Upper Airway Surgery See Also Chapter

There are several surgical options for sleep apnea patients including UPPP (tonsil-lectomy and removal of the uvula, distal margin of soft palate, and any excessive tissue), uvulopalatopharyngo-glossoplasty (UPPGP—combines UPPP with limited resection of the tongue), transpalatal advancement pharnyngoplasty (TPAP—resection of the posterior hard palate with advancement of the soft palate to enlarge the retropalatal airway), sliding genioplasty or genioglossus advancement (advancing the tongue forward by displacing its attachment to the genial tubercle forward), hyoid advancement (displacement of the hyoid bone forward to enlarge the retro-glossal airway), and maxillary-mandibular advancement (forward displacement of the maxillae and mandible to advance the soft tissue structures) (162). Typically, surgical options to treat sleep apnea are invasive and may require a staged approach. Since the upper airway obstruction may not be at one site, selecting the appropriate sleep apnea patient and a suitable surgical approach is important.

Surgical selection may be achieved by examining data from clinical, fiberoptic, and radiologic sources. The Müller maneuver (voluntary inspiration against a closed mouth and obstructed nares) permits visualization of the airway structures during a simulated apneic event and has been used to identify surgical candidates (78). CT and MRI can also be employed to provide detailed information about structural dimensions during wakefulness and sleep (28,163) and may predict surgical outcome (70).

UPPP, the most common upper airway surgical procedure, was introduced in 1981 and although there have been many studies in OSA patients examining this surgical technique its failure rate exceeds 50% (162). UPPP only corrects one vulnerable upper airway site, the retropalatal pharynx. Patients with retropalatal obstruction have been shown to have a 52% success rate with UPPP whereas patients with retroglossal obstruction have a 5% success rate with UPPP (164). CT and MRI studies have demonstrated that UPPP results in enlargement of the airway only in the operated area (162). Upper airway narrowing in the unresected portion of the soft palate post-UPPP is a recognized problem and likely explains the limited efficacy of UPPP. A further issue, highlighted by a study of LAUP, is that anatomical improvements in the airway postsurgery, as documented by videoendoscopy measurements during wakefulness, are not necessarily indicative or predictive of objective improvements in apnea severity during sleep (75).

Patients with craniofacial abnormalities should be considered for surgical techniques such as mandibular and/or maxillary advancement and sliding genio-plasty (24). Cephalometry and nasopharyngoscopy have shown that maxilloman-dibular advancement increases upper airway caliber in the retroglossal and retropalatal regions by physically expanding the skeletal boundaries of the upper airway (165). Maxillomandibular advancement is reported as the most effective surgical treatment for sleep apnea with success rates between 75% and 100% (165).

Sleep Apnea

Sleep Apnea

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