Sleep Apnea

Treatments for Obstructive Apneas, Palate and Tongue Surgeries

Posted on 22. Dec, 2009 by admin in Treatments for Obstructive and Mixed Apneas

Uvulopalatopharyngoplasty
Uvulopalatopharyngoplasty (UPPP) has been the most common type of surgery for sleep apnea. Under general anesthesia, a scalpel is used to remove approximately the rear third of the soft palate. The back of the soft palate is left in a streamlined shape that will be less likely to collapse during sleep (Figure 7.7).

Who Can Be Helped by UPPP? Whether a person can be helped by UPPP depends on the reason for surgery and on how one defines being “helped.” If the surgery is for purely “cosmetic” purposes (i.e., simply to cut down on snoring) and if a sleep study has shown that the person has only snoring and not sleep apnea, UPPP stands about a 90 percent chance of being successful. The bedmate’s report that snoring has disappeared after UPPP does not necessarily mean the disappearance of sleep apnea.

If the purpose of surgery is to eliminate sleep apnea, the chance of success is much lower and much more difficult to predict. In this case, the decision to have surgery is best reached after extensive discussion of the operation and the expected results with your sleep specialist and ENT surgeon.

It is important to distinguish between an attempt to help sleep apnea and an attempt to cure sleep apnea (i.e., eliminate all disease). Uvulopalatopharyngoplasty surgery can help sleep apnea to varying degrees in different people. For example, Patients A and B might both show significant improvement after surgery. However, Patient A might have started out with mild apnea and may not need further treatment despite some remaining sleep apnea. (An example would be a person who goes from a sleepy patient with a respiratory disturbance index (RDI) of 40 before surgery to an alert patient with an RDI of 10 after UPPP.) Patient B, on the other hand, might have started with more serious apnea and may need further treatment after UPPP. (An example would be a person whose RDI of 60 improves to 30 after surgery but who still has low blood oxygen at night and is still drowsy.)

How often is sleep apnea cured by UPPP? That is difficult to say, but probably less than 20 percent of the time. Results like those of Patient A, who needs no further treatment, probably account for 20 percent to 40 percent of UPPP cases. People like Patient B, who needs treatment after surgery, probably account for 50 percent to 70 percent of UPPP cases.

People who are the most likely candidates for success with this type of surgery meet the following criteria:

1. They are not more than 25 percent or 30 percent over their ideal weight, and they do not gain weight after surgery.
2. They have only slight to moderate apnea, and it is all obstructive apnea.
3. Their apnea arises mostly from some obvious anatomic obstruction of the upper part of the pharynx (throat) — the soft palate or upper throat area. This includes people with enlarged tonsils or adenoids (tonsils and adenoids often are removed during UPPP); people with a very long soft palate or a large, fleshy uvula; and people with excess fleshy tissue in the throat region.

In contrast, people with very severe apnea or those whose apnea arises from places other than the area of the soft palate are not good candidates for UPPP. Those with a lower jaw that is very short or placed far back, or with a tongue that is positioned fairly far back and low in the neck, or with apnea arising in the lower pharynx are less likely to be successful with UPPP.

Weight gain is an extremely important factor in the success of UPPP. The extra loading of the abdomen, which interferes with the breathing reflex, plus the fatty deposits in the neck, which help obstruct the airway, can overpower any positive results that may be gained from UPPP. Therefore, people who have UPPP and then gain weight are likely to see the return of obstructive apnea.

Until recently, not much was known about which people could best be helped by UPPP. With the aid of cephalometry (measurement of size and placement of structures in the head using radiographs, CAT scan, or MRI pictures) and fiberoptic examination of the inside of the airway, doctors are gradually gaining more information about how to choose the most likely candidates for successful UPPP. Nevertheless, no one can accurately predict the success of UPPP.

Determining whether you are a good candidate for UPPP must be done by consulting your sleep expert and a good otolaryngologist (ENT specialist) who has experience not only with eliminating snoring but also with sleep apnea problems. The otolaryngologist should examine your throat internally. He may order a radiograph, MRI, or CAT scan of your head so that he can measure the sizes and relationships between various anatomic features that cause your obstructive apnea. This will help him determine your chances of being helped by UPPP.

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Tags: Obstructive Apneas, Palate, Tongue Surgeries, Treatments