[WARNING: this article contains pictures of the throat before or after surgery only]
The Legend of UPPP
As a sleep surgeon who has watched the development and maturity of new procedures for sleep apnea, the biggest hurdle I fight in my practice is the legend of the UPPP (Uvulopatalopharyngoplasty, also known as UP3 or sometime just “sleep apnea surgery”). Many people know someone who went through this horrific experience without improvement. UPPP is the one-size-fits-all surgery that many have gotten from surgeons to treat their sleep apnea which originated in the 1980’s. Many subtle variations of the original procedure have been described and many surgeons, unfortunately, are still performing this same procedure not much different than its original form today. While some were helped, the recovery was difficult and side effects such a feeling something in throat, dry throat and mucous issues often persisted. Unfortunately, many of the patients who had this surgery for sleep apnea, didn’t have any significant improvement in their disease and would be referred back to CPAP. However after this tissue removal, many could not wear the more comfortable nasal masks and, instead, would have to rely on full face masks to treat their OSA.. To understand why, first understand what UPPP does to the throat.
Quick anatomy lesion: if you put your tongue on roof of mouth and push it backwards you will go from hard palate (bony part) to soft palate. The uvula is the “punching bag” that hangs off the soft palate. Traditional UPPP removes any tonsil tissue (tonsillectomy) and then cuts away the uvula and some of the soft palate (see diagram).
As technology advanced, it was determined that this could be done in the office with a laser. The LAUP (laser assisted uvulopalatoplasty) was devised requiring three to five sessions to remove and reshape the uvula and palate. Even though it is still performed today, it is extremely painful and many patients do not proceed further after the first step. While still utilized as a snoring procedure, I personally would not recommend it for sleep apnea.
Becoming a Uvula Lover
However, this surgery suffered from only about 40% improvement for patients and left many very unhappy. As surgeons we removed this tissue with good intention, thinking it would help the OSA. One major question that was not considered was, “what is the purpose of the uvula?”. Thanks to one leading sleep apnea expert, Tucker Woodson, MD, I am now aware that this once considered useless piece of anatomy is quite important in throat aerodynamics and mucous flow as well as containing many important sensory nerves which may be responsible for some of the bothersome side effects after its removal. Hence, Dr. Woodson converted me to being a “uvula lover”.
A new solution to the same problem
Understanding the purpose of palate surgery in sleep apnea is actually quite simple to imagine. Behind your soft palate and uvula is an imaginary space, a box so to speak. This box has four sides in total and is in part formed by the two side walls of your throat, where tonsils would still be if present or if not present called the lateral pharyngeal walls, really just the sides of your throat. The back wall is called the posterior pharyngeal wall, and is just another wall, one that is fixed in position and not changeable. That leaves the last was as the actual curvature of the soft palate into the uvula. There it is, four sides to create the space or box behind your palate. When this space is narrowed in any of these dimensions, obstruction and breathing problems in sleep may occur. Therefore understanding this space explains why traditional UPPP often fails. First, this excision doesn’t always improve the space from the back wall to the front wall in all cases despite what many would think. Those that only suffered from this type of narrowing and the procedure actually increased this space benefited. However, many patient suffer from narrowing of the side walls or lateral pharyngeal walls, which is not addressed in this surgery. Thanks to Dr. Pang and Dr. Woodson, a new way was created to address this problem. Instead of excising and removing tissue, a re-positioning is performed with existing structures that is non-destructive, accomplishing both enlargement of the front to back and lateral dimension of this “box”. Expansion sphincter pharyngoplasty (ESP) as it is called, re-positions tissue in the throat to accomplish just this and can be done without removing the uvula (see diagram)!
Making Progress by Evaluating Failure
Doctors and surgeons don’t like to admit failure. Well, really not many people do. But by closely evaluating the results, we are better able to move forward. New procedures as the one described above can only come from looking at the past. The following pictures are results of traditional UPPP and my commentary on why they may not have been successful. These pictures were mostly found by surgeons advertising a picture of their results. Of course, there is no correlate to how and if their sleep apnea improved or not, so please keep in mind this is my opinion and despite my commentary, these patients may have improved. At the end of the day, I think the patient should know what they are getting into before surgery.
Here is a before-and-after picture after traditional UPPP. I have no idea how the patient has done clinically, but notice that while there is improvement in the lateral dimension behind palate (after tonsil removal) that there is very little space from front to back behind the palate (minus the patient’s uvula which is now gone)
Here is a picture of someone after traditional UPPP where the front to back space appears as being narrowed despite wide space behind palate.
Here is another before and after picture after traditional UPPP. While I have no idea how the patient has done, pay attention to the lateral narrowing before surgery which has not changed at all after tissue removal (the blue bar highlights the width of this area in before and after pictures)
This is a picture of a throat with a lateral or sidewall narrowing. I do not suspect this patient would benefit from a traditional UPPP.
Here is a patient of mine with moderate sleep apnea, found to have large tonsils, but also narrowed lateral walls. Should he have had a traditional UPPP, he may have had minimal improvement, but after ESP he had a significant enlargement in space behind palate from side to side and front to back (it is hard to appreciate that there is ~1 centimeter behind palate in this picture). Notice the presence of uvula (yay) and a happy patient with less symptoms and no side effects from surgery.
Finding Success with Sleep Surgery
Whatever you should choose to treat your sleep apnea, the most important factor is a truly individualized approach. CPAP is not for everyone. An oral appliance is not for everyone. The latest surgical procedure is not for everyone. I tell every surgical candidate that “there is no guaranteed cure in sleep surgery” and it often requires a “multilevel or multi-staged approach”. While improvements in evaluation and surgical technique have improved outcomes, there are times patients while improved still have residual sleep apnea after surgery. I believe every patient should give a strong effort to tolerate CPAP therapy even if they are interested in surgery. A comprehensive upper airway evaluation coupled with surgery customized to your anatomy will be what creates a good result. While this article does not address tongue procedures or other sleep surgery, as a patient I think it is paramount to understand the changes that will be made to your body, the expected outcome and side effects regardless of the procedure.
Don’t let stories of past failures for sleep surgery stop you from pursuing more sophisticated and current approaches to this problem. If you have failed or are frustrated with your current treatment, feel free to make an appointment for a thorough upper airway examination and personalized treatment approach to your sleep apnea.