Uvulopalatoplasty

Background

Uvulopalatoplasty a surgical procedure performed to reduce or eliminate snoring. Habitual loud snoring affects nearly a quarter of the adult population. The carbon dioxide laser provides a convenient means for performing office-based uvulopalatoplasty for the treatment of snoring. With laser-assisted uvulopalatoplasty, a laser is used to remove part or all of the uvula. ^[1] Laser-assisted uvulopalatoplasty was developed and first performed in 1986 by Kamani (who used the term laser vaporization of the palatopharynx). Kamani reported that, after surgery, 85% of his patients had complete or near complete elimination of their snoring. ^{[2, 3]}

Certain modifications have taken place since Kamani’s original procedure. Coleman ^[4] introduced the modified procedure in 1992 and called it laser-assisted uvulopalatoplasty. In 1994, the most popular laser-assisted uvulopalatoplasty technique was described by Krepsy and Keidar. ^[5]

Laser-assisted uvulopalatoplasty is an office-based procedure performed under local anesthesia. It is a conservative approach to palatal shortening (avoiding velopharyngeal insufficiency) and patients generally experience less pain than with traditional uvulopalatopharyngoplasty. However, one disadvantage of laser-assisted uvulopalatoplasty is that the tonsils are not removed. Krespi and Ling ^[6] described a laser-assisted serial tonsillectomy that can be performed with laser-assisted uvulopalatoplasty, but this technique is not used frequently. ^[7]

Alternate options to laser-assisted uvulopalatoplasty include dental obturators, radiofrequency reduction of the palate ^[8] , injection snoreplasty, and traditional uvulopalatopharyngoplasty. ^[9]

Relevant anatomy

The soft palate marks the beginning of the oropharynx and is the movable posterior third of the palate. It forms an incomplete septum between the mouth and the pharynx. It is marked by a median raphe and is continuous with the roof of the mouth and the mucous membrane of the nasal floor (see the image below).

When the soft palate is relaxed, its anterior surface is concave and its posterior surface is convex. The anterior aponeurotic portion is attached to the posterior border of the hard palate, and the posterior muscular portion hangs between the mouth and the pharynx and is termed the palatine velum (or velopharynx).

The velum is prolonged by a median free process termed the uvula and 2 bilateral processes termed the palatoglossal and palatopharyngeal arches or pillars, which join the soft palate to the tongue and pharynx, respectively. The fauces represent the space between the cavity of the mouth and the oropharynx. They are bounded superiorly by the soft palate, inferiorly by the root of the tongue, and laterally by the pillars of the fauces.

For more information about the relevant anatomy, see Mouth Anatomy and Pharynx Anatomy.

Indications

Indications for laser-assisted uvulopalatoplasty include the following: ^{[10, 11]}

• Surgical management of snoring

• Surgical management of obstructive sleep apnea ^[12]

• Upper airway resistance syndrome

The ideal candidates for laser-assisted uvulopalatoplasty are patients with grade II or III snoring with mild apnea in whom the snoring is localized to the palate on a sleep study. ^[9]

Contraindications

Contraindications for laser-assisted uvulopalatoplasty include the following: ^{[10, 9]}

• Severe sleep apnea

• Uncontrolled hypertension

• Severe trismus

• Cleft palate

• Velopharyngeal insufficiency

• Uncooperative patient

• Hyperactive gag reflex

• Significant mandibular retrognathia

• Anticoagulant therapy

• Bleeding disorders

Patient education and consent

Patient education and counseling is essential before laser-assisted uvulopalatoplasty. The procedure should be fully explained to the patient and informed consent should be obtained. ^[4] Patients should be advised to develop a regular sleeping pattern and avoid sleeping in the supine position. Patients should avoid alcohol and tobacco, lose weight, and treat any gastroesophageal reflux disease.

Pre-procedure planning

Prior to laser-assisted uvulopalatoplasty, a complete history of sleep problems should be obtained from the patient and family members. Medical history should be taken and a detailed medical examination, including vital signs and body mass index, should be performed.

A full head-and-neck evaluation is indicated, including tongue base size, uvula and palate assessment, and gag reflex. A fiberoptic endoscopic examination should be conducted for assessment of the nasal airway, nasopharynx/velopharynx, tongue base, pharyngeal walls, and larynx/hypopharynx.

The Muller maneuver should be performed during flexible endoscopy. ^[13] The level at which snoring is generated can be assessed using the Muller maneuver. In this technique, the upper airway is visualized using a flexible nasendoscope when the patient attempts a forced inspiratory effort against a closed nose and mouth. The procedure is repeated with the nasendoscope in the postnasal space to assess the velopharyngeal sphincter. The degree of collapse at different levels within the pharynx is reported to correlate with the site of obstruction causing the snoring.

Diagnostic tests should include overnight pulse oximetry and complete diagnostic polysomnogram. ^[10] Radiological studies are usually not required before laser-assisted uvulopalatoplasty.

Equipment

A carbon dioxide (CO₂) laser is used in laser-assisted uvulopalatoplasty because it is an excellent cutting instrument with favorable tissue interaction. In addition, it has adequate coagulation abilities for the vessel size encountered during this procedure. ^[4]

SwiftLase (Sharplan Lasers) is a laser flash-scanner used in laser-assisted uvulopalatoplasty. It moves the beam rapidly over the tissue, allowing for thermal relaxation and decreased heat buildup in the tissues. SwiftLase produces less char and therefore less granulation tissue, which results in faster healing. It also allows for precise layer-by-layer surface ablation and the ability to seal small vessels.

Patient preparation

Anesthesia

Laser-assisted uvulopalatoplasty is performed under local anesthesia, with 10% lidocaine spray applied to the palate and the base of tongue regions. Injection of 1% lidocaine with 1:100,000 epinephrine mixed in equal parts with 0.5% bupivicaine is used for infiltration into the treatment area.

The entire uvula, including its base within the soft palate, is injected (see the image below). The soft palate is injected on each side, 1 cm above free edge and the midway between the midline and the level of the medial aspect of the tonsillar pillars.

In patient with severe gag reflexes, 1 mL of anesthetic is injected into the posterior tonsillar pillar, to anesthetize the glossopharyngeal nerve and to reduce the gag reflex. Surgery is started 10 minutes after infiltration.

Positioning

Laser-assisted uvulopalatoplasty is performed in an upright, sitting position in an otolaryngology examination chair.

Monitoring and follow-up

Postoperative monitoring includes vital signs and observation for 20-30 minutes. Antibiotics are prescribed for 1 week, with analgesics and/or anesthetic lozenges as needed. A soft diet is recommended for several days.

The patient should be reevaluated in 4-6 weeks to assess the effect of the procedure. After diminishing snoring, a polysomnogram should be performed in patients treated for obstructive sleep apnea. Sleep laboratory studies should be repeated 3 months after the procedure.

Complications

The following complications may occur after laser-assisted uvulopalatoplasty:

• Vasovagal episodes after the injection of local anesthetic

• Postoperative pain for 4-5 days

• Postoperative hemorrhage

• Local infection

• Temporary palatal incompetence

• Temporary loss of taste sensation

• Hypernasal speech

• Permanent palatal incompetence

• Nasopharyngeal stenosis

Approach considerations

The surgical goal is to reduce the length and reshape the palate and uvula.

Kamami originally described the standard laser-assisted uvulopalatoplasty technique, in which a bilateral vertical 1 cm transpalatal incision is made each time; this is followed by partial vaporization of uvula. ^[2] This is a multistage office procedure that requires a carbon dioxide laser, but does not need a new handpiece for each treatment. ^[14] Over time, Kamami began performing a one-step procedure.

In the single-stage laser-assisted uvulopalatoplasty, stepwise reduction of the uvula and soft palate is performed. After each step, the patient is asked to snort to recreate the snoring sound. Reduction of the uvula and soft palate is done until this sound can no longer be created by snorting. ^[9] Most surgeons perform laser-assisted uvulopalatoplasty as a one-stage procedure, which produce greater pain but eliminates the need for multiple visits. ^[14]

Procedure

All personnel and the patient wear CO₂ laser safety goggles. ^[15] A special pharyngeal handpiece with backstop is used to incise the soft palate. The laser power setting is 18-20 W in the continuous mode.

The tongue is retracted inferiorly with an ebonized tongue blade with the integrated smoke evacuation channel. The patient is advised to hold a deep breath while the surgeon works in the back of the throat for increments of 15-20 seconds, between which the patient is permitted to breathe freely. This technique is important because when patient is holding his or her breath, the palate is less likely to move. Also, the patient will not swallow during breath-holding, thus reducing palatal movements. In addition, breath-holding during tissue destruction prevents the patient from inhaling the laser smoke plume. ^[4]

By using a focused laser beam in a continuous mode, full-thickness vertical trenches measuring 1.0-1.5 cm are made on the free edge of soft palate on either side of the uvula (see the image below). These lateral trenches are then widened to allow the palate to scar upward and lateral as opposed to allowing the incision to close up in its existing position. This widening is done by turning the SwiftLase and ablating 0.5-cm crescents on either side of the incision. Lateral vaporization is carried out from the apex of the incision inferiorly and laterally to the superior tonsillar poles. This reduces the side-to-side healing of the palate incisions and increases the contraction. ^[4]

Shortening and thinning of the uvula is done by using the SwiftLase flash scanner attached to the CO₂ laser, using 18-20 W power. The uvula is shortened by ablating the muscle from within, creating a fish-mouth appearance, because the mucosae of the base of the uvula on the nasal surface and oral surface are preserved. The uvula is reduced to 60-90% of its original dimensions by coring it out from the bottom up. The residual uvula base will now have the appearance of a “neouvula" (see the image below).

During the procedure, patient is asked to make a snorting sound. An inability to produce a snorting sound indicates the completion of palatal reduction. ^[15]