Combination of transpalatal advancement pharyngoplasty and H-uvulopalatopharyngoplasty for obstructive sleep apnea

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In some patients with obstructive sleep apnea hypopnea syndrome (OSAHS), narrow bony nasopharynx is present. Uvulopalatopharyngoplasty (UPPP) can decrease retropalatal compliance in a certain extent, but retropalatal airway size does not increase significantly and, therefore, the response of this procedure is restricted. In our study, OSAHS patients with bony nasopharynx narrowing were enrolled and they all received revised uvulopalatopharyngoplasty with uvula preservation (H-UPPP) and concomitant transpalatal advancement pharyngoplasty. We followed up after more than 6 months, and the efficacy was remarkable. A total of 32 OSAHS patients were prospectively enrolled in this study. They were all men. Patients ranged in age from 27 to 54 years, with a mean age of 39.09 ± 7.75 (mean ± SD) years, ranged in body mass index from 22.87 to 36.73 kg/m2, mean 29.02 ± 3.57 kg/m2, preoperative apnea and hypopnea index (AHI) was 11.70 to 113.70/h, mean 61.75 ± 21.92/h, the lowest blood oxygen saturation was 10% to 85%, mean 64 ± 13%. With preoperative endoscopic technique, bony nasopharynx narrowing were present, and the shape of narrow section was similar to elliptical. Fourteen patients had concomitant tongue-based obstruction. All the patients underwent H-UPPP and concomitant transpalatal advancement pharyngoplasty. Fourteen patients with tongue-based obstruction had chin advancement at the same time. Patients combined with nasal disorder had endoscopic sinus surgery in 1 week to 1 month after surgery. A group of patients with severe nocturnal oxygen desaturation had CPAP therapy for approximately 1 to 3 months. We followed up at 6 months after operations and evaluated them by using the Epworth sleep scale, OSAHS filtration questionnaire scale, and polysomnography. Complication was observed at the same time. The criterion to estimate efficacy was as follows: effective, percent of AHI decreased more than 25%; significantly effective, with a 50% reduction from the baseline AHI or postoperative AHI was less than 20/h; cured, postoperative AHI was less than or equal to 10/h. We found that 27 of 32 patients were effectively cured (84.4%). Among them, in 22 patients surgery was significantly effective (68.8%), and 15 patients were cured (46.9%), including 8 patients with AHI less than 5/h after operation. In the other 5 patients, surgery was ineffective (15.6%). Mean value of preoperative AHTI was 29.70 ± 11.79 minute/h, postoperative AHTI was 9.45 ± 10.74 minute/h, t = 7.689, P = 0.000; mean value of postoperative AHI was 21.06 ± 21.60 /h, t = 8.224, P = 0.000; mean value of postoperative lowest blood oxygen saturation was 80.00 ± 10.45%, t = -5.455, P = 0.000. The syndrome and excessive daytime sleepiness after operation improved markedly, corresponding to the improvement of postoperative AHI and the lowest blood oxygen saturation. Each item and the total score of OSAHS questionnaire scale and Epworth sleep scale decreased significantly compared with the baseline value except BMI (P < 0.01). The combination of transpalatal advancement pharyngoplasty and H-UPPP can improve the efficacy and, in some patients with pure retropalatal airway narrowing, the cure rate can be improved. In 15.6% patients who were ineffective, their retropalatal airway sizes also were enlarged markedly. We suggest that the failure might be caused by the neuromuscular disorder of upper airway dilator muscles in these patients.

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