For more information about this procedure, please see Dr. Kezirian’s blog entry about the development of this modified technique and outcomes for expansion sphincter pharyngoplasty.

Expansion sphincter pharyngoplasty (with the modified technique renamed functional expansion pharyngoplasty) is performed under general anesthesia in the operating room. This procedure is used to treat obstructive sleep apnea and is combined with tonsillectomy in patients who have tonsils that have not previously been removed.

The procedure was developed as an alternative to standard soft palate surgery for sleep apnea (uvulopalatopharyngoplasty) as a method of combining tissue removal and tissue repositioning to increase the size of the airway without affecting normal functions such as breathing, speaking, and swallowing. Overall, it has shown better results than uvulopalatopharyngoplasty. However, Dr. Kezirian believes that the choice among soft palate procedures must be based on the unique anatomy of an individual patient rather than using a single soft palate surgery for all patients simply because one study showed improved outcomes.

How does Dr. Kezirian perform expansion sphincter pharyngoplasty?

Dr. Kezirian’s technique is based on the original description from Drs. Tucker Woodson and Kenny Pang but also incorporates modifications introduced to Dr. Kezirian by Italian colleagues (Drs. Aldo Campanini, Claudio Vicini, Giovanni Sorrenti, and Ottavio Piccin). This procedure involves dividing the muscle on the sides of the throat behind the tonsil (palatopharyngeus) and pulling it forward and laterally to sew it in place. The soft palate is then anchored forward, making it more difficult for the palate to fall towards the back of the throat, where it can block breathing in obstructive sleep apnea.

For more information about the selection of palate procedures, please see Dr. Kezirian’s blog entry about choosing the best palate surgery for snoring and sleep apnea.

View of the mouth before palate surgery

Repositioning of muscle during expansion sphincter pharyngoplasty

 

View of the mouth after healing from expansion sphincter pharyngoplasty

 

The following video presents a discussion of palate procedures, including modified expansion sphincter pharyngoplasty:

RISKS

Bleeding

Any palate surgery carries a risk of bleeding, and the risk is higher if tonsillectomy is also performed. A major factor in preventing serious bleeding is to avoid the use of aspirin, NSAIDs (such as ibuprofen, Advil®, Motrin®, naproxen, or Aleve®), vitamin supplements, or herbal medications for at least two weeks before and after surgery. Approximately 2-4% patients who undergo palate surgery or tonsillectomy experience bleeding after surgery. Half of these patients require an additional procedure—either in the outpatient clinic or the operating room—to control their bleeding. Please notify Dr. Kezirian immediately if you have bleeding of a teaspoon or more. If the bleeding is significant, immediately seek care in the closest emergency department or call 911.

Infection

Infection is rare but not impossible after palate surgery or tonsillectomy. Patients typically receive antibiotics at the time of surgery to reduce the chance of infection and decrease swelling. Patients should not use mouthwashes following surgery because many of these contain alcohol that can irritate the lining of the mouth and interfere with healing.

Difficulty swallowing

The palate is important in swallowing because it seals the connection between the back of the mouth and the back of the nose. After palate surgery, it is possible to have foods, especially liquids, come up in the back of the nose or occasionally through the nose. This happens in many patients for a brief period (1-2 days) due to swelling in the area, but it is unusual for this complication to be permanent and significant.

Changes in speech

Any operation on the palate can cause changes in speech, but these changes are rarely permanent.

Throat dryness or feeling of something stuck in the throat

Any operation on the palate can affect the throat in unpredictable ways, and it is possible for some patients to dryness or a feeling that something is stuck in the throat. These are usually temporary, but they can be permanent.

Narrowing at the top of the throat

Rarely, palate surgery will result in narrowing behind the palate—which is also the top of the throat. This complication can make breathing through the nose difficult as well as create problems with speaking and swallowing. Additional surgery may be necessary to correct this problem.

Change in sense of taste or tongue numbness

There are taste buds throughout the mouth, and it is possible that surgery of the palate can produce a change in the sense of taste or tongue numbness. This can be due to the surgery performed in the palate or pressure against the tongue from the surgical instrument placed in the mouth for the procedure. If there is a change in the sense of taste or tongue numbness, usually the damage is temporary with recovery over the course of days or weeks, but the damage can take months to recover or be permanent.

Tooth injury

Operating in the back of the throat is impossible unless an instrument is placed to keep the mouth open. This is the same instrument used when tonsillectomies are done. Rarely, a tooth may be injured by this instrument, and the risk is much higher if a tooth is loose or decayed prior to surgery.

Continued snoring

Most patients undergoing palate surgery will also have loud snoring. The goal of palate surgery is to eliminate obstructive sleep apnea. Usually snoring will improve dramatically if this goal is accomplished. However, many patients will continue to snore to some extent, even after surgery that resolves obstructive sleep apnea completely.

 

POSTOPERATIVE INSTRUCTIONS

NOTIFY DR. KEZIRIAN IMMEDIATELY IF YOU HAVE ANY TROUBLE BREATHING OR IF ANY BLEEDING DEVELOPS!

Hospital stay and discharge

Most patients stay in the hospital 1-2 days. The major concerns while you are in the hospital are making sure you are breathing freely, having no bleeding, controlling your pain with oral medications, and drinking enough fluids to have no risk of dehydration. Many people ask if they need someone to stay with them at home. You do need someone to stay with you the first night home after discharge, for safety. Beyond that, it is helpful to have someone available and checking on you to provide assistance when needed, although they do not have to stay with you 24 hours a day, every day. Planning before surgery (for example, buying milk or nutritional supplements) will decrease the amount of help you need at home after surgery.

Pain control

Like most surgeries, there is pain in the recovery period. However, we want to control your pain to make you comfortable during your recovery. Some people try to “hang in there” or suffer without taking pain medications. Controlling your pain is important for breathing, healing, and being able to swallow enough to maintain your nutrition.

While in the hospital, we will control your pain with oral medications, starting on the day of surgery. You can also hold ice chips inside your mouth to decrease swelling and reduce pain. Although we will use intravenous pain medications if necessary, the goal will be to use oral medications alone because this is what you will use when you go home after surgery. You will not receive a prescription for pain medications before surgery, as we will send you home with the type of medication and the amount that worked well for you in the hospital.

When you are at home, take your pain medication as you need it. You can also continue to hold ice chips inside your mouth to decrease pain and swelling. Use the pain medication in the same way as it worked in the hospital. Some days may be worse than others, and it may be frustrating because the pain continues at roughly the same level for 10-14 days after surgery. Try not to let the pain increase until it becomes intolerable before you take the medication. If you are running out of medication and need more, please call the office in advance to obtain another prescription. If you prefer to avoid narcotics, you should feel free to use acetaminophen (Tylenol®). Avoid aspirin, NSAIDs (such as ibuprofen, Advil®, Motrin®, naproxen, or Aleve®), vitamin supplements, or herbal medications for at least two weeks because they can increase your risk of bleeding after surgery. Your pain will be significant for at least the first 7-10 days following surgery, but it should improve markedly by 14 days following surgery.

Ice in the mouth

Holding ice in the mouth while they melt and cool the surgical area can help with pain control.  Doing this for the first 2-3 days after surgery is somewhat similar to applying ice to a sprained ankle.  It is one of the safest ways to reduce pain and can make the healing process easier.

Nutrition and fluids

It is very important to have good nutrition and avoid dehydration after surgery. Due to the pain and swelling that is expected after surgery, you will most likely only be able to tolerate a liquid diet for the first 4-5 days after surgery. Push yourself to drink fluids, even if it is painful. The first sign of dehydration is a decrease in urination, so keep track of this. In addition to water, it is It is helpful to drink other liquids, such as juices or Gatorade®. It is also essential that your body receive protein and fat in your diet to help with healing and maintaining your energy level. Every day, you should have 3 glasses of something with fat and protein like milk or chocolate milk, nutritional supplements like Muscle Milk® or Ensure®, or protein shakes. Dr. Kezirian may order a nutritional supplement like this while you are in the hospital. As your recovery continues, you will transition to soft solid foods such as eggs, yogurt, or mashed potatoes. You should be able to tolerate a fairly normal diet by 2 weeks after surgery. During the recovery period, you should avoid foods with sharp edges such as chips because these can cause bleeding. Otherwise, you can advance your diet according to your own schedule, being careful not to cause too much pain. Dr. Kezirian wants his patients to maintain their nutrition so that they do not lose weight in the few weeks right after surgery.

Antibiotics

Most patients receive an antibiotic while in the hospital. You may be prescribed an antibiotic to take when you go home. This can be useful for preventing infection and decreasing swelling. Take the antibiotics as directed. If you develop a rash or diarrhea (possible risks of antibiotics and other medications), stop the antibiotics and contact Dr. Kezirian immediately.

Activity

Walking after surgery is important. Patients should walk at least 3 times a day starting the day after surgery. Walking helps prevent blood clots from forming in your legs. Spending more time out of bed (walking or in a chair) than in bed is helpful because your lungs fill up with air, lowering the risk of fevers and pneumonia. Not walking enough is a major cause of fevers after surgery, so please do remember to walk at least 3 times every day. Patients should avoid strenuous activity for 4 weeks following surgery because that typically raises heart rate and blood pressure. For this reason, it can increase swelling or cause bleeding to start.

Do not use mouthwashes, lozenges, or throat sprays

Patients should not use mouthwashes, lozenges, or throat sprays following surgery because many of these contain alcohol or other chemicals that can irritate the lining of the mouth or numbing medication that can expose you to a serious complication when used for more than a couple of times.

Ear problems or jaw discomfort

The swelling in your throat that occurs after surgery can cause jaw pain or ear symptoms such as pain, pressure, or fullness. This is common and should improve within 1-2 weeks following surgery. It occurs because the soft palate and tonsils are next to the jaw and the small Eustachian tube that connects the space behind the eardrum to the top of the throat. Swelling in the throat can interfere with your ability to clear or pop your ears, and it can also be sensed by your body as pain coming from your ears even though the ears are not affected (a phenomenon called referred pain).

Sleep with head elevated (at 45 degrees) for at least three days

Elevating your head during sleep decreases blood flow to the head and neck regions. Therefore, it decreases swelling and the associated pain. Elevating the head during sleep may also improve breathing patterns in other ways. Therefore, we recommend elevating your head during sleep at 45 degrees for at least three days following the procedure.

Nausea and constipation

Nausea and constipation are very common after any surgery. The anesthetic medications that you receive during surgery and the narcotic pain medication you receive after surgery can cause these. You will receive medications after surgery to decrease nausea and constipation, but please notify Dr. Kezirian if you feel constipated or have not had a bowel movement in any 3 days after surgery.

Postoperative appointment

Dr. Kezirian likes to see his patients 1-2 weeks after surgery. If a postoperative appointment has not been scheduled, please contact the office to schedule this when you return home after your surgery.

Additional questions

For any emergencies, please call 911 or go to the nearest emergency room.  For other questions, please call the UCLA Health System page operator at (424) 259-6700 and ask for the Head and Neck Surgery resident on call.