Expansion Sphincter Pharyngoplasty

Considerations

• • 2007: Expansion sphincter pharyngoplasty: a new technique for the treatment of obstructive sleep apnea [Review]

  • 2014: Modified expansion sphincter pharyngoplasty for treatment of children with obstructive sleep apnea 

Preparation

• • DISE, if needed 

    • Tower 

    • Flexible scope 

  • GETA

  • Turn bed 180 degrees 

  • Trays

    • Intraoral

    • T&A, UVPPP 

  • Infiltration "cocktail" 

    • 30 ml of 0.5% Bupivacaine (Marcaine)

    • 2 ml of Methylprednisolone (Solu-Medrol) (125 mg) 

    • 0.3 ml of 1:1,000 Epinephrine 

Procedure

Sample operative report

Then a McIvor mouth gag was placed.  The oropharynx was suctioned and examined using inspection and palpation.  The patient demonstrated a *** uvula/soft palate and *** + ***phytic tonsils.  An Allis clamp was used to grasp the right tonsil and this was carefully dissected from the surrounding tissue using Bovie electrocautery with care to preserve the palatopharyngeus muscle.  A left sided tonsillectomy was performed in the same fashion.  The tonsils were passed off of the field for pathology.  The oral cavity was irrigated, suctioned, and hemostasis was achieved using suction Bovie electrocautery.  

The right sided palatopharyngeus muscle was freed from the underlying mucosa using blunt dissection, scissors and bipolar cautery.  A 3-0 monocryl suture was passed through the inferior aspect of the muscle and a ligation tie was performed at this location.  The palatopharyngeus muscle inferior to the previously placed tie was divided using bipolar and scissors.  The palatopharyngeus muscle was elevated off of the mucosa superiorly to form a muscular band.  Once adequate dissection was complete, a right angle clamp was used to dissect from the superior tonsillar fossa toward the pterygoid hamulus.  A 3-0 monocryl suture was passed through the soft palate, periosteum of the hamulus, then through the ligation suture on the inferior palatopharyngeus and back out through the soft palate.  A second suture was placed through the soft palate inferior to the prior stitch, then through the middle of the palatopharyngeus muscle band, then back through the soft palate.  Both sutures were tied and confirmed to have the correct angle of tension on the palatopharyngeus muscle.  The same procedure was performed on the patient's left side.

Then the inferior *** mm of the uvula was truncated and closed with 3-0 monocryl suture.  Care was taken to ensure adequate soft palate/uvula remained to ensure velopharyngeal closure.  Then the tonsillar fossa were irrigated, suctioned, and a combination of 0.5% marcaine, 1:100000 epinephrine and Solumedrol were infiltrated into the palate and tonsillar fossa.  The oropharynx was irrigated, suctioned, and hemostasis was confirmed.  Tthe bilateral posterior and anterior pillars were sewn together using 3-0 monocryl suture.  Again, the oropharynx was irrigated, suctioned, and hemostasis was confirmed.  The stomach contents were evacuated using an orogastric tube.  The McIvor mouth gag was removed.

Post-op

• • Overnight admission

    • Continuous pulse oximetry

    • HOB elevation

  • CLD ADAT FLD

  • Dexamethasone x 24h

    • Unasyn X 24h

    • Hycet 10, 15, 20 ml q4 PRN mild, moderate, severe pain (or ATC)

  • Oxycodone 10 mg PRN BTP

  • Nasal saline q6h

  • Colace BID

• Discharge medications 

  • • Hycet 960ml 10-15 ml q4 PRN pain

• • Oxycodone 5-10 mg q4 BTP

    • Augmentin X 10d

  • Nasal saline x 2w

  • Colace

  • Follow up

    • RTC 3 weeks 

  • At home

    • Sleep with a tennis ball in the mid back to prevent supine position 

• CPT codes

  • • 31575 - If DICE is performed - Laryngoscopy, flexible fiberoptic; diagnostic

    • 42826 - If tonsillectomy (adult) is perfored

    • 42950 - Pharyngoplasty (plastic or reconstructive operation on pharynx)

    • 42145 - Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty)

Pearls & Pitfalls

High-Yield

Links

• YouTube (50:15) - UPPP - Lateral Expansion Pharyngoplasty (Stanford)

• YouTube (1:09:01) - Surgical Treatment of Obstructive Sleep Apnea