Uvulopalatal Flap For

■ The uvulopalatal flap (UPF) is recommended as a surgical option for oropharyngeal obstruction in patients with sleep-related breathing disorders.

■ The procedure is a mucosal procedure; thus, swelling and swallowing problems are moderate and transient.

■ The success of the UPF depends on carefully selected patients and it is performed as a one-stage surgery.

■ Patients with sleep-related breathing disorders pose a significant anesthetic risk and are generally deemed as difficult intubations. Sedating and narcotic medications pose a significant anesthetic risk. They increase the collapsibility of the pharynx and oral soft tissues, leading to additional airway obstruction. The UPF appears to be a safe and effective procedure that can be easily performed under local anesthesia on an outpatient basis with low chance of significant complications.

■ There is reduction of pain and a decreased risk of wound contracture because sutures are not placed on the free edge of the palate.

■ The UPF results are anatomically and clinically comparable to uvulopalatopharyngo-plasty results.

■ The UPF procedure is reversible since the UPF can be released in the postoperative period if necessary.

Contents

Introduction 309

Indications and Patient Selection 310

Surgical Technique 310

Uvulopalatal Flap Under Local Anesthesia 313

Postoperative Care 313

Results 313

Complications 314

Conclusion 314

References 314

Introduction

Obstructive sleep apnea (OSA) is now seen as one end of a spectrum of sleep-related breathing disorders. It is a common event, occurring to a significant degree (more than five events per hour of sleep) in 49% of the population [16]. Severe disease (more than 50 events per hour) is associated with excess mortality [11] and patients present with complaints related to excessive daytime sleepiness, disturbed sleep, morning headache, impotence, and heavy snoring. In addition, OSA contributes to deficits in a number of cognitive processes, including intellectual abilities, executive functions, memory, and learning [5].

In a study by He et al. [2], the cumulative survival after 5 years in treated and untreated patients with an apnea index greater than 20 showed that cumulative survival was 100% for the continued positive airway pressure (CPAP) treated group versus about 75% for the untreated group. CPAP was demonstrated as effective in suppressing OSA, although long-term compliance remains a major problem. Many studies [3, 13, 14] report that patients with moderate to severe sleep apnea use their CPAP for only a mean of 4.7 h/night and for a mean 68% of their total sleep time. However, full-time use of CPAP is necessary to control the symptoms of OSA.

Tips and Pearls

■ Surgical treatments for OSA are considered when initial medical treatments have failed and the patients are unable to tolerate nasal CPAP.

mine the location of the obstruction. Surgery is indicated when conservative measures, including use of nasal CPAP, fail. The presurgical evaluation includes a physical examination and workup to confirm the location of obstruction.

Patients who cannot comply with medical therapies for their OSA become at risk of serious medical consequences, including a twofold to threefold increase in the risk of motor vehicle accidents [15].

Since uvulopalatopharyngoplasty (UPPP) was first introduced by Fujita et al. [1] in 1981, many other surgical procedures have been developed to enlarge the compromised upper airway in patients with OSA. The surgical concept for the treatment of OSA is to enlarge the upper airway, thereby restoring its patency during sleep.

The uvulopalatal flap (UPF) procedure described by Powell et al. [12] provides the same anatomical results as UPPP, but with less postoperative pain, less risk of developing velopharyngeal insufficiency, and fewer complaints of foreign-body sensation. The excess palate and uvula are tacked up to the remaining functional palate. If the reduction is too extreme, the flap can be released in the postoperative period. Huntley [4] in 2000 performed the procedure under local anesthesia in the outpatient setting using the same instruments as for the inpatient procedure. Other surgeons also reported on the UPF with successful outcomes. The procedure appeared to be safe and effective for the treatment of snoring [10] and OSA [9] in carefully selected patients. The UPF was also used in conjunction with genioglossus advancement and hyoid myotomy to treat patients with multilevel obstruction.

The advantages of the UPF procedure are:

Factors that may suggest the oropharynx as the site of obstruction are:

Reversible procedure

Low total cost with inexpensive instruments One-stage procedure

Decrease velopharyngeal insufficiency (VPI) Low scar contracture

Fewer complaints of foreign-body sensation Same anatomical results as UPPP Well-tolerated outpatient surgical procedure Safe and effective adjunct procedure for patients with multilevel obstruction

Body mass index below 31 kg/m2. No mandibular skeletal deficiency. Mild to moderate degree of OSA. Redundant soft palate. Retropalatal collapse on Müllers maneuver. Appropriate retrolingual space (posterior airway space greater than 11 mm.) Distance from the posterior nasal space to the tip of the soft palate of more than 37 mm.

As part of the preoperative evaluation the surgeon should carefully review the site of obstruction on physical examination, nasopharyngoscopy, and the cephalogram. Patients with a respiratory disturbance index (RDI) greater than 40 and lowest oxygen saturation less than 80% are advised to use CPAP for 2 weeks prior to surgery. Patients with multilevel obstruction should have hypopharyngeal surgery performed simultaneously with UPF.

Indications for the UPF procedure are:

Failure of appropriate medical therapy in OSA and upper airway resistance syndrome Habitual snoring which disturbs the sleeping partner

Contraindications for the UPF procedure are:

Submucous cleft Hemangioma of the soft palate Bleeding disorder Severe trismus Cleft palate

Velopharyngeal insufficiency Uncontrolled medical condition

Indications and Patient Selection

A high degree of success with the UPF can be achieved when the patients have obstruction in the region of the oropharynx. Surgical success depends upon the ability of the surgeon to assess the airway and deter-

Surgical Technique

The UPF procedure is performed under general anesthesia with the patient in the Rose position. After orotracheal intubation has been performed, a self-retaining mouth gag is inserted to maintain adequate exposure. The oropharyngeal structures are careful ly inspected to determine the dimension of the inlet (Fig. 32.1a). The soft palatal arch and the uvula are frequently in direct contact with the posterior pha-ryngeal wall. The uvula is pulled away from the pharyngeal wall and reflected back toward the soft palate, expanding the oropharyngeal space. We can estimate the potential airspace to be achieved and the amount of the tissue to be removed (Fig. 32.1b). Five to 10 ml of 1% lidocaine with 1:100,000 epinephrine solution is injected at three points 1 cm from the lower rim of the palatal arch. This is to promote ho-meostasis and is done by agreement with the anesthesiologist.

The flap is designed as a rhombus on the soft palate, one angle of which is on the uvula and the opposite angle is on the soft palate near the hard-palate and soft-palate junction. The outline is not brought onto the edge of the palate. It can be carried out laterally to achieve the lateral advancement.

The mucosa, submucosa with glands, and fat on the lingual surface of the uvula and soft palate are stripped away from the muscular layers beginning at the top corner in the soft palate (about 2 cm from the base of the uvula) and moving downward, toward the uvula (Fig. 32.1c). A bleeding point will often be encountered near the left and right corners of the incision.

The uvular tip is amputated and excess mucosa is carefully removed inside the outline. The uvula should be clamped before amputation to prevent troublesome bleeding from the uvular artery. If bleeding occurs, it is controlled with electrocoagulation. The

Fig. 32.1. a Before the uvulopalatal flap procedure. b The amount of palatal shortening desired is estimated by reflecting the uvula forward. c The mucosal strip is dissected and a por
tion of the tip of the uvula is amputated. d The uvula is reflected back toward the soft palate and fixed into its new position

uvula is reflected back toward the soft palate and fixed into its new position with a 3-0 polyglactin suture (Vicryl) beginning with a mattress suture at the top corner and then with simple interrupted sutures (Fig. 32.1d). Tension can be varied to allow adjustment in elevating the edge of the soft palate and trimming redundant mucosa during suturing.

Tonsillectomy is performed avoiding damage to the underlying musculature. The palatopharyngeal muscle is pulled anterolaterally and sutured to the palatoglossal muscle. Several interrupted sutures are placed through the muscles between the two palatal arches. The tonsillar fossa is closed and redundant mucosa is eliminated.

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