al. (28) have very recently published a study of 80 patients using three-dimensional upper airway computed tomography with pre- and postsurgical polysomnography (28). Although patients had oxymetric and inductive plethysmographic monitoring, hypopneas were not considered. Their results are excellent, in terms of apnea per hour of sleep (83% good responses to UPPP). But because hypopnea episode:s were not taken into account, one does not know what merit to attribute to this paper. Finally, it is surprising that snoring has seldom been evaluated after surgery for OSAS (and even for simple snoring). Most authors agree that snoring is eliminated or greatly diminished after UPPP. However, these statements are based on the verbal accounts ofpatienlts and their families, not on snoring recordings during polysomnography. After other forms of surgical treatment for OSAS, it has been shown that subjective accounts are not verified when confronted with objective results, even for snoring and not only for subjective complaints of daytime sleepiness or restless sleep (29).

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UVULOPALATOPHARYNGOPLASTYINSLEEPAPNEA and one patient staying several days in the intensive care unit for postoperative ventilatory failure (17). Most authors mention transient nasopharyngeal regurgitation, rhinolalia and infection as the most common complications ofUPPP. Surgery-related mortality has seldom been quantified, although references can be found in the literature (35,36).

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Many attempts have been made to identify preoperatively those patients most likely to benefit from surgery. Patients have been studied by a variety of methods, including physical examination, simple fiberoptic endoscopy, fiberoptic endoscopy with the so-called Muller maneuver, physiologic pharyngeal pressure measurements, cephalometries, computed tomography and fluoroscopy. An excellent review on this subject has been published recently (37). Many have claimed a good predictive value for most of these methods. Unfortunately, independent confirmation of the validity of these methods is still awaited. This should not be surprising. Indeed, several of the above-mentioned techniques explore the upper airway with the patient awake, whereas apneas are related to sleep. By measuring pharyngeal pressures with mUltiple catheters, Rudgel et al. (38) have shown that upper airway segments with greater resistance are not the same in a given patient during wakefulness and sleep. Even during sleep, collapsing sites may vary in a given individual (38,39). The Muller maneuver is currently widely used to identify the collapsing segment of the pharynx. It involves asking the patient to make an inspiratory effort against a closed mouth and nose while the pharynx is monitored through a fiberoptic endoscope. The negative intraluminal pressure results in the collapse of the pharynx, and the site of maximal collapse is assessed through visual inspection and is considered to be representative ofthe collapsing site during sleep. The problems with the Muller maneuver are two-fold: on the one hand, the intensity of the inspiratory effort is neither measured nor controlled, so that each patient performs the maneuver as he wishes, making comparisons impossible. On the other hand, the pharyngeal muscular activity (antagonistic with respect to the collapsing forces) is not monitored either, so that for a given negative intraluminal pressure the degree and site of collapse may be very different, depending upon the activation of the pharyngeal dilating muscular structures. Finally, as Shepard and Thawley and Rudgel et al. (21,22) have shown, patients with collapse confined to the velopharyngeal region (as assessed preoperatively with pharyngeal pressure measurements during sleep) may still present with collapse after UPPP, not only at other pharyngeal levels not affected by the

surgical procedure, but at this same velopharyngeal level. CONCLUSIONS We conclude that there are patients who are cured after UPPP. From the data we have reviewed, we conclude that the number of those patients is less than what most papers present as "responders" to UPPP. The second important consideration is that a small number of patients have died as a direct consequence of surgery. Other points to be remembered are: patients with snoring as their only symptom frequently have OSAS on polysomnographic evaluation; subjective benefits are uniformly better than objective ones; after UPPP, oxygen-derived indices improve generally more than disordered breathing events or than sleep structure; UPPP is not proven to modify mortality due to OSAS, whereas tracheostomy and nCPAP do improve survival; no single method (or combination Of methods) has allowed the reliable prediction of surgical results in terms of either breathing abnormalities or sleep quality; weight gains after surgery may turn a UPPP success into a UPPP failure; and sleep-related breathing abnormalities worsen in the immediate postoperative period. A number of primary conclusions emerge from these facts: - Presurgical polysomnographic evaluation of patients with snoring as the only complaint is highly advisable. - Polysomnographic evaluation of UPPP results is mandatory, preferably performed 2-3 months after surgery. - Any patient showing> 20 apnealhypopneas per hour of sleep and an abnormal sleep structure or excessive sleep fragmentation after UPPP should be considered a surgical failure and offered an alternative treatment. -Patients showing 5-20 apnea/hypopneas per hour of sleep should be followed closely to appreciate longterm cardiovascular morbidity. - Patients submitted to UPPP must be encouraged to lose weight. -Close-up monitoring of the patient should be available in the immediate postoperative period, unless nCPAP is administered as a protective measure preand postoperatively (40). Since 1981, several hundred, if not thousands, of OSAS patients have been treated by UPPP. Compared to tracheostomy, UPPP offers the enormous advantages of far less mutilation and untoward effects. Compared to nCPAP, it has the advantage of being a onceand-for-all treatment (though cure after nCPAP and Sleep, Vol. 15, No.6, 1992

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Acknowledgements: This study was supported by a grant from NY Phillips Petroleum Chemicals and by grant No, 3-4567-91 from the Belgian Fonds de la Recherche Scien·· tifique Medicale.

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weight loss is not impossible). However, we are reo, sponsible for making sure that the therapy we offer is the best. With the data at our disposal, we cannot consider that UPPP is the best alternative for OSAS patients, but neither can we dismiss it as totally inef-, fective. Finally, we conclude that UPPP can no longer be considered as a standard treatment for OSAS. We: recommend that UPPP be performed only as part of controlled trials, with pre- and postsurgical objective assessment and long-term follow-up.

Assessment of uvulopalatopharyngoplasty for the treatment of sleep apnea syndrome.

Uvulopalatopharyngoplasty (UPPP) consists in the surgical removal of the uvula, part of the muscular portion of the soft palate and redundant palatal ...
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