LACK OF EFFECTIVENESS OF UVULOPALATOPHARYNGOPLASTY (UPPP) AND LASER ASSISTED UVULOPALATOPLASTY (LAUP) IN SLEEP DISORDERED BREATHING

Helmut S. Schmidt1, Brian P. Berendts1, and Robert M. Hinkle2

Ohio Sleep Medicine Institute1, and Dublin Oral & Facial Surgery Inc.2

Columbus, Ohio U.S.A.

Surgical treatment for sleep disordered breathing remains controversial. Success rates, defined as a 50% reduction in apnea + hypopnea index (A+HI) pre- to postoperatively, are generally described as being less than 40% for UPPP and LAUP4. However, studies to date have not taken into account the more subtle respiratory associated arousals typically seen in UARS1,3, where the A+HI is <5/hr. Since UPPP and LAUP are used to "cure" snoring it is imperative to measure success using the more specific respiratory arousal index (RAI)2 that more accurately measures fragmentation of sleep architecture, the primary reason for excessive daytime sleepiness (EDS).

We report 20 patients (18 male, 2 female) who had either UPPP (n=14) or LAUP (n=6) done by various ENT surgeons in central Ohio. All have had preoperative and postoperative nocturnal polysomnogram (NPSG), and a lateral cephalometric x-ray. All NPSG’s (aside from three preoperative studies) were done at Ohio Sleep Medicine Institute and all cephalometric analysis were done at Dublin Oral and Facial Surgery Inc. Their mean age was 45.9yrs (+/- 11.0), and mean postoperative body mass index (BMI) 34.9kg/m2 (+/- 7.6). Success criterion of a 50% improvement in A+HI indicates that 9 patients, or 45%, achieved "success". However, two of these nine "success" patients still had an A+HI>25/hr, and an five of the nine "success" patients had postoperative RAI well over 30/hr (up to 56). Only one patient out of fourteen achieved a postoperative RAI<10/hr and reported long term (four years) postoperative improvement in snoring and EDS. This patient was of normal weight (BMI=28.6kg/m2), had normal upper airway anatomy (post UPPP), a normal preoperative A+HI (0.2), and only a mildly elevated preoperative RAI (13.7). If success is defined as a postoperative RAI<20, then only two of the other patients achieved successful intervention and all of them continued with EDS and mild to severe snoring. Cephalometrically, only seven patients had normal posterior airway space or PAS > 10mm whereas the mean PAS for the remaining 13 patients was only 9.6mm (range 3 - 15).

Conclusions: Patients with indications of retrolingual (type II and III) narrowing or collapse should not be considered for UPPP/LAUP alone. The patients most likely to succeed with UPPP/LAUP are not obese, have a PAS>10mm, and have relatively mild preoperative sleep disordered breathing.

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1 Guillemenuit C, Stoohs R, Clerk A, Cetel M, Maistros P. A Cause of Excessive Daytime Sleepiness: The Upper Airway Resistance Syndrome. Chest 1993; 104:781-7.

2 Schmidt HS, Berendts BP. Sleep Research 26, 1997:498.

3 Schmidt HS, Laposky AD. Sleep Research 23, 1994: 323.

4 Sher ES, Schechtman KB, Piccirillo JF. The Efficacy of Surgical Modifications of the Upper Airway in Adults With Obstructive Sleep Apnea Syndrome. Sleep 1996; 19(2):156-177.

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