Published: February 14, 2025

Palatal Surgery: Expanding Options for Pediatric Sleep Apnea Treatment

Palatal surgery at the time of adenotonsillectomy can often address soft palate collapse and prevent persistent disease.


James M. Ruda, MD, and Cristina M. Baldassari, MD


Presented At Am24 Blue 1500x845The following article provides highlights from the authors’ Expert Lecture of the same title, presented at the AAO-HNSF 2024 Annual Meeting & OTO EXPO. A webcast of the lecture is also available on OTO Logic, the AAO-HNFS learning platform.

Adenotonsillectomy is the mainstay of treatment for pediatric obstructive sleep apnea (OSA). Within the U.S., approximately 500,000 cases are performed annually in children less than 15 years of age.1 Adenotonsillectomy has been shown to improve obstruction, quality of life, and behavior. However, certain populations of children such as those with severe OSA (apnea-hypopnea index>10), craniofacial anomalies, or obesity, are at increased risk for persistent obstruction following adenotonsillectomy. Recent research in pediatric drug-induced sleep endoscopy has shown that multilevel airway collapse at baseline is common among these at-risk populations. Thus, there has been growing interest among pediatric sleep surgeons as to whether addressing additional sites of obstruction at the time of adenotonsillectomy could improve OSA outcomes.

Beyond tonsil and adenoid hypertrophy, one of the most common sites of airway collapse in pediatric OSA is the palate. Palatal surgery for pediatric OSA has typically been reserved for children with persistent obstruction following prior adenotonsillectomy. However, in recent years, pediatric sleep surgeons have also begun performing palatal surgery at the time of adenotonsillectomy to address soft palate collapse and prevent persistent disease. Procedures aimed at structural modification of the soft palate and pharynx, such as palatopharyngoplasty, have been performed to help stabilize a crowded, collapsible upper airway. Much of the literature regarding different techniques to address palate obstruction has been published in the adult OSA literature. Increasingly, these palatal procedures are being modified and used to safely and effectively treat pediatric OSA.

To view an accompanying video from the authors demonstrating soft palatal surgery in a pediatric patient, visit the Academy's YouTube channel.

Since 1988, palatopharyngoplasty has been reported in a variety of case series of children for the treatment of OSA. This includes both neurologically normal and impaired children.18-21 Palatopharyngoplasty is often reserved for children with severe baseline OSA and multiple comorbidities. It can be performed at the time of adenotonsillectomy or secondarily in a staged fashion following adenotonsillectomy. In adults, the surgical success rate with palatopharyngoplasty has been reported greatest when performed concomitantly with tonsillectomy, and not secondarily.22 Originally, the standard uvulopalatopharyngoplasty (UPPP), as described by Ikematsu, was used as the mainstay surgical technique in both adults and children.23 This was commonly performed in children with OSA with significant comorbid medical conditions such as developmental delay, Down Syndrome, Prader-Willi Syndrome, cerebral palsy, and craniofacial abnormalities.18-21 Increasingly, palatopharyngoplasty is also being considered for children with obesity and/or severe baseline OSA.

UPPP involves the modification of the soft palate, tonsillar arches, and uvula either by trimming or excision of these structures followed by apposition of the tonsillar pillars. Over the past four decades, UPPP has been performed in combination with multiple procedures as part of a multilevel surgery for children with OSA. This includes adenotonsillectomy, inferior turbinate reduction, tongue base reduction, supraglottoplasty/epiglottoplasty, septoplasty, and others.19 Concomitant UPPP is often successful in improving multiple polysomnographic parameters, especially AHI and SpO2 nadir. Within the literature, average AHI reductions range from 29 to 75 events/hour less in children treated by adenotonsillectomy and UPPP.18,21,25 Among a recent study from Velu et al. of 26 studies, UPPP complications were reported in approximately 25.6% of children, including postoperative reintubation, additional required sleep surgery, tracheostomy, and one case of postoperative VPI.19 However, the authors acknowledged that there was significant patient heterogeneity within compiled studies, and many of the postoperative complications were likely related to the underlying severity of patients’ OSA and their characteristics and less to the surgical procedure itself.

Since 2007, the technique of UPPP has evolved following the introduction of the expansion sphincter palatopharyngoplasty (ESP) by Drs. Tucker and Pang.26 With this technique, trimming and resection of the soft palate were abandoned in favor of a more reconstructive technique that involved rearranging palatal musculature to improve airway patency. ESP was developed to improve the lateral velopharyngeal ports while minimizing the risks of postoperative complications such as VPI, nasal regurgitation, and persistent velopharyngeal obstruction that can occur after standard UPPP via scar contracture. It involves the division of the palatopharyngeus muscle and the creation of a superior-based palatopharyngeus muscle flap that is superolaterally rotated and pexied to the palatine muscles. Later, in 2012, this technique was modified by Sorrenti et al. who created a submuscular tunnel through the palatine muscles with pexy of the palatopharyngeus muscle to the fibrous condensation of the pterygomandibular raphe.27

Since Sorrenti’s modification, multiple additional modifications have been devised and frequently employed in adults and children over the past decade by sleep surgeons across the U.S. Within the literature, ESP has been shown to cumulatively decrease AHI by 22.3 events/hour in 747 adults over a 15-year interval by Pang et al.28 Within children, Ulualp showed a superior AHI reduction of 58 events/hour among 25 children treated by ESP and adenotonsillectomy compared to adenotonsillectomy alone.25 Barbed suture pharyngoplasty is another palatal surgery technique that has been used to successfully treat palatal collapse in adult OSA, although studies on this technique for the treatment of pediatric OSA are lacking.

Although data are still emerging regarding improvement in outcomes when pharyngoplasty is performed at the time of adenotonsillectomy, the authors described their clinical experience with palatal surgery in the management of pediatric OSA during the AAO-HNSF 2024 Annual Meeting & OTO EXPO. For surgical indications, we both agreed that we typically perform palatopharyngoplasty for children who are at least four years of age, have severe baseline disease (AHI >20), and have risk factors for persistent OSA. Often, we perform drug-induced sleep endoscopy (DISE) before palatopharyngoplasty in children to characterize the pattern of palatal collapse. Patterns of upper airway collapse on sleep endoscopy such as anterior-posterior palatal collapse versus circumferential collapse, and lateral oropharyngeal/hypopharyngeal wall collapse can help determine which palatal procedure is most appropriate.

One of the authors, Dr. Ruda, also frequently performs in-office, flexible fiberoptic laryngoscopy beforehand and compares this to DISE findings intra-operatively to determine palatopharyngoplasty candidacy. Palatopharyngoplasty in children, similar to adults, may be easier to perform in surgically naïve patients who lack any anatomic palatal or pharyngeal distortion following wound contracture and healing after prior adenotonsillectomy.

Recovery after palatopharyngoplasty in children may be longer than after adenotonsillectomy alone. Patients are often counseled to expect a recovery of seven to 14 days and with a similar risk for post-tonsillectomy bleeding after adenotonsillectomy. Patients are counseled about the risks of temporary postoperative VPI, nasal regurgitation, and dysphagia, although these have been very uncommon in both authors’ experience. Following palatopharyngoplasty, patients are admitted for at least overnight observation for pain control, ability to take adequate PO, and any postoperative respiratory support needs.

Palatal surgery techniques to treat OSA continue to evolve. There is a role for palatopharyngoplasty in the treatment of pediatric obstruction. However, additional prospective randomized trials are needed to confirm that palatal surgery at the time of adenotonsillectomy improves surgical outcomes. Hopefully, additional experience and research on palatopharyngoplasty in children will lead to advances in treatment algorithms for pediatric OSA.


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