UPPP Revisited for Obstructive Sleep Apnea

The uvulopalatopharyngoplasty (UPPP) procedure is probably one of the most controversial issues in sleep medicine for sleep apnea treatment. Despite study after study showing limited success rates, surgeons continue performing this procedure. Some in the sleep community are adamant that with such low success rates, it should not be performed anymore. But then there are studies that come out once in a while that show there’s some benefit to this procedure. With all the conflicting information and confusion, who are you to believe?

 

A recent paper published in the Mayo Clinic Proceedings concluded that there’s still a role for the UPPP in some sleep apnea patients. While not "curative" in all patients, a significant number of people had improvements not only in their sleep apnea scores, but also in quality of life measures. (Take a look at my response to Sleep Apnea Ed’s blog here.)

 

With the UPPP, the overall "success" rate is found to be around 40% in numerous studies. You could say that it doesn’t work most of the time (60%), or that it worked 40% of the time. Is there a way to predict who’ll respond and who won’t? A common screening system developed by Dr. Friedman showed that if you have very large tonsils and a relatively low-sitting tongue, and you’re not very overweight, then you’ll have about an 80% chance of surgical "success." Unfortunately, not too many people fit into this category.

 

ENT surgeons tend to overly focus on the soft palate, mainly because that’s where the snoring is coming from, and it’s the traditional operation that we do for snoring and sleep apnea. Now we know that the soft palate is only a small part of the condition that causes sleep apnea. Once you address the entire upper airway (from the tip of the nose to the voice box), then surgical success rates can go as high as 80%. If you make the jaws much larger (the maxilla-mandibular advancement, or the MMA), success rates are well above 90%. The thinner you are, the better these procedures will work.

 

One study that I recall showed that even the 40% success rate was better in the long term than CPAP. Patients were recruited from a VA hospital with newly diagnosed sleep apnea and two groups were followed: CPAP users and UPPP patients. What why found a few years later was that you had a higher chance of being alive if you underwent a UPPP than if you were assigned to the CPAP group. Even though the overall success rate for UPPP is only 40%, these 40% stayed "successful", at least for the first few years. CPAP users, on the other hand, probably began to drop off in using their CPAP machines, at after a few years, compliance was poor. Based on research that shows that your overall risk of dying from cardiovascular disease in much higher if your have untreated sleep apnea, these results make sense.

 

Of course there’s still a lot more we as physicians can do for sleep apnea patients before they even consider surgery (counseling for CPAP, oral appliances, etc.), but once they run out of all other options, it’s important to know the facts and see the big picture. With good patient selection, intensive counseling, and setting realistic long-term goals, surgery can be a good option for some people. Usually, a UPPP alone is never the answer.

 

How many of you have undergone a UPPP operation and it didn’t help? How much counseling, follow-up and support did you receive with CPAP or oral appliances? Was multi-level surgery offered besides just a UPPP? Please enter your response in the text area below.

 

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14 thoughts on “UPPP Revisited for Obstructive Sleep Apnea

  1. I have had sleep apnea for seven horrible years. Immediately started using CPAP machine. After two years of not sleeping well and feeling tired all of the time, I had surgery…UPPP. I felt better for 10 months, then had to start using CPAP again. Before surgery I stopped breathing 35 times an hour…since surgery I stop breathing 9 times an hour. Definite improvement but not a cure. I still feel tired all of the time even though I use the machine almost every night.
    Recently I was told that use of CPAP machine will eventually cause Central Apnea… a rare condition …my brain will stop telling me to breathe…needless to say, I am very upset about this. Why did it take seven years for me to hear about this? If this is true every person with sleep apnea should be warned about this dangerous side effect before they decide to start using a CPAP machine!

  2. CPAP can cause central apneas occasionally, especially if the pressure is too high. This is why a proper titration study is so important. If your AHI went from 35 to 9, and kept using your CPAP at the same pressure, it may be too high for you and make you more at risk for central sleep apnea.

  3. I have been diagnosed with sleep apnea, I could not stand the Cpap machine, so I use now a mandibular orthesis tah keep my jaw advanced. This did not resolve my sleeping apnea I think, because I am still very tired when I wake up, I have nightmares, and I am very sure those nightmares are directly related to stop breathing while sleeping, because when I wake up during nightmare, I feel that I awas not breathing , and I need some time to start breathing again.I also think but I am not very sure, that I stop breathing, but it is not related to obstruction. Is this possible that I forgot to breath or something else is wrong with me and its not sleep apnea? I have a feeling that this stoping is due to brain orders or something like that. I saw the documentary about the plasma blade surgery, but I am very afraid of it since I cant find too much testimonials regarding it.
    I need a proffesional advice, on whta to do and who to consult who can redo all the necessary tests to have a clear diagnostic about my case.
    Thank you
    Johny Hayne

  4. Mr. Hayne,

    Did you ever undergo a sleep study with your oral appliance in place? Can it be adjusted any further?

    What you're describing sounds all related to your sleep apnea. It can ultimately lead to breathing confusion, and even central apneas, where your brain forgets to tell your body to breathe.

    If you haven't done so already, take a look at my report on surgery for obstructive sleep apnea, which you can find on the upper right corner of my homepage. Ultimately, the type of cutting tool is not as important as how it's used and where it's used.

  5. After having a sleep study done about fifteen years ago I was diagnosed with obstructive sleep apnea. A short time after the diagnosis I under went surgery removing my uvula and some of my soft palate. At the time that I choose the surgery it was presented to as having a high cure rate for sleep apnea. The other option was to sleep with a CPAP machine for the rest of my life, I chose the surgery. The surgery seemed to have been somewhat successful for about five or six years. About five years ago after another sleep study I was prescribed a CPAP machine, of which I've used diligently over the years. However I would very much like not to be tethered to the CPAP machine. What your feelings on the Plasma Blade surgery? If positive would I be viable candidate for the Plasma Blade surgery for sleep apnea? I’m in my late forties, relatively good heath, about ten percent over my ideal body weight. Your thoughts would be great appreciated. Thanks
     

  6. I have no idea to whom I am emailing,but would like more info re Blade Plasma Surgery.
    I became acutely ill in 1998–lost the ability to fall asleep or stay asleep, with moderately severe sleep apnea(46 x's/min.)–undiagnosed for over 5 years.Have been using CPAP for 7 yrs.with no follow-up medical care.I detest strapping the mask to my face every night,almost always remove it during sleep.Have never heard of Central Apnea!! Would very much like to know if candidate for BPS.Is it available in Canada?

  7. Mr. Jones,
    I've written extensively about surgical options for sleep apnea. You can read a summary by signing up for my report on sleep apnea surgery on my homepage, or in my book. 
    Regarding Plasma blade technology, all it is is another option as a cutting tool. All the different options (plasma, coblation, harmonic, laser, Bovie), with unique advantages and disadvantages. It's how well you do the surgery and which anatomic areas you address that determines long-term success rates. I think you'll agree that Tiger Woods can clobber you using Wilson starter golf clubs, even if you use the most expensive golf clubs.

  8. I was diagnosed with tendency to asthma and mild to moderate sleep apnea. I feel like it's always hard to breath despite that I tried several types of medications for asthma. For sleep apnea I was prescribed mouth piece which I used for 6 months and it did not help at all. In fact, I was sleepier and fatigue than ever. Here are two treatments I already have mentioned that I get from doctors. Any thoughts or ideas on why asthma, if it's just tendency to it, and mild to moderate apnea disrupt my daily activities. I tried stimulants to stay awake, but with no luck.
    Otolaryngologist said that 'tonsils are on larger side and soft palate on lower side. That means that tonsils are a bit larger than usual and soft palate is a bit lower too. Her suggestion was not to get uppp. Should get a second opinion? 

  9. Dr. Park, I am a 38 year old male, 5 ft 11in and about 220 lbs (weight lifter with a belly!). I did a sleep study this past August that showed I had 29 apneas per hour. My ENT doctor saw that I had a deviated septum and I eventually had it operated on in mid-September. While I now breathe much better (I used to be a mouth breather all day long and was stuffy all year round), my sleep has not improved, nor has my snoring.

    My ENT told me there were two routes – CPAP or UPPP. I tried a mouth piece, but I snored right through it. I am hesitant to get more surgery, but the thought of wearing a mask all the time in bed mortifies me. I sleep in our guest room almost year round due to my snoring keeping my wife awake, and I can’t see even a quieter CPAP letting my wife sleep. I have a large uvula and lots of soft palate tissue, and my ENT thinks I would benefit from the surgery. While I am hesitant to get surgery, the chance of it working makes it worth it over the thought of wearing a mask for life. I would like your opinion based my information. While I am a bit over-weight, I have snored for two decades no matter my weight or time of year. Thank you.

  10. I had uppp, tonsillectomy, and septoplasty in 2005, and I’m very glad I did. I was too heavy at the time and probably shouldn’t have had it before losing weight, but now (May 2011), I am much healthier. I still don’t snore, I don’t wake up to urinate nearly as often, I have lost a great deal of weight and am much more physically active, and I just feel much better all around. Recovery was…..interesting……but if I had it to do all over again, I’d do it, even though the 2 weeks following surgery were easily the worst physical discomfort of my life.

    My tonsils were very, very large, my uvula was always getting stuck between them when my mouth was dry and I had a lot of sore throats then, as well.

  11. I had surgery to remove my soft palate and tonsils about 15 years ago and I have gone through hell ever since. I can not sleep on my back, nor can I dose sitting on the sofa. If i do these things I will wake up choking and gasping for breath almost to the point of passing out. What I believe happens to me is that saliva starts to run down that back of my throat and because I now do not have a Uvula which would normally tell your wind pipe to close, I choke. I feel that one night I will not wake from one of these episodes, so I would think twice before anyone has this procedure.

  12. Back in January of 2011 I was living and working in Germany. During that time, I was seeing a German ENT for slight breathing dificulties through my nose and severe snoring. I had two sleep studies, the most recent was January 2011. The results of both studies indicated that my ‘numbers’ were mostly in the normal range, and that at the worst, I had mild Apnea. My German ENT suggested a rhinopasty procedure to open my nasal airways (taking cartilage from my ear and using it to ‘brace open’ my nasal passages) and also a LAUP procedure to treat the snoring. But because I was leaving Germany to come back to the states, I decided to postpone any treatment. I now live in Florida, and just yesterday I met with an ENT specialist. After reviewing the ‘numbers’ from my last sleep study in Germany, the ENT came to a different conclusion, and said I had mild to moderate Apnea. And after reviewing a recent CT scan and eliminating the possibility of a deviated septum, the ENT recommended a UPPP, to include removal of my tonsils. I have done quite a bit of internet research and have found mostly ‘horror stories’ from past UPPP patients and very low UPPP success rates. To me, there are much less invasive procedures, such as the LAUP, Somnoplasty, or Pillar Procedure, that seem to have similar success rates. And from my experience from living in Europe, American doctors are much more likely to prescribe drugs and recommend surgeries. My question is, why is UPPP the procedure of choice, considering its low success rate and the severity of the procedure, compared to other surgical alternatives? I told my American ENT about the LAUP the German ENT recommended, and he said the LAUP method was just a way to sell high-tech lasers (paraphrasing here, but essentially accurate) and a way for patients to have repeated procedures (I.E. doctors make more money). Bottom line – After consulting two ENT doctors and doing a lot of online research, I am more confused and disheartened than ever. Online doctor reviews consistently state that ‘more research is needed’ to be able to make any definitive conclusions as to the success or failure of surgical procedures. These procedures and conditions have existed for a number of decades. How much more ‘research’ do they need? Is UPPP the best surgical altenative we have?

  13. I am considering having the UPPP procedure done. I was diagnosed with mild sleep apnea about 7 years ago. I’ve used the CPAP, which I don’t mind using, but the noise of the CPap still keeps my husband awake. He has tried different earplugs but nothing has worked. I have also tried the dental appliance but that was a even more uncomfortable than using a mask. I am horrified about the complications with the UPPP. I am 5’2″ and my BMI is just on the edge of normal-overweight (18-20). but my marriage has been compromised because my husband and I cannot sleep together. I don’t know whether to try the surgery.

  14. I had UPPP about 10 years ago. It was unsuccessful. I still sleep with cpap. It was a horrible recovery. I was not informed about the horrible choking that i would experience. It has gotten so bad that i have been very close to passing out. I have lost a lot of weight but no success. Curious about pacemaker for throat?? Kim scanland