Long-Term Incidence of Velopharyngeal Insufficiency and Other Sequelae following Uvulopalatopharyngoplasty

Abstract

Objective

The aim of this study is to (1) assess incidence of long-term velopharyngeal insufficiency (VPI) and (2) determine other sequelae following classic and modified uvulopalatopharyngoplasty (UPPP and mUPPP) for treatment of obstructive sleep apnea (OSA).

Data Sources

Medline, PubMed, Cochrane Library database.

Review Methods

A systematic review was performed following standard Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Original research articles reporting on sequelae of UPPP and mUPPP for treatment of OSA, at a mean of 1 year follow-up, were included. Articles were retrieved using keywords UPPP complications and UPPP questionnaire. A random-effects model was used for pooling data.

Results

A total of 24 studies were included in this review. Complications included VPI (24 studies, n = 191), difficulty swallowing (7 studies, n = 83), taste disturbances (4 studies, n = 10), voice changes (7 studies, n = 46), foreign body (9 studies, n = 427), and dry pharynx (7 studies, n = 150). When pooling all studies together, VPI was the least common sequelae reported in 8.1% of the cases. Foreign body sensation was the most commonly reported sequelae at 31.2%, with difficulty swallowing (17.7%), dry pharynx (23.4%), voice changes (9.5%), and taste disturbances (8.2%) being the most to least likely.

Conclusions

The long-term effectiveness of UPPP and mUPPP is limited by the number of studies reporting short-term follow-up only. Despite this, long-term data suggest that complications such as VPI are more common than previously reported. Other sequelae, such as foreign body sensation, may be one of the most frequently expected complications after UPPP surgery.

Keywords

uvulopalatopharyngoplasty velopharyngeal insufficiency difficulty swallowing taste disturbance voice change foreign body dry pharynx

Despite recent advances in surgical strategies to treat obstructive sleep apnea (OSA), continuous positive airway pressure (CPAP) remains the preferred treatment due to its high efficacy in reversing many of the adverse effects of OSA.¹ There are circumstances, however, in which CPAP is not a viable option, either due to patient intolerance or patients simply removing the mask in their sleep, both of which may lead to low adherence rates.^2,3 In such cases, surgery may still offer significant benefit to these patients. One of the first procedures to be developed for treating OSA was popularized in the 1980s in the form of uvulopalatopharyngoplasty (UPPP).⁴ As with all surgeries, complications and side effects exist and must be weighed against potential advantages. For UPPP, these adverse effects range from temporary to permanent⁵ consequences of voice changes, taste disturbances, globus sensation, difficulty swallowing, and velopharyngeal insufficiency (VPI).⁶ VPI is a somewhat loose term and therefore difficult to quantify since studies use multiple different synonyms, including nasal regurgitation, nasopharyngeal reflux, swallowing reflux, pharyngonasal reflux, palatopharyngeal incompetency, and even nasopharyngeal unclosure. In essence, however, VPI refers to the inability to temporarily close the communication between the nasal cavity and the mouth that leads to dysfunctional problems with speech, eating, and breathing.⁷ If performed correctly, a 100% rate of VPI after UPPP might be expected initially due to the nature of the surgery that anatomically disrupts the soft palate and lateral or posterior wall of the pharynx that facilitates closure of the communication between the mouth and nasal cavity.

Not only is the rate of VPI after UPPP difficult to capture due to the myriad of synonyms used to describe the phenomenon, but also the studies that report VPI mostly convey short-term outcomes. The incidence of VPI is often captured through questionnaires and patient reports of their satisfaction regarding surgery. Yet, it is common knowledge that satisfaction with surgeries can often differ largely between immediate vs long-term follow-up. Even when evaluating patient satisfaction with septoplasty, one of the most common otolaryngologic procedures, patient satisfaction by the 60th day postoperatively was 94.4%, as defined by patients reporting improved nasal breathing determined by a symptom questionnaire,⁸ but only 55.9%, as found in another long-term 10-year follow-up study.⁹

UPPP is already a nonideal, second-line treatment for OSA, and it is a procedure that is not without adverse outcomes or long-term complications. In fact, the results of a study by Värendh et al¹⁰ that followed patients 19 to 25 years postoperatively suggest that reported side effects associated with UPPP may actually be considered permanent. As many as 38% of patients reported persistent side effects of nasal regurgitation, swallowing difficulty, voice changes, and oral pain. Without a doubt, these are important points on which to counsel patients regarding expectations, especially if potential side effects of UPPP may be long term.

The primary aims of this study are to perform a systematic review and meta-analysis to assess the incidence of long-term VPI and to determine other sequelae following classic and modified uvulopalatopharyngoplasty (UPPP and mUPPP) for the treatment of OSA.

Materials and Methods

A systematic review was performed following standard Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Institutional review board approval was exempt for this study. A literature search was conducted using Medline, PubMed, and the Cochrane Library database. Original research articles reporting on sequelae of UPPP and mUPPP for treatment of OSA were included. Articles were retrieved using keywords UPPP complications and UPPP questionnaire. The term UPPP questionnaire was used as a search term because many studies capture the rate of VPI through patient self-report in the form of questionnaires. Furthermore, because the objective of the study was to quantify the incidence of VPI, which has been described through a variety of other phrases, the general term UPPP complications was used to gather all studies that potentially reported VPI using another descriptive term. Inclusion criteria were studies that (1) were written in English; (2) discussed the complications of UPPP, specifically reporting the incidence of VPI or another variation of VPI such as nasal regurgitation, nasopharyngeal reflux, swallowing reflux, pharyngonasal reflux, palatopharyngeal incompetency, or nasopharyngeal unclosure; and (3) included only classic or modified UPPP procedures. Exclusion criteria were studies that (1) were not written in English, (2) did not mention VPI or any other descriptive form of VPI as a complication of UPPP, (3) performed other methods of UPPP outside of the classic or modified approach such as laser-assisted or radiofrequency-assisted, and (4) reported the incidences of VPI in combination with other sequelae such as difficulty swallowing. Techniques outside of the classic or modified UPPP approach were excluded because these are generally reserved for very mild cases of OSA or snoring and would be expected to have less morbidity. These excluded techniques included procedures such as radiofrequency reduction or laser-assisted UPPP. We specifically also excluded techniques such as the expansion sphincter pharyngoplasty given that its popularity among sleep surgeons was largely due to the avoidance of VPI and other side effects. In more detail, techniques that were considered modified UPPP included those involving tonsillectomy, an extended uvulopalatal flap (which includes bilateral tonsillectomy, dissection and removal of submucosal adipose tissue of the soft palate and supratonsillar area, imbrication, and reposition of the denuded uvulopalatal flap), and uvula-preserving techniques. While even these modified techniques may also result in less complications, including VPI, including these techniques in the study would, if anything, err on the side of reporting a more conservative incidence of VPI and other complications after surgery.

Of the articles that were included in the study, data were collected regarding the sample size, mean follow-up time, and incidence of VPI. Each included study was also further analyzed to document other sequelae of UPPP, including but not limited to difficulty swallowing, taste disturbances, voice changes, dry pharynx, foreign body sensation, and hypersecretion.

A random-effects model was used for pooling data (SAS Institute, Cary, North Carolina) based on a Q value of 21.9 and I² value of −5.2 (confidence interval [CI], 6.8-12.6). In addition to assessing the overall incidence of VPI across all included studies, the studies were also analyzed between those that had a mean follow-up time of greater than 1 year and those that had a mean follow-up time less than or equal to 1 year. For the purposes of the study, mean follow-up time greater than 1 year was defined as long term, while mean follow-up time less than or equal to 1 year was defined as short term. A Shapiro-Wilks test was used to determine normality of data (P > .341). Differences between incidences of sequelae following VPI were statistically analyzed using unpaired t tests with significance set at P < .05.

Results

The initial search terms pulled up 2487 studies, 2437 of which were excluded because they did not report any descriptive form of VPI as a complication. The remaining 50 articles reporting VPI or other variations of VPI were evaluated in full text to assess eligibility. Twenty-three studies were further excluded because they included patients who underwent UPPP outside of the classic or modified approach. An additional 3 studies were excluded because they reported incidences of VPI as a combined percentage with other sequelae such as difficulty swallowing ( Figure 1 ).

Figure 1.

Flowchart for articles identified through Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.

A total of 24 studies were included in this review ( Table 1 ). Complications included VPI (24 studies, n = 191), difficulty swallowing (7 studies, n = 83), taste disturbances (4 studies, n = 10), voice changes (7 studies, n = 46), foreign body (9 studies, n = 427), and dry pharynx (7 studies, n = 150).

Table 1.

List of Articles Included in This Study.

Lead Author	Year	Follow-up Time	No.	VPI, No. (%)	Swallowing Difficulty, No. (%)	Taste Disturbance, No. (%)	Voice Change, No. (%)	Dry Pharynx, No. (%)	Foreign Body, No. (%)	Level of Evidence
Värendh¹⁰	2012	20 y	129	18 (14)	26 (20)	—	15 (12)	48 (37)	—	2b
Goh¹¹	2007	17-20 y	49	14 (28.5)	12 (24.4)	—	8 (16.3)	11 (22.4)	10 (20.4)	2b
Lu¹²	1995	5 y	15	3 (24)	—	—	—	—	—	2b
Walker-Engstrom¹³	2002	4 y	40	3 (8)	4 (10)	—	—	—	—	1b
Carpenter¹⁴	2008	3-8 y	145	15 (10.3)	—	—	11 (8)	—	22 (15)	2b
Chen¹⁵	2012	2-15 y	451	15 (3.33)	—	—	—	—	230 (51)	2b
Ugur¹⁶	2013	2 y	24	8 (33.3)	—	—	—	—	10 (41.9)	1b
Grøntved¹⁷	2000	2 y	69	9 (13)	6 (9)	—	5 (7)	—	—	2c
Aneeza¹⁸	2011	1-7 y	14	6 (42.8)	5 (35.7)	1 (7.1)	5 (35.7)	—	4 (28.5)	2c
Croft¹⁹	1990	1+ y	50	5 (10)	—	5 (10)	—	11 (22)	—	2b
Katsantonis²⁰	1987	1+ y	85	1 (1)	—	—	—	—	—	4
Levring-Jaghagen²¹	1999	1 y	68	9 (13.2)	20 (29.4)	—	—	—	—	2b
Tegelberg²²	1999	12 mo	95	3 (8)	—	—	—	—	—	2b
Liu²³	2009	6-12 mo	586	3 (0.51)	—	—	—	—	140 (23.9)	2b
Xiong²⁴	2001	6+ mo	70	9 (12.9)	—	—	—	—	—	4
Han²⁵	2005	6 mo	68	0	—	—	—	—	—	2b
Li²⁶	2003	6 mo	37	1 (2.7)	—	—	—	—	—	2b
Choi²⁷	2011	3 mo	41	2 (4.9)	—	1 (2.4)	—	2 (4.9)	5 (12.2)	2b
Haavisto²⁸	1994	6 wk to 1 y	101	25 (24)	10 (10)	—	—	32 (31)	—	2b
Simmons²⁹	1984	1-2 mo	60	15 (25)	—	—	0	—	—	2b
Salami³⁰	2010	1 mo	40	1 (2.5)	—	—	—	—	2 (5)	1b
Rombaux³¹	2003	1 wk to 6 mo	17	2 (11.8)	—	3 (17.6)	2 (11.8)	2 (11.8)	4 (23.5)	1b
Cahali³²	2004	4-6 mo	12	4 (33.3)	—	—	—	—	—	1b
Zohar³³	1993	90+ d	87	20 (23.0)	73 (83.9)	—	—	—	—	2b

Abbreviations: VPI, velopharyngeal insufficiency; —, not reported by the studies.

When pooling all studies together, VPI was the least common sequela reported in 8.1% of the cases. Foreign body sensation was the most commonly reported sequela at 31.2%, with difficulty swallowing (17.7%), dry pharynx (23.4%), voice changes (9.5%), and taste disturbances (8.2%) being the most to least likely ( Figure 2 ).

Figure 2.

Pooled incidences of sequelae following uvulopalatopharyngoplasty (UPPP). VPI, velopharyngeal insufficiency.

When separating the studies between those that had a mean follow-up time greater than 1 year (long term) and those that had a mean follow-up time less than or equal to 1 year (short term), the short-term incidence of VPI was 7.3% and long-term incidence of VPI was 9.1% (P = .396). Other sequelae had a short-term and long-term incidence as follows ( Figure 3 ): 6.9% short-term and 9.4% long-term incidence of taste disturbance (P = .242), 22.1% short-term and 40.4% long-term incidence of foreign body sensation (P = .762), 22.6% short-term and 23.6% long-term incidence of dry pharynx (P = .639), 2.6% short-term and 10.8% long-term incidence of voice change (P = .698), and 17.8% short-term and 17.6% long-term incidence of difficulty swallowing (P = .762). None of these comparisons between short-term and long-term sequelae reached significance.

Figure 3.

Percentages of short-term vs long-term complications following uvulopalatopharyngoplasty (UPPP). Short-term complications were identified through studies with a mean follow-up less than or equal to 1 year or less. Long-term complications were identified through studies with a mean follow-up greater than 1 year. VPI, velopharyngeal insufficiency.

Discussion

Based on the results of our study, foreign body sensation is the most common side effect reported after UPPP or mUPPP, closely followed by dry pharynx and difficulty swallowing. Voice change, VPI, and taste disturbances are much less likely. These patterns hold true even in the few months to a year after surgery with foreign body sensation, dry pharynx, and difficulty swallowing reported around 17.8% to 22.6% of the time and VPI, taste disturbances, and voice changes occurring roughly 2.6% to 7.3% of the time. Over time, even years after surgery, foreign body sensation remains the most common side effect and is reported at higher incidences than the early postoperative time period. VPI, voice changes, and taste disturbances are also reported at higher incidences in studies with longer follow-up times. On the other hand, the incidences of dry pharynx and difficulty swallowing remain almost unchanged between short- and long-term follow-up. While none of the incidences of these sequelae of UPPP significantly changed with longer follow-up, there is a clear trend that these sequelae do not resolve over time.

Specifically with regard to VPI after UPPP, VPI would almost be an expected result immediately postoperatively because the UPPP procedure essentially disrupts the very anatomic structures that facilitate closure of the communication between the oral and nasal cavities. While it is optimistic to hope that VPI would diminish with greater recovery time after surgery, it appears that VPI may actually be a complication that persists more frequently than reported.

Short-term outcomes of UPPP are well recognized, but long-term efficacy and side effect profile of UPPP remain less well known. The difference between transient and persistent complications is an absolutely fundamental concern to patients. After all, temporary discomfort may be inconveniences that patients are more willing to endure if they know that their condition will eventually improve. Permanent complications are another story altogether because suffering through the side effects of surgery over many years may ultimately affect the patients’ decisions regarding whether to proceed with surgery. The results of this study suggest that patients be made aware of certain side effects of UPPP that may be more than just momentary distress. Of note, foreign body sensation, dry pharynx, difficulty with swallowing, and VPI have greater than 10% incidence reported years after surgery. Indeed, with a 38.6% incidence of foreign body sensation years after surgery, patients should be counseled that this may the most common expected complication after surgery.

Conclusion

The long-term effectiveness of UPPP and mUPPP is limited by the number of studies reporting short-term follow-up only. Despite this, the studies that report long-term data suggest that complications such as VPI are more common than previously reported. Other sequelae, such as foreign body sensation, are the most frequently reported complications after UPPP surgery. However, it is important to note that long-term complication rates are not significantly lower than short-term complication rates, and it is exceptionally important to disclose this information to patients regarding the lasting side effects that may accompany UPPP. A primary focus on realistic expectations should be adopted when counseling patients on both the short-term and potentially persistent long-term complications that may not resolve after UPPP.

Author Contributions

Jessica A. Tang, acquisition, analysis, and interpretation of data for the work, drafting the manuscript, agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; Anna M. Salapatas, acquisition, analysis, and interpretation of data for the work, drafting the manuscript, agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; Lauren B. Bonzelaar, acquisition, analysis, and interpretation of data for the work, drafting the manuscript, agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; Michael Friedman, substantial contributions to the conception or design of the work, revising it critically for important intellectual content, agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Disclosures

Competing interests: None.

Sponsorships: None.

Funding source: None.

Footnotes

No sponsorships or competing interests have been disclosed for this article.

This article was presented at the 2016 AAO-HNSF Annual Meeting and OTO EXPO; September 18-21, 2016; San Diego, California.

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