HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Yaremchuk

Table 1 Friedman staging system based on Friedman tongue position, tonsil size, and body mass index

Friedman Tongue Position

Tonsil Size

BMI

Stage I

1 2

3, 4 3, 4

<40 <40 <40 <40 <40 >40

Stage II

1, 2 3, 4 3, 4 Any

0, 1, 2

3, 4

Stage III

0, 1, 2

Any

From Friedman M, Ibrahim H, Bass L. Clinical staging for sleep disordered breathing. Otolaryngol Head Neck Surg 2002;127:16; with permission.

excision of the posterior pharyngeal mucosa could be done. The posterior pharyngeal mucosa was elevated and stretched laterally and sutured ( Fig. 2 ).

THE UVULOPALATAL FLAP

The uvulopalatal flap (UPF) was reported by Powell and colleagues 9 who used a tech- nique to advance the uvula and distal palate by creating a flap of tissue that was reversed on itself and sutured close to the hard palate. The advancement flap started with the ventral surface of the soft palate, and the uvula had the mucosa removed and was sutured in place. An incision was made that also released the lateral aspects of the palate. Huntley’s 10 drawings described the steps of the procedure very well (see Fig. 2 ). 10 Initially, local anesthetic with a vasoconstrictor was injected in the ventral surface of the soft palate and uvula to assist with separating a plane between the muscular layer and the mucosa, which also helped with pain control and hemostasis. The soft palate and uvula were retracted toward the hard palate to allow an outline to be drawn for the incision. The ventral mucosa was removed, and relaxing incisions were made at the lateral aspect to provide greater anterior release of the UPF and in- crease the retro-palatal area. The palate was then folded on itself, and the mucosa of the dorsal palate and uvula was sutured into position. The procedure can be done as an outpatient or under general anesthesia. An advan- tage was that the procedure was potentially reversible if velopharyngeal insufficiency occurred. Because muscular tissue was not removed, the normal physiologic mobility of the palate was maintained and the likelihood of scar contracture and subsequent nasopharyngeal stenosis would be decreased. An important additional benefit was a decrease in postoperative pain because there was no disruption of muscle tissue or presence of denuded surfaces. An extended UPF (EUPF) described by Li and colleagues 11 included the previous procedure but used dissection and removal of submucosal adipose tissue of the soft palate and supratonsillar area ( Fig. 3 ). The EUPF was done in conjunction with tonsillectomy. The EUPF was done under general anesthesia, and in their series there was one occurrence of bleeding from the tonsillar fossa during the postoperative period and 3% of patients had occasional nasal regurgitation. Surgical success was reported in 81.8% based on a 50% or greater decrease and less than 20 apnea-hypopnea index (AHI) reported in 27 men with only retro-palatal obstruction. The mean BMI in this series was 26.7, which is less than usual patients with obstructive sleep apnea in the United States but was considered “overweight for middle aged Taiwanese.”

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