Uvulopalatopharyngoplasty

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List of terms related to Uvulopalatopharyngoplasty

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Uvulopalatopharyngoplasty (also known by the abbreviations UPPP and UP3) is a surgical procedure used to remove tissue in the throat. It involves the removal of tissues which may or may not include:

• The uvula (see uvulotomy)
• The soft palate.
• The tonsils
• The adenoids, and
• The pharynx.

How UPPP is Administered

Patients undergo the UPPP operation in two very different ways, with the majority of patients receiving UPPP as a stand-alone procedure. Other patients undergo UPPP as the first procedure in a stepped plan known as "The Stanford Protocol Operation". The way in which UPPP is administered greatly affects the overall prognosis of the intervention.

Standard UPPP (The operation as a stand-alone surgical intervention)
UPPP is typically administered to patients with obstructive sleep apnea in isolation. It is administered as a stand-alone procedure in the hope that the tissue that obstructs the patient's airway is localized in the back of the throat. The rationale is that, by removing the tissue, the patient's airway will be wider and breathing will become easier.

The Role of UPPP in the "Stanford Protocol" Operation
UPPP is also offered to sleep apnea patients who opt for a more comprehensive surgical procedure called "The Stanford Protocol", first attempted by Doctors Nelson Powell and Robert Riley of Stanford University. The Stanford Protocol is essentially a "cocktail" of surgeries that aim to address the entire airway and thereby treat (or possibly cure) sleep apnea. It has been found that obstructive sleep apnea usually involves multiple sites where tissue obstructs the airway; the base of the tongue is often involved. The Protocol successively addresses these multiple sites of obstruction.

The Protocol operation involves two phases. First, the patient undergoes soft tissue surgeries, UPPP along with Genioglossus Advancement or Hyoid Suspension. After the first phase, the patient is given a sleep study and reassessed. The vast majority of patients fail the first phase, and the course of treatment may then proceed to Phase Two.

Phase Two involves maxillomandibular advancement, a surgery which moves the jaw top (maxilla) and bottom (mandible) forward. The tongue muscle is anchored to the chin, and translation of the mandible forward pulls the tongue forward as well. If the procedure achieves the desired results, when the patient sleeps and the tongue relaxes, it will no longer be able to block the airway. Success is much better for Phase two than for Phase One- approximately 90 percent benefit from the second phase, and the success of the Stanford Protocol Operation therefore is due in large part to this second phase.

Because of its high rate of complications, the role of UPPP in the Stanford Protocol operation is an important consideration that surgeons must weigh. Some surgeons, including Doctors Powell and Riley, feel that UPPP contributes to the overall success of the Stanford Protocol operation. This assertion is open to debate. In 2002, an Atlanta based surgical team, led by Dr. Jeffrey Prinsell, published results which have approximated those of the Stanford team when UPPP was not included in their mix of surgeries.

Success

The Effectiveness UPPP in Isolation
When UPPP has been administered in isolation, the results have tended to be disappointing. As explained above, sleep apnea is often caused by multiple co-existing obstructions at various locations of the airway such as the nasal cavity, and particularly the base of the tongue. It has been the experience of some patients that their breathing improved immediately following the sugery, but that the improvements tended to deteriorate after about two years. Studies suggest that when UPPP is administered as a stand-alone procedure, it is effective in less than 40% of patients. The effectiveness of many of the studies on UPPP have been criticized for being methodologically unsound.

Effectiveness of "The Stanford Protocol" Operation
Over one thousand people have undergone The Stanford Protocol Operation and received follow-up PSG testing. The results have been that 60 to 70 percent of patients have been entirely cured. In approximately ninety percent of patients, a significant improvement can be expected.

Laser-assisted uvulopalatopharyngoplasty

Laser-assisted uvulopalatopharyngoplasty (LAUP) became popular during the 1980s when it was aggressively marketed as a so-called "cure" for snoring. It was first emloyed by Yves Victor Kamami, a surgeon of the Marie-Louise Clinic in Paris, France, on people who were of slender build. Early results seemed favourable, and studies of flawed methodology were published. Longterm follow-up information was omitted entirely. The practice of using lasers to address snoring became widespread. During the late 1990s, researchers (including Finkelstein, Schmidt and others) published data which demonstrated that in a considerable number of cases, laser-assisted uvulopalatoplasty may also cause mild OSA in patients who formerly were nonapneic snorers, or lead to deterioration of existing apnea. These results are attributable to thermal damage inflicted by the laser beam. The laser may induce progressive palatal fibrosis, accompanied by medial traction of the posterior tonsillar pillars ie., scar tissue reduces the airspace in the pharynx leading to velopharyngeal insufficiency. The scar tissue can also make the airway more prone to collapse during sleep. LAUP can be a medically induced cause of sleep apnea. Despite adverse results, LAUP continues to be administered by a minority of surgeons. To this day, few if any patients who have undergone laser-assisted uvulopalatopharyngoplasty for primary (social) snoring have been provided with pre- and postoperative polysomnogram (sleep testing) or followup. An LAUP procedure typically costs between two and three thousand American dollars. It takes roughly thirty minutes and is usually done in a surgeon's office as an outpatient procedure. Typically a CO₂ type laser is used.

• 
  Radiofrequency surgical unit. Radiofrequency-assisted uvulopalatoplasty (RAUP) is similar to laser-assisted uvulopalatoplasty (LAUP). It is done with a radiofrequency (RF) instrument, instead of a laser .
• 
  Local anesthesia. A topical anesthetic spray and an injection of lidocaine are used to numb the soft palate and uvula.
• 
  A special RF electrode is used to make two vertical cuts on either side of the uvula. These are joined by a horizontal cut and the uvula is removed. Occasionally, the edge of the soft palate is trimmed as well.
• 
  RF Instrument.
• 
  Designing the cuts.
• 
  Vertical cut.
• 
  Horizontal cut.
• 
  Final appearance.
• 
  Radiofrequency-Assisted Uvulopalatoplasty (6 months post-op.)

Risks

One of the risks is that by cutting the tissues, excess scar tissue can "tighten" the airway and make it even smaller than it was before UPPP. Some individuals who have undergone UPPP as a stand alone procedure have written on internet forums that they experienced a worsening of their breathing following UPPP[2][3][4]. Others have spoken of severe acid reflux.

After surgery, complications may include:

• Sleepiness and sleep apnea related to post-surgery medication
• Swelling, infection and bleeding
• A sore throat and/or difficulty swallowing
• Drainage of secretions into the nose and a nasal quality to the voice. Speech does not seem to be affected by this surgery.
• Narrowing of the airway in the nose and throat (hence constricting breathing) snoring and even iatrogenically caused sleep apnea.
• Patients who have had the uvula removed will become unable to speak French or any other language that has a uvular 'r' phoneme.

References

• WebMDHealth. Uvulopalatopharyngoplasty for snoring Retrieved August 26 2005.
• Royal College of Surgeons Audit Symposium March 8th 2002 Retrieved April 22 2006.
• University of Maryland Medical Center Patient Education - UPPP Retrieved April 22 2006.
• The Vancouver Sleep and Breathing Centre May 30 2006 Risks associated with LAUP surgeries

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