The pharyngeal stage of swallowing presumably begins with the triggering of the swallow reflex at the base of the anterior faucial pillars which appears to be the most sensitive place for the elicitation of this reflex. Resection of the anterior faucial pillars is included in the UPPP surgery in almost all patients. The swallow reflex may not be triggered if there is a lack of proprioceptive or cutaneous receptors in this area.

If the swallow reflex is absent or modified, several important physiologic activities may not occur. These include: 1) elevation and retraction of the velum and complete closure of the velopharyngeal port to prevent material from entering the nasal cavity, 2) initiation of pharyngeal peristalsis to transport the bolus as it passes the anterior faucial pillars, and 3) elevation and closure of the larynx to prevent material from entering the airway. The choking and nasal regurgitation reported by the UPPP patients would suggest reduced oral sensation or an absent or delayed swallow reflex.

In contrast, a hyperactive gag reflex, as found in some subjects, may not be involved in swallowing problems. The hyperactive gag reflex found in these subjects might be explained by a preponderance of sensory receptors in one area. This might be a function of the surgical manipulation or repositioning of tissue. Other reasons for continued gagging might be the presence of foreign material or an alteration of tissue in the oropharyngeal area such as stitches from the surgery or subsequent scar tissue as was found in some UPPP subjects.
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Conclusion

Although there remains no definitive way to predict the outcome of the UPPP surgery, it continues to be performed. Fortunately, the results of this study indicate that adequate velopharyngeal functioning for speech is possible after UPPP surgery. Although some patients do continue to have a mild velopharyngeal malfunctioning problem, ie, nasal regurgitation, the subjects in this study report that the benefit from the surgery was sufficient to override the complication.

It is important for practitioners to alert their patients to the problematic recovery variables identified in this study. Because of the significant finding of dryness, it is recommended that some form of humidification be used especially immediately postoperatively. On the other hand, because no problem was found regarding nasal resonance, the results of this study allow the physician to be more confident in recommending the UPPP surgery without expectation of serious velopha­ryngeal malfunctioning.

Research that will provide more information regard­ing phonation problems in the sleep apnea population should continue. Another area that would be pertinent to the speech-language pathologist includes study of the apnea patients who have received UPPP combined with the more radical maxillary, mandibular, and hyoid advancement. Perhaps in this population nasal reso­nance problems might be identified. Because the majority of these patients previously have undergone UPPP and are possibly at greater risk for velopharyn­geal malfunctioning, further expansion of the posterior airway space could result in nasal resonance problems.

The uvula is involved in uvular trill and uvular /г/ productions in several world languages. Phonetic changes, in the Hebrew language, involving /г/ and /t//, have been reported in 7 of 57 patients following UPPP surgery. It would be of interest to evaluate the results of the UPPP surgery in other populations as well. A more detailed analysis of articulation problems identified in apnea subjects with and without surgery also is suggested. cialis soft tabs

Although central or arrhythmic apneas were not addressed in this study, obstructive and central apnea can coexist. Study of their common physiologic basis and their implications for speech, such as potentially modified respiratory activity, would be important in future research.