Dr. David Fairbanks, author of Snoring and Obstructive Sleep Apnea, Third Edition (2003) states
“UPPP has been practiced and refined, praised and maligned, yet it remains the standard against which all other surgical procedures will be compared”.
UPPP stands for Uvulopaltopharyngoplasty. It literally means to reshape the uvula, palate, and pharynx. The internet is full of both horror stories and miraculous cures with this procedure. The concept began over 50 years ago with palatal procedures being done and conceptualized by Ikematsu of Japan. In 1979, Fujita of the United States developed the more classic UPPP, similar to the one still practiced today. There have been several changes over the years to improve results, decrease the chance of complications, and reduce pain but the concepts have remained the same. The goals are:
1. To enlarge the airway
2. To stabilize the airway
3. To correct anatomical abnormalities
The main steps are to remove the tonsils and identify and remove redundant palate and uvula (that dangly thing at the back of your throat).
The procedure can be done with or without raising a mucosal flap, with electrocautery or with a ‘cold’ technique (using a scalpel), and there are variations in certain releasing incisions and stitching techniques. There is very little evidence in the literature to show one technique is better than another so most decisions are based on surgeon experience.
In my opinion, the key to success of the procedure are:
1. Leave a small part of the uvula (makes sure the palate can still reach the back wall of the throat to decrease the chance of liquid coming out your nose when you drink). Be conservative with midline resections.
2. Lift mucosal flaps first and conservatively trim mucosa. This makes sure the wound is closed without tension
3. Incise the posterior pillar at 45 degrees. The pillar is than advanced forward and up to stretch out the oropharyngeal tissue. This widens the throat and tightens it so there is less chance of collapse. The posterior pillar should never be stitched under tension as this would increase complications.
4. Goal is a boxy or rectangular look to the soft palate.
5. The ‘cold’ technique causes no burning of tissue therefore there is less ‘collateral damage’. In my patients this has resulted in significantly less pain and quicker return to work.
Again, I stress that these are my opinions and there is very little evidence to back them up however many other sleep surgeons share these opinions based on their own patient observations. The procedure is tailored to the individual so the procedure is not identical in everyone.
The largest study on complication with this procedure suggest a rate of about 4% (Mickelson, 1998). Others have reported rates from 13% to 30%. In the past, this procedure was done much more frequently than it is today, and with less discretion on patient selection. The major reported complications in the literature are difficulties with anaesthetic and intubation, airway problems from swelling after the surgery or from premature extubation, heart problems, bleeding, velopalatine insufficiency (where liquids come out your nose when you drink them too fast – usually temporary but can be permanent), palatal-nasopharyngeal stenosis (scarring behind the palate making the airway even smaller), difficulty swallowing, the sensation of a lump in your throat, worsening of a gag reflex, numbness of the tongue, temporary taste change, and persistent sleep apnea.
The most common complications are bleeding (2 to 4%) and velopalatine insufficiency. It is actually quite common for the first few days after surgery (10 to 20%) that drinking water quickly will result in it coming out your nose. This is temporary and a result of swelling. It is very rare for this to persist more than a few weeks.
What to expect after surgery?
Where you stay the night of surgery depends on the severity of sleep apnea, whether or not you are already using a CPAP machine, and if there are other medical problems. Many patients can go home several hours after their surgery, others are monitored on the wards, others spend a night in the ICU (Intensive Care Unit) for closer monitoring.
To go home there must be:
1. A secure airway (no risk of having breathing difficulties)
2. Drinking enough fluid
3. Pain is well controlled with oral medication.
After surgery I am very careful with any narcotic pain killers, gravol, and I never give sleeping pills. These all relax the airway and decrease the body's drive to breath. There have been reports of serious complications and even deaths because of these medications given after UPPP. At home you should avoid spicy, salty, sour, or sharp foods. You are prescribed pain medications and a ‘miracle mouthwash’. Some people are prescribed a short course of oral steroids to decrease the swelling. You should expect 1 to 3 weeks of pain and recovery and plan for 3 weeks off of any significant physical exercise or labor. Some people only require a few days off. The recovery period is impossible to predict. You will follow-up in one week for stitch removal.
What are the chances of a “CURE”?
This depends on what is defined by cure. In most papers and studies a cure is defined as a 50% improvement in the AHI and an AHI of less than 20. In considering the new papers on health consequences of sleep apnea, I think surgical success should include an AHI of less than 10 and resolution of daytime symptoms. As well, some patients who initially do well will start snoring and having apnea again within 1 year, especially if there is any weight gain.
Patient selection is the most important factor in surgical success. Success in a young, heathy, non-obese patient with mild apnea, obstructing tonsils and a long uvula and palate is probably greater than 90%. Without proper pre-operative examination, success rate is probably closer to 40%. In my opinion the best paper published on selecting patients for this procedure was published by Dr. Friedman in the Laryngoscope. His grading system for the palate and staging system for sleep apnea is probably already the most widely used and is the one used in my clinic. Using his criteria, if this procedure is recommended to you, the chance of success is about 80%. This still means that about 20% of people need other procedures or treatment.
What is the cause of Failures?
Some studies show most people with sleep apnea have obstruction involving multiple levels of the airway. UPPP addresses only one of these areas. Every effort is made before surgery to identify the other areas of obstruction but there are times when these other areas only become evident after the UPPP. The most likely site of persistent obstruction is at the level of the base of the tongue and pharyngeal sidewalls. Another procedure may be recommended if there is inadequate improvement after UPPP.