Lateral pharyngoplasty versus uvulopalatopharyngoplasty; a comparative study in the treatment of obstructive sleep apnea hypopnea syndrome



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Lateral pharyngoplasty versus uvulopalatopharyngoplasty; a comparative study in the treatment of obstructive sleep apnea hypopnea syndrome.

Ahmed Farag Allam MD, Adel Ahmed Helmy MD, Taha Mohamed Abdelaal MD and Abdelrahman Ahmed Abdelaleem MSc

Department of Otorhinolaryngology, Faculty of Medicine, Benha University, Benha, Egypt

Abstract

Objectives: The aim of this study is to explore the efficiency of lateral pharyngoplasty as a new treatment for obstructive sleep apnea hypopnea syndrome (OSAHS) versus uvulopalatopharyngoplasty.

Study design: Prospective randomized study.

Patients and methods: This study was submitted on 30 patients diagnosed to have OSAHS with retropalatal obstruction classified randomly into 2 groups: in one group, we performed the lateral pharyngoplasty (15 cases) with blunt palatal tunneling, and in the other, we did the uvulopalatopharyngoplasty (15 cases). We compared the efficiency of surgeries subjectively through the Epworth Sleepiness Scale (ESS) and objectively through clinical and polysomnographic findings.

Results: In the lateral pharyngoplasty; the mean AHI improved from 40.95±28.50 to 8.92±7.9 (P<0.01) and in the uvulopalatopharyngoplasty; the mean AHI improved from 33.87±20.92 to 15.66±8.7 (P<0.01). Comparing the post-operative mean AHI in both groups (8.9±7.9 and 15.66±8.7 respectively) there was a statistically significant difference. In contrast with uvulopalatopharyngoplasty; the group of lateral pharyngoplasty shows improvement in the average PsO2 from (91.93±4.67%) to (94.27 ±3.53%) (P<0.05) and in the lowest PsO2 from (71.8±10.56%) to (81.27±8.92%) (P<0.01). In the lateral pharyngoplasty group the median ESS changed from (11) to (7) and the persistent nasal regurge was not recorded (0.0%) but in uvulopalatopharyngoplasty group the persistent nasal regurge was recorded in 4 patients out of 15 (26.7%) (P<0.05).

Conclusion: The lateral pharyngoplasty may offer benefits over uvulopalatopharyngoplasty in treatment of OSAHS patients with retropalatal obstruction. We observed improvements after the 2 surgeries but the lateral pharyngoplasty gave better polysomnographic findings with less complications.

Keywords: lateral pharyngoplasty, obstructive sleep apnea, uvulopalatopharyngoplasty.

Introduction

Obstructive sleep apnea syndrome (OSAS) is a very frequent major health problem [1]. It is associated with many medical conditions, including pulmonary hypertension, right-sided heart failure, nocturnal hypoxemia, cerebrovascular disease, cardioarrhythmia, and systemic hypertension [2]. The vibration of the soft structures in the oral cavity causes snoring [3]. The lateral pharyngeal muscular walls have a key role in the pathophysiology of obstructive sleep apnea syndrome "OSAS" [4].

Uvulopalatopharyngoplasty (UPPP) is the most common specialized procedure that directly enlarges the upper airway used for treating OSAS. The rationale for UPPP, as for most of the operations already proposed for treating OSAS, is widening of pharyngeal airway [5]. But, it does not reverse the underlying structural or neuromuscular tendency of pharyngeal narrowing in OSAS patients [6].

The surgical treatment for OSAS should not be focused on changing pharyngeal space but, rather, should be focused on dealing with the pharyngeal muscular wall properties [4]. The lateral pharyngoplasty was first described by Cahali[7]. Pang and Woodson [8] presented an innovative technique in creating this tension in the lateral pharyngeal walls, preventing its collapse namely the expansion sphincter pharyngoplasty or lateral pharyngoplasty.



Patients and methods

The study was submitted prospectively on 30 patients during the period from March 2013 till August 2015. All patients had been selected from the outpatient clinics of Benha University Hospital. Patients included in this study were over 18 years of age, presented with habitual snoring and diagnosed with OSAHS with Fujita type I and failed to accommodate or refused therapy with continuous positive airway pressure (CPAP) treatment.

We excluded from this study patients with central or mixed sleep apnea, patients with a multilevel obstruction or patients with history of previous velopharyngeal or lingual surgeries. We also excluded from this study patients with gross mandible deformities or genetic disorders, patients with Body Mass Index > 40 kg/m2 or patients with contraindication of surgery.

All patients in this study underwent a thorough clinical assessment including; complete history taking and administering a questionnaire (ESS) according to Johns[9] and general examination including BMI and neck circumference. Full ORL examination was done including head and neck examination and rigid endoscopic nasal examination. All patients in this study were subjected to fiber-optic nasopharyngoscopy with Mueller’s maneuver in supine position, nocturnal polysomnography and routine preoperative investigations. All patients had been subjected to a one-night polysomnographic study at a sleep lab with a test time of 6 to 8 hours. The apnea-hypopnea index (AHI) was recorded denoting the total numbers of apneic plus hypopneic events divided by total sleep time in hours. The average pulse rate, average O2 saturation and lowest O2 saturation were also recorded.

Surgical Techniques:

We had randomly selected our patients to undergo the lateral pharyngoplasty or the uvulopalatopharyngoplasty (UPPP) operations by subjecting patients with odd sheet numbers for the lateral pharyngoplasty surgery group A and subjecting patients with even sheet numbers for the UPPP surgery group B. All the procedures were performed by the same surgeon, under general anaesthesia and in the tonsillectomy position using the Boyle-Davis mouth gag with trans-nasal endotracheal intubation.



In group A the lateral pharyngoplasty was performed according to Pang and Woodson [8] with the minimal modification of Vicini et al [10] starting with bilateral tonsillectomy. The palatopharyngeus muscle was identified and dissected from the covering mucosa medially [Figure 1].

Figure 1: showing the dissection of the mucosa covering the



right palatopharyngeus muscle.
The palatopharyngeus muscle inferior end was transected horizontally using the bipolar diathermy and a superiorly based flap was dissected with a width of about 5 mm then rotated superolaterally [Figure 2].

Figure 2: showing (A) The transection of the palatopharyngeus muscle



using bipolar diathermy and (B) The superiorly based flap after the dissection.
The modification of Vicini et al [10] was in the form of blunt palatal tunneling without mucosal incisions. A superolateral soft palate tunnel was made on the anterior pillar arch bilaterally using blunt dissection with the curved tonsillar clamp. The palatopharyngeus muscle flap was then inserted through the tunnel of the soft palate using pull up Vicryl suture 3/0 passed through the oral surface of the palate near the pterygoid hamulus to the tunnel and back again [Figure 3].

Figure 3: showing (A) The passage of the needle through the



oral surface of the palate and (B) The pull up suture near the pterygoid hamulus.
Tonsillar pillars were then opposed with Vicryl suture 3/0. The same steps were repeated on the opposite side. A partial uvulectomy was then performed [Figure 4].