Uvulopalatopharyngoplasty is a recent surgical procedure for the treatment of sleep apnoea syndrome. Prior to the advent of this procedure the accepted treatment for severe sleep apnoea was tracheostomy.

Sleep apnoea syndrome is defined by the presence of multiple apnoeic episodes while sleeping. Apnoea is defined as the cessation of airflow at the nostrils and the mouth for at least 10 s. The apnoea index, the most widely used measure of the degree of sleep apnoea, is the number of apnoeas and hypopnoeas per hour of sleep. When this exceeds five episodes per hour, or greater than 30 episodes per 7 h, the diagnosis of sleep apnoea syndrome can be made.

The syndrome itself consists of a number of symptoms, the most common of which are loud snoring and excessive daytime somnolence. Other problems arising from this entity are attention deficits, personality changes, systemic hypertension, pulmonary hypertension, nocturnal enuresis, impotence, and, in the most severe cases, cardiac arrhythmias and sudden death.

There are three types of sleep apnoea: central, obstructive, and mixed. Uvulopalatopharyngoplasty is effective mainly in the treatment of the obstructive form, in which there is no airflow despite respiratory effort.

Most authors agree that the area of obstruction is the velopharyngeal space, which includes the soft palate, uvula, tonsils, anterior and posterior tonsillar pillars, and the posterior pharyngeal wall mucosa. These tissues tend to collapse during the inspiratory phase of respiration.

The diagnosis is confirmed both by the history and polysomnography. The physical examination is very subjective, and is often described as grossly normal. The Mueller manoeuvre (sitting nasopharyngoscopy) should be performed for a more objective physical evaluation. Polysomnography includes EOG, EEG, ECG, EMG, continuous oxygen saturation monitoring, and monitoring of chest respirations.

The rationale for surgery is two-fold: the airflow resistance can be decreased by enlarging the nasopharynx, and the airway tract collapsibility diminishes following elimination of tissue.

Many techniques have been described. Fujita first described the technique as palatopharyngoplasty. He did not completely excise the uvula, but recontoured it. Hernandez, whose technique will be described here, removed the uvula and a small part of the soft palate. Simmons excised a large part of the soft palate, leaving only the levator muscles. Dickson and Kimmelman found it necessary to remove some mucosa and muscle, leaving only 1.5 to 2.0 cm of soft palate intact proximal to the uvula.

In the technique as described by Hernandez, (Figs 1–4) 2405,2406,2407,2408 the Rose position is used, with oroendotracheal intubation. A tonsillectomy is performed first, if necessary, preserving as much mucosa of the tonsillar pillars as possible. If the tonsils have been removed, the mucosa is excised and the pillars are mobilized. An incision is made in the anterior soft palate, and extended to the anterior tonsillar pillar. An incision is then made in the posterior portion of the soft palate and extended to the posterior tonsillar pillars. The anterior and posterior incisions of the soft palate are joined. A small portion of soft palate muscle is excised in the midline to facilitate closure. The edges of the palate and pillars are approximated with 3–0 chromic catgut. A small portion of the inferior tonsillar fossa is left open.

Overall, most of the studies demonstrate an excellent response rate regarding snoring and daytime somnolence. The actual decrease in apnoea index is not as good: most studies report a reduction in apnoeas of more than 50 per cent in only 50 to 65 per cent of patients.

Complications of uvulopalatopharyngoplasty include immediate or delayed haemorrhage, nasal regurgitation, hypernasality, and postoperative cardiac arrhythmias. Other complications may arise from difficult intubations, as these patients may have abnormal airway anatomy such as short thick necks, and retrognathia.

Patients with severe cardiac arrhythmias or oxygen saturations below 50 per cent should undergo tracheotomy concurrently with uvulopalatopharyngoplasty.

These patients are often obese, and the usual mouth gag equipment may not be adequate due to chest compression. The extension apparatus described by Oppenheimer is useful in this situation.

Overall, uvulopalatopharyngoplasty is an effective procedure for the treatment of sleep apnoea syndrome, easy to perform, and should be in every otolaryngologist's surgical armamentarium.

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