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Zetapalatopharyngoplasty (ZPP)
SECTION I
CHAPTER
33
PALATAL SURGERY
Zetapalatopharyngoplasty (ZPP) Michael Friedman and Paul Schalch
1 INTRODUCTION Due to its limited success in curing obstructive sleep apnea/ hypopnea syndrome (OSAHS),1 many adjunctive procedures and modifications were proposed after the introduction of the classic uvulopalatopharyngoplasty (UPPP) by Fujita et al. in 1981.2 Its role as part of a comprehensive treatment plan remains, however, solidly accepted in most situations in which the palate, with or without the tonsils, is contributing to airway turbulence and obstruction. The goal of UPPP is to widen the airspace in three areas: 1. the retropalatal space; 2. the space between tongue base and palate; 3. the lateral dimensions.
Fig. 33.1 After traditional UPPP, an anteriomedially directed pull eventually causes narrowing of the pharyngeal airway at the midline.
This is accomplished through two components: (a) the palatoplasty component, which involves palatal shortening with closure of mucosal incisions; and (b) the pharyngoplasty component, which is composed of a classic tonsillectomy with pharyngeal closure. These goals, however, are not always achieved with classic UPPP and, in spite of our best efforts, patients may end up with an extremely narrow palatal arch in which the diameter of the oropharyngeal inlet is decreased due to a forward approximation of the posterior palatal mucosa. The resulting new shape of the free edge of the palate is triangular, rather than square. Further contraction of the wound occurs due to scarring secondary to the resection of the posterior tonsillar pillars, and additional narrowing is caused, which further affects long-term results (Fig. 33.1)3 (see also Chapter 32: Submucosal Uvulopalat opharyngoplasty). Additionally, patients who previously underwent tonsillectomy are particularly poor candidates for classic UPPP due to scarring or absence of the posterior pillar from the previous tonsillectomy. These patients have an already narrowed space between the soft palate and the posterior pharyngeal wall and often do not have any redundant pharyngeal folds. Important modifications of the classic UPPP proposed by Fairbanks, in which the posterior pillar is advanced lateral cephalad in order to widen the retropalatal space,4 are, hence, not possible. It is well known
that when UPPP fails, the severity of obstruction may actually worsen.5 It became apparent that appropriate selection criteria needed to be implemented in order to identify the patients with a higher likelihood of cure after UPPP. A staging system introduced by Friedman et al.6 identified that patients with anatomic stage I disease (Friedman Tongue Position (FTP) I and II) with large tonsils have a better than 80% chance of success, whereas patients with stage II and III disease (FTP III and IV) are less than ideal candidates and should therefore undergo a combined procedure that addresses both the palate and the hypopharynx. The zetapalatopharyngoplasty (ZPP) technique was developed as a more aggressive technique for patients with stage II and III disease. This includes all patients who have had previous tonsillectomy, as well as patients with small tonsils and those with unfavorable tongue positions. A modification, useful for revision UPPP, is presented in Chapter 62. The goal of ZPP is to widen the space between the palate and the posterior pharyngeal wall, between the palate and the tongue base and to either maintain or even widen the lateral dimensions of the pharynx. This is accomplished by changing the scar contracture tension line to an anterolateral vector and by widening the anteroposterior and
201
SECTION
I
PALATAL SURGERY
Fig. 33.2 After ZPP, the anterolateral direction of pull on the soft palate widens the retropharyngeal space.
Fig. 33.3 Outline of the palatal flaps, marked before incision.
lateral oropharyngeal air spaces at the level of the palate. By splitting the soft palate and retracting it anterolaterally, an effective anterolateral pull is created, which actually continues to widen the airway as healing and contracture occur (Fig. 33.2). None of the palatal musculature is resected, in spite of the aggressive palatal shortening, thereby addressing and minimizing the risk for permanent velopharyngeal insufficiency (VPI). This procedure is performed with adjunctive tongue base reduction by radiofrequency (TBRF), which addresses the hypopharyngeal airway.
2 PATIENT SELECTION General guidelines for surgical intervention include significant symptoms of snoring and daytime somnolence, documented failure of a continuous positive airway pressure (CPAP) trial, documented failure of conservative measures such as dental appliances, changes in sleeping position and sleep hygiene in general. Apparent obstruction at the level of the soft palate must be determined by fiberoptic nasopharyngolaryngoscopy and Mueller maneuver, or sleep endoscopy. Adequate medical clearance and a thorough review of the procedure, its implications, potential outcomes and complications with the patient are essential components of the preoperative work-up. Specific criteria for ZPP include patients classified as stage II and III according to Friedman’s Anatomic Staging System7 (see also Chapter 16). Because ZPP produces a significant widening of the retropalatal space, it is an aggressive procedure, with significant temporary VPI and the risk for permanent VPI. It should be reserved for patients with moderate to severe OSAHS with moderate to severe symptoms. It is not a surgical option for snoring only.
3 SURGICAL TECHNIQUE Candidates eligible to undergo a modified uvulopalatopharyngoplasty technique can be divided into patients with
202
Fig. 33.4 The mucosa over the palatal flap is removed and the palatal musculature is exposed.
intact tonsils and patients status post tonsillectomy. The revision UPPP technique is outlined in Chapter 62. The key main goals of ZPP are the removal of the anterior mucosa only and the splitting of the soft palate in the midline. The key features are the cutting of the palatoglossus muscle, and the sewing of the posterior palatal mucosa to the anterior resection margin, which retracts the midline anterolaterally and widens the retropharyngeal area. The surgical technique for the modified ZPP is illustrated in Figures 33.3 to 33.10. Two adjacent flaps are outlined in the palate (Fig. 33.3). The anterior midline margin of the flap is halfway between the hard palate and the free edge of the soft palate, and the distal margin corresponds to the free edge of the palate and uvula. The lateral extent is posterior to the midline, and extends to the lateral extent of the palate. The mucosa from only the anterior aspect of the two flaps is subsequently removed (Fig. 33.4). Figure 33.5 illustrates how the preoperative uvula and palate hang close to the posterior pharyn-geal wall, narrowing the retropharyngeal space. The two flaps are then separated from each other by splitting the palatal segment down the midline (Fig. 33.6), extending them
CHAPTER
Zetapalatopharyngoplasty (ZPP)
33
Fig. 33.7 The uvular flaps along with the soft palate are reflected back and laterally, over the soft palate.
Fig. 33.5 Lateral view of the soft palate and uvula after excision of the anterior mucosa. The uvula and palate hang close to the posterior pharyngeal wall, narrowing the retropharyngeal space.
Fig. 33.8 Two-layered closure of the palatal flaps. The submucosal layer is approximated first with 2-0 Vicryl™ (Ethicon, Inc., Somerville, NJ).
Fig. 33.6 The uvula and palate are split in the midline with a cold knife.
laterally, in a butterfly fashion (Fig. 33.7), and dividing the palatoglossus muscle. A two-layer closure is then done, which brings the midline all the way to the anterolateral margin of the palate (Figs 33.8 and 33.9). The primary closure is done at the submucosal level, which then enables a tension-free closure of the mucosa. A distance of at least 3–4 cm between the posterior pharynx and the palate is created.8 Figure 33.10 illustrates the widening of the nasopharynx after the midline palatoplasty. The lateral dimension of the palate is usually increased to approximately 4 cm. TBRF is adjunctively performed in all patients by administering 3000 joules (rapid lesion technique by Gyrus™,
Fig. 33.9 Two-layered closure of the palatal flaps with 3-0 chromic suture.
Gyrus ENT, Memphis, TN), which are distributed to ten points along the midline of the tongue behind the circumvallated papillae. This initial treatment is followed by monthly sessions, as needed. The addition of TBRF has been shown to provide significantly better subjective and objective improvement in stage II and III patients undergoing UPPP, when compared to patients that undergo UPPP only.9
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PALATAL SURGERY
Table 33.1 Comparison of complications between ZPP and classic UPPP, based on a series of 25 matched patients that underwent each procedure
Tongue base infection Bleeding Postnasal drip Dysphagia Foreign body sensation Temporary VPI Permanent VPI
ZPP (n ⴝ 25)
UPPP (n ⴝ 25)
1 (4%) 0 3 (12%) 1 (4%) 11 (44%) 12 (48%) 0
2 (8%) 0 4 (16%) 11 (44%)* 17 (68%) 7 (28%) 0
* P 0.001 Modified from Friedman et al.3
Fig. 33.10 Lateral view showing the widening of the nasopharynx after ZPP.
4 POSTOPERATIVE MANAGEMENT AND COMPLICATIONS As with any intervention that involves resection of the soft palate, significant morbidity is observed in the first 24 to 72 hours postoperatively in the form of significant pain and dysphagia. The ability of the patient to tolerate at least a liquid diet, oral pain medications, antibiotics and steroids determines the moment when the patient can be safely discharged home. While the discharge could in theory be on the same day of the surgery, most patients will need 1 or 2 days of intravenous fluids and medications before they can start taking an oral diet. Prior to discharge, patients are prescribed acetaminophen with codeine elixir as needed for pain. Pain medication requirements average 6.5 days, and so does the progression from liquid or soft diet to normal diet. Postoperative antibiotics and steroids are also recommended, for a total of 7 days. Additional TBRF sessions may be necessary, depending on the improvement of symptoms of each individual patient. Complications of the procedure are comparable to classic UPPP (Table 33.1). Bleeding is always a potential complication and the risk is, again, comparable to classic UPPP. Typically, patients can eat a normal diet after 2 weeks. Mild VPI may become manifest when drinking quickly and may persist for up to 3 months. After 3 months, patients have a normal deglutition. Severity of VPI symptoms diminish with time and are expected to progressively resolve. Permanent VPI is a potential complication that must be considered in every patient. Additional
204
morbidity of the procedure is usually related to throat discomfort symptoms, including globus sensation, mild dysphagia, dry throat, and inability to clear the throat. These symptoms are almost universal after any form of uvulopalatopharyngoplasty. Other complications are related to the adjunctive procedures performed. Tongue base infection is related to TBRF and requires antibiotic treatment. In rare cases, it may lead to tongue base abscess formation, which may require incision and drainage.
5 SUCCESS RATE OF THE PROCEDURE 5.1 SUBJECTIVE AND OBJECTIVE SYMPTOM ELIMINATION The subjective success is based on comparative improvement on snoring level, daytime sleepiness and overall well-being. Patients that underwent ZPP were compared to patients who had previously undergone UPPP for the treatment of OSAHS and the results achieved in these parameters were far superior with ZPP, particularly with adjunctive TBRF. Quality of life scores improve significantly more after ZPP than after UPPP.8 When focusing on objective success, ZPP shows considerable improvement over UPPP. Objective cure rates for stage II patients treated with ZPP and TBRF are close to 70%, compared to about 30% for classic UPPP with TBRF. Limitations of this technique include a higher risk of temporary VPI due to a more aggressive modification of the palatal anatomy, even though the resection is limited to the mucosa. While VPI was only temporary, should permanent VPI ensue, this procedure is probably not reversible. There are also no clear anatomic landmarks to assist in describing the size of the flaps and, ultimately, the
CHAPTER
Zetapalatopharyngoplasty (ZPP)
guidelines outlined in this chapter do not substitute for the surgeon’s judgment. The procedure is significantly more difficult technically and takes longer to perform. A learning curve, as with any other procedure, leads to progressively better results.
33
each patient. Laterally rerouting the uvula together with the soft palate improves the airway characteristics by enlarging the retropalatal space, which is a distinct advantage over the traditional UPPP. This acquires even more importance when addressing the obstruction at the level of the palate in patients without tonsils.
5.2 WHAT TO DO IF THE PROCEDURE FAILS REFERENCES The treatment, as any other, may fail. Failure can be defined as a persistence of symptoms, which would demand additional treatment. Failure can also occur when symptoms of snoring and daytime sleepiness are eliminated but polysomnography (PSG) scores indicate persistent disease. Typically, patients that fail will show a pattern of elimination of apneas but persistent hypopneas. In spite of an abnormal PSG, however, many patients will have a lower C-reactive protein, indicating a possible reduction of cardiovascular risk10 (see also Chapter 13: The Impact of Surgical Treatment of OSA on Cardiac Risk Factors). Failure in achieving satisfactory results may in some cases convince the patient to accept CPAP therapy. When CPAP is not accepted by the patient, further evaluation and treatment are essential. The first step should be a thorough investigation in order to identify the site of failure. Sleep endoscopy evaluation may be a valuable test at this point. If the level of obstruction continues to be retropalatal, a transpalatal advancement pharyngoplasty can be considered.11 If the persistence of obstruction is at the tongue base or hypopharyngeal level, then genioglossus advancement alone or in combination with thyrohyoid suspension could be an option.12 Bimaxillary advancement should be kept in mind as a second-line procedure if the above interventions fail. This procedure will correct failures at both the retropalatal and retrolingual levels.13
6 CONCLUSION No single procedure is effective in treating all OSAHS patients. Treatment should be tailored to the anatomy of
1. Sher AE, Schechtman KB, Piccirillo JF. The efficacy of surgical modifications of the upper airway in adults with obstructive sleep apnea syndrome. Sleep 1996;19:156–77. 2. Fujita S, Conway W, Zorick F, Roth T. Surgical correction of anatomic abnormalities in obstructive sleep apnea syndrome: uvulopalatopharyngoplasty. Otolaryngol Head Neck Surg 1981;89:923–34. 3. Friedman M, Landsberg R, Tanyeri H. Submucosal uvulopalatopharyngoplasty. Op Tech Otolaryngol Head Neck Surg 2000;11:26–9. 4. Fairbanks DN. Operative techniques of uvulopalatopharyngoplasty. Ear Nose Throat J 1999;78:846–50. 5. Senior BA, Rosenthal L, Lumley A, Gerhardstein R, Day R. Efficacy of uvulopalatopharyngoplasty in unselected patients with mild obstructive sleep apnea. Otolarynol Head Neck Surg 2000;123:179–82. 6. Friedman M, Ibrahim H, Joseph N. Staging of obstructive sleep apnea/hypopnea syndrome: a guide to appropriate treatment. Laryngoscope 2004;114:454–9. 7. Friedman M, Ibrahim H, Joseph N. Staging of obstructive sleep apnea/hypopnea syndrome: a guide to appropriate treatment. Laryngoscope 2004;114:454–9. 8. Friedman M, Ibrahim HZ, Vidyasagar R, Pomeranz J. Z-palatoplasty (ZPP): a technique for patients without tonsils. Otolaryngol Head Neck Surg 2004;131:89–100. 9. Friedman M, Ibrahim H, Lee G, Joseph NJ. Combined uvulopalatopharyngoplasty and radiofrequency tongue base reduction for treatment of obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg 2003;129:611–21. 10. Friedman M, Bliznikas D, Vidyasagar R, Woodson BT, Joseph NJ. Reduction of C-reactive protein with surgical treatment of obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg 2006;135:900–5. 11. Woodson BT, Toohill RJ. Transpalatal advancement pharyngoplasty for obstructive sleep apnea. Laryngoscope 1993;103:269–76. 12. Powell NB, Riley RW, Guilleminault C. The hypopharynx: upper airway reconstruction in obstructive sleep apnea syndrome. In: Snoring and Obstructive Sleep Apnea, 2nd edn. Fairbanks DNF, Fujita S, eds. New York: Raven Press; 1994, pp. 193–209. 13. Li KK, Riley RW, Powell NB, Guilleminault C. Maxillomandibular advancement for persistent OSA after phase I surgery in patients without maxillomandibular deficiency. Laryngoscope 2000;110: 1684–8.
205
CHAPTER
33
PALATAL SURGERY
Zetapalatopharyngoplasty (ZPP) Michael Friedman and Paul Schalch
1 INTRODUCTION Due to its limited success in curing obstructive sleep apnea/ hypopnea syndrome (OSAHS),1 many adjunctive procedures and modifications were proposed after the introduction of the classic uvulopalatopharyngoplasty (UPPP) by Fujita et al. in 1981.2 Its role as part of a comprehensive treatment plan remains, however, solidly accepted in most situations in which the palate, with or without the tonsils, is contributing to airway turbulence and obstruction. The goal of UPPP is to widen the airspace in three areas: 1. the retropalatal space; 2. the space between tongue base and palate; 3. the lateral dimensions.
Fig. 33.1 After traditional UPPP, an anteriomedially directed pull eventually causes narrowing of the pharyngeal airway at the midline.
This is accomplished through two components: (a) the palatoplasty component, which involves palatal shortening with closure of mucosal incisions; and (b) the pharyngoplasty component, which is composed of a classic tonsillectomy with pharyngeal closure. These goals, however, are not always achieved with classic UPPP and, in spite of our best efforts, patients may end up with an extremely narrow palatal arch in which the diameter of the oropharyngeal inlet is decreased due to a forward approximation of the posterior palatal mucosa. The resulting new shape of the free edge of the palate is triangular, rather than square. Further contraction of the wound occurs due to scarring secondary to the resection of the posterior tonsillar pillars, and additional narrowing is caused, which further affects long-term results (Fig. 33.1)3 (see also Chapter 32: Submucosal Uvulopalat opharyngoplasty). Additionally, patients who previously underwent tonsillectomy are particularly poor candidates for classic UPPP due to scarring or absence of the posterior pillar from the previous tonsillectomy. These patients have an already narrowed space between the soft palate and the posterior pharyngeal wall and often do not have any redundant pharyngeal folds. Important modifications of the classic UPPP proposed by Fairbanks, in which the posterior pillar is advanced lateral cephalad in order to widen the retropalatal space,4 are, hence, not possible. It is well known
that when UPPP fails, the severity of obstruction may actually worsen.5 It became apparent that appropriate selection criteria needed to be implemented in order to identify the patients with a higher likelihood of cure after UPPP. A staging system introduced by Friedman et al.6 identified that patients with anatomic stage I disease (Friedman Tongue Position (FTP) I and II) with large tonsils have a better than 80% chance of success, whereas patients with stage II and III disease (FTP III and IV) are less than ideal candidates and should therefore undergo a combined procedure that addresses both the palate and the hypopharynx. The zetapalatopharyngoplasty (ZPP) technique was developed as a more aggressive technique for patients with stage II and III disease. This includes all patients who have had previous tonsillectomy, as well as patients with small tonsils and those with unfavorable tongue positions. A modification, useful for revision UPPP, is presented in Chapter 62. The goal of ZPP is to widen the space between the palate and the posterior pharyngeal wall, between the palate and the tongue base and to either maintain or even widen the lateral dimensions of the pharynx. This is accomplished by changing the scar contracture tension line to an anterolateral vector and by widening the anteroposterior and
201
SECTION
I
PALATAL SURGERY
Fig. 33.2 After ZPP, the anterolateral direction of pull on the soft palate widens the retropharyngeal space.
Fig. 33.3 Outline of the palatal flaps, marked before incision.
lateral oropharyngeal air spaces at the level of the palate. By splitting the soft palate and retracting it anterolaterally, an effective anterolateral pull is created, which actually continues to widen the airway as healing and contracture occur (Fig. 33.2). None of the palatal musculature is resected, in spite of the aggressive palatal shortening, thereby addressing and minimizing the risk for permanent velopharyngeal insufficiency (VPI). This procedure is performed with adjunctive tongue base reduction by radiofrequency (TBRF), which addresses the hypopharyngeal airway.
2 PATIENT SELECTION General guidelines for surgical intervention include significant symptoms of snoring and daytime somnolence, documented failure of a continuous positive airway pressure (CPAP) trial, documented failure of conservative measures such as dental appliances, changes in sleeping position and sleep hygiene in general. Apparent obstruction at the level of the soft palate must be determined by fiberoptic nasopharyngolaryngoscopy and Mueller maneuver, or sleep endoscopy. Adequate medical clearance and a thorough review of the procedure, its implications, potential outcomes and complications with the patient are essential components of the preoperative work-up. Specific criteria for ZPP include patients classified as stage II and III according to Friedman’s Anatomic Staging System7 (see also Chapter 16). Because ZPP produces a significant widening of the retropalatal space, it is an aggressive procedure, with significant temporary VPI and the risk for permanent VPI. It should be reserved for patients with moderate to severe OSAHS with moderate to severe symptoms. It is not a surgical option for snoring only.
3 SURGICAL TECHNIQUE Candidates eligible to undergo a modified uvulopalatopharyngoplasty technique can be divided into patients with
202
Fig. 33.4 The mucosa over the palatal flap is removed and the palatal musculature is exposed.
intact tonsils and patients status post tonsillectomy. The revision UPPP technique is outlined in Chapter 62. The key main goals of ZPP are the removal of the anterior mucosa only and the splitting of the soft palate in the midline. The key features are the cutting of the palatoglossus muscle, and the sewing of the posterior palatal mucosa to the anterior resection margin, which retracts the midline anterolaterally and widens the retropharyngeal area. The surgical technique for the modified ZPP is illustrated in Figures 33.3 to 33.10. Two adjacent flaps are outlined in the palate (Fig. 33.3). The anterior midline margin of the flap is halfway between the hard palate and the free edge of the soft palate, and the distal margin corresponds to the free edge of the palate and uvula. The lateral extent is posterior to the midline, and extends to the lateral extent of the palate. The mucosa from only the anterior aspect of the two flaps is subsequently removed (Fig. 33.4). Figure 33.5 illustrates how the preoperative uvula and palate hang close to the posterior pharyn-geal wall, narrowing the retropharyngeal space. The two flaps are then separated from each other by splitting the palatal segment down the midline (Fig. 33.6), extending them
CHAPTER
Zetapalatopharyngoplasty (ZPP)
33
Fig. 33.7 The uvular flaps along with the soft palate are reflected back and laterally, over the soft palate.
Fig. 33.5 Lateral view of the soft palate and uvula after excision of the anterior mucosa. The uvula and palate hang close to the posterior pharyngeal wall, narrowing the retropharyngeal space.
Fig. 33.8 Two-layered closure of the palatal flaps. The submucosal layer is approximated first with 2-0 Vicryl™ (Ethicon, Inc., Somerville, NJ).
Fig. 33.6 The uvula and palate are split in the midline with a cold knife.
laterally, in a butterfly fashion (Fig. 33.7), and dividing the palatoglossus muscle. A two-layer closure is then done, which brings the midline all the way to the anterolateral margin of the palate (Figs 33.8 and 33.9). The primary closure is done at the submucosal level, which then enables a tension-free closure of the mucosa. A distance of at least 3–4 cm between the posterior pharynx and the palate is created.8 Figure 33.10 illustrates the widening of the nasopharynx after the midline palatoplasty. The lateral dimension of the palate is usually increased to approximately 4 cm. TBRF is adjunctively performed in all patients by administering 3000 joules (rapid lesion technique by Gyrus™,
Fig. 33.9 Two-layered closure of the palatal flaps with 3-0 chromic suture.
Gyrus ENT, Memphis, TN), which are distributed to ten points along the midline of the tongue behind the circumvallated papillae. This initial treatment is followed by monthly sessions, as needed. The addition of TBRF has been shown to provide significantly better subjective and objective improvement in stage II and III patients undergoing UPPP, when compared to patients that undergo UPPP only.9
203
SECTION
I
PALATAL SURGERY
Table 33.1 Comparison of complications between ZPP and classic UPPP, based on a series of 25 matched patients that underwent each procedure
Tongue base infection Bleeding Postnasal drip Dysphagia Foreign body sensation Temporary VPI Permanent VPI
ZPP (n ⴝ 25)
UPPP (n ⴝ 25)
1 (4%) 0 3 (12%) 1 (4%) 11 (44%) 12 (48%) 0
2 (8%) 0 4 (16%) 11 (44%)* 17 (68%) 7 (28%) 0
* P 0.001 Modified from Friedman et al.3
Fig. 33.10 Lateral view showing the widening of the nasopharynx after ZPP.
4 POSTOPERATIVE MANAGEMENT AND COMPLICATIONS As with any intervention that involves resection of the soft palate, significant morbidity is observed in the first 24 to 72 hours postoperatively in the form of significant pain and dysphagia. The ability of the patient to tolerate at least a liquid diet, oral pain medications, antibiotics and steroids determines the moment when the patient can be safely discharged home. While the discharge could in theory be on the same day of the surgery, most patients will need 1 or 2 days of intravenous fluids and medications before they can start taking an oral diet. Prior to discharge, patients are prescribed acetaminophen with codeine elixir as needed for pain. Pain medication requirements average 6.5 days, and so does the progression from liquid or soft diet to normal diet. Postoperative antibiotics and steroids are also recommended, for a total of 7 days. Additional TBRF sessions may be necessary, depending on the improvement of symptoms of each individual patient. Complications of the procedure are comparable to classic UPPP (Table 33.1). Bleeding is always a potential complication and the risk is, again, comparable to classic UPPP. Typically, patients can eat a normal diet after 2 weeks. Mild VPI may become manifest when drinking quickly and may persist for up to 3 months. After 3 months, patients have a normal deglutition. Severity of VPI symptoms diminish with time and are expected to progressively resolve. Permanent VPI is a potential complication that must be considered in every patient. Additional
204
morbidity of the procedure is usually related to throat discomfort symptoms, including globus sensation, mild dysphagia, dry throat, and inability to clear the throat. These symptoms are almost universal after any form of uvulopalatopharyngoplasty. Other complications are related to the adjunctive procedures performed. Tongue base infection is related to TBRF and requires antibiotic treatment. In rare cases, it may lead to tongue base abscess formation, which may require incision and drainage.
5 SUCCESS RATE OF THE PROCEDURE 5.1 SUBJECTIVE AND OBJECTIVE SYMPTOM ELIMINATION The subjective success is based on comparative improvement on snoring level, daytime sleepiness and overall well-being. Patients that underwent ZPP were compared to patients who had previously undergone UPPP for the treatment of OSAHS and the results achieved in these parameters were far superior with ZPP, particularly with adjunctive TBRF. Quality of life scores improve significantly more after ZPP than after UPPP.8 When focusing on objective success, ZPP shows considerable improvement over UPPP. Objective cure rates for stage II patients treated with ZPP and TBRF are close to 70%, compared to about 30% for classic UPPP with TBRF. Limitations of this technique include a higher risk of temporary VPI due to a more aggressive modification of the palatal anatomy, even though the resection is limited to the mucosa. While VPI was only temporary, should permanent VPI ensue, this procedure is probably not reversible. There are also no clear anatomic landmarks to assist in describing the size of the flaps and, ultimately, the
CHAPTER
Zetapalatopharyngoplasty (ZPP)
guidelines outlined in this chapter do not substitute for the surgeon’s judgment. The procedure is significantly more difficult technically and takes longer to perform. A learning curve, as with any other procedure, leads to progressively better results.
33
each patient. Laterally rerouting the uvula together with the soft palate improves the airway characteristics by enlarging the retropalatal space, which is a distinct advantage over the traditional UPPP. This acquires even more importance when addressing the obstruction at the level of the palate in patients without tonsils.
5.2 WHAT TO DO IF THE PROCEDURE FAILS REFERENCES The treatment, as any other, may fail. Failure can be defined as a persistence of symptoms, which would demand additional treatment. Failure can also occur when symptoms of snoring and daytime sleepiness are eliminated but polysomnography (PSG) scores indicate persistent disease. Typically, patients that fail will show a pattern of elimination of apneas but persistent hypopneas. In spite of an abnormal PSG, however, many patients will have a lower C-reactive protein, indicating a possible reduction of cardiovascular risk10 (see also Chapter 13: The Impact of Surgical Treatment of OSA on Cardiac Risk Factors). Failure in achieving satisfactory results may in some cases convince the patient to accept CPAP therapy. When CPAP is not accepted by the patient, further evaluation and treatment are essential. The first step should be a thorough investigation in order to identify the site of failure. Sleep endoscopy evaluation may be a valuable test at this point. If the level of obstruction continues to be retropalatal, a transpalatal advancement pharyngoplasty can be considered.11 If the persistence of obstruction is at the tongue base or hypopharyngeal level, then genioglossus advancement alone or in combination with thyrohyoid suspension could be an option.12 Bimaxillary advancement should be kept in mind as a second-line procedure if the above interventions fail. This procedure will correct failures at both the retropalatal and retrolingual levels.13
6 CONCLUSION No single procedure is effective in treating all OSAHS patients. Treatment should be tailored to the anatomy of
1. Sher AE, Schechtman KB, Piccirillo JF. The efficacy of surgical modifications of the upper airway in adults with obstructive sleep apnea syndrome. Sleep 1996;19:156–77. 2. Fujita S, Conway W, Zorick F, Roth T. Surgical correction of anatomic abnormalities in obstructive sleep apnea syndrome: uvulopalatopharyngoplasty. Otolaryngol Head Neck Surg 1981;89:923–34. 3. Friedman M, Landsberg R, Tanyeri H. Submucosal uvulopalatopharyngoplasty. Op Tech Otolaryngol Head Neck Surg 2000;11:26–9. 4. Fairbanks DN. Operative techniques of uvulopalatopharyngoplasty. Ear Nose Throat J 1999;78:846–50. 5. Senior BA, Rosenthal L, Lumley A, Gerhardstein R, Day R. Efficacy of uvulopalatopharyngoplasty in unselected patients with mild obstructive sleep apnea. Otolarynol Head Neck Surg 2000;123:179–82. 6. Friedman M, Ibrahim H, Joseph N. Staging of obstructive sleep apnea/hypopnea syndrome: a guide to appropriate treatment. Laryngoscope 2004;114:454–9. 7. Friedman M, Ibrahim H, Joseph N. Staging of obstructive sleep apnea/hypopnea syndrome: a guide to appropriate treatment. Laryngoscope 2004;114:454–9. 8. Friedman M, Ibrahim HZ, Vidyasagar R, Pomeranz J. Z-palatoplasty (ZPP): a technique for patients without tonsils. Otolaryngol Head Neck Surg 2004;131:89–100. 9. Friedman M, Ibrahim H, Lee G, Joseph NJ. Combined uvulopalatopharyngoplasty and radiofrequency tongue base reduction for treatment of obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg 2003;129:611–21. 10. Friedman M, Bliznikas D, Vidyasagar R, Woodson BT, Joseph NJ. Reduction of C-reactive protein with surgical treatment of obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg 2006;135:900–5. 11. Woodson BT, Toohill RJ. Transpalatal advancement pharyngoplasty for obstructive sleep apnea. Laryngoscope 1993;103:269–76. 12. Powell NB, Riley RW, Guilleminault C. The hypopharynx: upper airway reconstruction in obstructive sleep apnea syndrome. In: Snoring and Obstructive Sleep Apnea, 2nd edn. Fairbanks DNF, Fujita S, eds. New York: Raven Press; 1994, pp. 193–209. 13. Li KK, Riley RW, Powell NB, Guilleminault C. Maxillomandibular advancement for persistent OSA after phase I surgery in patients without maxillomandibular deficiency. Laryngoscope 2000;110: 1684–8.
205