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Purpose: Obesity can cause disturbed breathing and is one of the most significant risk factors for obstructive sleep apnea (OSA). However, the anatomic basis of OSA and, specifically, the anatomic mechanisms leading from obesity to OSA are still unclear. We examined the anatomic features of the velopharynx in patients with OSA versus those without in correlation with the body mass index (BMI), age, history of snoring, and OSA severity and re-evaluated the contribution of adding a frontal view to the cephalometric analysis of patients with OSA., Materials and Methods: Lateral and frontal cephalometric measurements were taken to assess the velopharyngeal anatomic features of 306 men with various degrees of OSA and 64 men without OSA and without a history of snoring. The demographic, polysomnographic, and cephalometric features were compared., Results: The patients with OSA had an increased pharyngeal length, thicker velum, a thicker posterior pharyngeal wall, a reduced pharyngeal width, and a consequent narrowing of the pharyngeal lumen. As the BMI increased, the OSA severity increased. Also, in parallel, the velum and posterior pharyngeal wall thickness increased and the pharyngeal width decreased. Three types of velopharyngeal narrowing, with an increased occurrence in severe degrees of OSA, were identified: bottle shape, hourglass shape, and tube shape. These aerodynamically unfavorable changes might cause increased upper airway resistance, explaining the development of both OSA and hypoventilation syndrome in obese patients., Conclusions: Velopharyngeal thickening and lumen narrowing were shown to be features of obese men with OSA. However, these features developed only above a threshold BMI value. The combination of frontal and lateral cephalometry is important for comprehensive evaluation of patients with OSA., (Copyright © 2014 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the effects of 2 different anesthetic techniques on early complications after superior pharyngeal flap surgery., Design: Randomized, prospective, single-blind study., Setting: Large referral hospital., Patients: One hundred patients undergoing superior pharyngeal flap surgery for the correction of velopharyngeal insufficiency were randomly divided into 2 equal groups to receive either isoflurane or propofol-based anesthesia., Interventions: Following induction of anesthesia with fentanyl citrate and propofol, patients were randomized to receive either isoflurane or propofol for the maintenance of general anesthesia. The inspired isoflurane concentration and propofol infusion rate were adjusted to maintain a stable depth of anesthesia as judged by clinical signs and hemodynamic responses to surgical stimuli., Main Outcome Measures: Recovery from anesthesia, recovery from surgery, and early postoperative complications., Results: The groups were similar in age, weight, height, induction time, surgery time, extubation time, and anesthetic time. The time (mean +/- SD) required to achieve a maximal Steward Recovery Score was 7 +/- 14 minutes in the propofol group compared with 32 +/- 28 minutes in the isoflurane group (P<.04). No significant differences in postoperative patient satisfaction scores, time to first swallow, drinking time, and time to "home readiness" were noted. Overall, 17 patients (17%) developed airway-related complications and 2 of the patients (2%) were accounted as severe. Two patients (2%) bled from the operation site. However, there was no difference in the incidence of postoperative complications between the groups., Conclusions: When compared with isoflurane administration for maintenance of general anesthesia, propofol-based anesthesia was associated with more rapid mental and psychomotor recovery. However, airway-related complications and "home readiness" were similar between the groups.

Objective: To assess and compare anatomical changes in the velopharynx produced by conventional uvulopalatopharyngoplasty and by laser-assisted uvulopalatoplasty., Design: A before-after trial of patients who underwent conventional or laser-assisted palatal surgical procedures., Patients and Interventions: A total of 174 patients (157 men and 17 women; age range, 22-71 years; mean age, 48 years) who were suffering from heavy snoring (n = 16) or obstructive sleep apnea. The first 100 consecutive patients underwent conventional uvulopalatopharyngoplasty, and the remaining 74 underwent 1 of 2 surgical variations of laser-assisted uvulopalatoplasty., Main Outcome Measures: Preoperative and postoperative examinations included peroral photographs of the oropharynx and nasopharyngoscopic examination of the velopharyngeal valve. In 10 randomly selected patients, postoperative lateral and frontal cephalometric radiographs, enhanced with contrast media, were compared with routine preoperative radiographs., Results: Uvulopalatopharyngoplasty results in an enlargement of the oropharynx and an increased velopharyngeal air space. Laser-assisted uvulopalatoplasty, by producing a raw surface, involves circumferential scarring, the severity of which depends on the velopharyngeal axial configuration; therefore, it can result in a diminished velopharyngeal air space and decreased distensibility., Conclusions: From an anatomical viewpoint, laser-assisted surgery of the palate is significantly inferior to conventional uvulopalatopharyngoplasty and may even be deleterious. The results of preoperative and postoperative polysomnographic comparisons in patients who undergo laser-assisted operations should be evaluated to determine whether future laser-assisted surgery is an adequate option, even for snoring as an isolated symptom.

The variability of the normal velopharyngeal (VP) closure mechanism was studied by investigating VP anatomy in relation to its closure mechanism in 60 patients. The axial configuration of the VP isthmus, as observed in axial CT scans at rest, was found to be correlated with VP function in terms of its closure patterns in speech as observed by nasendoscopy. A flat VP isthmus was found to be closed mainly in the anteroposterior direction, forming the coronal closure pattern. A deep VP isthmus is closed by movement of the velum and medial movement of the lateral pharyngeal walls, forming the circular closure pattern. A flat VP isthmus occurs when the hamuli are posteriorly located and the muscular slings, therefore, open more posteriorly. We conclude that posterior insertion of the velar muscles on to the skull base results in a flatter, larger VP axial configuration, whereas an anterior insertion results in a VP axial configuration that is deeper and less flat. A flat VP isthmus contracts mainly in an anteroposterior direction, exhibiting a coronal closure pattern, while a deep or round VP isthmus contracts centripetally, exhibiting a circular closure pattern. Variability of the VP valving mechanism is of anatomic and not of functional origin.

Unlabelled: Polysomnography is currently used for diagnosis, evaluation and selection of therapy in patients with obstructive sleep apnoea (OSA), but clinically successful uvulopalatopharyngoplasty (UPPP) is not necessarily reflected by post-operative improvement of polysomnographic recordings. Post-operative polysomnography may suggest deterioration of pre-existing OSA or, in snorers, de-novo precipitation of OSA. Thus, if polysomnography is a reliable indicator of OSA, then OSA may be a post-operative risk of UPPP., The Aims of Our Study Were: (i) to assess the possible deleterious effect of UPPP on sleep patterns; (ii) to further define the role of cardioisotope scanning in the evaluation of OSA; (iii) to assess the reliability of polysomnography given the clinical and cardiosotope scan findings. Symptoms, polysomnography and radionuclide ventriculography were prospectively compared pre- and post-operatively in 41 patients undergoing UPPP. In 12 patients (29 per cent), there were disparate results between pre- or post-operative polysomnography and the clinical and/or radionuclide ventriculography, as follows: In four of 16 patients with abnormal pre-operative ventricular performance, there was pre-operative symptomatology of severe OSA and a bedmate's reports of apnoeic episodes. This was in contrast to normal or near normal sleep apnoea recordings. In eight patients, post-operative improvement of symptoms was reported, despite deterioration of post-operative polysomnographic recordings. In these patients the post-operative improvement of symptoms was also reflected by improved ventricular performance. Worsening of ventricular performance was not demonstrated in any patient. In conclusion, UPPP does not induce OSA. Polysomnography may underestimate or even misdiagnose cases of OSA.(ABSTRACT TRUNCATED AT 250 WORDS)

A patient presenting with persistent dramatically offensive fetid malodor 1 year after pharyngeal flap surgery is described. Nasendoscopic examination revealed the presence of a foreign body within the nasopharynx lying on the flap. The foreign body was immediately removed by endoscopic telebiopter and revealed itself to be a gauze pad forgotten during the pharyngeal flap surgery. Modern endoscopic equipment allowed both quick diagnosis of this very rare complication and immediate and simple treatment under topical anesthesia.

Objective: To determine the effectiveness of the two basic surgical types of uvulopalatopharyngoplasty (UPPP), as classified by us. The two basic surgical variations of UPPP differ for the width of the anteroposterior palatal resection, being 1 to 2 cm (type 1) and 0.5 to 1.0 cm (type 2)., Design: Randomized, retrospective study., Patients: Eighty-seven patients with obstructive sleep apnea hospitalized in our department from 1983 to 1991. All patients had a complete preoperative and postoperative polysomnographic evaluation., Results: The operation was found to be an effective treatment of obstructive sleep apnea in most patients. Snoring improvement was found in 95% (29/31) of patients with type 1 UPPP and in 96% (54/56) of the patients with type 2 UPPP, whereas, apnea index improvement was detected in 65% (20/31) of the patients with type 1 UPPP vs 64% (36/56) of the patients with type 2 UPPP. Postoperative dysphagia was found in 94% (29/31) vs 79% (44/56), P = .0025; nasal reflux was found in 81% (25/31) vs 11% (6/56), P = .0001; and hypernasality was found in 100% (31/31) vs 13% (7/56), P = .0001, in type 1 and type 2 UPPP operations, respectively. Chi-square analysis shows highly significant differences., Conclusions: Type 2 UPPP is the recommended surgical procedure of obstructive sleep apnea, mainly due to the minimal postoperative morbidity.

Obstructive sleep apnea syndrome (OSAS) is associated with severe cardiac arrhythmias and conduction abnormalities. Cor pulmonale and right-sided heart failure may ensue. Uvulopalatopharyngoplasty (UPPP) is one of several treatment modalities suggested for OSAS. Tracheotomy and CPAP treatment in adult OSAS patients and adenotonsillectomy in children with OSAS were shown to lead to improvement in some cardiac parameters. Cardiac function was prospectively evaluated in 19 OSAS patients before and after UPPP. No significant changes after surgery were noted on electrocardiographic studies. Improvement in global and regional function of both ventricles was seen in 91% of the patients. A trend toward significant elevation in left ventricular ejection fraction and a statistically significant increase in right ventricular ejection fraction were observed (45% +/- 9% to 50% +/- 7% [p = 0.007]). Our results support performance of UPPP in selected OSAS patients for relief of potentially life-threatening cardiac pathologies.

The oropharynx stripped of the tonsils and the excessive mucosal folds after the uvulopalatopharyngoplasty operation allows a closed observation of the outline of the pharyngeal muscles. Forty-two consecutive patients undergoing uvolopalatopharyngoplasty were subjected to peroral examination of the oropharynx combined with nasendoscopic examination of the velopharyngeal valve. At rest, the oropharynx of the patients with coronal closure patterns was found to be flat relative to the oropharynx of the patients with the other closure patterns. During closure of the velopharyngeal valve, an anteroposterior movement of the velum, forming the nasendoscopic coronal closure pattern, was observed in patients with a flat oropharynx. On the other hand, a medial movement of the pharyngeal walls was found, forming the circular or sagittal closure pattern seen in patients with a deep oropharynx. Our conclusion is therefore that a different muscular orientation is responsible for both the different pharyngeal configuration at rest and the different contribution of the lateral and posterior pharyngeal walls to velopharyngeal valve closure.

The magnitude of hearing loss caused by negative middle ear pressure is a controversial issue. We present a clinical, prospective and controlled study on the effect of negative middle ear pressure on hearing in human ears. Sixty-two ears of patients undergoing uvulopalatopharyngoplasty were examined pre- and postoperatively. The test group consisted of 31 ears in which negative postoperative middle ear pressure ranging between -150 and -400 mmH2O had developed. The control group consisted of 31 ears in which no middle ear pressure change was recorded after the same operation. Bone conduction hearing loss up to 20 dB (with a mean of 11 dB) at 250 Hz, up to 25 dB (with a mean of 13.1 dB) at 500 Hz and up to 10 dB (with a mean of 7.6) at 1,000 Hz was the dominant finding. An additional air-bone gap up to 15 dB (with a mean of 4.3 dB) was found only at 250 Hz. Basic theories about the acoustic response of the ear are discussed and new theories proposed.

A study of 71 patients with obstructive sleep apnea syndrome was performed to evaluate the effectiveness, complications, and late sequelae of uvulopalatopharyngoplasty. Postoperative immediate complications were of minor importance. In 96% of the patients, the snoring was improved; it was completely resolved in 48%. The postoperative apnea index remained pathologic in all patients who underwent postoperative polysomnography, although mild improvement was noted. Seventy-four percent of our patients felt a subjective postoperative improvement which was not always confirmed by the polysomnographic examination. A record of improvement was obtained in 64% of the operated patients. Our results establish the beneficial effect of uvulopalatopharyngoplasty, which is the recommended surgical procedure for obstructive sleep apnea syndrome.

We have studied the mechanism of velopharyngeal valving in 27 patients undergoing uvulopalatopharyngoplasty for obstructive sleep apnea before and after surgery. The patients were assessed by peroral examination and nasendoscopy. Our observations and findings of the readaptation process of the velopharyngeal valve following the operation show us that its different closure patterns are due to a variable anatomy. A certain compensatory mechanism is possible mainly in the circular pattern and the circular pattern with Passavant's ridge and sagittal patterns. Passavant's ridge is an anatomic variant rather than a compensatory mechanism. The muscularis uvulae is important mainly in nonphonetic activities of the velopharyngeal valve. This information is important for clinical purposes in order to better correct problems associated with velopharyngeal incompetence.