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Sleeping disorders

The uvulo-palato-pharyngoplasty (UPPP) and tonsillectomy are often performed as a part of Obstructive Sleep Apnea surgery. The UPPP procedure shortens and stiffens the soft palate by partial removal of the uvula and reduction of the edge of the soft palate. Since there may be other sites of restriction to breathing, such as the tongue base, the UPPP and tonsillectomy may not resolve the OSA. Most patients who snore, but do not have apnea should enjoy a dramatic decrease in loudness of snoring after UPPP.

Complications of the UPPP procedure are not common, but merit discussion. The palate is a valve which separates the nose from the mouth. This valve is like any other in that it may be broken and stuck in an open or closed position. A palate that no longer completely seals the nose from the mouth has the sound of excess nasal tones and possible leakage of liquids out of the nose. On the other hand, rare instances of severe scarring of the palate could potentially worsen the OSA and make speech unusually non-nasal sounding. Care is taken to avoid either complication by judicious planning and careful technical execution of the procedure. Some patients do note a foreign body feeling when they swallow after having had a UPPP and is due to scar formation.

The tonsillectomy can be an important component of surgery for OSA, especially if the tonsils are at all enlarged. The removal of redundant tissue by tonsillectomy increases the caliber of the throat thereby reducing blockage to breathing. Since the quality and quantity of tissue of the throat changes after tonsillectomy there can be a subtle alteration in voice quality. In a mature adult, pain following tonsillectomy can be unpleasant, but is reasonably well controlled with prescription medication. The UPPP and tonsillectomy remain a very important part of surgery to expand the upper breathing passage for treatment of OSA.

Adverse effects of UPPP include:

  • Pain
  • Bleeding
  • Risk of infection
  • Changes in voice frequency
  • Decreased efficacy of CPAP after UPPP

What type of operation do you really need? It all depends on what structure (or structures) are obstructing your airway during sleep. If it's your soft palate and uvula that are "falling backwards," blocking your airway, then a UPPP (uvulopalatopharyngoplasty) is worth considering. If you still have your tonsils, we usually remove the tonsils at the same time we perform the UPPP. Tonsils can be obstructive. By removing the tonsils, the surgeon (1) gets rid of one obstruction, and (2) has the opportunity to "tighten up" the throat when he/she sutures the wounds created by the tonsillectomy. This can greatly improve the caliber of the airway.

The tongue may also "fall backwards" during sleep, causing an obstructed airway. There are a variety of "tongue advancement" operations. Some individuals have obstruction from the tongue AND soft palate/uvula; if only one problem is dealt with, the results of surgery will usually be very disappointing.

In order to determine what type of operation(s) you need, your doctor must first evaluate your airway to see where you are obstructing. This usually includes an endoscopic examination of the patient's airway, while the patient is supine. During this examination, your doctor might ask you to "imitate a snore," or perhaps, "try to take a breath with your nose pinched and your mouth tightly closed." These maneuvers will sometimes reveal the primary source of airway obstruction. In addition to endoscopy, some doctors also obtain special skull and neck X-rays in order to more objectively evaluate the airway.

In a UPPP, the surgeon will trim off the lower part of the soft palate, including the uvula. If you still have tonsils, the surgeon will remove them at this time. He/she will then place sutures to bring the raw tissue edges together. You will have an "upside-down U" of stitches in the back of your throat. Depending on whether or not you needed a tonsillectomy, the operation may take about an hour, more or less.

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