The Many Flavors of Palate Surgery Which One is Best? Edward M. - PowerPoint PPT Presentation

The Many Flavors of Palate Surgery – Which One is Best? Edward M. Weaver, MD, MPH University of Washington Harborview Medical Center Seattle VA Medical Center

Acknowledgments • This material is the result of work supported in part by the U.S. Department of Veterans Affairs, Office of Research & Development, Clinical R&D Program. • Dr. Weaver is a staff physician, surgery service line, Department of Veterans Affairs Medical Center, Seattle, Washington. • Grants: – VA Epidemiologic Research & Information Center Pilot Study Grants (Weaver) – American Geriatrics Society Jahnigan Award funded by the John A. Hartford Foundation of NYC and Atlantic Philanthropies (Weaver) – NIH K23 HL068849 (Weaver)

Disclosures • No industry disclosures

Outline • General UPPP outcomes • Modern UPPP concepts – Reconstructive – Anatomic – Functional • UPPP Flavors • Best Flavor!

UPPP & Physiology

Sher, Sleep 1996;19:156-177

UPPP: Physiology Palate Obstruction 100 75 Improvement (%) 80 60 33 40 25 20 0 AI RDI AHI LSAT Adapted from Table 7 Level 4 Sher, Sleep 1996;19:156-177

UPPP & Quantity of Life (Survival)

Weaver, Sleep 2004;27:A208

UPPP: Quantity of Life UPPP Survival No Tx UPPP = 3,977 No Tx = 116,678 Level 2 Weaver, Sleep 2004;27:A208

UPPP & Quality of Life

Weaver, OtoHNS 2011;144:623-31

UPPP: Quality of Life * * 20.0 17.5 17.2 * p<0.001 FOSQ Score 14.3 15.0 10.0 5.0 0 mos 3 mos 6 mos Time from UPPP Level 4 Weaver, OtoHNS 2011;144:623-31

UPPP: Symptoms Level 4 Weaver, OtoHNS 2011;144:623-31

UPPP & Side Effect (CPAP Leak)

Han, Sleep Breath 2006;10:37-42

• Classical UPPP = Excisional • Modified UPPP = Uvula-sparing Han, Sleep Breath 2006;10:37-42

Classical Modified UPPP UPPP p (N=24) (N=7) Severe Oral 5/24 0/7 NS Leak Level 4 Han, Sleep Breath 2006;10:37-42

UPPP Modifications • Reduce side effects – Preserve function • Improve outcomes – Address specific anatomical or functional problem • Multiple modifications – Reconstructive rather than excisional

UPPP Concepts • Open & stabilize all dimensions of velopharynx & oropharynx • Address anatomy • Preserve function

Normal Oral Exam

Sample of UPPP Flavors • Lateral Pharyngoplasty • Expansion Sphincter Pharyngoplasty • Palatal Advancement Pharyngoplasty • Modified Australian UPPP • Relocation Pharyngoplasty • Suspension Palatoplasty • Uvulopalatal Flap • Z-Palatoplasty • Barbed Suture Palatopharyngoplasty

Sample of UPPP Flavors • Lateral Pharyngoplasty • Expansion Sphincter Pharyngoplasty • Palatal Advancement Pharyngoplasty • Modified Australian UPPP • Relocation Pharyngoplasty • Suspension Palatoplasty • Uvulopalatal Flap • Z-Palatoplasty • Barbed Suture Palatopharyngoplasty

Lateral Pharyngoplasty Cahali, Sleep 2004;27:942-50

UPPP vs. Lateral PP 80% 70% AHI Delta% N3% 62% 60% % Improvement 60% 50% 40% REM% Delta% N3% 30% 27% 25% REM% AHI 20% 15% 14% LSAT LSAT 9% 9% 10% 0% UPPP (N=12) Lateral PP (N=15) Adapted from Tables 3 & 4 Level 1 Cahali, Sleep 2004;27:942-50

Thick Lateral Musculature

Expansion Sphincter PP Pang, OtoHNS 2007;137:110-4

UPPP vs. ESP 50 Baseline, 44 45 40 Baseline, 38 35 30 AHI 25 Final, 20 20 15 Final, 12 10 5 0 UPPP (N=22) ESP (N=23) Level 1 Pang, OtoHNS 2007;137:110-4

Lateral narrowing

ESP post-op 4 mos

Why Expansion Sphincter Pharyngoplasty? • Stabilized lateral collapse • Opens AP dimension • Can be combined with other tech

Velopharynx Narrow AP

Velopharynx Narrow AP

Palatal Advancement Woodson, OtoHNS 2005;133:211-17

UPPP vs. Palatal Adv 60 Baseline Baseline 48 48 50 40 Final Change 31 29 AHI 30 Final Change 20 20 17 10 0 UPPP (N=44) Pal Adv (N=30) Adapted from Table 3 Level 2 Woodson, OtoHNS 2005;133:211-17

Retropalatal Airspace

Why Palatal Advancement? • Anterior reposition • Can be combined with other flavors • Salvage palate procedure • Well tolerated – Less invasive than maxillary advancement

Best UPPP Flavor?

Best UPPP Flavor? • It depends!! – Anatomy – Pattern of obstruction – Goals – Surgeon – . . .

What UPPP Do I Use?

Why? • Opens and stabilizes airway – Anterior-posterior (VP) – Lateral (VP, OP, HP) – Superior-inferior (uvula, lateral palate) • Minimizes morbidity – Uvula / VPI – Palatal scar

UPPP Summary • UPPP helps OSA • Modern UPPP – Reconstructive – Anatomic – Functional • Many UPPP flavors

The Many Flavors of Palate Surgery – Which One is Best? REFERENCES 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(2):156-77. Weaver EM, Maynard C, Yueh B. Mortality of veterans with sleep apnea: untreated versus treated. Sleep 2004;27:A208 (Abstract). Weaver EM, Woodson BT, Yueh B, Smith T, Stewart MG, Hannley M, Schulz K, Patel MM, Witsell D. Studying life effects & effectiveness of palatopharyngoplasty (SLEEP) study: Subjective outcomes of isolated uvulopalatopharyngoplasty. Otolaryngol Head Neck Surg 2011;144(4):623-31. Han F, Song W, Li J, Zhang L, Dong X, He Q. Influence of UPPP surgery on tolerance to subsequent continuous positive airway pressure in patients with OSAHS. Sleep & Breathing 2006;10:37-42. Cahali MB, Formigoni GGS, Gebrim EMMS, Miziara ID. Lateral pharyngoplasty versus uvulopalatopharyngoplasty: a clinical, polysomnographic and computed tomography measurement comparison. Sleep 2004;27:942-50. Pang KP, Woodson BT. Expansion sphincter pharyngoplasty: a new technique for the treatment of obstructive sleep apnea. Otolaryngol Head Neck Surg 2007;137:110-4. Woodson BT, Robinson S, Lim HJ. Transpalatal advancement pharyngoplasty outcomes compared with uvulopalatopharyngoplasty. Otolaryngol Head Neck Surg 2005;133:211-. MacKay SG, Carney AS, Woods C, Antic N, McEvoy RD, Chia M, Sands T, Jones A, Hobson J, Robinson S. Modified uvulopalatopharyngoplasty and coblation channeling of the tongue for obstructive sleep apnea: a multi-centre Australian trial. J Clin Sleep Med 2013;9:117-24.