Objective: To establish the efficacy of uvulopalatopharyngoplasty with tonsillectomy for treating selected patients with severe obstructive sleep apnea syndrome

Methodology: Retrospective study of patients who underwent clinical/instrumental evaluation and surgical treatment.

Setting: University ENT division with a tertiary snoring referral center

Participants: Twenty-two patients with normal body mass index affected by severe obstructive sleep apnea syndrome-

Main outcome measures: Pre and post operative cardiopulmonary monitoring during sleep, daytime sleepiness evaluation, post treatment complication recording.

Results: Complete response to therapy was obtained in 78% of patients. Four patients had relief of symptoms but retained apnea-hypopnea index scores greater than 5

Conclusions: Uvulopalatopharyngoplasty associated with tonsillectomy can be employed safely to treat patients with normal body mass index who suffer from severe obstructive sleep apne

Ballacchino, A

Dispenza, F

GALLINA, Salvatore

Kulamarva, G

SPECIALE, Riccardo

Archivio istituzionale della ricerca - Università di Palermo

B-ENT, 2009, 5, 245-250IntroductionThe prevalence of habitual snor-ing in adult males and females isabout 24% and 14%, respectively.1Among these, obstructive sleepapnea syndrome (OSAS) affects4% of men and 2% of women. Thepathophysiology of this conditionis thought to be excessive narrow-ing of pharyngeal airway that alsocollapses during inspiration,resulting in increased negativeintrathoracic pressure, which inturn exacerbates the condition.When complete obstructionoccurs, the drastic reduction inairflow to the lungs arouses thepatient from sleep.Symptoms of OSAS are generally vague. Neurocognitivesymptoms such as memory andlearning deficits may be present,and patients can exhibit daytimefatigue due to loss of sleep orhypoxia itself. In these patients,cardiovascular diseases, such ashypertension and stroke, are relatedto sleep apnea secondary toincreased intrathoracic pressure.2As initial therapy, life-stylemodifications, such as avoidingalcohol and drugs and weightreduction, are encouraged. Whenmedical treatment is indicated,continuous positive airway pres-sure (CPAP) therapy during sleepor the use of jaw/tongue advance-ment devices may be effective.If these prove unsuccessful, surgical options are available. Thechoice of surgical proceduredepends on the site and degree ofobstruction. Uvulo palato pharyn -go plasty (UPPP) is one of themost common surgical interven-tions used to treat OSAS.Originally proposed by Ikematsu,3it was popularized in 1980 byFujita et al.4The aim of the present workwas to establish the efficacy ofUPPP with tonsillectomy in thetreatment of selected patients withsevere OSAS. Materials and methodsWe retrospectively reviewed thecharts of all patients with OSASwho were treated surgically in ourdepartment between January 2000and December 2005. A detailedhistory of all patients was recorded.All patients underwent a com-plete head and neck examination,static and dynamic endoscopicevaluation of the upper aerodiges-tive tract, Muller maneuver evaluation, body mass index(BMI) calculation, and cardio-pulmonary monitoring (CPM)during sleep. The parameters evaluated during CPM were1) apnea/hypopnea index (AHI),Uvulopalatopharyngoplasty with tonsillectomy in the treatment of severe OSASS. Gallina*, F. Dispenza**, G. Kulamarva***, A. Ballacchino**** and Riccardo Speciale*****Dipartimento Neuroscienze Cliniche, U.O. Otorinolaringoiatria, Università degli Studi di Palermo, Italia;**Dipartimento Discipline Chirurgiche e Oncologiche, U.O. Otorinolaringoiatria, Università degli Studi di Palermo,Italia; ***ENT Clinic Kasaragod, India; ****Dipartimento Neuroscienze Cliniche, U.O. Otorinolaringoiatria, Universitàdegli Studi di Palermo, ItaliaKey-words. Snoring; obstructive sleep apnea; tonsillectomy, uvulopalatopharyngoplasty; surgeryAbstract. Uvulopalatopharyngoplasty with tonsillectomy in the treatment of severe OSAS. Objective: To establish theefficacy of uvulopalatopharyngoplasty with tonsillectomy for treating selected patients with severe obstructive sleepapnea syndrome.Methodology: Retrospective study of patients who underwent clinical/instrumental evaluation and surgical treatment. Setting: University ENT division with a tertiary snoring referral center.Participants: Twenty-two patients with normal body mass index affected by severe obstructive sleep apnea syndrome.Main outcome measures: Pre- and post-operative cardiopulmonary monitoring during sleep, daytime sleepiness evalua-tion, post-treatment complication recording.Results: Complete response to therapy was obtained in 78% of patients. Four patients had relief of symptoms but retainedapnea/hypopnea index scores greater than 5.Conclusions: Uvulopalatopharyngoplasty associated with tonsillectomy can be employed safely to treat patients withnormal body mass index who suffer from severe obstructive sleep apnea.246 S. Gallina et al.calculated as the summation oftotal events per hour; 2) oxygendesaturation index (ODI); and3) saturation value reached duringsleep. Apnea was considered ascessation of breathing for at least10 seconds and hypopnea wasdefined as reduction of breathingeffort with 4% desaturation. Weevaluated the daytime sleepinessin all patients based on theEpworth’s sleepiness scale ques-tionnaire.Patients were selected for thestudy based on the followingparameters: 1) OSAS grade severe(AHI > 30) on CPM; 2) Palateposition grade I-II accordingto Friedman’s classification5;3) Palatal tonsillar hypertrophygrade 2-4 in accordance withFriedman’s grading6 (Table 1);4) Oropharyngeal (retropalatal)collapse grade 3 (50-75% of spacereduction) to grade 4 (collapse> 75%) on Muller’s maneuver(Table 2); 5) BMI < 28. Patientswho did not meet the above crite-ria were excluded from the study.Patients receiving CPAP therapywere excluded from the study.Twenty-two patients wereincluded in the study. All22 patients had been treated surgically with UPPP plus tonsillectomy under generalanaesthesia. CPM during sleepwas repeated three months afterthe surgical intervention. Post-operative apnea/hypopnea indexand ODI scores below 5 indicateda complete response to therapy.An improvement in AHI exceed-ing 50% and an AHI less than 20was considered successful treat-ment.7,8 Post-operative complica-tions and chronic adverse effects(hemorrhage, palatal insufficien-cy, rhinolalia, and disgeusia) wererecorded.Our institutional review boardapproved the study protocol.Informed consent was obtainedfrom all patients. Surgical techniqueTonsillectomies were performedusing the cold dissection method.The oropharyngeal aspect of thesoft palate mucosa was incised25-mm distal to the posterior endof the hard palate. The mucosawas then dissected off the under-lying muscle up to the free edge ofthe soft palate and then removed,leaving a myo-mucosal flap of thesoft palate mucosa on thenasopharyngeal side (Figure 1).The free soft palate mucosal edgeof the nasopharyngeal side wasthen sutured to the original inci-sion line on the palatal side(Figure 2). This process increasesthe velopharyngeal inlet. ResultsSixteen males and six femalesaffected by OSAS were includedin the study. The mean age of thepatients was 47 years (range 24-58). The median pre-operative andpost-operative scores are shown inTable 3. Mean follow up was 31months (range 20-38; Figure 3).According to Friedman’s stagingsystem,5 18 patients were stage Iand four were stage II. All of thepatients classified as stage II pre-sented with tonsil size grade 2 andpalate position 1-2.Complete response to therapywas obtained in 17 patients (78%).Four patients had relief of symp-toms but retained AHI and ODIscores greater than 5 (Table 3).Thus, treatment was successful in21 of 22 patients (96%). Onepatient (4%) was classified as notderiving any benefit from treat-ment because their post-operativeAHI score was 21. All patientswere discharged on the secondpost-operative day. Subjectivepain and swallowing discomfortdisappeared in all patients bythe eighth post-operative day(median 6; range 6-8). Returnto normal diet was used as anindex of  swallowing improve-ment. No patients complainedof velopharyn geal insufficiency.Table 1Tonsillar Hypertrophy, Friedman’s gradingGrade Clinical Features0 Previous tonsillectomy1 Tonsils inside the tonsillar fossa hidden behind the anterior palatal pillar2 Tonsils partially outside the tonsillar fossa occupying 25% of the oropharynx3 Tonsils occupying 50% of the oropharyngeal space4 Tonsils occupying more than 75% of the oropharynx, almost meeting in themidlineTable 2Grading of oropharyngeal (retropalatal) obstruction on Muller’s maneuverGrade Endoscopic Features1 Minimal movement of pharyngeal wall with space reduction between 0-49%2 Pharyngeal wall movement with space reduction between 50-74%3 Pharyngeal wall movement with space reduction between 75-99%4 Complete occlusion of pharyngeal lumenUPPP and tonsilletomy in OSAS management 247Three patients experienced per-sistent dry mouth for a mean of13 months. Two patients had aslight subjective taste disturbance,which recovered spontaneouslysix months after surgery.DiscussionIn the last decade, attention to per-sistent snoring, particularly whenassociated with apnea syndrome,has increased tremendously.OSAS is a relatively common dis-order that affects about 4% ofadults.1 It is often ignored by thepatients, which can result in seri-ous complications and evenendanger the patient’s life. Qualityof life in such patients is generallypoor as compared to that of thegeneral population, because ofdaytime somnolence and its asso-ciated consequences, such asincreased risk of accidents whiledriving and at work. Male sex isknown to be a major risk factor forrhonchopathy, this is wellexplained by the higher preva-lence of OSAS in men.9Until 1990, the procedures usedto diagnose OSAS were inade-quate for establishing the precisesite of obstruction. Therefore,patient selection for surgery wasnot accurate, which affected theeventual outcome of surgery. Currently, there are varioustherapeutic options for managingOSAS. The first approach is toencourage the patient to reducetheir body weight, improve theirsleep hygiene, and avoid alcoholand sedative consumption justbefore sleep. Medical treatmentsconsist of CPAP devices and oralappliances that advance themandible to allow the airway toremain patent. Patients show a lowcompliance with CPAP use andoften discontinue or interrupt thetreatment for various reasons. Surgery is generally considereda second-line option. Several tech-niques have been described inliterature , based on the grade ofOSAS. Surgery can be performedon either an inpatient or an outpa-tient basis, depending on theseverity of sleep apnea and thesurgical procedure chosen.Historically, lack of under-standing of the pathophysiologyof OSAS contributed to the erro-neous application of some surgicaltechniques, such as removingFigure 1Dissection of the mucosa off the underlying muscle up to thefree edge of the soft palate, creating a myo-mucosal flap of thesoft palate mucosa on the nasopharyngeal side.Figure 2Suturing the palatal flap using an absorbable sutureba248 S. Gallina et al.muscles of the soft palate alongwith its mucosa in order to debulkthe soft palate, which invited poorresults. Implementation of thesetypes of procedures was likelymain reason behind the highprevalence of complications andfailure in the treatment of OSAS.excluding those patients withhypopharyngeal (retroglossal andlateral wall) collapse from UPPP.10For young patients in goodgeneral health, we propose surgi-cal correction of the predominantcause of OSAS. Accurate patientselection and use of the least inva-sive technique that gives the bestsuccess rate are paramount forsuccess. UPPP is a procedure witha reasonably short post-operativerecovery period that is charac -terized by swallowing difficultyand pain.7 In our series, allpatients had complete resolutionof pain and improvement in swal-lowing discomfort by the eighthpost-operative day. The long-termsuccess rate of UPPP ranges from50% to 80%.11-14 In a recent meta-analysis, Sher et al.11 found anoverall success rate of 40.7%. Thesuccess rate was related to thelevel of obstruction and was52.3% in patients with onlypalatal narrowing or collapse,dropping to just 5.3% in patientswith a retro-glossal obstructionwith or without palatal compo-nent.11 Because this surgery is per-formed in patients who have expe-rienced labored breathing for avery long time before surgery,they should be observed closelyfollowing surgery. However, theviews regarding post-operativeobservation vary. Spiegel andRaval15 suggested monitoringpatients for only 2-3 hours aftersurgery and then discharging themhome. Kezirian et al.16 reported anonfatal complications rate of1.5% and mortality of 0.2% in aseries of more than 3000 cases ofUPPP.Great care should be exercisedwhen intubating and extubatingthese patients for general anaes-thesia, because patients withOSAS typically have difficultTable 3Cardiopulmonary monitoring and daytime sleepiness variations Pre-operative Post-operativemedian score (range) median score (range)Apnea/Hypopnea index 45 (40-56) 4 (3-21)Oxygen desaturation index 39 (36-43) 4 (4-24)Sleeping oxygen saturation 71% (68-80) 92% (80-95)Epworth sleepiness scale 15 (12-17) 5 (5-9)Advances in diagnostic deviceshave allowed for more preciseevaluation of patients who sufferfrom snoring. Endoscopic evalua-tion of upper respiratory tract col-lapse on Muller’s maneuver andits grading have enabled moreeffective surgical approaches byFigure 3A patient affected by severe OSAS stage II who was treatedwith UPPP and tonsillectomy. a) Pre-operative photograph.b) Post-operative features after 6 months of follow-up.baUPPP and tonsilletomy in OSAS management 249 airways. Riley et al.17 reported thatmost post-operative complicationswere related to hypertension andat that only six of 182 patients hada post-operative saturation lessthan 90% (possibly attributable tonarcotics used for general anaes-thesia). It is mandatory that regu-lar CPM be performed during sur-gical follow up in order to assessfor residual disease and evaluatetreatment efficacy. Indeed, the riskof developing cardiovascular com-plications in patients with unre-solved OSAS is nearly 50%.18UPPP is associated with bothshort-term and long-term compli-cations. However, as noted bySher et al.,11 it is impossible todetermine the true rate of compli-cations because of the majority ofpapers on UPPP have not reportedthe presence or absence of compli-cations. The more common com-plications described in literatureare velopharyngeal insufficiency,post-operative bleeding, nasopha-ryngeal stenosis, and voicechange. In our study, the maincomplications encountered weretaste disturbance in two patientsand mouth dryness in threepatients. Damage to taste buds onthe soft palate during UPPP mightbe a factor in post-operative tastefunction impairment, which isobserved in 7-10% of patients.19However, taste function mayrecover over time, as wasobserved in our patients.UPPP is contraindicated inthose patients with only retroglos-sal obstruction. In a previousreport, negative predictors of out-come were combined palatal andretroglossal obstruction and previ-ous tonsillectomy.13 A pharyngealsurgical approach may be recom-mended for patients with severegrade OSAS. As demonstrated byour data, a greater than 50%reduction of the pre-operative AHIwas obtained in 96% of patientswith severe OSAS, indicatinggood efficacy of UPPP plus tonsillectomy. These data coincidewith those reported by Friedmanet al.,6 who obtained an 80% success rate in stage I patientsmanaged with UPPP. In our opinion, tonsillectomy should beperformed during the same surgical session in a day-surgeryregimen.20 Friedman et al.21 asserted that in patients withpalatal obstruction who haveundergone previous tonsillectomy,it might be better to perform aZ-palatoplasty during UPPP. It is known that a BMI greaterthan 27 drastically reduces theefficacy of UPPP, even with combined genioglossus advance-ment and hyoid suspension.Symptomatic relief by UPPP isknown to deteriorate during long-term follow-up. In a survey ofpatients at 17-20 years post UPPP,the percentage of symptomaticrelief had decreased significant-ly.18 Weight gain was the main predisposing factor for recurrenceof symptoms. ConclusionsPatients suffering from OSASshould be evaluated using a multidisciplinary approach. Deter -mining the site and grade ofobstruction is mandatory forselecting the appropriate treat-ment strategy. Although surgeryremains a second-line option, itcan help to reduce snoring andthe frequency of sleep apneaepisodes. Our data suggest thatUPPP associated with tonsillec -tomy can be safely employed totreat even those patients withsevere OSAS with stage I-II disease and normal BMI.References1. Woodhead CJ, Davies JE, Allen MB.Obstructive sleep apnoea in adultspresenting with snoring. ClinOtolaryngol Allied Sci. 1991;16:401-405.2. White DP. Sleep apnea. Proc AmThorac Soc. 2006;3:124-128.3. Ikematsu T. Study of snoring, 4threport: therapy. J Jpan Otol RhinolLaryngol Soc. 1964;64:434-435.4. Fujita S, Conway W, Zorick F, Roth T.Surgical correction of anatomicabnormalities in obstructive sleepapnea syndrome: uvulopalatopharyn-goplasty. Otolaryngol Head NeckSurg. 1981;89:923-934.5. Friedman M, Ibrahim H, Joseph NJ.Staging of obstructive sleep apnea/hypopnea syndrome: a guide toappropriate treatment. Laryngoscope.2004;114:454-459.6. Friedman M, Ibrahim H, Bass L.Clinical staging for sleep-disorderedbreathing. Otolaryngol Head NeckSurg. 2002;127:13-21.7. Friedman M, Ibrahim H,Lowenthal S, Ramakrishnan V,Joseph NJ. Uvulopalatoplasty (UP2):a modified technique for selectedpatients. Laryngoscope. 2004;114:441-449.8. Sher AE. Upper airway surgery forobstructive sleep apnea. Sleep MedRev. 2002;6:195-212.9. Walker RP, Durazo-Arvizu R,Wachter B, Gopalsami C.Preoperative differences betweenmale and female patients with sleepapnea. Laryngoscope. 2001;111:1501-1505.10. Stuck BA, Maurer JT. Airway evalua-tion in obstructive sleep apnea. SleepMed Rev. 2008;12:411-436.11. Sher AE, Schechtman KB,Piccirillo JF. The efficacy of surgicalmodifications of the upper airway inadults with sleep apnea syndrome.Sleep. 1996;19:156-177.12. Pépin JL, Veale D, Mayer P,Bettega G, Wuyam B, Lévy P. Criticalanalysis of the results of surgery in thetreatment of snoring, upper airwayresistance syndrome (UARS), andobstructive sleep apnea (OSA). Sleep.1996;19(9 Suppl):S90-S100.13. Hessel NS, de Vries N. Results ofuvulopalatopharyngoplasty after diag-nostic workup with polysomnography250 S. Gallina et al.and sleep endoscopy: a report of136 snoring patients. Eur ArchOtorhinolaryngol. 2003;260:91-95.14. Röösli C, Schneider S, Häusler R.Long-term results and complicationsfollowing uvulopalatopharyngoplastyin 116 consecutive patients. Eur ArchOtorhinolaryngol. 2006;263:754-758.15. Spiegel JH, Raval TH. Overnight hospital stay is not always necessaryafter uvulopalatopharyngoplasty.Laryn goscope. 2005;115:167-171.16. Kezirian EJ, Weaver EM, Yueh B, etal. Incidence of serious complicationsafter uvulopalatopharyngoplasty.Laryngoscope. 2004;114:450-453.17. Riley RW, Powell NB,Guilleminault C, Pelayo R, Troell RJ,Li KK. Obstructive sleep apnea surgery: risk management and complications. Otolaryngol HeadNeck Surg. 1997;117:648-652.18. Goh YH, Mark I, Fee WE Jr. Qualityof life 17 to 20 years after  uvulo -palato pharyngoplasty. Laryngoscope.2007;117:503-506.19. Kamel UF. Hypogeusia as a complication of uvulopalatopharyn-goplasty and use of taste strips asa pratical tool for quantifying hypogeusia. Acta Otolaryngol. 2004;124:1235-1236.20. Laureyns G, Lemkens P, Jorissen M.Tonsillectomy as a day-case surgery:a safe procedure? B-ENT. 2006;2:109-116.21. Friedman M, Ibrahim HZ,Vidyasagar R, Pomeranz J, Joseph NJ.Z-palatoplasty (ZPP): a technique forpatients without tonsils. OtolaryngolHead Neck Surg. 2004;131:89-100.22. Riley RW, Powell NB,Guilleminault C. Obstructive sleepapnea syndrome: a review of 306 con-secutively treated surgical patients.Otolaryngol Head Neck Surg. 1993;108:117-125.F. Dispenza, M.D.Via Paolo Emiliani Giudici, 37 90127 Palermo, ItalyE-mail: francesco.dispenza@gmail.com

Uvulopalatopharyngoplasty with tonsillectomy in the treatment of severe OSAS

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Uvulopalatopharyngoplasty with tonsillectomy in the treatment of severe OSAS

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