Sleep. 15:S63-S68 © 1992 American Sleep Disorders Association and Sleep Research Society

Surgical Alternatives to Uvulopalatopharyngoplasty in Sleep Apnea Syndrome

*Service ORL, H6pital Saint Charles, CHU Montpellier, 34059 Montpellier CEDEX, France; and tUniti! des Troubles du Sommeil, H6pital Gui de Chauliac, CHU Montpellier, 34059 Montpellier CEDEX, France

Summary: Uvulopalatopharyngoplasty (UPPP) is the surgery most often performed for sleep apnea syndrome (SAS). However, good results with UPPP, demonstrated by polysomnography, have been reported in only 50% of cases. Failure ofUPPP may be caused by: 1) bad management of the SAS, which is better treated in some patients with nasal CPAP than with surgery; and 2) an airway obstruction located not only at the palatopharynx (PP) level. Other surgical procedures to enlarge other sites of obstruction are described. Retro-tongue-base-pharynx (RTBP) surgery is emphasized, including mandibular advancement, hyoid bone suspension, and tongue base reduction. Maxillomandibular advancement is the most efficient technique but also the most complicated. Key Words: Uvulopalatopharyngoplasty - Retro-tongue-base-Pharynx surgery - Maxillomandibular advancement- Sleep apnea syndrome.

Uvulopalatopharyngoplasty (UPPP) is probably the best known and the most frequently performed operation for sleep apnea syndrome (SAS). However, polysomnography demonstrates good results following UPPP in about 50% of cases. There are many other surgical procedures that may be useful in association with UPPP. Their principles, indications, and results should be known. ANATOMICAL BASIS The main issue is to define exactly the sites of apneic collapse so that treatment can be accurately directed. This requires clinical examination of the upper airway, fiberoptic evaluation, and X-ray analysis (CT scan and, more often, cephalometric data). Where in the upper airway can the obstruction be located?

tive apneas, and their narrowing may only aggravate the obstruction at a lower level. The oropharynx is an area bounded by muscular structures. The compliance ofthe oropharyngeal walls explains apneic pharyngeal collapse, which starts at the junction of the lower part of the soft palate, the posterior-superior part of the base of the tongue and the posterior pharyngeal wall, and then spreads in a rostrocaudal way. The oropharynx can be divided into a superior area called the palatopharynx (PP) and an inferior area called the retro-tongue-base-pharynx (RTBP). The RTBP area is sometimes called the "hypopharynx". However, this is an incorrect term because the hypopharynx is located below the larynx (and cannot be the site of an obstructive apnea). Riley and Guilleminault (1) have established a classification for oropharyngeal closure: type 1 - PP; type 2 - PP and RTBP; type 3-RTBP. The supraglottic level of the larynx may contribute to obstructive apnea, but only in few cases.

The nose and rhinopharynx, which are cavities limited by facial and skull base bones, have noncollapsible walls. Thus they are not a possible site of obstruc-

SURGICAL PROCEDURES Surgery of the PP (UPPP excepted)

Accepted for publication August 1992. Address correspondence and reprint requests to L.Crampette, Service ORL, CHU Montpellier, 34059 Montpellier CEDEX, France.

Tonsillectomy without soft palate correction is rarely sufficient in adults, but it is often performed in chil-

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*L. Crampette, tB. Carlander, *M. Mondain, tM. Billiard, *B. Guerrier and *Y. Dejean

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Maxillary advancement procedure Lefort I osteotomy allows a maxillary mobilization that involves soft palate advancement. Because this operation increases PP size, it is described in this article. However, maxillary advancement is usually FIG. 1. Cephalometric analysis used for evaluation of patients with SAS. SNA = 82 (SD ± 2), maxilla to cranial base; SNB = 80 (SD associated with mandibular osteotomy, a combined ± 2), mandible to cranial base; PAS = 11 mm (SD ± 1), posterior procedure that enlarges both PP and RTBP. airway space; PNS-P = 37 mm (SD ± 3), length of soft palate; MPTo conclude this section, we must emphasize that, H = 15.4 mm (SD ± 3), distance of hyoid from inferior mandible [in Riley et al. (6)]. in adults, UPPP remains the prevailing surgical procedure of the PP level. dren with SAS, usually associated with adenoidectomy. It must be stressed that it would be useless and dangerous for apneic children with both tonsillar and RTBP surgery adenoid hypertrophy to receive adenoidectomy alone:. The R TBP can be transversally narrowed by the In apneic children whose soft palates are excessive, inferior part of the tonsils, and thus tonsillectomy, alone UPPP may be useful, without complications. Howor as part of the UPPP operation, enlarges this area. ever, one may hesitate to perform UPPP in children But this is a rare occurrence, and usually the R TBP is for fear of growth problems in the future. Thus, another narrowed in an anterior-posterior plane, through a desurgical technique has been proposed for children (2). of the posterior airway space, whose cause is crease This procedure uses a tranpalatal approach to remove hypertrophy, retroposition and/or changes in the orithe posterior part of the hard palate and to advance of the base of the tongue. Cephalometric analentation the soft palate. ysis provides the best method to evaluate RTBP and is essential to plan the surgical therapy (Fig. 1). Laser applied to the soft palate 0

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Laser is used in snoring patients by some head and neck surgeons in the area just lateral to the uvula. But laser does not allow a lateral pharyngeal correction (pharyngoplasty) as UPP does, because of the risk of stenotic complications. Thus, laser at the PP site is not considered an effective treatment but only an adjunctive technique.

Mandibular and maxillomandibular advancement

The goal of mandibular osteotomy is to advance the genial tubercles, to which the tongue is attached anteriorly. Mandibular advancement with no changes in dental occlusion. The first operation described (4) was a subapical horizontal sliding osteotomy. The current technique, called anterior mandibular osteotomy (AMO) Intrapalatine resection (IPR) requires a more limited osteotomy (5), shown in Fig. ·Intrapalatine resection (IPR) is a full-thickness re- 2. This procedure is easier and does not require transection of the proximal part of the soft palate, like an sient tracheotomy, jaw fixation or orthodontic correcSleep, Vol. 15, No.6, 1992

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orange segment (3). The advantage of this technique is that the uvula and the aesthetic appearance of the palate are kept intact. Some remarks can be made: 1) This technique removes a part of the muscular system of.the soft palate, which is known to be necessary for good soft palate function. 2) It preserves the edematous part of the soft palate, which is involved in the pathological process. This explains why of the five cases reported by Crestinu (3), one has required an additional resection. 3) IPR limits postoperative pain, which is a classical complication ofUPPP. This advantage is counterbalanced with the hazard of suture breakage, described in one of the five cases presented by Crestinu (3).4) The need to perform lateral pharyngoplasty for managing SAS is hazardous to soft palate vitality, and IPR should be reserved for snoring treatment.

ALTERNATIVES TO UPPP IN SAS

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tions. It can be associated, without any biomechanical complications, with a hyoidopexy. Anatomical indications for AMO combined with hyoidopexy are RTBP narrowings with no tongue enlargement and normal skeletal development (normal SNB) (Fig. 1). Good results (apneic index 50 per hour. All these criteria are known to be pronostic factors for the success of various surgical procedures. MMO procedure is the only one to be efficient even if morbid obesity is present (1). 2) All sites of obstruction must be corrected: type 1 obstruction - UPP alone; type 3 obstruction - AMO + hyoidopexy, or sagittal ramus split, or tongue base reduction (according to cephalometric data); and type 2 obstruction - the first stage may be UPP + AMO + hyoidopexy or UPP + tongue base reduction + hyoldopexy. The second stage, if necessary: MMO. 3) Results must be assessed by postoperative poiysomnography because no procedure is constantly effective except the MMO. The patient may be satisfied because snoring is attenuated but may still have numerous obstructive apneas. In case of poor results, another surgical procedure must be performed. We recommend that the patient be informed about the possibility of two or more stages being required for successful operative treatment. Alternatively, nasal CPAP should be considered. REFERENCES I. Riley RW, Powell NB, Guilleminault C. Maxillofacial surgery

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Surgical alternatives to uvulopalatopharyngoplasty in sleep apnea syndrome.

Uvulopalatopharyngoplasty (UPPP) is the surgery most often performed for sleep apnea syndrome (SAS). However, good results with UPPP, demonstrated by ...
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