*3.2.2 Uvulopalatopharyngoplasty (UPPP)*

It represented as the first surgical procedure specifically designed to treat obstructive sleep apnea (OSA) and remains the most commonly performed surgical procedure to treat OSA.

There are multiple approaches have been introducing to address the narrowing or collapse of the retropalatal region (**Table 2**). It traditionally involved removal of the uvula, a portion of the soft palate, tonsils and closure of the tonsillar pillars. All the new techniques involve resection or repositioning of the palatal tissues and pharyngeal walls to increase the dimension of the pharyngeal airway to reduce obstruction.

To determine the likelihood for successful resolution of OSA after UPPP, a staging system was developed based on tonsil size, tongue-palate position, and BMI (**Table 3**) [18].


#### **Table 2.**

*UPPP different procedure approaches.*


#### **Table 3.**

*Friedman clinical staging system for sleep-discorded breathing.*

#### **Figure 1.**

*The Friedman Palate Position is based on visualization of structures in the mouth with the mouth open widely without protrusion of the tongue. Palate grade I allows the observer to visualize the entire uvula and tonsils. Grade II allows visualization of the uvula but not the tonsils. Grade III allows visualization of the soft palate but not the uvula. Grade IV allows visualization of the hard palate only. Adapted from Ref. [18].*

**179**

with stage III [18].

**Figure 2.**

<0.00 [19].

technique [20].

pharyngeal airway.

*Surgical Treatment Options for Obstructive Sleep Apnea DOI: http://dx.doi.org/10.5772/intechopen.91883*

Patients with stage I found to have successful outcome of 80% when treated with UPPP. Stage II patients has success rate of 37.9% and only 8.1% for patients

*Tonsil size is graded from 0 to 4. Tonsil size 0 denotes surgically removed tonsils. Size 1 implies tonsils hidden within the pillars. Tonsil size 2 implies the tonsils extending to the pillars. Size 3 tonsils are beyond the pillars* 

*but not to the midline. Tonsil size 4 implies tonsils extend to the midline. Adapted from Ref. [18].*

In a study where they used DISE to evaluate the site of the obstruction with the Friedman clinical staging system for patients selected for UPPP. There was a significant success rate. The result of the surgery as defined by 50% reduction in preoperative AHI with postoperative AHI < 20/h was seen to be 95.2%. There were significant changes in major presenting symptoms (e.g., snoring, excessive daytime sleepiness, disturbed sleep, morning headaches, dry mouth, and forgetfulness) documented 6 months after surgery. Postoperative change in AHI done after 6-month interval was seen to be statistically significant with P value

Most common adverse effects of UPPP are severe transient throat pain and chronic subjective dysphagia [20, 21]. Trouble with smell and taste, pharyngeal dryness, globus sensation, voice change, and pharyngonasal reflux were presented after UPPP [20]. The new technique used in UPPP like radiofrequency tissue volume reduction (RFTVR) is safer and less painful than resection

For patients, who may still need a CPAP therapy after UPPP surgery, important considerations may include compromise CPAP therapy by increasing mouth air leak and reducing the maximal level of pressure that can be tolerated, especially in

Multiple procedures were designed to improve the obstruction in the lower

procedures with greater resection of soft palate [22, 23].

**4. Lower pharyngeal and laryngeal procedures**

*Surgical Treatment Options for Obstructive Sleep Apnea DOI: http://dx.doi.org/10.5772/intechopen.91883*

#### **Figure 2.**

*Updates in Sleep Neurology and Obstructive Sleep Apnea*

II 1–2

*UPPP different procedure approaches.*

Zetapalatopharyngoplasty (Z-palatoplasty)

Expansion sphincter pharyngoplasty

**Table 3.**

**Table 2.**

*Adapted from Ref. [18] and Figures are adapted from Ref. [18].*

*Friedman clinical staging system for sleep-discorded breathing.*

3–4

**Stage Friedman palate position (Figure 1) Tonsil size (Figure 2) BMI** I 1–2 3–4 <40

Palatal advancement Soft palate is elevated by advancing it towards the hard palate.

**Relocation pharyngoplasty Advancing the soft palate and splinting the lateral pharyngeal wall** Lateral pharyngoplasty Microdissection of the superior pharyngeal constrictor muscle

widen the lateral dimensions of the pharynx

anterior and posterior tonsillar pillars

palatoglossus muscle

III 3–4 3–4 <40 IV Any any >40

*The Friedman Palate Position is based on visualization of structures in the mouth with the mouth open widely without protrusion of the tongue. Palate grade I allows the observer to visualize the entire uvula and tonsils. Grade II allows visualization of the uvula but not the tonsils. Grade III allows visualization of the soft palate* 

*but not the uvula. Grade IV allows visualization of the hard palate only. Adapted from Ref. [18].*

0–1-2 3–4

within the tonsillar fossa, sectioning of this muscle, and suturing of the created laterally based flap of that muscle to the same side

Widen the space between the palate and posterior pharyngeal wall, between the palate and tongue base, and either to maintain or even

Consist of tonsillectomy, expansion pharyngoplasty, rotation of the palatopharyngeal muscle, a partial uvulectomy, and closure of the

> <40 <40

**178**

**Figure 1.**

*Tonsil size is graded from 0 to 4. Tonsil size 0 denotes surgically removed tonsils. Size 1 implies tonsils hidden within the pillars. Tonsil size 2 implies the tonsils extending to the pillars. Size 3 tonsils are beyond the pillars but not to the midline. Tonsil size 4 implies tonsils extend to the midline. Adapted from Ref. [18].*

Patients with stage I found to have successful outcome of 80% when treated with UPPP. Stage II patients has success rate of 37.9% and only 8.1% for patients with stage III [18].

In a study where they used DISE to evaluate the site of the obstruction with the Friedman clinical staging system for patients selected for UPPP. There was a significant success rate. The result of the surgery as defined by 50% reduction in preoperative AHI with postoperative AHI < 20/h was seen to be 95.2%. There were significant changes in major presenting symptoms (e.g., snoring, excessive daytime sleepiness, disturbed sleep, morning headaches, dry mouth, and forgetfulness) documented 6 months after surgery. Postoperative change in AHI done after 6-month interval was seen to be statistically significant with P value <0.00 [19].

Most common adverse effects of UPPP are severe transient throat pain and chronic subjective dysphagia [20, 21]. Trouble with smell and taste, pharyngeal dryness, globus sensation, voice change, and pharyngonasal reflux were presented after UPPP [20]. The new technique used in UPPP like radiofrequency tissue volume reduction (RFTVR) is safer and less painful than resection technique [20].

For patients, who may still need a CPAP therapy after UPPP surgery, important considerations may include compromise CPAP therapy by increasing mouth air leak and reducing the maximal level of pressure that can be tolerated, especially in procedures with greater resection of soft palate [22, 23].

### **4. Lower pharyngeal and laryngeal procedures**

Multiple procedures were designed to improve the obstruction in the lower pharyngeal airway.
