Lateral Pharyngoplasty

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Introduction

As new concepts have emerged in the medical literature for sleep apnea and also based on our own experience, lateral pharyngoplasty (LP) was developed and updated several times since we first published it in 2003 ( ; ; ; ; ; ; ; ).

The main factors that have led to the evolution of our technique described here and wider applicability to patients are the role of the retropalatal airway as the primary site of obstruction in sleep apnea, the physiologic integration of the upper airway (tongue–palate coupling), the role of the lateral wall as an extension (i.e. insertion of the soft palate), the lack of anteroposterior enlargement of the retropalatal area in our previous LPs, and residual supine obstructions in some of our patients who underwent prior versions of the procedure ( ; ; ; ; ; ; ).

The main changes in our technique were designed to avoid any stretching of the pharyngeal mucosa, to increase retropalatal enlargement, and to splint the upper lateral pharyngeal wall with a myomucosal palatopharyngeus flap.

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Indications

We use LP to treat the spectrum of sleep-disordered breathing from habitual heavy primary snoring to obstructive sleep apnea (OSA) in adults, regardless of OSA severity. All patients are counseled about available nonsurgical treatments like mandibular repositioning devices and continuous positive airway pressure (CPAP). A nonsurgical therapy trial is not mandatory prior to a patient electing surgery for OSA in Brazil.

We recommend LP in a spectrum of patients, from those who have large tonsils to patients without tonsils, including cases with failed previous uvulopalatopharyngoplasties or even unsuccessful LPs. The soft palate–tongue position is not a factor for selection, nor is the thickness of the posterior tonsillar pillar. So far, we have found no reason to believe that the location or pattern of obstruction found in drug-induced sleep endoscopies would better indicate or contraindicate this technique.

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Contraindications

As any technique designed to enlarge the retropalatal area, LP is contraindicated in patients with previous velopharyngeal insufficiency. Although we perform the surgery in obese patients routinely, we usually contraindicate it in patients with a body mass index above 35 kg/m ² because of the increased perioperative anesthetic risk. Mild or moderate maxillary or mandible deformities are common in OSA patients and are not contraindications to the LP. Severe facial skeletal deformity is a contraindication. A very limited mouth opening is also an exclusionary criterion for the procedure.