Palatal surgery

This section is an in-depth look at surgery of the palate for snoring and OSAS. You may scroll through the entire section or click on the subject of most interest to you

q Introduction

q How effective is palatal surgery?

q UPPP (Uvulopalatopharyngoplasty)

q UPF (Uvulopalatal flap)

q LAUP (Laser-assisted uvulopalatoplasty)

q TPPP (Transpalatal advancement pharyngoplasty)

q RFVR (Somnoplasty™)

Introduction

The palate, or roof of the mouth, is the major noisemaker during sleep. The fluttering that results from the end of the palate and uvula (the little flipper that hangs down from the middle of the end of the palate) results in the typical guttural noise that we recognize as snoring. In addition to making annoying noise, though, the palate is often a major contributor to upper airway narrowing in OSAS. This noise and blockage at the palate level can be corrected surgically.

Yet though most snoring noise (90%) results from abnormalities occurring at this region, only 40% or so of the airway obstruction that constitutes OSAS occurs solely from palatal obstruction. Palate surgery is therefore frequently successful in eliminating or significantly reduce snoring, but not necessarily in curing OSAS by itself.

There are a number of different techniques available to treat the palate. A partial list includes the uvulopalatopharyngoplasty (UPPP), uvulopalatal flap (UPF), transpalatal pharyngoplasty (TPP), laser-assisted uvulopalatoplasty (LAUP), and radiofrequency volumetric reduction (RFVR). (As you can notice, physicians love abbreviations.) All are designed to relieve obstruction arising from the palate. They are not equal in their effectiveness, however.

How effective is palatal surgery?

The most thoroughly studied of the palatal surgeries is the UPPP, which is discussed in detail below. It is the most aggressive of the available techniques. Its success in alleviating snoring is approximately 75-90%, but it is important to realize that the lack of snoring does not equate with cure of OSAS. As previously stated, the success rate in curing OSAS by UPPP is approximately 41%.

This cure rate may seem a bit low, but that should not been used as an argument that the procedure is ineffective. The UPPP is an excellent way to take care of the airway obstruction due to the palate and tonsils, but it must be remembered that sleep apnea can also be due to structural problems elsewhere in the throat. The most common area is the base of the tongue. But surgical treatment for tongue base obstruction is not widely available, as such techniques are not widely taught in surgical training programs yet. Many people are therefore not familiar with these techniques and might incorrectly argue that sleep apnea surgery in general cures less than 50% of people. This simply demonstrates that they are unaware of the other surgical procedures that can boost the cure rate to the 90% range.

Here is an example. A person has obstructive sleep apnea because of problems at both the palate and the tongue base, and undergoes a UPPP for treatment. Though he heals well, he still exhibits OSAS afterwards. This should not be surprising. Rather than condemn the procedure as ineffective, it should be recognized that his treatment is just incomplete and that he could still be cured with attention to the tongue base.

Interestingly, this patient mentioned above might note that he no longer snores, even though he still stops breathing at night. The reason for this is that unlike the palate, tongue base obstruction can be silent. Airway obstruction at the tongue base level can be quite significant even though it doesn’t produce typical snoring noise. It is therefore possible for a UPPP to cure snoring but not completely take care of the obstruction problem. This is one of the reasons that a postoperative polysomnogram is important after sleep apnea surgery.

Palate surgery usually goes very well, and complications are uncommon. Your surgeon can discuss this in detail with you preoperatively.

UPPP Click on palatal surgery

UPPP is an abbreviation for uvulopalatopharyngoplasty, which is quite a mouthful, to say the least. In fact, this surgery is performed for people who have quite a mouth full of a large palate and uvula, which can block the throat off during sleep.

The UPPP is the most commonly performed surgery for OSAS. As mentioned above, it is a very effective treatment for obstruction due to the palate. It involves the removal of the end of the soft palate, including the uvula, which is the little hangy-down thing in the back of the throat. The tonsils are also usually removed at the same time. The cut ends of the tissue are sewn together with a dissolvable suture.

The UPPP is performed under general anesthesia, and is generally followed by an overnight stay in the hospital.

UPF Click on palatal surgery

The UPF, or uvulopalatal flap, is a recently described variation of the UPPP. It involves the folding of the end of the soft palate on itself rather than removing the excessive tissue. The final result looks just like a UPPP and it accomplishes the same thing as that procedure.

There are a few potential advantages to this technique over the UPPP. It has the possibility of being reversible, so if it appears that the palate has been shortened too much, the sutures may be removed and it can be adjusted. The UPF achieves the same anatomic results of the UPPP, though perhaps with less pain.

It can even be performed under local anesthesia in the office for snoring or mild OSA for selected patients.

LAUP Click on palatal surgery

The LAUP, or laser-assisted uvulopalatoplasty, is another variation of the UPPP. As opposed to UPPP, though, LAUP is an office-based procedure performed under local anesthesia. It involves the cutting or vaporization of palate tissue with a CO₂laser.

There are two different versions of the procedure. The classical LAUP is a staged technique, consisting of several procedures spaced about a month or so apart. At each of these sessions, a portion of the uvula and palate are removed. After several of these sessions (usually three to five), enough tissue has been removed to significantly reduce or eliminate snoring and relieve the palatal obstruction with OSA. Because less tissue is removed at each session than with a UPPP, there should be less chance for removing too much tissue. The LAUP can also be performed in one session, with all of the targeted tissue removed at once.

Though most patients can return to work the same day, the procedure (like the UPPP and UPF) is followed by significant pain that usually requires pain medications for 7-14 days. It is often not covered by insurance.

LAUP results in eliminating or reducing snoring to a tolerable level is excellent (75-90%), and its results in the treatment of OSAS can be good, but it does not accomplish quite the same thing as the UPPP. As such, it is not thought by most physicians to be as effective as UPPP in the treatment of significant OSAS. Most surgeons feel that LAUP should be limited to patients with non-apneic snoring or milder sleep apnea (e.g., RDI < 20 with lowest O₂saturation > 85%).

TPP

The transpalatal advancement pharyngoplasty involves pulling the soft palate forward, and can be done in conjunction with or following one of the palatal shortening procedures described above, if needed. It is performed through an incision over the bony or hard palate. The back centimeter or so of palate bone is removed, and the soft palate is suspended forward to the new bony edge. It is particularly helpful for palates that project too far posteriorly.

Radiofrequency volumetric reduction (RFVR) of the palate

SomnoplastyÔ Click on palatal surgery

This is a relatively new procedure for the treatment of snoring, and is undergoing testing to determine its role in the treatment of OSAS. This is an office-based procedure that results in shrinkage of the palate, and does not involve any cutting or suturing. RFVR can be accomplished with equipment manufactured by several companies, but the best and probably safest equipment for this technique is marketed under the name SomnoplastyÔ. The name SomnoplastyÔ will be used interchangeably with RFVR in this website.

Somnoplasty™ involves the placement of a small needle electrode in several places of the palate under local anesthesia. Radiofrequency energy —sort of like microwave energy—is delivered through the electrode to produce a painless lesion within the tissue of the palate below its surface. As this lesion heals, it is replaced by scar tissue. As that scar tissue matures, it contracts, and the target area shrinks, which pulls the palate upward and shortens it.

Like the traditional LAUP, Somnoplasty™ is a staged procedure, and is performed in the office under local anesthesia. Unlike the LAUP, however, it involves no surface tissue destruction, and is therefore relatively painless. Most patients require nothing stronger than Tylenol for pain afterwards.

Preliminary results suggest that this procedure is about as good as the LAUP in treating snoring, but more long-term data is needed. Because there is no published data on its benefit in treating significant OSA, its use is at present limited to the treatment of snoring or mild apnea. Somnoplasty is generally not covered by insurance.