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Uvulopalatoplasty (UP2): a Modified Technique for Selected Patients

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Uvulopalatoplasty (UP2): a Modified Technique for Selected Patients The Laryngoscope Lippincott Williams & Wilkins, Inc. © 2004 The American Laryngological, Rhinological and Otological Society, Inc. Uvulopalatoplasty (UP2): A Modified Technique for Selected Patients Michael Friedman, MD; Hani Ibrahim, MD; Sarah Lowenthal, MD; Vidyasagar Ramakrishnan, MBBS, MS; Ninos J. Joseph, BS Objectives: The goal of uvulopalatopharyngo- return to solid diet, and less long-term complaints of plasty (UP3) in the treatment of obstructive sleep ap- globus sensation. Conclusions: UP2 with tonsil cobla- nea–hypopnea syndrome (OSAHS) is to reduce ob- tion offers some reduction in postoperative morbidity struction by eliminating redundant tissue in three without affecting outcome for selected patients with areas: the soft palate, tonsils, and pharynx. However, OSAHS. Pain levels, however, are still very signifi- some OSAHS patients may present with tonsil hyper- cant. Key Words: Uvulopalatoplasty, modified uvulo- trophy and elongated soft palate without redundant palatoplasty, OSA treatment, radiofrequency for OSA pharyngeal folds. We treated this group of patients treatment. with tonsil reduction using radiofrequency coblation Laryngoscope, 114:441–449, 2004 combined with uvulopalatoplasty (UP2) using a pala- tal flap technique without pharyngoplasty. Morbidity and outcome was then compared with a group of pa- INTRODUCTION tients who underwent classic UP3. Study Design: A The goal of uvulopalatopharyngoplasty (UP3) in the retrospective, nonrandomized study comparing mor- treatment of obstructive sleep apnea–hypopnea syndrome bidity and outcomes of the modified technique (UP2) (OSAHS) is to reduce obstruction through elimination of with patients who underwent standard UP3. Methods: redundant mucosal folds, obstructing tonsils, and excess Patients were all staged according to the previously soft palate. The “pharyngoplasty” component of classic described Friedman staging system. Those with re- UP3 specifically addresses redundant loose mucosal folds ؍ dundant pharyngeal folds were treated with UP3 (n 33), and those without redundant pharyngeal folds in the pharynx. Although this portion of the procedure theoretically widens the pharyngeal air space, it may also .(30 ؍ were treated with tonsil coblation and UP2 (n Charts of patients undergoing UP2 and UP3 between be responsible for significant morbidity. Morbidity of UP3 July 1, 2001 and July 1, 2002 were reviewed. Thirty- is significant both in the early postoperative period as well three consecutive patients who underwent UP3 were as in the permanent sequelae often associated with the selected for study as well as 30 consecutive patients procedure.1–3 Early morbidity, including pain and dyspha- who underwent UP2. Pre- and postoperative quality gia, is at least partially caused by the pharyngoplasty of life questionnaires and patient questionnaires fo- component.2,4,5 In addition, permanent complaints of ab- cusing on diet, pain, and return to activity were re- normal sensations in the throat, such as “inability to clear viewed to assess subjective morbidity and elimina- the throat” and dysphagia, are also likely caused by the tion of symptoms. Objective measurements include 3,6 preoperative and postoperative (6–18 months) poly- pharyngeal component of the surgery. Logic would also somnography (PSG). Results: Symptom elimination suggest that the pharyngeal component of the surgery and objective PSG results were compared. There was exposes the patient to increased risk of postoperative no statistical difference in results between the UP3 bleeding. group and the UP2 group. Morbidity, however, was Pharyngeal obstruction can be attributed to various significantly more prominent, and recovery was more factors, including tonsil size, redundant folds in the phar- prolonged, in the UP3 group. Patients undergoing ynx, tongue-base position and size, and other factors. UP2 had fewer pain days, less narcotic use, quicker However, many patients have tonsillar hypertrophy with- out redundant pharyngeal folds and, therefore, may not Presented at the Annual Meeting of The Triological Society, May benefit from the pharyngoplasty component of classic 4–6, 2003, Nashville, TN. UP3. Obstructing tonsillar tissue can be eliminated by From the Department of Otolaryngology and Bronchoesophagology (M.F., H.I., N.J.J.), Rush–Presbyterian-St. Luke’s Medical Center, Chicago, subcapsular tonsil coblation technique, and when no re- IL; and the Division of Otolaryngology (M.F., H.I., S.L., V.R., N.J.J.), Advocate dundant pharyngeal folds are present, pharyngoplasty Illinois Masonic Medical Center, Chicago, IL, U.S.A. can be eliminated. Soft palate reduction can be per- Editor’s Note: This Manuscript was accepted for publication Septem- formed as needed to widen the retropalatal space. Thus, ber 2, 2003. Send Correspondence to Dr. Michael Friedman, 30 N. Michigan, a uvulopalatoplasty (UP2) might be more appropriate Suite 1107, Chicago, IL 60602, U.S.A. E-mail: [email protected] for these patients and might spare them the discomfort Laryngoscope 114: March 2004 Friedman et al.: Uvulopalatoplasty, A Modified Technique 441 and possibly permanent morbidity associated with the bodily pain (BP), (4) general health (GH), (5) vitality (energy/ pharyngoplasty. fatigue) (VT), (6) social functioning (SF), (7) role limitation be- This study was designed to assess a modified tech- cause of emotional problems (RE), and (8) mental health (psycho- 8 nique of UP2 combined with subcapsular tonsil coblation logic distress and psychologic well-being) (MH). A score of 0 to 100 is calculated for each domain on the basis of patient re- with respect to early and late morbidity and success in sponses. A score of 100 represents the best possible health. eliminating symptoms and normalizing polysomnographic findings in selected OSAHS patients. The experimental Physical Examination Parameters group was compared with a group of patients treated with Chart review recorded significant physical findings. Pa- standard UP3. tients underwent preoperative physical examinations that in- cluded a full assessment of the upper airway with nasopharyn- MATERIALS AND METHODS golaryngoscopy, Mueller maneuver, and standard examination. Since 2001, patients who had no redundant pharyngeal In addition, patients were staged according to the previously folds have been treated with a modified technique including tonsil described Friedman staging system on the basis of the Friedman coblation and UP2. Institutional review board approval was ob- palate position (FPP), tonsil size, and body mass index8 (BMI) tained to conduct a retrospective study comparing morbidity and (Table I). Weight and height were recorded at the initial visit, and success of patients treated with UP2 with tonsil coblation tech- the BMI (kg/m2) was calculated. nique (UP2 group) versus with a standard UP3 technique (UP3 Stage I disease was defined as those patients with FPP I or group). All patients had complaints of loud snoring and excessive II, tonsil size 3 or 4, and BMI of less than 40 kg/m2 (Table I). Stage daytime somnolence. All patients were extensively questioned on II disease is defined as FPP I or II and tonsil sizes 0, 1, or 2 or FPP symptoms indicative of OSAHS, including restless sleep, loud and III and IV with tonsil sizes 3 or 4 and BMI of less than 40 kg/m2. heavy snoring, daytime sleepiness, decreased daytime alertness, Stage III disease is defined as FPP III or IV, tonsil sizes 0, 1, or irritability and short temper, morning headaches, forgetfulness, 2, and BMI less than 40 kg/m2. All patients with a BMI greater mood or behavior changes, anxiety or depression, or a decreased than 40 kg/m2, regardless of FPP or tonsil size, as well as those interest in sex. Patients were asked to rate these symptoms on patients with significant craniofacial or other anatomic abnor- the basis of the pattern of occurrence: always, frequent, or rare. malities, were designated as Stage IV8 (Table I). Those patients who described loud snoring and the occurrence of at least two other of the above symptoms as “always” or “fre- Polysomnography quent” fulfilled the basic criteria for further investigation, includ- An all-night attended, comprehensive sleep study was per- ing physical examination, quality of life (QOL) survey, and formed using a computerized polygraph to monitor electroencepha- polysomnography. logram (C3-A2, C4-A1), left and right electro-oculogram, electrocar- The charts of patients treated during a 1 year period be- diogram, chin and anterior tibialis electromyogram, abdominal and tween July 1, 2001 and July 1, 2002 were reviewed. Thirty-three thoracic movement by inductive plethysmograph, nasal oral air- patients who underwent UP3 were identified. Although more flow, oxygen saturation by pulse oximetry (SaO2), and throat than 33 UP3 procedures were performed during this time span, sonogram. Apnea was defined as cessation of breathing for at this group represented a consecutive series of patients undergo- least 10 seconds. Hypopnea was a decreased effort to breathe at ing this procedure who fulfilled the inclusion criteria listed below least 50% less than the baseline and with at least a 4% decrease and for whom complete data were available. These patients com- in SaO2. Airflow was measured by a thermister (Protech model prised the control group. The charts of 30 additional patients who fulfilled the inclusion criteria and underwent UP2 with tonsillar coblation were also identified. This group comprised the experi- mental group. TABLE I. Friedman
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