Primary Screening Of The Indications Of Uvulopalatopharyngoplasty

Objective:Uvulopalatopharyngoplasty (UPPP) remains themost common surgical procedure performed for OSAHS.Butmeta-analysis of the data indicates a success rate of only 40%above six-months follow-up after surgery and this result isnot satisfied. To improve the achievement ratio of surgery,itis important of mastering the indications. The purpose of thisstudy is to valuate clinical staging system based on tonguesize and tonsil size, and select surgical indications ofuvulopalatopharyngoplasty (UPPP).Method: We retrospectively reviewed 33 patients to dividethree stages based on tongue size and tonsil size ,who hadcomplete case document,operated with UPPP successfully andthen followed up.Refer to Friedman staging stardard in2002,stage 1 was defined as having tongue size Ⅰ or Ⅱcombined with tonsil size Ⅱor Ⅲ. Stage 2 was defined ashaving tongue size Ⅲ or Ⅳ and tonsil sizeⅡor Ⅲ. StageIII was defined as having tongue size Ⅲ or Ⅳ and tonsil size0 orⅠ. The results of UPPP were then graded as success orfailure as based on postoperative polysomnography results andthe curative efficiency was compared by stage. Success of UPPPwas defined as a reduction of AHI to 50% and less than 20. Thisstudy was also to analyse the severity of OSAHS and bodymass index on the effect of the surgical efficiency ofUPPP .Result: The results of follow-up and questionnaireexamination demonstrate: Stage 1 patients who underwent UPPPhad a curative efficiency of 81.8 %,stage 2 had a curativeefficiency rate of 41.2%,and stage 3 patients had a curativeefficiency of 0%. Stage I preoperative and postoperative AHIvalues were significantly lower.In stage II and stage IIIpatients, postoperative mean AHI did not differ frompreoperative values. The surgical efficiency of UPPP had notrelation to the severity of OSAHS, and was better in patientswith BMI<30kg/m2.Discussion: To improve the achievement ratio ofsurgery,it is important of mastering the indications,whilethe critical fator of curative effect is the definition ofobstruction.Numerous methods have been used to predict thelocation of the upper airway obstruction. These includephysical examination, cephalometric fluoroscopy, computedtomography, magnetic resonance imaging. These studies are allvaluable in research studies but have not been shown to be ofclinical value. The most commonly used test is the MullerManeuver (MM). Borowiecki and Sassin first described thismaneuver for the preoperative assessment of OSAHS. The testis widely used and simple to perform. Despite this,its use iscontroversial. Criticism of the test is based on 3 areas. Onecriticism of the test is that it is subjective. The second ischangeable.The third area of criticism is whether the use ofMM helps predict success of UPPP.In addition, we have foundthat patients with minimal collapse of the hypopharynx asdetermined by MM before UPPP may have moderate or severecollapse in the tongue base (by MM) after UPPP.Various studyverified that it can not predict the location of the upperairway obstruction in sleep by MM operated in wake.Fridman et al. proposed a staging system based on palateposition, tonsil size, and BMI ,BMI≥40 is considered asindependent prognosis factor and is arranged stage Ⅲ.Theothers is the same with us and the result is verified . StageI disease with enlargement of tonsil size and small tongue basehave better than an 80% chance of success with UPPP and is thebest surgical indications of UPPP. Patients with stage II andstage III disease should never undergo UPPP alone as a surgicalcure of OSAHS. They should be treated with a combination ofprocedures that address both the palate and hypopharynx. Someof them may require tongue base advancement procedures ormaxillary mandibular advancement procedures. a meta-analysisby Sher et al. demonstrated limited success rate innonselected patients. In patients with retrolingualobstruction and for severe OSAHS, the success rate was as lowas 5% to 10%.Severe OSAHS is generally associated with tonguebase collapse.Therefore, the collapse of the tongue base mustbe corrected.Tongue enlargement is an important prognostic indicatorof success of surgical treatment. Shintani et al. performeddynamic MRI to determine the narrowing site and the severityof OSAHS during sleep. They found that the severity of AHIand SpO2 are significantly associated with the width of theairway space at the base of the tongue and the hypopharynx.Mehmet et al. included that the tongue base suspensioncombined with UPPP had reduced RDI better than UPPP or tonguebase suspension alone. This technique yields a highlysuccessful surgical cure rate at 81.81% when combined withUPPP in the severe OSAHS patients with multilevel airwayobstruction.Riley et al.considered that the patients ofmiddle and severe degree should be performed by hyoidsuspension plus UPPP ,then were performed genioglossusadvancement with whose curative effect was bad .Fridman et al.verified that tongue base radiofrequency reduction plus UPPPwith stage Ⅱand Ⅲ can get better therapeutic efficacythough retrospective study in 2004.Cai et al.consider that it is short of recognitiondelineation causal relation of enlargement of soft palate anduvula palatine.It is because long-term snore to inducehyperemia and enlargement of soft palate and uvula palatinethat is not the cause of occlusion.We conclude that theclinical staging system for OSAHS based on tongue size andtonsil size appears to be a valuable preditor of the successof UPPP and would help selective surgical indications of UPPP.Certainly,the staging system is not a substitute for detailedevaluation through clinical examination and radiologicalstudies, but it provides stratification of patients that helpsin treatment selection and helps in assessment of results.The surgical efficiency of UPPP have not relation to theseverity of OSAHS, which is said that the severity of diseasewas not a prognostic indicator of success of surgicaltreatment ,and we have similar results with foreign study.Obesity is the important factor of the curative effect ofUPPP.Because fat metabolism is in disorder,fatty depositionis in spatium intermusculare that influences the function ofmusucles ,that is to say the tension of muscle degrade and themuscles are easy to collapse.Though it is excided part oftissue, the accommodation function of the center is notchanged, periphery tissue is filled quickly again to collapseand occlude again ,which makes the surgery fail.So thepatients should control weight strictly.Surgical results wasbetter in patients with BMI<30kg/m2.The compliance of airpassage wall increase high,and the muscles of the pharyngealportion and soft palatine taper, and the mucous membranerelax gradually with age. Surgical results were worse inpatients with age above 50.Conclusion:A clinical staging system for OSAHS based ontongue size and tonsil size appears to be a valuable preditorof the success of UPPP and would help selective surgicalindications of UPPP。We should take individual therapyaccording to the age ,the weight, the severity of disease andthe site of occlusion of patients to the quality of lives ofpatients with OSAHS.