Cai Xiaolan, Liu Hongying, Liu Yanxun, Sun Fusheng, Wang Tingji, Chinese Journal of Otolaryngology, Head and Neck Surgery, 2005, No. 4 Related Articles
[Abstract] Objective To investigate the indications for Uvulopalatopharyngoplasty (UPPP) surgery and the clinical staging of oropharyngeal stenosis in patients with obstructive sleep apnea syndrome (OSAS). Methods Clinical staging of oropharyngeal stenosis was performed by analyzing the body mass index (BMI), palatoglossal plane position, lateral pharyngeal wall hypertrophy and tonsil size in 66 OSAS patients. The indications for UPPP surgery were discussed based on the polysomnography (PSG) data before and after UPPP surgery. Results Patients with palatoglossal plane grade 1-2 and no obvious tongue hypertrophy were designated as clinical stage I (32 patients); patients with palatoglossal plane grade 3-4 and tongue hypertrophy were designated as clinical stage II (34 patients); patients with tonsil grade 0-1 were classified as stage Ia (5 patients) and stage IIa (10 patients), and patients with tonsil grade 2-4 were classified as stage Ib (27 patients) and stage IIb (24 patients), respectively. Postoperative PSG monitoring showed that there was no significant relationship between the efficacy of UPPP surgery and the severity of the disease (preoperative AHI, LSaO2); patients with BMI <30 Kg/m2 had better efficacy; patients with stage Ib without significant tongue hypertrophy (palatoglossal plane grade 1-2) and with tonsillar hypertrophy (grade 2-4) were the best indications for UPPP surgery, with a success rate of 70.4% (19/ 27 cases), which was significantly higher than the rest of the stages. Conclusion Clinical staging of oropharyngeal cavity stenosis based on palatoglossal plane and tonsil size can help in the selection of indications for UPPP surgery in patients with OSAS. Cai Xiaolan, Department of Otolaryngology, Qilu Hospital, Shandong University
[Keywords] Sleep apnea, obstructive; Surgery, treatment; Indications; Polysomnography
[Key words] Sleep apnea, obstructive; Surgery, treatment.
Indication of operation; Polysomnography
Uvulopalatopharyngoplasty (UPPP) is the most common surgical procedure for the treatment of obstructive sleep apnea syndrome (OSAHS), but due to the lack of objective and uniform criteria for selecting surgical indications, the success rate of UPPP has hovered at 40%. However, the success rate of UPPP has been hovering around 40% due to the lack of objective and uniform criteria for selecting surgical indications (1), and it is an urgent clinical problem to improve the long-term cure rate by reasonably selecting surgery, continuous positive airway pressure (CPAP) and comprehensive treatment. The clinical data of 66 patients treated by UPPP surgery from February 2000 to August 2002 are retrospectively analyzed and reported as follows.
Clinical data
I. General data: Among the 66 patients, 4 were female and 62 were male; age ranged from 21 to 65 years, with an average of 40.99±8.98 years.
(1) Body Mass Index (BMI) 23.46-38.02 Kg/m2, mean 29.64±2.86 Kg/m2; according to the standard of “Chinese adult body mass index classification recommendation” (2), 18.5≤BMI < 24.0 Kg/m2 was considered appropriate. 24.0 Kg/m2 as the appropriate range (grade 0, 1 person), 24.0 ≤ BMI <28.0 Kg/m2 as overweight (grade 1, 20 persons), 28.0 ≤ BMI <30.0 Kg/m2 as obese (grade 2, 21 persons), and BMI ≥30.0 Kg/m2 as morbidly obese (grade 3, 24 persons; including 9 persons above 33.0 Kg/m2).
(2) Palatal tongue plane grading: patients were asked to relax as much as possible, open their mouths, not to extend their tongues and not to use tongue depressors, so that the tongue body was in a natural state in the midline position of the oral cavity, and the relative positions of the soft palate and the tongue body were observed; this was repeated 5 times to ensure accurate and consistent recording.
Grade 1: low and flat tongue body with peeking of the posterior pharyngeal wall, intact uvula, tonsils and lateral pharyngeal wall (1 case)
Grade 2: elevated tongue body, with the complete uvula, part of the tonsils, and lateral pharyngeal wall visible (31 cases)
Grade 3: hypertrophy of the tongue body with peeking of the root of the uvula (27 cases)
Grade 4: obvious hypertrophy of the tongue body, only the hard palate could be detected (7 cases), 42.42% of the cases were grade 3 and 4.
The palatoglossal plane grade 1-2 suggests no obvious tongue hypertrophy; the palatoglossal plane grade 3-4 suggests tongue hypertrophy.
(3) Pharyngeal lateral wall hypertrophy grading: the distance between the lateral walls of the pharynx as a proportion of the width of the tongue body.
It is mainly for measuring the degree of fatty tissue hyperplasia in the parapharyngeal space and should be identified to exclude pharyngeal-palatal arch pterygoid hypertrophy.
Grade 0: intersection of the lateral pharyngeal wall with the edge of the tongue body (3 cases).
Grade 1: the lateral pharyngeal wall occupies 1/4 of the width of the tongue body (5 cases)
Grade 2: lateral pharyngeal wall occupying 1/2 of the width of the tongue body (44 cases)
Grade 3: lateral pharyngeal wall occupying 3/4 of the width of the tongue body (14 cases, 21.21%).
(4) Tonsil size grading: grade 0: post-tonsillectomy (3 cases).
Grade 1: confined to the tonsillar fossa and not accessible to the eye (12 cases).
Grade 2: located behind the lingual-palatal arch and could be visualized (27 cases).
Grade 3: protruding from the tonsillar fossa and occupying 3/4 of the oropharyngeal airway (15 cases).
Grade 4: Both tonsils were almost conjoined and blocked the oropharyngeal airway (9 cases).
Second, polysomnography (PSG) monitoring: All 66 patients were monitored by PSG for the whole night sleep and respiration before and after surgery. To ensure the accuracy of the monitoring data, we selected patients who must have a sleep efficiency of 50% or more on the night of monitoring, and must have supine sleep and REM stage sleep. Preoperatively, AHI 8.0-91.4 beats/h, mean 60.26±21.31 beats/h; LSaO2 32%-90%, mean 69.60±11.68% were performed at our hospital using Polysmith from Neurotronics, U.S.A. The PSG was rechecked after UPPP with a follow-up of 1-2 years, mean 1 year and 7 months. 21 cases at our hospital , 45 cases were performed at Jinan Railway Hospital using Embla from ResMed, Australia, with AHI 1.6-77.0 beats/h, mean 32.42±20.71 beats/h; LSaO2 was 59%-95%, mean 84.14±12.10%. According to the diagnostic criteria for OSAS developed by the Chinese Medical Association’s Branch of Otolaryngology (Hangzhou Standard) [3], the severity of OSAS was judged based on AHI 5-20 times/h as mild, AHI 21-40 times/h as moderate, and AHI >40 times/h as severe; the degree of hypoxia was judged based on LSaO2 ≥85% as mild, LSaO2 65-84% as The degree of hypoxia was judged based on LSaO2≥85% as mild, LSaO2 65-84% as moderate, and LSaO2<65% as severe. The condition monitoring before and after surgery is shown in Table 1.
Third, UPPP surgery: 3-5 days before surgery, the pharyngeal cavity was treated with local nebulized inhalation therapy (Telbivitol 0.1 Bid, dexamethasone 1-2 mg Qd) using the comprehensive treatment table of Nagashima Medical Co., Ltd. in Japan, and positive pressure ventilation treatment with Auto CPAP from ResMed Australia for 3-5 nights, which was effective in stabilizing blood pressure, eliminating congestion and edema in the oropharyngeal cavity, improving intraoperative tolerance, and reducing intraoperative stress. The treatment was effective in stabilizing blood pressure, eliminating oropharyngeal congestion and edema, improving surgical tolerance, and reducing intraoperative bleeding. All patients underwent palatopharyngoplasty with preservation of the uvula under local anesthesia in the pharyngeal cavity. In addition to intravenous fluids and antimicrobial therapy, nebulized inhalation was continued for 3-5 days (42 patients) and positive pressure ventilation for 2-3 days (14 patients with severe disease) after surgery.
IV. Statistical methods: Paired signed rank sum test (Wilcoxon method) was used for the comparison of condition monitoring before and after surgery, and rank sum test (Wilcoxon method and Kruskal-Wallis method) was used for the comparison between two samples and multiple samples. All data were statistically analyzed using Spss 10.0.
Results
I. Condition monitoring of OSAS patients before and after surgery (AHI, times/h) (see Table 1)
II.
Table 1 Changes in AHI in OSAS patients before and after surgery (number of cases)
Pre-operative AHI
(times/h)
Postoperative AHI (times/h)
Total
(Number of cases)
Normal
Mild
Moderate
Severe
41-60
61-80
>80
Total
Mild
1
4
0
0
0
0
0
5
Moderate
0
4
2
0
0
0
0
6
Severe
0
17
15
12
8
3
23
55
41-60
0
8
5
2
1
0
3
16
61-80
0
7
8
8
4
0
12
27
>80
0
2
2
2
3
3
8
12
Total
1
25
17
12
8
3
23
66
There was a significant difference in AHI before and after surgery (u=5.397, P=0.000), suggesting that UPPP surgery had some overall efficacy in patients with OSAS. 37 of 66 patients had remission, of which 58.2% (32/55 patients) were severe, 66.7% (4/6 patients) were moderate, and 20% (1/5 patients) were mild; 17 cases changed from preoperative severe The number of cases changed from severe preoperative to mild postoperative. Among those in remission, 29 cases had no significant change in their condition; there were no patients with exacerbation.
Preoperative PSG monitoring and evaluation of the efficacy of BMI and UPPP (see Tables 2, 3, and 4): according to the criteria for evaluating the efficacy of OSAS developed by the Chinese Medical Association’s Branch of Otolaryngology (Hangzhou Standard) [3] and combined with foreign data [4], AHI <5 times/h and LSaO2 >90%, and basic disappearance of symptoms were considered as cured (1 case); AHI <20 times/h and decrease ≥50% and significant symptom reduction was considered as successful surgery (24 cases); AHI >20 times/h but decrease ≥50% was considered as effective (17 cases, 25.8%); AHI decrease ≥25% with symptom reduction was considered as effective (9 cases, 13.6%); AHI decrease <25% and no significant change in symptoms was considered as ineffective (15 cases, 22.7%).
Statistical analysis showed that there was no significant relationship between the severity of OSAS patients’ disease (preoperative AHI) and the efficacy of UPPP surgery (X2 =3.762, P=0.152. Table 2); the severity of preoperative hypoxemia (preoperative LSaO2) was not significantly related to the efficacy of UPPP surgery (X2 =3.066, P=0.216. Table 3). It is suggested that with proper selection of surgical indications, patients with severe OSAS can also achieve good results with UPPP surgery. Morbidly obese patients with a BMI ≥ 30 had a poor surgical outcome compared to those with a BMI < 30 (u = 2.272, P = 0.023. Table 4).
Table 2 Preoperative AHI (times/h) and surgical efficacy of UPPP in patients with OSAS
Preoperative AHI
Surgical efficacy
Total
(number of cases)
Ineffective
Effective
Apparent effect
Successful
Mild
2
0
0
3
5
Moderate
0
0
2
4
6
Severity
13
9
15
18
55
41-60
2
1
4
9
16
61-80
6
5
9
7
27
>80
5
3
2
2
12
Total
15
9
17
25
66
=3.762, P=0.152
Table 3 Pre-operative LSaO2 (%) and surgical efficacy of UPPP in patients with OSAS
Pre-operative
Surgical efficacy
Total
(Number of cases)
LSaO2
Ineffective
Effective
Effective
Successful
Mild
2
0
0
3
5
Moderate
9
4
10
18
41
Severe
6
5
5
4
20
Total
15
9
17
25
66
=3.066, P=0.216
Table 4 OSAS patients and body mass index (BMI, Kg/m2) and UPPP surgical outcomes
BMI
Surgical efficacy
Total
(Number of cases)
Ineffective
Effective
Apparent effect
Successful
Level 0-2
6
5
12
19
42
Level 3
9
4
5
6
24
Total
15
9
17
25
66
=2.272, P=0.023
III. Clinical staging of oropharyngeal cavity stenosis and UPPP efficacy assessment (see Tables 5 and 6).
(A) Clinical staging of oropharyngeal cavity stenosis: according to the palatoglossal plane, the degree of hypertrophy of the lateral pharyngeal wall, and the size of the tonsils.
Stage I: Patients with palatolingual plane grade 1-2 (32 cases), no obvious tongue hypertrophy, and pharyngeal lateral wall grade 0-2.
Stage Ia: Patients without tonsillar hypertrophy (grade 0-1, 5 cases). There was no obvious oropharyngeal cavity narrowing in the awake state; PSG monitoring showed no significant improvement of the patient’s condition after surgery and poor efficacy of UPPP surgery.
Stage Ib: Patients (27 cases) with tonsillar hypertrophy (grade 2-4, 13 cases of grade 2, 9 cases of grade 3, and 5 cases of grade 4).
The success rate of UPPP surgery for oropharyngeal cavity narrowing caused by simple tonsillar hypertrophy (70.4%, 19/27 cases) was significantly higher than the overall success rate (37.9%, 25/66 cases).
Stage II: Patients with palatolingual plane grade 3-4 (34 cases). Significant lingual hypertrophy, including 20 cases of grade 2 and 14 cases of grade 3 in the lateral pharyngeal wall.
Stage IIa: Patients (10 cases) without tonsillar hypertrophy (grade 0-1, 3 cases of grade 0 and 7 cases of grade 1).
Narrowing of the oropharyngeal cavity caused by simple lingual hypertrophy was successful in 20% of the patients.
50.0% (5/10 cases) of patients with poor UPPP surgical outcome.
Stage IIb: Patients (24 cases) with tonsillar hypertrophy (grade 2-4, 17 cases of grade 2, 3 cases of grade 3, and 4 cases of grade 4).
narrowing of the oropharyngeal cavity caused by a combination of lingual hypertrophy and tonsillar hypertrophy.
The efficacy of UPPP surgery was limited, and only 16.7% (4/24 cases) of patients could achieve surgical success.
(B) Analysis of the clinical stage of oropharyngeal stenosis and the severity of OSAS (see Table 5)
1. a significant difference in preoperative AHI between stage I and stage II patients (=2.494, P=0.013).
It was suggested that stage II patients with lingual hypertrophy (palatoglossal plane grade 3-4) had a significantly higher preoperative AHI.
2, preoperative AHI was not significantly different between patients with tonsillar grade 0-1 and grade 2-4 (Ⅰa+Ⅱa versus Ⅰb+Ⅱb) (=0.472, P=0.637); suggesting no significant relationship between preoperative AHI and tonsillar size.
Table 5 Relationship between clinical staging of oropharyngeal stenosis and severity of OSAS (preoperative AHI, times/h)
Preoperative AHI
Palatoglossal plane grade 1-2 (stage I)
Palatolingual plane grade 3-4 (stage II)
Total
(Number of cases)
Ⅰa：Tonsil 0-1
Ⅰb: tonsil 2-4
Total
Ⅱa：Tonsils 0-1
Ⅱb：Tonsils 2-4
Total
Mild
2
3
5
0
0
0
5
Moderate
0
4
4
1
1
2
6
Severe
3
20
23
9
23
32
55
41-60
1
8
9
2
4
6
15
61-80
1
10
11
4
13
17
28
>80
1
2
3
3
6
9
12
Total
5
27
32
10
24
34
66
(iii) Analysis of the clinical stages of oropharyngeal stenosis and the efficacy of UPPP surgery (see Table 6)
1. Comparison between different clinical stages (stage I and II): there was a significant relationship between the efficacy of UPPP surgery and tongue hypertrophy (= 3.113, P=0.002), and the efficacy of surgery was significantly worse in patients with tongue hypertrophy (stage II).
2. Comparison between different tonsil grades (Ia+IIa vs. Ib+IIb): There was a significant relationship between the surgical efficacy of UPPP and tonsil grade (u=3.656, P=0.000), and patients with tonsil grades 2-4 (Ib+IIb) had significantly better surgical efficacy than patients with grades 0-1 (Ia+IIa).
The patients were further stratified and then analyzed:
3, In patients with tonsils grade 0-1 (Ⅰa versus Ⅱa), no significant relationship was seen between lingual hypertrophy and surgical efficacy (u=1.827, P=0.068); suggesting that the surgical efficacy of UPPP was poor in patients with tonsils grade 0-1, with or without lingual hypertrophy.
4. In the two groups of patients with tonsils grade 2-4 (Ib and IIb), the efficacy of UPPP surgery was significantly better in patients without lingual hypertrophy (Ib) than in those with lingual hypertrophy (IIb) (=4.088, P=0.000). It is suggested that patients with OSAS without significant lingual hypertrophy (palatopharyngeal plane grade 1-2) and tonsils grade 2-4 are the best indications for UPPP surgery.
Table 6 Clinical staging of oropharyngeal stenosis and surgical efficacy of UPPP (% of cases)
Surgical efficacy
Palatoglossal plane grade 1-2 (stage I)
Palatolingual plane grade 3-4 (stage II)
Total
(Number of cases %)
Ⅰa：Tonsil 0-1
Ⅰb: tonsil 2-4
Total
Ⅱa：Tonsils 0-1
Ⅱb：Tonsils 2-4
Total
Ineffective
5(100)
0
5
5(50.0)
5(20.8)
10
15 (22.7)
Valid
0
2( 7.4)
2
1(10.0)
6(25.0)
7
9(13.6)
Apparent effect
0
6(22.2)
6
2(20.0)
9(37.5)
11
17(25.8)
Success
0
19(70.4)
19
2(20.0)
4(16.7)
6
25(37.9)
Total
5
27
32
10
24
34
66
DISCUSSION
Currently, the treatment options available for OSAS patients are still limited, with bariatric and behavioral therapy only available for a very small number of patients; positive pressure ventilation has a high success rate but is limited by poor tolerance in some patients; uvulopalatopharyngoplasty (UPPP) relieves the anatomical narrowing of the oropharyngeal cavity by removing the hypertrophic tonsils and some of the hypertrophic soft palate tissue; by removing the fatty tissue in the palatal sail space; and by suturing and retracting the soft palate tissue. UPPP is the main surgical treatment to reduce the compliance and collapsibility of the uvula and soft palate by removing the fatty tissue in the palatal sail space, suturing and stretching the soft tissues of the pharynx.
The etiology of OSAS is complex, and both characterization and localization are required before surgical treatment. Qualitative diagnosis mainly relies on PSG to determine the nature and severity of obstruction; localization can understand the site of obstruction and the abnormal structures causing obstruction, which can help to develop a targeted surgical plan. At present, localization diagnostic techniques are still in the exploratory stage and far less mature than PSG. A large number of detection means about OSAS patients, such as: lateral cephalometric radiography, upper airway CT, MRI, fiberoptic nasopharyngoscopy, etc., are costly, complicated to operate and difficult to analyze, which determines that they can only be used as a research tool and cannot be used as a routine selection tool for the indications of UPPP surgery, and have limited practical application in the clinic; there is a lack of reproducible for disease diagnosis and selection of surgical indications There is a lack of repeatable objective physical examination indicators for disease diagnosis and surgical indication selection.
I. Discussion of indications for UPPP surgery
The indications for UPPP surgery in OSAS patients were proposed in Hangzhou Standard (3) in 2002: the obstruction plane in the oropharynx, mucosal hypertrophy resulting in narrow pharyngeal cavity, hypertrophy or overgrowth of the uvula, undergrowth or overgrowth of the soft palate, and overgrowth of the tonsils. The UPPP is proposed for patients with OSAS who have narrowed oropharynx due to mucosal hypertrophy, enlarged or elongated uvula, low soft palate, enlarged tonsils or type IV (nasopharynx, oropharynx and hypopharynx are narrowed or more than two parts are narrowed). As a national guideline document in the field of otolaryngology, it has three limitations: 1) lack of description of the important factors causing oropharyngeal cavity stenosis – hypertrophy of the tongue and lateral wall of the pharynx; 2) lack of understanding of the causal relationship between oropharyngeal cavity stenosis and hypertrophy of the soft palate and uvula; 3) lack of standardized diagnostic criteria for the reproducibility of physical examination, which making the analysis and communication of clinical data difficult.
In this study, we analyzed the effects of BMI, palatoglossal plane, lateral pharyngeal wall, and tonsil size on oropharyngeal cavity stenosis in OSAS patients, combined with pre- and postoperative PSG monitoring, to investigate which type of patients might be relieved and cured by UPPP surgery? This selection process is based on routine physical examination, is standardized, noninvasive, inexpensive, and has good reproducibility and clinical operability.
A common misconception is that the 40% success rate of UPPP surgery is mainly for patients with mild OSAS. Therefore, surgical treatment is mainly recommended for mild and moderate patients (4). In this study, 83.3% (55/66 cases) of patients with severe OSAS had fair overall UPPP surgical outcomes (Table 1), with a surgical success rate of 37.9% (25/66 cases); statistical analysis showed that there was no significant relationship between UPPP surgical outcomes and the severity of the disease (preoperative AHI, LSaO2) (Tables 2 and 3).Friedman (4) concluded that. Patients with BMI > 40 Kg/m2 have poor surgical outcome and can be used as an independent prognostic factor in the efficacy analysis; in this group, patients with BMI 23.46 – 38.02 Kg/m2, in which patients with BMI < 30 Kg/m2 had better UPPP surgical outcome than the group with BMI > 30 Kg/m2 (Table 4).
II. Clinical staging of oropharyngeal stenosis in OSAS patients and its clinical significance
The standardization of diagnosis and efficacy assessment is the basis of clinical research and an indispensable objective basis for academic communication. Although, the reported success rate of UPPP surgery varies widely, multifactorial analysis shows that: the success rate of surgery in long-term follow-up has been hovering at 40%, which is greatly related to the lack of objective and unified criteria for selecting surgical indications. The establishment of clinical staging of oropharyngeal stenosis in patients with OSAS is not a substitute for objective PSG examination and imaging studies, but helps to avoid the continued use of criteria such as “narrow pharyngeal cavity, hypertrophy or overgrowth of the uvula, low soft palate, overgrowth of the tonsils” in practice. It helps to avoid the continued use of vague, difficult to characterize, difficult to repeat, and subjective physician’s experience terms and concepts such as “narrow pharynx, enlarged or overgrown uvula, low soft palate, and enlarged tonsils”; it provides an important reference standard for the unification of diagnostic criteria, selection of treatment methods, and evaluation of treatment outcomes in OSAS patients.
In 1985, Mallampati (6) et al. proposed the relative position of the palatoglossal plane as an important predictor of the ease of endotracheal intubation. in 1999, Friedman (1) used the palatoglossal plane grading for clinical staging of OSAS patients and found that: by palatoglossal plane grading (grade 1-4), tonsil size (grade 0-4) and BMI grading (grade 0: < 20, grade 1: 20-25, grade 2: 25-30, grade 3: 30-40, grade 4: >40) derived from the OSAS score divided the patients into two groups.
The positive OSAS score group was the total palatoglossal plane grading + tonsil size + BMI grading ≥ 8, with at least one = 4 or two each = 3; 90% of these patients had an RDI > 20 beats/h; 74% of them had an RDI ≥ 45 beats/h.
The negative OSAS score group was palatoglossal plane classification + tonsil size + BMI classification total score ≤ 4, no single item = 4; 67% of these patients had an RDI < 20 beats/h.
In 2002, Friedman’s (4) clinical staging of the degree of oropharyngeal stenosis based on palatoglossal plane grading, tonsil size, and BMI
Stage I: palatoglossal plane grades 1 and 2 + tonsils grades 3 and 4; and BMI < 40 Kg/m2;
Stage II: palatoglossal plane grades 1 and 2 + tonsils grades 0-2.
and palatoglossal plane grade 3, 4 + tonsils grade 3, 4; and BMI < 40 Kg/m2;
Stage III: patients with palatoglossal plane grades 3 and 4 + tonsils grades 0-2; or BMI > 40 Kg/m2 alone.
The results of UPPP surgery were classified as: success and failure, and surgical success was defined as 50% reduction in AHI and postoperative AHI < 20 beats/h; 50% reduction in AI and postoperative AI < 10 beats/h. After UPPP, the surgical success rate was 80.6% for stage 1 patients, who should be selected for UPPP surgery; 37.9% for stage 2 patients; and 8.1% for stage 3 patients, who should not be selected for simple UPPP surgical treatment should be considered for both maxillofacial and tongue root advancement surgery.In 2004, Friedman(7) performed radiofrequency ablation of tongue root tissue in stage 2 and 3 OSAS patients on the basis of UPPP surgery, and at 6-month postoperative follow-up, the surgical success rate increased from 37.9% to 74.0% in stage 2 patients; from 8.1% to 43.8% in stage 3; and the overall The success rate increased from 40% to 59.1%, resulting in a significant reduction in patients with surgical failure.
Tongue hypertrophy is an important factor in causing oropharyngeal stenosis, but its relationship with OSAS severity and surgical outcome has not been reported. In this study, patients were divided into clinical stage I and stage II based on the presence or absence of lingual hypertrophy; statistical analysis showed that patients with lingual hypertrophy (stage II, palatoglossal plane grade 3-4) were more severely ill, and the efficacy of UPPP surgery was less than that of patients without significant lingual hypertrophy. The tonsils were the most common site for UPPP surgical treatment, and the study showed that there was no significant difference in severity of disease (preoperative AHI) between patients with tonsils grade 0-1 and grade 2-4 (Table 5), but patients with tonsils grade 2-4 had better UPPP surgical outcomes (Table 6). The study showed that stage IIb patients without significant tongue hypertrophy (palatoglossal plane grades 1 and 2) and tonsils grades 2-4 are the best indications for UPPP surgery. Clinical staging of oropharyngeal stenosis not only provides an objective descriptive index for patients with OSAS and standardizes the physical examination; it also predicts the severity of OSAS, helps in the selection of indications for UPPP surgery, and can prompt the use of appropriate treatment modalities for patients with different staging.
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