Tag Archives: OSA

Palate, uvula, and tongue

OSA Surgery: The Truth about UPPP

[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.

Illustration_mouth

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).

Uvulopalatopharyngoplasty

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.

Laser Assisted Uvulopalatoplasty

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)!

Diagram of Expansion Sphincter Pharyngoplasty

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)

UPPP-beforeafter-narrowAP

Here is a picture of someone after traditional UPPP where the front to back space appears as being narrowed despite wide space behind palate.

UPPP-narrowAP

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)

UPPP-before-after-narrowlat

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.

UPPP-severelateralnarrowing

 

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.

Enlarged tonsils Post UPPP 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.

Sleep Apnea Tongue Obstruction

Minimally-Invasive Tongue RF for Sleep Apnea

Stopping the obstruction behind the tongue continues to be an important part of treating sleep apnea surgically.  Many techniques have been employed, from tissue excision or removal, suture slings to suspend the tongue from falling backwards during sleep as well as pending FDA approval techniques such as a nerve stimulator that will push the tongue out of the way at the appropriate time.  However, most of these techniques require general anesthesia and some carry difficult postoperative recoveries.

 

The advent of radiofrequency (RF) energy has given way to a host of new surgical approaches for not only sleep apnea but many other specialties as well.  It’s main advantage is in how this special energy is delivered, allowing much lower temperatures than traditional instrumentation which translates into more controlled release with less damage and pain for patients.  This technique is often used for reducing the size of structures in the nose called turbinates.  Turbinoplasty, or radiofrequency turbinate reduction, accomplishes shrinking of this tissue and improved nasal breathing with the technology.  It can be performed in the operating room in conjunction with another procedure such as septoplasty or sinus surgery, but it can also be performed alone in the office under local anesthesia very successfully.  I will sometimes offer this to patients who are seeking better nasal breathing, but it is unclear how much their deviated septum is contributing to this problem.  By doing this first in the office, some may be spared having unnecessary septal surgery in the operating room.

Radiofrequency is also great for shrinking the base of tongue, which is often falling into the throat and causing an obstructive apnea for patients.  It is accomplished with local anesthesia in the office with a special needle probe that delivers the advanced energy.  While causing minimal pain, it does require multiple sessions to find significant clinical improvement.  The risks, while rare, do include infection, abscess, bleeding and swelling, and should be taken seriously if there is any concern.  If a patient is experiencing worsening pain after two to three days, they should immediately contact their doctor.  I routinely use antibiotics and steroids post-procedure which reduce this risk dramatically.  Patient experience mild discomfort after the procedure which reduces over a few days and is generally well tolerated.

This procedure is not for everyone, and like all sleep apnea procedures, results are never guaranteed.  However, if you are interested in this procedure, a detailed evaluation of the head and neck by an Otolaryngologist specializing in Sleep Surgery will help determine your candidacy.  Feel free to make an appointment if this minimally-invasive office procedure could be helpful for you.