Uvulopalatopharyngoplasty
Encyclopedia
Uvulopalatopharyngoplasty (also known by the abbreviation
s UPPP and UP3) is a surgical procedure used to remove tissue in the throat. It involves the removal of tissues which may or may not include:
UPPP is typically administered to patients with obstructive sleep apnea
in isolation. It is administered as a stand-alone procedure in the hope that the tissue that obstructs the patient's airway is localized in the back of the throat. The rationale is that, by removing the tissue, the patient's airway will be wider and breathing will become easier.
The Role of UPPP in the "Stanford Protocol
" operation
UPPP is also offered to sleep apnea patients who opt for a more comprehensive surgical procedure called "The Stanford Protocol", first attempted by Doctors Nelson Powell and Robert Riley of Stanford University
. The Stanford Protocol is essentially a "cocktail" of surgeries that aim to address the entire airway and thereby treat (or possibly cure) sleep apnea. It has been found that obstructive sleep apnea
usually involves multiple sites where tissue obstructs the airway; the base of the tongue is often involved. The Protocol successively addresses these multiple sites of obstruction.
The Protocol operation involves two phases. First, the patient undergoes soft tissue surgeries, UPPP along with Genioglossus Advancement
or Hyoid Suspension. After the first phase, the patient is given a sleep study and reassessed. The vast majority of patients fail the first phase, and the course of treatment may then proceed to Phase Two.
Phase Two involves maxillomandibular advancement
, a surgery which moves the jaw top (maxilla) and bottom (mandible) forward. The tongue muscle is anchored to the chin, and translation of the mandible forward pulls the tongue forward as well. If the procedure achieves the desired results, when the patient sleeps and the tongue relaxes, it will no longer be able to block the airway. Success is much better for Phase two than for Phase One- approximately 90 percent benefit from the second phase, and the success of the Stanford Protocol Operation therefore is due in large part to this second phase.
Because of its high rate of complications, the role of UPPP in the Stanford Protocol operation is an important consideration that surgeons must weigh. Some surgeons, including Doctors Powell and Riley, feel that UPPP contributes to the overall success of the Stanford Protocol operation. This assertion is open to debate. In 2002, an Atlanta based surgical team, led by Dr. Jeffrey Prinsell, published results which have approximated those of the Stanford team when UPPP was not included in their mix of surgeries.
When UPPP has been administered in isolation, the results have tended to be disappointing. As explained above, sleep apnea is often caused by multiple co-existing obstructions at various locations of the airway such as the nasal cavity
, and particularly the base of the tongue
. It has been the experience of some patients that their breathing improved immediately following the surgery, but that the improvements tended to deteriorate after about two years. Studies suggest that when UPPP is administered as a stand-alone procedure, it is effective in less than 40% of patients. The effectiveness of many of the studies on UPPP have been criticized for being methodologically unsound.
Effectiveness of "The Stanford Protocol" operation
Over one thousand people have undergone The Stanford Protocol operation and received follow-up PSG testing. The results have been that 60 to 70 percent of patients have been entirely cured. In approximately ninety percent of patients, a significant improvement can be expected.
Multilevel approach
In the recent years, many surgeons in the world try to fix the different levels of obstruction in only one surgical event, the "Multilevel approach" (septum, turbinates, UP3, base of tongue, etc, at the same time). This approach seems to importantly improve postoperative results in very well selected patients.
After surgery, complications may include these:
In 2008, Dr. Labra, et al, from Mexico, published a variation of UP3, by adding a uvulopalatal flat, in order to avoid such complications, with a good rate of success.
Abbreviation
An abbreviation is a shortened form of a word or phrase. Usually, but not always, it consists of a letter or group of letters taken from the word or phrase...
s UPPP and UP3) is a surgical procedure used to remove tissue in the throat. It involves the removal of tissues which may or may not include:
- The uvulaUvulaThe palatine uvula, usually referred to as simply the uvula , is the conic projection from the posterior edge of the middle of the soft palate, composed of connective tissue containing a number of racemose glands, and some muscular fibers .-Function in language:The uvula plays a role in the...
(see uvulotomyUvulotomyA uvulotomy or staphylotomy is any cutting operation performed on the uvula.The procedure was performed in European medieval medicine. The Norwegian Eiríkr Hákonarson bled to death following such an operation....
) - The soft palateSoft palateThe soft palate is the soft tissue constituting the back of the roof of the mouth. The soft palate is distinguished from the hard palate at the front of the mouth in that it does not contain bone....
. - The tonsilTonsilPalatine tonsils, occasionally called the faucial tonsils, are the tonsils that can be seen on the left and right sides at the back of the throat....
s - The adenoidAdenoidAdenoids are a mass of lymphoid tissue situated posterior to the nasal cavity, in the roof of the nasopharynx, where the nose blends into the throat....
s, and - The pharynxPharynxThe human pharynx is the part of the throat situated immediately posterior to the mouth and nasal cavity, and anterior to the esophagus and larynx. The human pharynx is conventionally divided into three sections: the nasopharynx , the oropharynx , and the laryngopharynx...
.
How UPPP is administered
Patients undergo the UPPP operation in two very different ways, with the majority of patients receiving UPPP as a stand-alone procedure. Other patients undergo UPPP as the first procedure in a stepped plan known as "The Stanford Protocol Operation". The way in which UPPP is administered greatly affects the overall prognosis of the intervention.Bottom line up front
Standard UPPP (The operation as a stand-alone surgical intervention)UPPP is typically administered to patients with obstructive sleep apnea
Sleep apnea
Sleep apnea is a sleep disorder characterized by abnormal pauses in breathing or instances of abnormally low breathing, during sleep. Each pause in breathing, called an apnea, can last from a few seconds to minutes, and may occur 5 to 30 times or more an hour. Similarly, each abnormally low...
in isolation. It is administered as a stand-alone procedure in the hope that the tissue that obstructs the patient's airway is localized in the back of the throat. The rationale is that, by removing the tissue, the patient's airway will be wider and breathing will become easier.
The Role of UPPP in the "Stanford Protocol
Stanford Protocol
The Stanford Protocol is a combination of surgeries that are undertaken to treat obstructive sleep apnea. The Protocol involves two phases, the first of which involves UPPP and one or more of Genioglossus Advancement or Hyoid Suspension. The Second Phase of the operation involves...
" operation
UPPP is also offered to sleep apnea patients who opt for a more comprehensive surgical procedure called "The Stanford Protocol", first attempted by Doctors Nelson Powell and Robert Riley of Stanford University
Stanford University
The Leland Stanford Junior University, commonly referred to as Stanford University or Stanford, is a private research university on an campus located near Palo Alto, California. It is situated in the northwestern Santa Clara Valley on the San Francisco Peninsula, approximately northwest of San...
. The Stanford Protocol is essentially a "cocktail" of surgeries that aim to address the entire airway and thereby treat (or possibly cure) sleep apnea. It has been found that obstructive sleep apnea
Sleep apnea
Sleep apnea is a sleep disorder characterized by abnormal pauses in breathing or instances of abnormally low breathing, during sleep. Each pause in breathing, called an apnea, can last from a few seconds to minutes, and may occur 5 to 30 times or more an hour. Similarly, each abnormally low...
usually involves multiple sites where tissue obstructs the airway; the base of the tongue is often involved. The Protocol successively addresses these multiple sites of obstruction.
The Protocol operation involves two phases. First, the patient undergoes soft tissue surgeries, UPPP along with Genioglossus Advancement
Genioglossus Advancement
Genioglossus Advancement , is a surgical procedure where the base of the tongue is pulled forward, usually to increase airway size due to deformity or a sleep breathing disorder - See Sleep Apnea....
or Hyoid Suspension. After the first phase, the patient is given a sleep study and reassessed. The vast majority of patients fail the first phase, and the course of treatment may then proceed to Phase Two.
Phase Two involves maxillomandibular advancement
Maxillomandibular advancement
Maxillomandibular Advancement or orthognathic surgery, also sometimes called Bimaxillary Advancement , or Maxillomandibular Osteotomy , is a surgical procedure which moves the jaw top and bottom forward....
, a surgery which moves the jaw top (maxilla) and bottom (mandible) forward. The tongue muscle is anchored to the chin, and translation of the mandible forward pulls the tongue forward as well. If the procedure achieves the desired results, when the patient sleeps and the tongue relaxes, it will no longer be able to block the airway. Success is much better for Phase two than for Phase One- approximately 90 percent benefit from the second phase, and the success of the Stanford Protocol Operation therefore is due in large part to this second phase.
Because of its high rate of complications, the role of UPPP in the Stanford Protocol operation is an important consideration that surgeons must weigh. Some surgeons, including Doctors Powell and Riley, feel that UPPP contributes to the overall success of the Stanford Protocol operation. This assertion is open to debate. In 2002, an Atlanta based surgical team, led by Dr. Jeffrey Prinsell, published results which have approximated those of the Stanford team when UPPP was not included in their mix of surgeries.
Success
The effectiveness of UPPP in isolationWhen UPPP has been administered in isolation, the results have tended to be disappointing. As explained above, sleep apnea is often caused by multiple co-existing obstructions at various locations of the airway such as the nasal cavity
Nasal cavity
The nasal cavity is a large air filled space above and behind the nose in the middle of the face.- Function :The nasal cavity conditions the air to be received by the other areas of the respiratory tract...
, and particularly the base of the tongue
Tongue
The tongue is a muscular hydrostat on the floors of the mouths of most vertebrates which manipulates food for mastication. It is the primary organ of taste , as much of the upper surface of the tongue is covered in papillae and taste buds. It is sensitive and kept moist by saliva, and is richly...
. It has been the experience of some patients that their breathing improved immediately following the surgery, but that the improvements tended to deteriorate after about two years. Studies suggest that when UPPP is administered as a stand-alone procedure, it is effective in less than 40% of patients. The effectiveness of many of the studies on UPPP have been criticized for being methodologically unsound.
Effectiveness of "The Stanford Protocol" operation
Over one thousand people have undergone The Stanford Protocol operation and received follow-up PSG testing. The results have been that 60 to 70 percent of patients have been entirely cured. In approximately ninety percent of patients, a significant improvement can be expected.
Multilevel approach
In the recent years, many surgeons in the world try to fix the different levels of obstruction in only one surgical event, the "Multilevel approach" (septum, turbinates, UP3, base of tongue, etc, at the same time). This approach seems to importantly improve postoperative results in very well selected patients.
Risks
One of the risks is that by cutting the tissues, excess scar tissue can "tighten" the airway and make it even smaller than it was before UPPP. Some individuals who have undergone UPPP as a stand alone procedure have written on internet forums that they experienced a worsening of their breathing following UPPPhttp://www.sleepnet.com/noncpap12/messages/172.htmlhttp://www.sleepnet.com/noncpap18/messages/552.htmlhttp://www.sleepnet.com/noncpap19/messages/549.html. Others have spoken of severe acid reflux.After surgery, complications may include these:
- Sleepiness and sleep apneaSleep apneaSleep apnea is a sleep disorder characterized by abnormal pauses in breathing or instances of abnormally low breathing, during sleep. Each pause in breathing, called an apnea, can last from a few seconds to minutes, and may occur 5 to 30 times or more an hour. Similarly, each abnormally low...
related to post-surgery medication - Swelling, infection and bleeding
- A sore throat and/or difficulty swallowing
- Drainage of secretions into the nose and a nasal quality to the voice. English language speech does not seem to be affected by this surgery.
- Narrowing of the airway in the nose and throat (hence constricting breathing) snoring and even iatrogenically caused sleep apnea.
- Patients who have had the uvula removed will become unable to correctly speak FrenchFrench languageFrench is a Romance language spoken as a first language in France, the Romandy region in Switzerland, Wallonia and Brussels in Belgium, Monaco, the regions of Quebec and Acadia in Canada, and by various communities elsewhere. Second-language speakers of French are distributed throughout many parts...
or any other language that has a uvular 'r' phoneme.
In 2008, Dr. Labra, et al, from Mexico, published a variation of UP3, by adding a uvulopalatal flat, in order to avoid such complications, with a good rate of success.