Palate Procedures for Obstructive Sleep Apnea

Palate procedures for obstructive sleep apnea are one of the surgical options available for the treatment of OSA. In this section, we will explain the procedure, and discuss how it works.

Eric Kezirian, MD, MPH

The soft palate (roof of the mouth) can play an important role in blocking breathing in patients with obstructive sleep apnea.  Palate surgery includes a group of procedures that are generally performed under general anesthesia in the operating room. Palate surgery is combined with tonsillectomy in most patients who have tonsils that have not previously been removed. Palate surgery can be performed alone or in combination with hypopharyngeal procedures. These palate procedures involve a combination of tissue removal and tissue repositioning that aims to increase the size of the airway without affecting normal functions such as breathing, speaking, and swallowing.  Specific features of the procedures include the following:

Uvulopalatopharyngoplasty (UPPP) was the first procedure used to treat obstructive sleep apnea.  The procedure includes removal of the uvula and a portion of the soft palate, with sewing together the cut edges of the remaining portion of the soft palate and sides of the throat.  Compared to other procedures, UPPP typically involves more tissue removal from the soft palate.

Expansion sphincter pharyngoplasty involves almost no tissue removal but more tissue repositioning. In this procedure, the muscle that is directly behind the tonsil (palatopharyngeus muscle) is freed up from the side of the throat and moved forward. Because it is still attached to the soft palate, it pulls the soft palate forward to open the area behind the soft palate for breathing.  In a randomized trial comparing it to UPPP, this procedure showed better results than UPPP in certain types of patients.

Lateral pharyngoplasty involves some tissue removal but more-extensive repositioning of tissue of the soft palate as well as the lateral pharyngeal tissues (side of the throat). This procedure is more-involved, but it has also shown better results among certain patients in a randomized trial comparing it to UPPP.

The Pillar Procedure typically involves the insertion of 3-5 braided polyester implants (pillars) into the soft palate at the back of the mouth. Each implant is 18 mm (3/4 inch) long and is made of a polyester material that has been used in other medical implants for decades. The Pillar Procedure is usually performed in a surgeon’s office, which is one of its advantages.  More-recent research has examined the benefits of the Pillar Procedure, showing that there are certain patients that seem to benefit more than others.  The most-favorable patients tend to be those with small tonsils (or who had them removed already) and who are not excessively overweight.

Uvulopalatal flap can be used in patients with thin soft palates.  The procedure involves almost no removal of muscle of the soft palate.  Instead, the lining of the mouth (mucosa) over a portion of the soft palate and uvula is removed to allow a folding of the soft palate muscle onto itself.  Effectively, it makes the soft palate shorter without removing muscle because muscle removal could be more likely to affect swallowing in these patients.

Palatal advancement pharyngoplasty treats the palate by removing some of the bone towards the back of the roof of the mouth (hard palate).   After removal of the bone, the soft palate is then pulled forward and sewn into place.  This opens the space for breathing behind the soft palate in a slightly different way.

Also, see Hypopharyngeal Procedures and Jaw Advancement Surgery

Z-palatoplasty requires dividing part of the soft palate in the middle and pulling each half forward and laterally.  This can be most effective for patients with scarring on the sides of the throat that can occur after tonsillectomy or previous other soft palate procedures.  Z-palatoplasty tends to be associated with more difficulty with swallowing following surgery than other palate procedures, but it can be necessary and important in certain patients.

Relocation pharyngoplasty incorporates very little tissue removal but includes sewing together the muscles on the side of the throat to open the space for breathing in a slightly different way.

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