Options for Obstructive Sleep Apnea Palate Surgery Reviewed

The lateral pharyngoplasty procedure enlarges the pharyngeal airway by cutting the superior constrictor muscle and mobilizing, dividing and relocating the palatopharyngeus muscle. The survival of the palatopharyngeus flap and preserving the soft palate and uvula to avoid velopharyngeal insufficiency are key to success in this procedure, said Michel Cahali, MD, PhD, an otorhinolaryngologist at the University of São Paolo in Brazil. When the procedure fails, it’s usually because there has been only lateral enlargement of the space, a lack of mobility or division of the palatopharyngeus or bilateral necrosis of the palatopharyngeus flap, he said.

Z-palatoplasty: Michael Friedman, MD, chairman of otolaryngology at Rush University Medical Center in Chicago, developed Z-palatoplasty (ZPP) as an option in patients for whom UPPP has failed. The procedure is designed to create an anterolateral direction of scar contracture that opens the airway as healing occurs. Objective success rates are much higher for ZPP than UPPP, at 68 percent and 28 percent, respectively (Otolaryngol Head Neck Surg. 2004;131:89-100).

“Since the procedure involves considerable morbidity, it should be considered only for very select patients with severe disease who are not candidates for alternative therapy,” Dr. Friedman said in his presentation. “Selected patients who proceed with the procedure are likely to have subjective and objective improvement, with a reasonable chance for ‘cure.’”

Palatal advancement: In palatal advancement, a section of the hard palate is removed to make more space at the back of the pharynx. The soft palate is then moved forward and re-attached. This enlarges the space and gives more tension to the soft palate to help avoid collapse.

Indications for the procedure are retropalatal stenosis or scarring, failure of the UPPP with persistent narrowing and proximal pharyngeal narrowing, said B. Tucker Woodson, MD, chief of the division of sleep medicine and professor of otolaryngology at the Medical College of Wisconsin in Milwaukee. Patients are not candidates if there’s a concern about compromised palatal blood supply, if they’re are unable to tolerate an oral splint, if they have poor lateral wall movement, if they have impaired swallowing or speech or if they have maxillofacial surgery planned.

Soft-palate implants: These implants are not a good treatment for sleep apnea but can work well in snoring for patients with palate flutter and realistic expectations, said Brian Rotenberg, MD, MPH, director of the sleep surgery program at Western University in London, Ontario, Canada. The implants are contraindicated for smokers, obese patients, those with an AHI over 15, those with symptomatic OSA and a tonsil size two or greater. Studies have shown minimal improvements in AHI scores (approximately three to four points difference before and after the surgery) and extrusion rates of 2 to 4 percent. Often, there’s early improvement, followed by some clinical decline over time, so patients should be counseled about expectations.