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Overcoming Gag Reflex for Awake Transnasal Laryngeal SurgeryClick Here


last modified on: Thu, 03/28/2024 - 23:04


  1. Indications
    1. Obstructive sleep apnea (OSA) demonstrated by polysomnography that is refractive to conservative measures (CPAP, positional therapy, dental devices, weight loss)
    2. Mueller maneuver demonstrates collapse at the level of the palate
  2. Contraindications
    1. Preoperative evidence of velopharyngeal insufficiency or submucous cleft
    2. Not usually indicated without concomitant tracheotomy in patients with severe OSA with life-threatening arrhythmias or desaturations


  1. Evaluation
    1. Obtain polysomnogram (sleep study) to diagnose and determine the degree of obstructive sleep apnea
    2. Patient has demonstrated trial of CPAP and other nonsurgical treatments that have failed or were not tolerated by the patient
    3. Review of patient's medical history and degree of cardiac or pulmonary disease as a result of OSA
    4. Nasopharyngoscopy with Mueller maneuver to identify the level and degree of airway narrowing
    5. Complete head and neck examination
    6. Obtain from patient and bed partner history addressing snoring and severity of apnea-related symptoms
  2. Consent
    1. Describe the anatomy of the upper airway and the etiology of airway obstruction during sleep.
    2. Describe the procedure: "Remove the uvula and some of the palate (along with the tonsils if present) to help open up the airway."
    3. Explain the possible need for a tracheotomy.
    4. Explain the possible need for further staged procedures to help fully resolve OSA.
    5. Explain the need for intensive care monitoring in selected patients.
    6. Describe the expected degree and duration of postoperative pain with need for oral analgesics (acetaminophen with or without codeine or other mild narcotics).
    7. Discuss possible complications
      1. Bleeding, infection, reaction to anesthesia
      2. Airway obstruction
      3. Cardiopulmonary sequelae
      4. Wound dehiscence
      5. Nasal regurgitation (transient: approximately 30%; long-term: greater than 3%)
      6. Mild dysphagia or globus sensation
      7. Nasopharyngeal stenosis
      8. Taste disturbance
      9. Tongue numbness


  1. Room Setup
    1. See Basic Soft Tissue Room Setup
  2. Instrumentation and Equipment
    1. Standard (see Nursing protocols)
    2. Special
      1. Suction coagulator, 10 Fr
      2. Tonsil sponges
      3. Ear bulb syringe
      4. 10 cc control top syringe
      5. Needle: 27-gauge
      6. Bipolar cautery
  3. Preoperative Medications
    1. IV antibiotics: Unasyn
    2. Corticosteroids: Decadron, 10 mg IV
  4. Intraoperative Medication
    1. 1% lidocaine with 1:100,000 epinephrine
  5. Prep and Drape
    1. Oral prep: surgeon's preference
    2. Head drape
    3. Square off around mouth
    4. Split drape


  1. General
    1. Patient is orally intubated.
    2. Discuss with anesthesiologist before the case the possible need for awake fiberoptic intubation.
    3. Use RAE tube or standard orotracheal tube.

OPERATIVE PROCEDURE (There are many modifications of the procedure; only one is described)

  1. Patient positioned with shoulder roll in place and neck extended.
  2. Patient is given intravenous antibiotics (Unasyn) and corticosteroids.
  3. Self-retaining mouth gag placed (Crowe-Davis) with care to protect the teeth and tongue.
  4. Evaluate oropharyngeal anatomy to determine features contributing to narrowing: tonsils, redundant uvula or tonsillar pillars, redundant posterior pharyngeal mucosa with formation of folds.
  5. Perform tonsillectomy if tonsils present. Some surgeons perform tonsillectomy last.
  6. Determine point of palatal incision. Should evaluate patient preoperatively for the point where soft palate comes in contact with posterior pharyngeal wall. Observe palate during gag or phonation for "dimple" where approximation of palate occurs. This point is termed the "J point", and is usually approximately 2 cm posterior to the edge of the hard palate. A useful maneuver intraoperatively is to place the tip of the Yankauer suction into one nostril while closing off the other side. This forms suction in the nasopharynx causing the palate to move back and close against the pharyngeal wall. This will replicate to some degree the point of closure seen in the awake patient. This area can also be palpated to feel for the edge of the palatal muscles.
  7. Once the location of the incision is determined, infiltrate the palate with 1% lidocaine with epinephrine 1:100,000 for hemostasis.
  8. Make the mucosal incision with a #15 blade curving laterally to meet the tonsillectomy incisions. If a tonsillectomy has been performed previously, portions of the pillar and underlying scar tissue will need to be resected. Careful dissection in this region should be used to avoid damage to the underlying musculature and carotid sheath structures.
  9. The palatal incision should be beveled to leave the nasal mucosa longer than the oral mucosa. This allows for closure of the mucosa over the raw surface of the palate and further facilitates opening of the nasopharyngeal inlet. Hemostasis is obtained with bipolar electrocautery.
  10. Closure begins by suturing the tonsillar fossae with interrupted 3-0 vicryl. The corners should be closed first with mattress sutures passing through the mucosal edges and superficial layers of muscle. This approach reduces tension on the closure and eliminates the dead space where hematomas can form. The closure then progresses toward the tongue leaving a small opening inferiorly to allow for drainage of any blood.
  11. The palatal incision should then be closed by approximating the nasal and oral mucosal edges together. Care should be taken not to overly tighten the sutures to allow for some edema and avoid dehiscence.
  12. The nasopharynx should be irrigated to remove accumulated blood. Suction the hypopharynx and esophagus with a soft catheter to remove any blood.
  13. The mouth gag is then removed, and the teeth and tongue are examined for any injury.


  1. The patient should be admitted to an intensive care unit for 24 hours if indicated. This should be a consideration if concomitant nasal surgery is performed, if the patient has significant underlying cardiac or pulmonary disease. This should also be considered if the patient cannot be closely monitored for airway compromise on a general inpatient unit.
  2. Patients not admitted to the intensive care unit should be monitored closely with continuous pulse oximetry.
  3. Kandasamy et al show that patients with BMI ≥ 30 and/or AHI ≥ 22 are more likely to require oxygen in the post-PACU setting and should be monitored overnight (see Kandasamy et al. 2013)
  4. Use of narcotics (IV morphine or acetaminophen with codeine) for postoperative pain should be used cautiously due to the associated respiratory suppression. If airway edema seems excessive, a short course of steroids may be helpful.
  5. The patient should follow a soft diet should for two weeks.
  6. Oral rinses with salt water or half strength hydrogen peroxide after meals should be done for the first seven to 10 days.
  7. The first postoperative visit is at three weeks.
  8. A repeat sleep study is obtained routinely at four to six months postoperatively. If a concomitant tracheotomy is performed and decannulation is a consideration, the study is obtained with the tube capped.


Fairbanks DNF. Uvulopalatopharyngoplasty complications and avoidance strategies. Otolaryngol Head Neck Surg. 1990;102:239-245.

Fujita S, Conway WA, Zurich F, et al. Surgical correction of anatomic abnormalities in obstructive sleep apnea syndrome: uvulopharyngoplasty. Otolaryngol Head Neck Surg. 1981;89:923-934. (vm)

Kandasamy et al. The incidence of early post-operativecomplications following uvulopalatopharyngoplasty: identification of predictive risk factors. Journal of Otolaryngology-HeadandNeckSurgery 2013,42:15