Functional expansion pharyngoplasty in the treatment of obstructive sleep apnea

Abstract

INTRODUCTION Continuous positive airway pressure is usually prescribed as first-line treatment in preventing the upper airway collapse in patients with obstructive sleep apnea syndrome (OSAS), but long-term treatment adherence represents an evident problem. Among the variety of surgical procedures described to expand the pharyngeal lumen, uvulopalatopharyngoplasty (UPPP) remains the most frequently performed technique for the treatment of retropalatal obstruction. Uvulopalatopharyngoplasty was first described by Fujita in 1981, and basically consists of a tonsillectomy, trimming of the soft palate and uvula, and suturing of the tonsillar pillars. Due to its low success rate and the considerable morbidities involved, the role of this technique has been questioned since the 1990s, and in the last two decades many modifications of UPPP have been proposed. The recent evolution regarding the techniques of pharyngoplasty has been focused on the concept of obtaining the expansion and stabilization of the pharyngeal airspace through the treatment of lateral pharyngeal wall (LPW) collapse rather than through ablation of the redundant pharyngeal soft tissue. The role of LPW in the pathogenesis of OSAS has been demonstrated by Schwab. The narrowing of the LPW appears to be the sole independent risk factor for OSAS. The aim of this article is to present a new surgical technique, functional expansion pharyngoplasty (FEP), which represents a conservative modification of expansion sphincter pharyngoplasty (ESP), as described by Pang and Woodson. Applying the original technique, which includes a superolateral incision of the soft palatal mucosa to expose the anterior arching fibers of the palatoglossus muscle bilaterally, and the preparation of a dorsal palatal flap, we experienced dehiscence of the rotated palatopharyngeus muscle and troubles related to palate incisions, such as globus sensation and dry throat. The FEP technique involves splinting of the LPW and advancement of the soft palate. This is obtained by means of the supero-lateral repositioning of the palatopharyngeus muscle, with a less aggressive and more ‘‘physiologic’’ approach to the LPW and soft palate, in order to both increase pharyngeal airspace and decrease pharyngeal collapse without undermining velum muscles, and in doing so avoiding scarring of the velum.