Background: This paper aims to examine published articles between January 2008 and January 2019 on the different palatal surgeries performed on OSA patients and the treatment outcomes, which in turn will be used to determine the effectiveness of various palatal surgical techniques in treating OSAS and the most effective of the palatal surgical techniques in treating OSAS. Patients and Methods: The current review followed the guidelines of preferred reporting items for systematic reviews and meta-analysis statement 2009 (PRISMA). The quality of relevant studies was assessed using NIH quality assessment tool for observational cohort and cross-sectional studies as well as NIH tool for quality assessment for case series studies. Results: Meta-analyses of relevant studies showed that the surgical technique that achieved the best reduction on AHI (Apnea/Hypopnea Index) was the lateral pharyngoplasty followed by the Anterior Palatoplasty, with a significant mean reduction of [(SMD = −0.848, 95% CI (−1.209 - −0.487), p-value < 0.001) and (SMD = −0.864, 95% CI (−1.234 - −0.494), p-value < 0.001), respectively]. The technique responsible for the best improvement in Epworth Sleepiness Score (ESS) was the Relocation Pharyngoplasty, with a significant mean reduction of [SMD = −0.998, 95% CI (−1.253 - −0.743), p-value < 0.001]. Minimal O2 saturation level improved most with the Expansion Sphincter Pharyngoplasty, with a significant mean reduction of [SMD = 1.011, 95% CI (0.581 - 1.440), p-value < 0.001]. The surgical procedure that results in the best post-operative Visual Analogue Scale (VAS) was Z-Palatoplasty, with a significant mean reduction of [SMD = −1.551, 95% CI (−2.049 - −1.052), p-value < 0.001]. Soft palate length changes with a significant mean reduction of [SMD = −2.219, 95% CI (−2.730 - −1.708), p-value < 0.001]. Finally, meta-analyses of relevant studies showed that expansion sphincter pharyngoplasty achieved the overall highest success rate [event rate = 77%, 95% CI (65.4% - 85.5%), p-value < 0.001]. Conclusion: The best procedure for treating OSA varies from patient to patient and there is no universal cure-all. Careful patient selection and pre-operative evaluation are mandatory.
Charles Dickens in “The Posthumous Papers of the Pickwick Club” published the first description of a patient with obstructive sleep apnea in 1836 [
We are presenting a systematic review for published articles between January 2008 and January 2019 on the different palatal surgeries performed on OSA patients and the treatment outcomes that could determine the effectiveness of various palatal surgical techniques in treating OSA including those being the most effective in treating OSA.
The current review followed the guidelines of preferred reporting items for systematic reviews and meta-analysis statement 2009 (PRISMA) [
The quality of relevant studies was assessed using NIH quality assessment tool for.
Observational cohort and cross-sectional studies as well as NIH tool for quality assessment for case series studies. (Study Quality Assessment Tools) “National Heart, Lung, and Blood Institute (NHLBI)” 2019. Regarding cross section and cohort studies, each study was given a score out of 14 based on answering each question (Yes = 1, No = 0, NA = 0). A score of 10 - 14 indicated a good quality article, 5 - 9 for fair, and 1 - 4 for poor quality article. Regarding case series studies, total evaluation score was 9, a score from 7 - 9 indicated good quality article, whereas score from 4 - 6 for fair, and 1 - 3 for poor quality article.
Statistical analysis was performed as the following: prior to analysis phase, if the published study only reported the mean, the estimated standard deviation (SD) was derived from linear regression of log (published SDs) against log (published means) according to Van Rijkom, H. M., Truin, G. J., & Van’t Hof, M. A. (1998) [
As depicted in
With regard to quality assessment, 44 of 52 studies evaluated showed good quality, whereas the other eight studies showed fair quality (
1) AHI (Apnea/Hypopnea Index)
Reference ID | Sample size | Type of Study | Technique used | Type of surgery | Follow up period (Months) | QA assessment |
---|---|---|---|---|---|---|
Amali/2017/Iran | 20 | Prospective | UPPP | Classic Palatoplasty | 6 | Good |
Amali/2017/Iran | 20 | Prospective | MRTA | Classic Palatoplasty | 6 | Good |
Adzreil/2016/Malaysia | 31 | Prospective | AP + TBD | Anterior Palatoplasty | 12 | Good |
Atan/2017/Turkey | 14 | Prospective | AP + MESP | Antero-lateral Palatoplasty | 6 | Good |
Binar/2016/Turkey | 23 | Prospective | ESP | Lateral Palatoplasty | 3 | Good |
Browaldh/2013/Sweden | 32 | Prospective | UPPP | Classic Palatoplasty | 6 | Good |
Cammaroto/2017/Italy | 10 | Retrospective | UPPP | Classic Palatoplasty | 6 | Good |
Cammaroto/2017/Italy | 10 | Retrospective | ESP | Lateral Palatoplasty | 6 | Good |
Cammaroto/2017/Italy | 10 | Retrospective | BRP | Lateral Palatoplasty | 6 | Good |
Carrasco-Llatas/2015/Spain | 10 | Retrospective | LP | Lateral Palatoplasty | 7 | Good |
Carrasco-Llatas/2015/Spain | 7 | Retrospective | UPPP | Classic Palatoplasty | 7 | Good |
Carrasco-Llatas/2015/Spain | 10 | Retrospective | EP | Lateral Palatoplasty | 7 | Good |
Carrasco-Llatas/2015/Spain | 4 | Retrospective | ZP | Lateral Palatoplasty | 7 | Good |
Carrasco-Llatas/2015/Spain | 22 | Retrospective | PPR | Classic Palatoplasty | 7 | Good |
Chen/2015/Taiwan | 32 | Retrospective | RP | Antero-lateral Palatoplasty | 6 | Good |
Cheng/2008/Taiwan | 50 | Prospective | MEUP | Anterior Palatoplasty | 6 | Fair |
Chi/2014/Taiwan | 25 | Prospective | LP | Lateral Palatoplasty | 6 | Good |
Cho K-S/2013/South Korea | 23 | Prospective | LPMR | Anterior Palatoplasty | 6 | Good |
Choi/2013/Korea | 20 | Prospective | UPPP | Classic Palatoplasty | 6 | Good |
Despeghel/2016/Belgium | 19 | Prospective | ESP | Lateral Palatoplasty | 6 | Good |
DizdaR/2015/Turkey | 9 | Prospective Cohort | UPPP | Classic Palatoplasty | 20 | Good |
Dizdar/2015/Turkey | 14 | Prospective | LP | Lateral Palatoplasty | 20 | Good |
El-Anwar/2016/Egypt | 24 | Prospective | EP w/ SS | Lateral Palatoplasty | 6 | Good |
El-Anwar/2017/Egypt | 22 | Prospective | DSS-ESP | Antero-lateral Palatoplasty | 6 | Good |
Elbassiouny/2014/Egypt | 28 | Prospective | SPFP | Lateral Palatoplasty | 6 | Good |
Elbassiouny/2016/Egypt | 21 | Prospective | SPWF | Antero-lateral Palatoplasty | 6 | Good |
Emara/2016/Egypt | 38 | Prospective | AAP | Anterior Palatoplasty | 6 | Good |
Guler/2018/Turkey | 81 | Retrospective | ESP | Lateral Palatoplasty | 3 | Good |
Karakoc/2018/Turkey | 28 | Prospective | LP | Lateral Palatoplasty | 6 | Good |
Karakoc/2018/Turkey | 31 | Prospective | ESP | Lateral Palatoplasty | 6 | Good |
Karakoc/2018/Turkey | 20 | Prospective | AP | Anterior Palatoplasty | 6 | Good |
Kim/2013/South Korea | 92 | Prospective | UPF + LP | Lateral Palatoplasty | 6 | Good |
Lee/2010/Italy | 30 | Prospective | RP | Antero-lateral Palatoplasty | 6 | Fair |
Li/2009/Taiwan | 10 | Prospective | RP | Antero-lateral Palatoplasty | 6 | Fair |
---|---|---|---|---|---|---|
Li/2013/Taiwan | 47 | Prospective | RP | Antero-lateral Palatoplasty | 6 | Good |
Li/2015/Taiwan | 32 | Prospective | RP | Antero-lateral Palatoplasty | 6 | Good |
Li/2016/Taiwan | 60 | Retrospective | RP | Antero-lateral Palatoplasty | 6 | Good |
Li/2018/Taiwan | 25 | Retrospective | SP | Lateral Palatoplasty | 6 | Good |
Liu/2013/China | 51 | Retrospective | H-UPPP/ Z-PPP | Classic Palatoplasty | 9 | Good |
Lunkvist/2008/Sweden | 120 | Prospective | UPPP | Classic Palatoplasty | 12 | Fair |
Mantovani/2012/Italy | 4 | Prospective | VUPL | Lateral Palatoplasty | 6 | Fair |
Mantovani/2015/Italy | 32 | Prospective | BRB | Lateral Palatoplasty | 12 | Good |
Mantovani/2017/Italy | 19 | Prospective | Alianza | Lateral Palatoplasty | 6 | Good |
Marzetti/2013/Italy | 15 | Prospective | AP | Anterior Palatoplasty | 2 | Good |
Marzetti/2013/Italy | 19 | Prospective | UPF | Anterior Palatoplasty | 2 | Good |
Montevecchi/2017/Italy | 111 | Prospective | BRP | Lateral Palatoplasty | 6 | Good |
Neruntarat/2011/Thailand | 83 | Prospective | UPF | Anterior Palatoplasty | 55 | Fair |
Pang/2009/Multi-center | 77 | Prospective | AP | Anterior Palatoplasty | 33 | Fair |
Pang/2016/Multi-center | 73 | Prospective | AP + ESP | Antero-lateral Palatoplasty | 6 | Good |
Pianta/2017/Italy | 17 | Retrospective | BESP | Lateral Palatoplasty | 6 | Good |
Piccin/2013/Italy | 85 | Prospective | FEP | Lateral Palatoplasty | 6 | Good |
Plaza/2019/Multi-center | 75 | Prospective | ESP | Lateral Palatoplasty | 12 | Good |
Rashwan/2017/Italy | 25 | Prospective | UPPP | Classic Palatoplasty | 6 | Good |
Rashwan/2017/Italy | 25 | Prospective | ESP | Lateral Palatoplasty | 6 | Good |
Rashwan/2017/Italy | 25 | Prospective | BRP | Lateral Palatoplasty | 6 | Good |
Salamanca/2014/Italy | 24 | Prospective | BAP | Lateral Palatoplasty | 6 | Good |
Soares/2013/ Brazil | 18 | Prospective | LP | Lateral Palatoplasty | 6 | Good |
Sommer/2016/Germany | 23 | Prospective | UPPP | Classic Palatoplasty | 3 | Good |
Suslu/2017/Turkey | 28 | Retrospective | ESP | Lateral Palatoplasty | 6 | Good |
Ugur/2013/Turkey | 42 | Prospective | AP | Anterior Palatoplasty | 24 | Good |
Vicini/2015/Italy | 10 | Prospective | BRP | Lateral Palatoplasty | 6 | Good |
Wu/2016/China | 24 | Prospective | UPPP | Classic Palatoplasty | 6 | Good |
Yi/2009/China | 34 | Prospective | ZPPP | Classic Palatoplasty | 6 | Fair |
Yousuf/2013/India | 22 | Prospective Cohort | UPPP | Classic Palatoplasty | 6 | Good |
UPF: Uvulopalatal Flap; LP: Lateral Pharyngoplasty; RP: Relocation Pharyngoplasty; MEUP: Microdebrider Assisted Extended Uvulopalatoplasty; ESP: Expansion Sphincter Pharyngoplasty; UPPP: Uvulopalatopharyngoplasty; LPMR: Limited Palatal Muscle Resection; SPFP: Soft Palatal Webbing Flap Pharyngoplasty; EP + SS: Expansion Pharyngoplasty with Suspension Sutures; PPR: Partial Palatal Resection; ZP: Z-Palatoplasty; MESP: Modified Expansion Sphincter Pharyngoplasty; DSS + ESP: Double Suspension Sutures + Expansion Sphincter Pharyngoplasty; MRTA: Modified Radiofrequency Tissue Ablation; FEP: Functional Expansion Pharyngoplasty; H-UPPP: Han’s Uvulopalatopharyngoplasty; Alianza Technique: BAP + BRB; SPW: Soft Palatal Webbing Flap; SP: Suspension Palatoplasty; BRP: Barbed Reposition Pharyngoplasty; BESP: Barbed Expansion Pharyngoplasty; BAP: Barbed Anterior Palatoplasty; BRB: Barbed Roman Blinds.
UPPP | UPF | LP | AP | ESP | RP | Roman Blinds |
---|---|---|---|---|---|---|
Bilateral tonsillectomy with trimming and resection of excess pharyngeal mucosa. Arch shaped incisions are then made on either side of the uvula followed by blunt dissection to remove the fat from the spatium veli palate. The free palatal mucosa is then sutured together and the anterior and posterior pillars are sutured together | The Uvula is reflected upwards on the palate and an outline is marked. A diamond shaped segment of mucosa and submucosa starting from the outline downwards is removed in addition to the anterior aspect of the uvular mucosa. The uvular tip is shortened. Finally, the uvula is then reflected onto the soft palate and sutured into place | The technique entails performing a tonsillectomy. If the patient had previously undergone a tonsillectomy, then a vertical myotomy is done in the tonsillar bed in order to access the Superior Pharyngeal Constrictor (SPC) muscle. The SPC Is then vertically sectioned resulting in two flaps, the lateral of which is sutured to the anterior pillar on the same side. A half thickness incision is made in the oral aspect of the soft palate extending supero-laterally from the base of the uvula to the lateral soft palate margin. The Palatopharyngeus muscle is sectioned transversely. Z plasty is used to suture the upper palatopharyngeal muscle flap with the palatine flap created previously. The lower palatopharyngeal muscle flap is then sutured to the anterior pillar on the same side. The same steps are repeated on the opposite side. | A rectangular strip of mucosa midway between the hard palate and the uvula is removed down to the muscle layer without removing any of the muscles. The skin edges are then approximated thus bringing the soft palate antero-superiorly. Partial uvulectomy may be done if needed | Tonsillectomy followed by identification and horizontal transection of the Palatopharyngeus muscle near its inferior end. A superolateral incision is made extending from the base of the uvula to the soft palate margin, in order to uncover the arching palatoglossal fibers of the soft palate. A suture is taken through the bulk of the Palatopharyngeus muscle and attached to the arching palatoglossal fibers. The anterior and posterior pillars are then sutured together. The same steps are repeated on the opposite side. Partial Uvulectomy for patients with enlarged uvula. | Tonsillectomy is the first step followed by bilateral incisions extending from the base of the uvula supero-laterally to a point (near the pterygoid hamulus) and then from there downwards to connect to the base of the anterior pillar. The mucosa, submucosa and adipose tissue in the superolateral corner of the palate bounded by the incisions made previously is dissected. The Palatopharyngeus (PPM) muscle near the uvula is rotated supero-laterally to be sutured to the area previously dissected. The medial aspect of the Superior Pharyngeal Constrictor muscle (SPC) is sutured to the ipsilateral Palatoglossus (PGM) muscle thus splinting the SPC to the ipsilateral tonsillar fossa. The remaining PPM is sutured to the remaining PGM | Three stab incisions are made in the palate. Two at thpterygoid hamulae and one just before the posterior nasal spine. Using a 2-0 non-resorbable polyester thread mounted on a cutting needle, the periosteum and fibromuscular layer of the posterior nasal spine is entered sideways. The thread is then guided downwards to the free edge of the soft palate using multiple in and out sutures, each through the same hole. The needle emerges on one side of the uvular base and then passed sideways through the uvular base to emerge on the contralateral side. The thread is then passed upwards towards the posterior nasal spine in the same manner as before. At the posterior nasal spine, the thread is tightly knotted and buried in the stab incision which is subsequently close using resorbable thread. The same steps are repeated twice more on either side of the palate at the Pterygoid hamulae |
Meta-analyses of relevant studies showed that the surgical technique that achieved the best reduction on AHI was the lateral pharyngoplasty followed by the anterior palatoplasty, with a significant mean reduction of [(SMD = −0.848, 95% CI (−1.209 - − 0.487), p-value < 0.001) and (SMD = −0.864, 95% CI (−1.234 - −0.494), p-value < 0.001), respectively] (
2) ESS (Epworth Sleepiness Scale)
Meta-analyses of relevant studies showed that the surgical technique that achieved the best reduction on ESS was the relocation pharyngoplasty, with a significant mean reduction of [SMD = −0.998, 95% CI (−1.253 - −0.743), p-value < 0.001] (
3) Minimal Oxygen Saturation Percentage
Meta-analyses of relevant studies showed that the surgical technique that achieved the most reduction in O2 saturation was the expansion sphincter pharyngoplasty, with a significant mean reduction of [SMD = 1.011, 95% CI (0.581 - 1.440), p-value < 0.001] (
4) VAS (Visual Analogue Scale) for Snoring
Meta-analyses of relevant studies showed that the surgical technique that achieved the best reduction in VAS was Z-Palatoplasty, with a significant mean reduction of [SMD = −1.551, 95% CI (−2.049 - −1.052), p-value < 0.001] (
5) Soft Palate Length
Meta-analyses of relevant studies showed that the UPPP surgical technique achieved soft palate length change with a significant mean reduction of [SMD = −2.219, 95% CI (−2.730 - −1.708), p-value < 0.001] (
6) Success Rate
Meta-analyses of relevant studies showed that expansion sphincter pharyngoplasty achieved the overall highest significant success rate [Event rate = 77%, 95% CI (65.4% - 85.5%), p-value < 0.001] (
OSA management can be divided into surgical and non-surgical with the earliest surgical technique being the UPPP. Subsequent modifications to the original technique and introduction of novel techniques have all been aimed at achieving consistently higher success rates and fewer complications.
This study included papers published in the last 10 years, starting in 2008. The reason being that the majority of the techniques with the exception of the Lateral Pharyngoplasty and modifications on the original UPPP, were introduced starting 2007. Therefore, including earlier papers would have possibly skewed the results in favor of older techniques.
The success of palatal surgical techniques in treating OSA is graded according to improvements in different parameters. These namely being the AHI, ESS, Oxygen desaturation index & VAS for snoring. Overall success in the majority of the papers was defined using Sher’s Criteria introduced by Sher & Colleagues in their 1996 publication [
In 2018, Pang et al. published a Systematic review and meta-analysis which concluded that ESP resulted in better post-operative outcomes than other traditional surgeries, namely the Anterior Palatoplasty, Classical UPPP and Uvulopalatal Flap procedures [
After reviewing the literature, several points of note have been identified:
- There is a general consensus that UPPP is no longer the best option for treating OSA. It is associated with significant post-operative pain and out of the previously discussed palatal surgeries has the highest risk of post-operative bleeding. Furthermore, UPPP can result in the much-disliked complication of velopharyngeal stenosis due to scar contracture according to Katsantonis, G. P., Friedman, W. H., Krebs, F. J., & Walsh, J. K. (1987) [
- BRP is a quicker and easier technique to perform than the ESP and fully respects the anatomical integrity of the palate. It is also the technique associated with the least blood loss. The success of the BRP and ESP techniques stems mainly from the widening of the lateral retro-palatal diameters. That being said, despite the ESP achieving the highest success rate in our analysis, the ESP procedure has been associated food residues in the pyriform fossae due to interruption of the pharyngeal muscles that protect them [
- The Barbed roman blinds technique tensions the lateral wall without interrupting palatopharyngeal muscles unlike FEP and ESP and this tension occurs along the whole length of the thread. Barbed suturing allows muscles to be moved along different vectors (anteriorly, posteriorly, laterally) as required based on DISE evaluation.
- Pre-operative evaluation and identification of the site of obstruction is critical to optimizing post-operative results. DISE has proven to be the best diagnostic procedure suited to this purpose. By correctly locating the site of collapse the surgical technique that best addresses that site can be chosen and techniques which do not adequately address the pathological site can be avoided, even if it means forgoing palatal surgery altogether because the collapse is hypopharyngeal for example.
- There isn’t always a single site of airway collapse and hence more than one surgery might be needed at different levels (multi-level surgery) to achieve a response.
- OSA severity can be graded as mild, moderate or severe. In many of the papers reviewed, authors would initially include only those patients with mild to moderate OSA. The main reasoning behind this was that they realized that the surgery they were proposing would not achieve adequate results in severe OSA patients. Nevertheless, this subsequently results in a distorted outcome.
- Some patients suffer from positional OSA. These patients tended to be in the mild to moderate group of OSA sufferers, whereas non-positional OSA subjects usually had severe OSA [
- Each procedure has its claimed advantages, however, objectively speaking, the best procedure would undoubtedly be the one that achieves the best post-operative results whilst minimizing palatal anatomical distortion and post-operative complications.
The best procedure for treating OSA varies from patient to patient and there is no universal cure-all. Careful patient selection and pre-operative evaluation are mandatory.
The authors declare no conflicts of interest regarding the publication of this paper.
Rabie, A.N., Mady, O., El-Shazly, A.N. and Abouzeid, A. (2021) Systematic Review and Meta-Analysis of the Palatal Surgeries in the Treatment of Obstructive Sleep Apnea. International Journal of Otolaryngology and Head & Neck Surgery, 10, 61-74. https://doi.org/10.4236/ijohns.2021.102007