Palatal Surgery

Palatal Surgery: Initial surgical intervention for snoring and obstructive sleep apnoea involve the palate. The earliest operations described were essentially destructive operations where the uvula was either amputated and the palate was scarred. By scaring the palate it was thought that the resultant fibrosis caused stiffening and reduced the flutter of the palate. These simplistic palatal operations are good for snoring but have very little impact on obstructive sleep apnoea.

It is interesting that tonsillectomy has a curative effect on obstructive sleep apnoea on 85-90% of children but in adults, even those adults with large tonsils taking out the tonsils is successful in significantly improving obstructive sleep apnoea in only about 20% of cases.

What is now know about palatal surgery is that two critical criteria needs to be achieved. One is that the palate needs to be widened. Most procedures now rather than being destructive are aimed at expanding the diameters of the pharynx and are called expansion pharyngoplasties. In addition there are two muscles, namely the palatopharyngeus and the palatoglossus, the tone of which during sleep can serve to narrow the airway.

Injection of Botox into palatopharyngeus is a good predictive sign in those patients suspected of having upper airway obstruction and snoring due to palatopharyngeal hyperactivity. If after a Botox injection symptoms are significantly amilierated the patient has two options, the Botox injection can be repeated at 3 monthly interval or the muscle could be cut or myotomised.

The epidemic of obstructive sleep apnoea seems to be very closely correlated with the fact that the populations in western countries are getting fatter. There is a strong correlation between body mass index (BMI) and the degree of fallback of the tongue or tongue back basetosis. Tongue base reduction procedures are aimed, in a minimally invasive way, to reduce the bulk at the back of the tongue and to open the airway. The technique usually involves a procedure performed under general anaesthesia where an incision is made half way back in the tongue, channels are made under the lining of the tongue and an electrical current either by way of coblation or diathermy or laser is introduced to vapourise, reduce tissue and induce scarring.

A potential complication of these procedures is that the major blood vessels to the tongue run a variable course in the base of the tongue, often they are towards the outside or lateral aspect of the tongue but these procedures run the risk of damaging major arterial vessels that are running an aborrhent course and patients should be counseled about the possibility of this occurring and appropriate interventions required to treat such complications. Submental liposuction particularly in males, in ageing males or males that are significantly overweight, a lot of additional fat accumulates under the chin. This is called dulap. In some instances a surgical procedure, most commonly performed in association with other surgical procedures, to reduce the amount of fat under the jaw can be helpful in reducing the amount of front to back compression of the airway.

Submental liposuction can be performed via multiple small incisions but usually a two inch incision is made so that the procedure can be used together with other procedures to open the airway such as, thyrohyoid apposition. This operation involves attaching the hyoid bone to the thyroid cartilage. The base of the tongue is tethered to the hyoid bone and by bringing that forward the base of the tongue is bought forward. The hyoid can be anchored either by non-absorbable sutures or by a small metallic plate. The submental liposuction performed in association with this improves access to these bony cartilaginous structures and improves the success rate of the operation.

Genial tubical advancement: the muscles of the tongue are attached to the inside of the jaw. A simple surgical procedure was performed under general anaesthesia where a block of bone was removed from the inside surface of the jaw bone, moved forward and anchored in that forward position. There was great optimism that this would bring the base of the tongue forward in a predictable, reliable and permanent fashion. Unfortunately this has not proven to be the case. Genial tubical advancement for the controlled forward displacement of the tongue base is very rarely practiced nowdays because results are not predictable.