Uvulovelopharyngoplasty

Uvulovelopharyngoplasty (UVPP/UPPP) is an ear, nose, and throat surgical therapeutic procedure used to treat a primary nocturnal breathing disorder (sleep apnea syndrome; SAS), which is primarily identifiable by snoring (rhonchopathy). To achieve the treatment goal and thus relieve the patient from snoring, tightening of the uvula (uvula), pharynx (pharynx) and velum (soft palate) is performed. The removal of tissue allows the cross-section of the airway to be increased. Thus, this procedure is an anatomical correction method to alleviate nocturnal breathing disorders. Accordingly, with the help of this change in anatomy, there is a reduction in nocturnal snoring. However, it must be noted during surgery that a reduction in the size of the uvula and soft palate will affect the pharyngeal closure, so speech disorders may occur as a result of the surgical procedure.

Indications (areas of application)

• Primary nocturnal breathing disorder (sleep apnea syndrome; SAS).

Often, however, snoring is also a consequence of a present obesity or chronic respiratory diseases. If this is the case, the patient is advised to eliminate the primary causes with the help of the attending physician. In principle, conservative treatment options should be exhausted.

Contraindications

• If an infection is present, UVPP should not be performed under any circumstances. In particular, symptoms in the ear, nose and throat area such as rhinitis should be considered absolute contraindications.

Before surgery

• There is a recommendation to perform uvulovelopharyngoplasty under general anesthesia because the procedure is a complex surgical intervention, so the exact course of surgery cannot be precisely planned. Only when using a laser (laser-assisted uvulovelopharyngoplasty) is it possible to perform the surgical procedure under local anesthesia (local anesthesia) without any significant disadvantages for the patient. Before the procedure, if general anesthesia is present, no food or liquid intake is allowed.
• Anticoagulants (anticoagulant drugs) such as acetylsalicylic acid (ASS) or Marcumar are to be discontinued in consultation with the attending physician before the operation, if necessary.

The surgical procedures

As already described, a tissue removal or tightening of the palate and pharynx area is performed as a therapeutic measure for existing snoring sounds. The procedure itself is performed in the supine position. An advantage of the procedure is the use of self-dissolving sutures for suturing the wound area, so that no subsequent removal of the sutures is necessary. In total, the operation takes an average of 20 minutes. However, before surgical therapy is used for treatment, it should be checked whether conservative measures (non-surgical treatment options) can also contribute to an improvement of the present symptoms. As a rule, the most important adjusting screw in the therapy of snoring is the overweight (obesity) of the patient. If weight reduction is achieved, a significant symptom relief can occur in the majority of cases. In addition to weight loss, it can also be useful to use special splints (snoring splints) as a treatment method. The snoring splints are usually made individually for the upper and lower jaw in a dental laboratory. Both splints are connected to each other by a hinge. As a result, the lower jaw is pushed forward about 10 mm. The basic principle of the use of such splints is based on the adjustable forward displacement of the lower jaw. This displacement automatically moves the base of the tongue forward during sleep, widening the cross-section of the airway. Depending on the symptoms, various splints are used, which differ in material and complexity. A comparatively simple model is a splint made of thermoelastic plastic. The affected patient can shape the splint as desired according to the instructions in the package insert in order to improve wearing comfort.However, there are also very complex splints that can be made exclusively in collaboration between dentist and technician, as special anatomical conditions must be taken into account. Outline of the uvulovelopharyngoplasty variants.

• Classic uvulovelopharyngoplasty – in the classic variant of uvulovelopharyngoplasty, which is usually performed in combination with tonsillectomy (removal of the palatine tonsils), the first step is the removal of a small strip of mucosa. The tissue to be removed is located between the anterior and posterior palatal arches. Once the removal has been performed, the edges of the incision can be sutured, which results in direct tightening of the tissue. After suturing the edges of the incision, partial removal of the uvula is also performed in the same procedure. However, it must be noted here that the back of the uvula should not be damaged under any circumstances, since the receptors localized here have an important function in the context of the pharyngeal closing mechanism during swallowing.
• Laser-assisted uvuloplasty (synonyms: LAUP; Laser-assisted uvula palatoplasty; English Laser Assisted Uvula Palatoplastic) – this method is a surgical variant based on classical uvulovelopharyngoplasty, which is mainly used in patients who have already undergone tonsillectomy (removal of the palatine tonsils). In addition, the use of the procedure is indicated in patients with very small tonsils (tonsils are lymphatic organs located in the area of the oral cavity and pharynx; when one speaks of tonsils, one usually means the palatine tonsil). The treatment effect is produced by laser treatment, in which an incision is made in the mucosa parauvularly (next to the uvula) on both sides, reaching the musculature. Depending on the severity and symptoms, there is also the option of specifically removing areas of mucosa. With the help of the laser, a parallel shortening of the uvula is performed. If one compares the classic form of surgery with laser-assisted uvuloplasty, it is noticeable that the form of anesthesia is far gentler with laser surgery than with the classic form, with similar treatment success, since a relatively simple local anesthetic (local anesthetic) can be used with laser surgery. Furthermore, it should be noted that the procedure is comparatively little cost and usually does not require several days of inpatient postoperative monitoring.

Influence of uvulovelopharyngoplasty on the pathogenesis mechanism of snoring.

• The snoring sound as an expression of a breathing disorder is due to the narrowing of the upper airway during sleep. The differences between the individual forms of snoring can be considered minor. Despite this almost identical symptomatology of the different subtypes of snoring, clear variations in the pathophysiology can be recognized. Ultimately, however, each primary cause leads to collapse of the upper airway due to the existing anatomical obstruction.
• However, correction of the narrowing is successful in most cases with varying causes. However, it should be noted that not all possible causes of snoring have been characterized, so the surgical procedure is not equivalently successful for each cause.
• As an example of a possible cause of snoring that has not yet been adequately explored, there is insufficient tension in the dilatation of the pharynx, which physiologically should cause pharyngeal dilation in the presence of an increase in the concentration of carbon dioxide in the blood. Although the cause is not due to an anatomical deformity, UVPP can be used to induce symptomatic improvement.

Combination with other surgical procedures

• Surgical intervention at the base of the tongue in combination with UVPP – in addition to the classic UVPP and the laser method, there is moreover the possibility to perform surgical therapy measures at the base of the tongue. Here, a reduction of the surface area can be distinguished from the removal of larger amounts of tissue. The aim of these interventions is generally to reduce the mass and mobility of the base of the tongue. Regardless of whether the reduction of the base of the tongue is performed in combination with UVPP or laser-assisted uvuloplasty, general anesthesia is essential. As a rule, the operation on the base of the tongue is performed with the laser.
• Other surgical procedures to improve air passage in sleep-related breathing disorders, ranging from tethering of the os hyoideum (hyoid bone) to tracheotomy (tracheotomy), are of no significant importance in the treatment of primary snoring, since the success is by no means better than with separate UVPP. The same applies to maxillofacial surgical measures, which bring about a widening of the upper airway through conversion osteotomies.

After surgery

After surgery, spicy and especially hard foods should be avoided for about two weeks. Cooling with cold foods or drinks may minimize swelling. Strong pain medications may be necessary depending on the course of the surgery.

Possible complications

• Post-bleeding
• Wound infections
• Dysphagia (difficulty swallowing)
• Speech impairments
• Pain