الفهرس 
Pathophysiology of Sleep-DisorderedOnly 14 pages are availabe for public view
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Abstract
All 20 patients, 16 males and 4 females, between 20 to 60 years old, without previous tonsillectomy at the time of the lateral pharyngoplasty. The follow-up period ranged from 3 to 6 months. The median Epworth Sleepiness Scale value, shown in table 10 , significantly improved from 16.0 pre operative (11.5, quartile range) to 3.0 post operative (P= 0.001), as well as the self-reported symptoms of snoring, shown in table 11, (median decreased from 5 pre operative to 1 post operative, P =0.001).
We noted a tendency toward improvement in daytime sleepiness,
in morning headaches and overall impact of the disease on quality of life af¬ter the surgeries.
The patients usually reported moderate pain postoperatively. After 10 days after the procedures, analgesics were usually no longer required. We detected no alterations in tongue mobility.
The polysomnographic data are shown in table 5 and page 94.
The group showed a statistically significant improvement.
The median AHI, as shown in table 7, decreased from 44.6 pre operative to 14.36 post operative ,The AI, as shown in table 8, decreased from 21.67 preoperative to 4.31 postoperative and no significant changes in the LSAT, as shown in table 9, (P=0.29).
Only two cases showed a worsening of the AHI (patients 4 and 8), and the patients reported no clinical benefit after the procedure. This may be due to a limited dissection of the SPC muscle.
They had been recommended to undergo further evaluation and management.
Extubation occurred uneventfully in all cases, and we did not observe immediate or delayed complications such as bleeding, abscesses, nasopharyngeal stenosis, and al¬terations in speech.
Wound dehiscence typically occurred in the region of the caudal stitch of the tonsillar fossa some days after the surgeries and did not demand any special attention.
Patients no. 14 and 16 referred to some episodes of mild oronasal reflux of liquids during swallowing that resolved after 6 weeks after the surgery.
There was no cases of permanent palatal incompetence in patiens of our study. Patient 9 reported mild taste loss, which recovered completely after 6 months after the procedure.
DISCUSSION
The prevalence of sleep-disordered breathing, defined as an apnea-hypopnea index (AHI) of at least five, is estimated to be 24% of adult males and 9% of adult females; the prevalence of OSAS is 4% of males and 2% of females in a cohort of employed 30- to 60-year-old individuals (Young et al., 1993).
Estimates for elderly males range from 28% to 67% and for elderly females from 20 % to 54% (Fairbanks, 1990).
The significance of these numbers in the elderly and the frequency with which the apnea occurs without pathologic significance has yet to be determined (lavie et al., 1983).
In fact, pharyngeal airflow resistance is higher in patients with OSAHS than in weight-matched control subjects without OSAHS even though there is no difference in pharyngeal cross—sectional areas between them, suggesting the existence of a func¬tional impairment of the pharynx (Bhattacharyya et al., 2000).
Therefore, in our study the surgical technique focused on changing the pharyngeal muscular wall properties to splint the entire collapsible pharynx.
The surgical techniques for treating OS¬AHS, apart from tracheotomy, reduce upper airway nar¬rowing by either removing soft tissues from the pharyn¬geal lumen or mobilizing the surrounding bones to enlarge the airway (American Sleep Disorders Association, 1996).
However, in the surgical technique of our study, soft tissues neither removed, apart from tonsillectomy, nor surrounding bones mobilized.
Iaddition, it changes the pharyngeal muscular wall properties to splint the entire collapsible pharynx and in turn enlarging the pharyngeal lumen.
In our study, the surgical technique dealt with the completely collapsible pharynx, and this matches with Schwab et al., (2000) who reported that the LPW in OSAHS, patients are more distensible and collapsible than normal when pressured by the airflow.
In addition, it matches also with Schwab et al., (1995) who reported that the LPW in OSAHS patients are thicker than normal and they are the pre ¬dominant anatomic factor-causing airway narrowing in apneic subjects.
In our study, changing the pharyngeal muscular wall properties is more effective in reducing upper airway collapsibility than anterior tongue displacement, and this matches with Schwartz et al., (1996) who reported that it is a valid assumption that treating retroglossal collapsibility does not necessarily mean treating the tongue, but rather dealing with the lateral pharyngeal muscular retroglossal wall.
It seems that problem in this region is likely to increase airway inspiratory pressures and, therefore, affect the stability of the tongue.
In addition,it matches also with Carrera et al.,(2000) who reported that the genioglossus muscle abnormalities found in OSAHS patients are likely a consequence and not a cause of this disease because both structural and func¬tional changes of that muscle in apneic subjects are corrected by CPAP .
However, the cause of the OSAHS, which is not known, is not corrected by CPAP.
In our study, Lateral pharyngoplasty was per¬formed in a group of patients selected for uvulopalatopha¬ryngoplasty according to standard criteria because uvulopalatopharyngoplasty is the most common surgical procedure for treating OSAHS in adults (American Sleep Disorders Association, 1996).
Cahali, (2003) described a surgical procedure for splinting the LPW in ten adult patients with OSAHS, underwent the lateral pharyngoplasty procedure, which consisted of dissection ,sectioning of the superior pharyngeal constrictor muscle within the tonsillar fossa, and suturing it to the same side palatoglossus muscle.In addition, a palatopharyngeal Z-plasty is performed to prevent retropalatal collapse.
The results of his study were nearly, more or less, the same as the results of our study, however our surgical procedure of our study did not include sectioning of the superior pharyngeal constrictor muscle, which in turn, avoides the risk of injury to great vessels in the Para pharyngeal space.
Although UPPP was originally described as a treatment for snoring, Fujita et al., (1981) modified this soft palate procedure to treat OSA.
It has proved to be an excellent method of controlling snoring; however, several retrospective reviews reported improvement in only 50 %( 20 cases out of40) of patients and complete control of the syndrome in only 30% (12cases out of 40) (Riley et al., 2000).
However, in our study we have improvement of snoring in 90%( 18 cases out of 20 patients), improvement of the syndrome in 90% (18 cases out of 20 patients) and complete control of the syndrome in 60 % (12 cases out of 20 of patients) as shown in tables 6, 7 and 8.
These results goes in hand with AHI criterion of Sher et al.,(1996) who reported that complete control of the syndrome means a reduction of the preoperative AHI over 50%, with a postoperative AHI of less than 20.
Haavisto and Suonpaa, (1994) retrospectively reviewed the charts of
101 patients who underwent UPPP.
Immediate postoperative complications were surveyed by retrospective chart review, while late complications (6 weeks, and 1 year following surgery) were surveyed by questionnaire (sent to 100 patients postoperatively and returned by 91 patients).
Eleven percent of patients (11/101) had postoperative airway obstruction. Ten of these patients were managed successfully, but 1% resulted in death (1/101).
However, in our study, there was no postoperative airway obstruction.
Five percent (5/101) had immediate postoperative hemorrhage, which required those patients to return to the operating room.
However, in our study, there was no immediate or delayed postoperative hemorrhage and this is due to the minimum tissue resection in this technique and to the postoperative control of infections.
Twenty-four percent (22/91) reported persistent symptoms of VPI at 1 year.
However, in our study, permanent velopharyngeal incompetence did not occur in patients of our study, unlike uvulopalato¬pharyngoplasty, only 10% (2/20) showed temporary oro nasal reflux that resolved 6weeks later after the surgery. This is due to the minimum tissue resection in this technique and to the postoperative control of infections.
Thirty-one percent, (28/91) reported dry throat, and 10 %( 9/91) had complaints related to swallowing.
However, in our study, there were no reported symptoms of dry throat or complaints related to swallowing.
Five percent (5/91) reported breathing difficulty at 1-year postoperatively.It was not specified whether these patients referred to persistent OSAS, which would represent no response rather than a complication of UPPP.
In our study, only two cases showed no response to the surgery.
This maybe attributed to a limited dissection of the SPC muscle be¬cause, initially, postoperative effects on swallowing func¬tion were not known.
Verse et al., (2000) reported excellent cure rates after removal of markedly enlarged tonsils in adults with OSAHS. In their series, the patients had enlarged tonsils. In our group, this did not seem to influence the out come we had because patients in our study had smaller tonsils.
In the surgical technique of our study, suturing of the SPC muscle to the same side palatoglossus muscle intend to provide lateral and anterior support to the oropharynx and tongue,and that matches with Koopmann and Moran,(1990)who reported that because the origins of the SPC mus¬cle in the upper airway are more lateral (mandibular mylohyoid line) and more posterior (side of the base of the tongue) than the palatoglossus muscle, those sutures intend to provide lateral and anterior support to the oropharynx and tongue.
In addition, the associated palatopharyngeal Z-plasty in the surgical technique of our study, provides palatine and oropharyngeal support through orienting soft tissue retractions in the lateral part areas,and that matches with Fairbanks, (1999) who reported that palatopharyngeal Z-plasty, provides palatine and oropharyngeal support through orienting soft tissue retractions in the lateral part areas.
Therefore, patients showed, statisti¬cal, objective, and subjective improvement after lateralpharyngoplasty.
CONCLUSION
A surgical option for treating OSAHS is the changing of the pharyngeal muscular wall properties to splint the entire collapsible pharynx. A straightforward approach to the lateral pharyngeal wall may be preferred to a stretch effect caused through bone repositioning. Lateral pharyn¬goplasty repositions pharyngeal muscles, giving support to the lateral pharyngeal wall and producing subjective and objective improvement in sleep in OSAHS patients.