Transpalatal Advancement Pharyngoplasty

The retropalatal airway is a common site of collapse in obstructive sleep apnea. Transpalatal advancement pharyngoplasty aims to address this site of upper airway collapse by advancing the soft palate anteriorly, increasing the cross-sectional area of the airway and decreasing pharyngeal collapsibility.

Surgeon: Raj C. Dedhia1, MD, MSCR

Video Production: Yifan Liu1,2, MD, Jason Yu1, MD

1 Perelman School of Medicine, Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania

2 Department of Otorhinolaryngology – Head and Neck, Affiliated Beijing Anzhen Hospital, Capital Medical University

-Incision is made with a Colorado microdissection needle. -Woodson and Cottle elevators are used to elevate hard palate mucosa off the bone. -Elevate mucosa laterally until you are able to place a Cottle into both GPFs (greater palatine foramen) in order to retract the mucosa. -If you are unable to fit Cottle elevators into the GPFs, you can alternatively use 2-0 silks to retract the flaps. -Elevate mucosa posteriorly to the PNS (posterior nasal spine). -Use a size 4 cutter and size 2 diamond drill bits to thin the posterior hard palate bone. -As bone gets thin, a Kerrison Rongeur or Mastoid Curette can be used to remove the bone. -Be careful to preserve the midline maxillary spine and avoid drilling onto nasal turbinates. -Once the palate bone is removed, elevate the nasal cavity mucosa off using a Woodson elevator being careful not to violate the mucosa and enter the nasal cavity. -The height of the bony trapezoid should be about 10mm, and the width should be as wide as possible without violating the GPFs on either side. -Using a Mayo scissor, separate the nasal septum off the maxillary spine along the midline as well as make lateral cuts to separate the bone from the alveolus. -Identify tensor veli palatine (TVP) tendon and release all bands and attachments to the soft palate in order to mobilize the midline soft palate. -A 1.6mm cross-cut fissure carbide burr is used to drill 2 holes into the hard palate 5mm from the free edge of the hard palate and 5mm from the midline on either side. -Four 0-vicryl sutures are passed anterior to posterior with blunt end as leading edge through the drill holes. Two sutures on each side. Do not remove needle heads from the suture yet -2 lateral sutures go through TVP. Medial ones through tensor aponeurosis. -Using a suction or a curved instrument, have your assistant get posterior to the uvula and bring the soft palate anterior to relieve tension. Then tie down all sutures. -The effect on the retrouvular space should be visualized. -Use 3.0 vicryl as deep stitch for closing, then chromic.
Obstructive sleep apnea with evidence of retropalatal airway collapse on clinical evaluation.
Large torus palatini, cleft palate, baseline velopharyngeal insufficiency.
Routine surgical setup for oral cavity access with head of bed turned to surgeon. Transoral intubation with wire reinforced tube. Use of mouth gag and Rose position to open mouth and access hard palate. Dingman mouth gag preferred but alternative mouth gags can be used.
Home sleep apnea testing or in-lab polysomnogram confirming a diagnosis of obstructive sleep apnea. Clinical evaluation including in-office flexible nasopharyngolaryngoscopy in sitting or supine position to evaluate the upper airway is recommended. Drug induced sleep endoscopy visualizing collapse at the retropalatal airway is also recommended.
Greater palatine foramen, tensor aponeurosis, tensor tendon, hamulus, nasal septum, soft palate and uvula.
Advantages: Advances the soft palate anteriorly without the need for full maxillary advancement surgery. Maintains muscle attachments with reduced soft tissue excision. May be performed in addition to other upper airway surgeries including uvulopalatopharyngoplasty, tongue base reduction, and epiglottoplasty. Disadvantages: See Complications/Risks.
Bleeding, infection, velopharyngeal insufficiency, soft tissue necrosis, hard palate necrosis, oronasal fistula, hard palate numbness, failure to improve obstructive sleep apnea.
No conflicts to disclose.
Woodson BT. Transpalatal advancement pharyngoplasty. Operative Techniques in Otolaryngology-Head and Neck Surgery. 2007;18(1):11-16. doi:10.1016/j.otot.2007.02.001 Chan L, Kitpornchai L, Mackay S. Causative Factors for Complications in Transpalatal Advancement. Ann Otol Rhinol Laryngol. 2020;129(1):18-22. doi:10.1177/0003489419867969

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