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Upper Airway Changes in Snorers and Mild Sleep Apnea Sufferers After Uvulopalatopharyngoplasty (UPPP): ConclusionSoft Palate Position and Relationship With Minimal CSA: There was an increase in the thickness of the soft palate in anteroposterior dimension (11.5±2.7 vs 13.6±3.5, p<0.006) observed on cephalometry following UPPP that contributed to a persistent narrowing of the oropharynx. This thickening of the palate appears to be linked in part to scarring and fibrotic contraction. This change in palatal shape was also found by Shepard and Thawley. In our study, the increase in the thickness of the palate occurred in a similar fashion in good responders and nonresponders. The complex relationship between the palate and the posterior pharyngeal wall and the tongue would appear to determine the surgical outcome. If the palate tended to have its long axis parallel to the posterior pharyngeal wall and the end resting on the base of the tongue, there was an enlargement of the phaiyngeal lumen, and UPPP was successful despite the widening of the soft palate. In contrast, if the palate bulged out into the pharyngeal lumen reducing the retropalatal space, UPPP failed (Fig 5). canada viagra

Welch et al have very recently used MRI in five patients to assess UA anatomic changes after UPPP. These data demonstrated that the airway decreased by 28 ±27% in the remaining retropalatal region due to an increasing soft palate width of 25±37%. These preliminary data are in accordance with our study and show the necessity of designing surgical techniques to enlarge the retropalatal area. Transpalatal advancement pharyngoplasty has been proposed to enlarge the velopharynx and retropalatal segment by excising the posterior hard palate and advancing the soft palate anteriorly into the defect. Woodson has suggested that such a procedure increases retropalatal size and decreases collapsibility in the immediate postoperative period. Randomized studies are needed to compare different surgical techniques in terms of long-term outcome and UA modification.
Conclusion
Only 7 of our 20 patients (35%) responded favorably to the surgical procedure, and some of them actually got worse. UPPP was effective in eliminating snoring in only half of them. In nonresponders, the number of microarousals and the total sleep time worsened after surgery. The change in minimal oropharyngeal CSA was correlated with surgical outcome with good responders showing an enlargement of the oropharynx. The persistence of oropharyngeal narrowing after UPPP was linked to an increase in the thickness of the soft palate that occurred in both good responders and nonresponders. The orientation of the palate after surgery was critical in surgical outcome in that UPPP was more likely to fail in patients in whom the residual palate bulged out into the pharyngeal lumen, thus reducing the CSA of the airway. This complex change in airway morphology as a result of UPPP may explain why there are no strict criteria that can be used to predict outcome after such surgeiy.

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  • Minimal Oropharyngeal Area: There was no change in the minimal CSA of the oropharynx for the population as a whole as a result of UPPP (79 ±36 vs 94±68 mm2). This is in agreement with Polo and colleagues who used CT to examine the UA preop-eratively and postoperatively. In contrast, Shepard and Thawley reported an increase in the minimal oropharyngeal CSA that was not, however, accompanied by a change in its mean value. The conflicting findings of these studies might be expected in relation to their small sample sizes. (more…)

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  • Upper Airway Changes in Snorers and Mild Sleep Apnea Sufferers After Uvulopalatopharyngoplasty (UPPP): DiscussionOur study is one of the few to report details of the microstructure of sleep before and after UPPP. As expected, improvement in sleep architecture occurred only in the good responders and consisted of a reduction in the number of microarousals and sleep stage changes and an increase in the amount of slow-wave sleep. In support of this observation, Boudewyns et al, in a retrospective study of 10 nonapneic snorers, demonstrated an improvement in the arousal index after UPPP. Conversely, the number of microarousals and the total sleep time worsened after surgery in nonresponders explaining a persistent daytime sleepiness. (more…)

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  • There was a 25% increase in the thickness (W) of the palate after surgery (from 11.5±2.7 to 13.6±3.5 mm, p>0.06). This increase was similar in both good responders and nonresponders.
    Thus, the combination of thickening of the soft palate together with a greater or lesser reduction in palatal length resulted in different spatial arrangements at the oropharyngeal level (Fig 5). The position of the soft palate was critical in the nonresponders with the palate projecting into the oropharyngeal lumen resulting in a reduction in caliber of the airway. Conversely, the long axis of the soft palate tended to be more parallel to the posterior wall of the pharynx in the good responders, resulting in a wider oropharynx. (more…)

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  • Upper Airway Changes in Snorers and Mild Sleep Apnea Sufferers After Uvulopalatopharyngoplasty (UPPP): Additional Treatments Required After UPPPTreatment supplementary to UPPP was required in nine patients (45%). Continuous positive airway pressure (CPAP) was instituted in four patients and refused by two patients. Positional treatment was initiated in two patients. One patient received both CPAP and maxillofacial surgery. canadian-familypharmacy.com

    Anatomic Modifications of the UA Induced by Surgery
    Minimal Oropharyngeal CSA—Size, Site, and Relation to Outcome: There was no significant increase in the minimal CSA of the oropharynx as a result of surgery for the patients as a whole (79 ±36 vs 94 ±68 mm2) (Table 2). In patients in whom surgery was successful, there was a trend toward an increase in the size of the minimal CSA (74±24 vs 133±82 mm2, p<0.09) that was not found in patients in whom surgery was unsuccessful. In addition, the change in size of the oropharynx was correlated with the change in AHI (r=— 0.54, p<0.02, Fig 1). The minimal CSAs of both nasopharynx and hypopharynx remained unchanged. (more…)

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  • Patient Symptoms After UPPP and Complications
    Ten patients (50%), of whom 2 were good responders and 8 were nonresponders, reported snoring persisting after UPPP. Three of 20 patients (15%) reported respiratory pauses during sleep and 7 others (35%) reported persistent daytime sleepiness. There were no major complications seen as a result of the surgery. Minor complications included nasal speech, nasal regurgitation (n=4, 20%) of which all regressed after 2 months, dehiscence at sutures (n=l), sensory symptoms of the pharynx (n=4, 20%), and minor perioperative hemorrhage (n=l). canadianneighborpharmacy.com

    Effect of UPPP on Sleep and Respiratory Disturbances
    The results of the surgery were mediocre with 7 good responders (35%) and 13 nonresponders (65%) defined by polysomnographic criteria (Table 1). The AHI for the population as a whole was not changed by the surgery (14±13 vs 18±16/h) despite the stability of the BMI (26±4 vs 26±4 kg/m2). In the case of the nonresponders, the AHI worsened, being initially 14.5±14 and subsequently 25±15/h after surgery (p<0.003). For the whole group, the sleep structure was modified with a significant reduction in stages 1 and 2 (75±10% vs 69±11%, p<0.04) in favor of stages 3 and 4 (4±5% vs 7±5%, p<0.01). However, the number of microarousals was unchanged for the group as a whole; the tendency for microarousals to be reduced in the good responders was offset by a significant increase in microarousals in the nonresponders (112 ±38 vs 175 ±104, p<0.02). The quality of sleep, while being marginally improved in patients in whom surgery was successful, was globally altered in patients with failure of surgery with a reduced total sleep time (445 ±88 vs 376±41 min, p<0.03) and a significant increase in the number of changes of sleep stage (312 ±85 vs 464±245, p<0.008).
    Table 1—Sleep and Anthropometric Characteristics Before and After UPPP

    Overall Group (n=20) Good Responders (n=7) Nonresponders (n=13)
    BeforeUPPP p Value AfterUPPP BeforeUPPP p Value AfterUPPP BeforeUPPP p Value AfterUPPP
    BMI, kg/m2 26±4 NS 26±4 25±2 NS 25±3 27±5 NS 27±5
    AH I, events/h 14±13 NS 18±16 13±12 <0.01 4.5±6.5 14.5±14 <0.003 25 ±15
    TST, min 428 ±78 NS 391±41 393 ±32 NS 421±21 445 ±88 <0.03 376±41
    Stage 1-2 sleep, % TST 75 ±10 <0.04 69±11 75±6 <0.07 69 ±14 75±11 NS 69±9
    Stage 3-4 sleep, % TST 4±5 <0.01 7±5 5±5 <0.06 8±7 4±5 <0.08 6±4
    REM sleep, % TST 17.1±7.0 NS 19.1±7.4 19.2±2.8 NS 18.7±6 16.1±8.3 NS 19.4±8.3
    Microanousals, No. 114±36 NS 141 ±100 117±37 NS 68 ±22 112±38 <0.02 175±104
    Sleep stage changes, No. 323 ±90 NS 385 ±236 349 ±110 NS 215 ±79 312±85 <0.008 464 ±245
    Mean Sa02, % 94±2 <0.05 95 ±2 94±2 NS 95±1 94±2 NS 95 ±2
    Minimal Sa02, % 83±11 NS 86±6 86±5 NS 88±5 83 ±14 NS 85 ±6
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  • Upper Airway Changes in Snorers and Mild Sleep Apnea Sufferers After Uvulopalatopharyngoplasty (UPPP): Computed TomographyFor measurements of CSA, an integral software program was used to determine the contours of the pharyngal lumen. In the cephalic regions of the UA, only the velopharyngeal airway posterior to the soft palate was measured. Air in the oral cavity anterior to the soft palate was ignored. The minimal airway CSA was determined also at the levels of the nasopharynx, the oropharynx, and the hypopharynx. The size of the base of tongue was estimated (as described by Larsson et al by the measurement of the interhyoglossal distance and the genioglossal width at the intersection with the hyoglossus. The window settings were standardized for all the patients. (more…)

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  • UA Imaging
    Anatomic Definitions: The inferior border of the nasopharynx was defined by the lowest extent of the hard palate, and the lower margin of the oropharynx was identified by the tip of the uvula. The hypopharynx extends from the tip of the uvula to the epiglottis.
    Cephalometry: Lateral cephalometric radiographs were obtained using the technique described by Riley et al. Briefly, the patient was seated with his head in a neutral position with the gaze parallel to the floor and the teeth together. The x-ray plate was placed next to the left side of the face, and the cone was 1.5 m from the patient. Exposures were taken with the patient remaining still while slowly exhaling a moderately deep breath. Each study gave 4.7 mGy of radiation to the skin. canadian health mall
    (more…)

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