Assessment of clinical and phoniatric outcomes of combined lateral expansion pharyngoplasty and anterior palatoplasty in obstructive sleep apnea patients

Assessment of clinical and phoniatric outcomes of combined lateral expansion pharyngoplasty and anterior palatoplasty in obstructive sleep apnea patients | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessment of clinical and phoniatric outcomes of combined lateral expansion pharyngoplasty and anterior palatoplasty in obstructive sleep apnea patients Sohair Reda Aboshady, Asmaa El-Dessouky Rashad, Ahmad Mahmoud Hamdan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8617320/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background Surgical techniques for managing obstructive sleep apnea syndrome (OSAS) focus on remodeling the narrow pharynx by advancing the soft palate and reinforcing the lateral pharyngeal wall, thereby enlarging the airway lumen and mitigating collapse. While palatal surgery demonstrates efficacy when structural anomalies are present, outcomes can be less predictable in cases driven primarily by neuromuscular collapsibility. Consequently, the primary aim of contemporary surgical innovation is to reduce this pharyngeal collapsibility. To address both palatal and pharyngeal components of collapse simultaneously, the present study proposes a combined procedure of anterior palatoplasty with lateral expansion pharyngoplasty, with subsequent evaluation of its clinical and phoniatric outcomes. Results Significant reductions were observed in postoperative apnea hypopnea index (AHI), and snoring duration relative to sleep time with 84% of patients showing more than 50% in AHI. There was a significant improvement in minimum oxygen saturation (p < 0.001 for all). A significant improvement in retropalatal/oropharyngeal space collapse was observed in postoperative flexible nasopharyngoscopic examination (p < 0.001). No life-threatening postoperative complications were observed. Dehiscence of the sutures between anterior and posterior tonsillar pillar was detected in 15 patients without any problem. Only one patient suffered from secondary post tonsillectomy hemorrhage which was managed medically. Conclusion Lateral expansion pharyngoplasty and Anterior palatoplasty represent an effective surgical combination for the treatment of OSAS in patients with palatal and lateral collapse. These techniques, performed as a one-stage procedure, led to improvements in apnea hypopnea index, snoring, and respiratory parameters in patients with OSAS by acting on lateral and retropalatal collapse. Anterior palatoplasty Apnea Hypopnea Index Lateral expansion pharyngoplasty Obstructive sleep apnea patients Figures Figure 1 Background Obstructive sleep apnea syndrome (OSAS) is defined by recurrent, periodic episodes of breathing cessation during sleep, resulting from upper airway obstruction. Continuous positive airway pressure (CPAP) is the established first-line therapy for OSAS and is effective when applied consistently according to American Academy of Sleep Medicine (AASM) standards ( 1 ). In practice, however, suboptimal patient adherence frequently limits its effectiveness, leading to a high rate of treatment discontinuation within the first year. In contrast, surgical intervention for OSAS offers a treatment outcome that is independent of patient adherence. Studies indicate that combining precise topodiagnosis with an appropriate pharyngeal procedure can achieve effective, long-term results ( 2 ). The fundamental objective of OSAS surgery is to address airway collapse at various anatomical levels, including the nasal, retropalatal, and retroglossal regions. Selecting the optimal treatment remains a clinical challenge. Recent innovations in surgical techniques focus on remodeling the narrow pharynx by advancing the soft palate and reinforcing the lateral pharyngeal wall, thereby enlarging the airway lumen and mitigating collapse ( 3 ). While palatal surgery demonstrates efficacy when structural anomalies are present, outcomes can be less predictable in cases driven primarily by neuromuscular collapsibility ( 4 ). Consequently, the primary aim of contemporary surgical innovation is to reduce this pharyngeal collapsibility. To address both palatal and pharyngeal components of collapse simultaneously, the present study proposes a combined procedure of anterior palatoplasty with lateral expansion pharyngoplasty, with subsequent evaluation of its clinical and phoniatric outcomes. Patients and Methods The current study was a prospective cohort study conducted on patients with obstructive sleep apnea syndrome subjected to lateral expansion pharyngoplasty combined with anterior palatoplasty approach. The operations were performed between May 2024 and August 2025 at a tertiary university hospital. The study was approved by the institutional review board of the affiliated university with an approval number 4/2024 ENT5. Informed written consent was obtained from all patients before participating in the study. The sample size was calculated using statistics and sample size pro program version 6, the least sample size was 25. The power of study is 80% and confidence level is 95%, Based on review of past literature (5). The study included 25 patients aged between 18 and 60 years old, having moderate or severe OSAS as detected by polysomnography, and having retropalatal /oropharyngeal obstruction collapse with concentric collapse having a combination of lateral and AP collapse as detected by Muller’s maneuver. Patients with upper airway tumors and/or polyps, craniofacial anomalies, and hypertrophy of the base of the tongue, nasal obstruction, and any other general contraindication against elective surgery were excluded from the study. Patients of the study were subjected to the following assessment protocol. Preoperative Assessment: All patients were subjected to history taking and complete otorhinolaryngology examination. Polysomnography (PSG) was performed for every patient to confirm the diagnosis of obstructive sleep apnea by having an apnea/hypopnea index (AHI) more than 5 apnea events per hour with grading of the severity of OSAS according to the AHI as mild (≥5 to<15 events/hour),moderate (≥15 to<30 events/hour), and severe (≥30 events/hour). Other variables were assessed by PSG including snoring duratiom relative to sleep time and oxygen saturation. To ensure consistency and eliminate inter-rater variability, a single author of the study performed all evaluations using flexible nasopharyngolaryngoscopy during the Muller’s maneuver. The assessment followed the NOHL classification by Vicini et al. (6) , examining the nasal cavity, retropalatal oropharynx, and retrolingual base of the tongue for the degree and pattern of upper airway collapse. Collapse of the pharyngeal walls was graded on a scale from 0 to 4: grade 4 (complete collapse), grade 3 (collapse <75%), grade 2 (collapse <50%), and grade 0 (no collapse). Nasal obstruction due to conditions like turbinate hypertrophy or septal deviation was similarly graded from 4 to 0. Patterns of pharyngeal collapse were categorized as: anterior-posterior (AP), concentric (C—a combination of lateral and AP collapse), or transversal (T—lateral walls moving inward). Laryngeal blockage at the supraglottic or glottic level was recorded as positive or negative. Additionally, significant palatine tonsillar hypertrophy (grade 3 or 4) was documented during grading. Surgical technique The procedure was performed under general anesthesia with orotracheal intubation. local injection of lidocaine was performed to the soft palate. After tonsillectomy, if no previous tonsillectomy was present, the palatopharyngeus muscle was identified and it's inferior end was transected and elevated then fixed with 2/0 vicryl suture around pterygomandibular ligament of the same side through a palatal tunnel. The palatal mucosa was then closed with 3/0 vicryl sutures. Approximation of the anterior and posterior pillars was done to give more tension to the lateral pharyngeal walls. A horizontal rectangular strip of mucosa and submucosa (about 4 cm in length and 7-10 mm in width) was removed from the soft palate with diathermy. Resection boundaries were 4 mm above the junction of the hard and soft palate, 4 mm below the uvula base and laterally from a line extending from the anterior tonsillar pillar to the soft palate. The stripped area of the palate was sutured with 4/0 vicryl resulting in anterior displacement of the palate. Partial uvulectomy was done using a diathermy and the raw area of the uvula was covered by suturing of the mucosa (Figure 1) . Postoperative Assessment: Patients had a weekly clinical examination for the first month postoperative. Polysomnography and flexible nasopharyngolaryngoscopy with muller maneuver were performed for every patient at 3 months postoperatively. Outcome measures Outcome parameters included a comparison between preoperative and postoperative AHI, lowest oxygen saturation (LOS), snoring duration from sleep time, Epworth sleepiness scale (ESS), and degree of collapse at retropalatal and oropharyngeal levels. Statistical Analysis: Data were collected, tabulated and statistically analyzed using an IBM compatible personal computer with Statistical Package for the Social Sciences (SPSS) version 26 (IBM Corp., Armnok, NY, US). Descriptive statistics included number (N) and percentage (%) for qualitative data, while quantitative data were expressed as mean ( x̅ ), standard deviation (SD). Analytic statistics included p aired t-test (t) for comparison of paired quantitative data of normally distributed variables of the same group. In contrast, the Wilcoxon Signed Ranks Test was used for comparison of paired quantitative data of not normally distributed variables of the same group. Marginal Homogeneity Test was used for the comparison of paired qualitative data. A p value less than 0.05 was considered statistically significant. Results The study sample included 16 (64.0%) male and 9 (36.0%) female. The ages of the patients ranged from 39 to59 years, with a mean age of 46.4±32.8 years. The mean preoperative BMI was 32.8±3.2 kg/m2 (Table 1) . The mean Epworth sleepiness scale score significantly improved from 15.8 ±4.9 preoperatively to 5.52 ± 2.9 postoperatively (p<0.001). The results of pre- and postoperative PSG showed significant reductions in mean AHI from 33.8± 13.5 to 12.2 ±11.1 (p<0.001) and snoring duration relative to sleep time from 4.3± 7.8% to 0.6 ±1.1% (p <0.001). There was a significant improvement in minimum oxygen saturation from 82.5 ± 4.2% to 91.4 ± 3.4% (p<0.001) (Table 2) . A significant improvement in retropalatal (oropharyngeal) space was observed in postoperative flexible nasopharyngoscopic examination (p<0.001) (Table 3). Twenty one patients (84%) showed more than 50% reduction in AHI while 4 patients (16%) showed less than 50% reduction in AHI. Table 1: Demographic characteristics of the studied group Variable studied group (n=25) No. % Gender Male 16 64.0 Female 9 36.0 Age (years) Mean ±SD 46.4±32.8 Range 39-59 Preoperative BMI (kg/m2) Mean ±SD 32.8±3.2 Range 29-41 Table 2: Results of Pre- and Postoperative Polysomnography Variable Pre-operative (n=25) Post- operative (n=25) Test of significance p value Mean ± SD Range Mean ± SD Range Epworth sleepiness scale 15.8 ±4.9 8-24 5.52 ± 2.9 2-15 W=4.380 <0.001* apnea/hypopnea A/H index /h sleep 33.8 ± 13.5 21.7 – 79.8 11.1 ± 12.2 4 - 50 W=4.374 <0.001* Lowest SpO2(%) 82.5 ± 4.2 73 – 88 91.4 ± 3.4 83-96 W=4.391 <0.001* Snoring duration from sleep time (%) 4.3 ± 7.8 0.01-35.2 0.6 ± 1.1 0 – 4 W=4.377 <0.001* *P value of < 0.05 statistically significant `Table 3: Results of Pre- and Postoperative Flexible nasopharyngolaryngoscopy with Muller maneuver. Variable Pre-operative (n=25) Post-operative (n=25) Marginal Homogeneity Test P value No. % No. % Retropalatal collapse Grade 1 Grade 2 Grade 3 Grade 4 0 2 13 10 0.0 8.0 52.0 40.0 10 9 1 5 40.0 36.0 4.0 20.0 4.064 <0.001* *P value of < 0.05 statistically significant No life-threatening postoperative complications were observed. Postoperative pain persisted for about 2 weeks. Velopharyngeal insufficiency or nasal regurgitation were not observed in any of the patients. Postoperative uvula edema was detected in all the patients with variable degrees with no respiratory distress. There was no dehiscence of the palatal sutures in any of the patients. Dehiscence of the sutures between anterior and posterior tonsillar pillar was detected in 15 patients without any problem. Only one patient suffered from secondary post tonsillectomy hemorrhage which was managed medically. Discussion Obstructive sleep apnea syndrome (OSAS) has garnered substantial attention within the medical community in recent years, owing to its strong associations with numerous systemic conditions, including cardiovascular disease, hypertension, obesity, depression, dyslipidemia, gastroesophageal reflux disease, and diabetes mellitus. These comorbidities contribute to a significant potential increase in healthcare expenditures. Furthermore, the characteristic sleep fragmentation and chronic intermittent hypoxia associated with OSAS adversely affect cognitive function and diminish overall quality of life ( 7 ). The pathophysiology of obstructive sleep apnea is fundamentally understood through the model of multifactorial airway obstruction, which implicates both the soft palate and lateral pharyngeal walls. This paradigm acknowledges that airway patency is compromised not by an isolated anatomical feature, but by a dynamic interaction of structural and neuromuscular factors. The soft palate, especially the uvular region, is frequently implicated in anteroposterior collapse. Concurrently, the lateral pharyngeal walls—comprising mucosa, submucosal tissues, and the pharyngeal constrictor muscles—constitute a primary site for lateral airway narrowing. The confluence of these collapse patterns results in a more severe, concentric reduction of the airway lumen. Therefore, effective therapeutic intervention frequently necessitates a multimodal strategy designed to concurrently address palatal redundancy and lateral wall collapsibility, such as surgical procedures that stiffen the palate and expand the lateral pharyngeal dimensions. The present study proposed anterior palatoplasty with lateral expansion pharyngoplasty at the same time to reduce both palatal and pharyngeal collapse. The study showed a significant reduction in apnea/hypopnea index and snoring time, and a significant improvement in lowest oxygen saturation postoperatively along with a significant reduction in the degree of oropharyngeal collapse as detected by Muller’s maneuver. Anterior palatoplasty is a minimally invasive surgical procedure designed to address retropalatal obstruction in patients with obstructive sleep apnea (OSA). Its rationale is based on stiffening and shortening the soft palate by removing a strip of mucosa and underlying tissue from its anterior surface. This tightening reduces both the vibratory tissue responsible for snoring and the dynamic collapse of the palate during sleep, thereby improving airway patency. It is often considered for patients with mild-to-moderate OSA who have failed CPAP, particularly those with palatal-level collapse, as it offers a less morbid alternative to traditional uvulopalatopharyngoplasty (UPPP) with a focus on preserving velopharyngeal function ( 8 ). The efficacy of anterior palatoplasty (AP) in the management of obstructive sleep apnea (OSA) has been evaluated in multiple studies. Research by Selcuk et al. ( 9 ), which utilized computerized tomography scans, examined upper airway volumetric changes in patients undergoing AP for pure snoring and mild-to-moderate OSA. Their findings indicated a significant post-operative increase in total upper airway volume and cross-sectional area, although lateral airway dimensions were not notably affected. This anatomical outcome is corroborated by clinical data; a systematic review by Pang et al. ( 10 ) reported a significant improvement in the apnea-hypopnea index following AP for mild-to-moderate OSA, with an overall pooled success rate of 72.5%. Further synthesizing the evidence, a systematic review and meta-analysis by Binar and Karakoc ( 8 ) determined a general surgical success rate for AP of 60.6%, noting an absence of serious complications in the literature. Comparative studies have also been conducted. Marzetti et al. ( 11 ), in preliminary results, compared AP to the uvulopalatal flap (UPF) technique, suggesting that the subjective and objective improvements observed might position AP as a superior method for inducing a fibrotic palatal scar. The importance of patient selection is highlighted by Gallino et al. ( 12 ), who assessed AP success rates using different diagnostic tools. Their results showed an improvement rate of 66.67% for patients selected via the Müller maneuver, which increased to 83.30% for those selected using drug-induced sleep endoscopy. The rationale for lateral expansion pharyngoplasty in OSA patients is to address collapse of the lateral pharyngeal walls, a primary site of obstruction in many individuals. Unlike procedures that solely stiffen the palate, this technique physically enlarges the retropalatal airway by surgically modifying the palatopharyngeus muscles and using sutures to reposition tissues laterally. This creates a more patent, "box-shaped" airway that is less prone to dynamic collapse during inspiration. It is particularly indicated for patients with concentric or lateral wall collapse at the velopharynx, as identified during drug-induced sleep endoscopy, and is often combined with other procedures to treat multi-level obstruction ( 13 ). The effectiveness of lateral pharyngoplasty techniques in addressing retropalatal and lateral pharyngeal wall collapse has been documented in several studies. Research by Pinto et al. ( 5 ) on lateral expansion pharyngoplasty reported significant post-operative improvements, including a reduction in the apnea-hypopnea index (AHI) and microarousal index, alongside an increase in minimum oxygen saturation. Similarly, Hong et al. ( 14 ) found that expansion sphincter pharyngoplasty (ESP), often performed concomitantly with other procedures, successfully corrected lateral collapse. Their results demonstrated a significant decrease in the mean AHI and an improvement in the lowest oxygen saturation at a six-month follow-up. The authors noted that postoperative complications such as pain and bleeding were minimal, although some patients reported transient abnormal sensations in the soft palate or mild dysphagia. They further identified severe circumferential palatal narrowing and bulky lateral pharyngeal tissue as favorable surgical indications for ESP. When compared to traditional techniques, lateral pharyngoplasty shows comparable efficacy. A systematic review by Maniaci et al. ( 15 ) comparing lateral pharyngoplasty (LP) to uvulopalatopharyngoplasty (UPPP) found that both procedures yielded statistically significant improvements in AHI, Epworth Sleepiness Scale (ESS) scores, and lowest oxygen saturation (LOS). Although lateral pharyngoplasty trends suggested better outcomes, the differences compared to UPPP did not reach statistical significance. The strength point of the current study is the combination of the two techniques addressing multifactorial obstruction in cases of OSA combining their positive outcomes on airway collapse. The limitations of this study include the small sample size due to no compliance of the patients to surgical indications. Another limitation is the dependance on awake endoscopy for assessment of the level of obstruction with its restrictions regarding its limited accuracy compared with Drug induced sleep endoscopy due its assessment of the patient while awake not during sleep with some difference in the underlying pathophysiology in the two conditions. However, the authors used this technique, being the most available, cost effective, and anesthesia free. Conclusion Lateral expansion pharyngoplasty and Anterior palatoplasty represent an effective surgical combination for the treatment of OSAS in patients with palatal and lateral collapse. These techniques, performed as a one-stage procedure, led to improvements in apnea hypopnea index, snoring, and PSG respiratory parameters in patients with OSAS by acting on lateral and retropalatal collapse. Declarations Consent to participate: Informed consent was obtained from all individual participants included in the study. Consent to publish: The authors affirm that human research participants provided informed consent for publication of the images in Fig. 1 Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Author Contribution All authors contributed to the study conception and design. Clinical assessment, and surgical procedures were performed by [Sohair Aboshady], and [Ahmad Hamdan]. Phoniatric Assessment was performed by [Asmaa Rashad]. Data collection and analysis were performed by all authors. Manuscript writing was performed by [Ahmad Hamdan]. All authors commented on previous versions of the manuscript. All authors read and approved of the final manuscript. References Sateia MJ. International classification of sleep disorders-third edition: highlights andmodifications. Chest 2014;146(05):1387–1394. Rotenberg BW, Vicini C, Pang EB, Pang KP. Reconsidering first-line treatment for obstructive sleep apnea: a systematic review of the literature. J Otolaryngol Head Neck Surg 2016;45(01):23. Pinto JA. Lessons from 50 Years of Uvulopalatopharyngoplasty. J Sleep Disord Ther 2016;5(03):3–5. White DP. Advanced Concepts in the Pathophysiology of Obstructive Sleep Apnea. Adv Otorhinolaryngol 2017;80:7–16. Pinto JA, Godoy LBM, Nunes HDSS, Abdo KE, Jahic GS, Cavallini AF, et al. Lateral-Expansion Pharyngoplasty: Combined Technique for the Treatment of Obstructive Sleep Apnea Syndrome. Int Arch Otorhinolaryngol. 2020 Jan;24(1):e107-e111. Vicini C, De Vito A, Benazzo M, Frassineti S, Campanini A, Frasconi P, Mira E. The nose oropharynx hypopharynx and larynx (NOHL) classification: a new system of diagnostic standardized examination for OSAHS patients. Eur Arch Otorhinolaryngol. 2012 Apr;269(4):1297-300. Lichtblau M, Bratton D, Giroud P,Weiler T, Bloch KE, Brack T. Risk of Sleepiness-Related Accidents in Switzerland: Results of an Online Sleep Apnea Risk Questionnaire and Awareness Campaigns.Front Med (Lausanne) 2017;4(April):34 Binar M, Karakoc O. Anterior Palatoplasty for Obstructive Sleep Apnea: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg. 2018 Mar;158(3):443-449. Selcuk A, Ozer T, Esen E, Ozdogan F, Ozel HE, Yuce T, Caliskan S, Dasli S, Bilal N, Genc G, Genc S. Evaluation of effects of anterior palatoplasty operation on upper airway parameters in computed tomography in patients with pure snoring and obstructive sleep apnea syndrome. Eur Arch Otorhinolaryngol. 2017 May;274(5):2183-2188. Pang KP, Pang EB, Pang KA, Rotenberg B. Anterior palatoplasty in the treatment of obstructive sleep apnoea - a systemic review. Acta Otorhinolaryngol Ital. 2018 Feb;38(1):1-6. Marzetti A, Tedaldi M, Passali FM. Preliminary findings from our experience in anterior palatoplasty for the treatment of obstructive sleep apnea. Clin Exp Otorhinolaryngol. 2013 Mar;6(1):18-22. Gallino N, Herranz F, Redivo M, Marinelli S, Ruggeri CS. Results of Anterior Palatoplasty to Treat Snoring and Obstructive Sleep Apnea. J Sleep Disord Manag. 2024; 9:045. Cahali MB. Lateral pharyngoplasty: a new treatment for obstructive sleep apnea hypopnea syndrome. Laryngoscope 2003;113 (11):1961–1968. Hong SN, Kim HG, Han SY, Ji JY, Kim MK, Han DH, et al. Indications for and Outcomes of Expansion Sphincter Pharyngoplasty to Treat Lateral Pharyngeal Collapse in Patients With Obstructive Sleep Apnea. JAMA Otolaryngol Head Neck Surg. 2019 May 1;145(5):405-412. Maniaci A, Di Luca M, Lechien JR, Iannella G, Grillo C, Grillo CM, et al. Lateral pharyngoplasty vs. traditional uvulopalatopharyngoplasty for patients with OSA: systematic review and meta-analysis. Sleep Breath. 2022 Dec;26(4):1539-1550. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 03 Mar, 2026 Editor assigned by journal 19 Jan, 2026 Submission checks completed at journal 19 Jan, 2026 First submitted to journal 16 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8617320","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":599926515,"identity":"b1203638-7427-4bcc-a09f-a08ffe8fb0b3","order_by":0,"name":"Sohair Reda Aboshady","email":"","orcid":"","institution":"Menoufia University, Faculty of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Sohair","middleName":"Reda","lastName":"Aboshady","suffix":""},{"id":599926516,"identity":"b444ec33-0123-4b72-b806-92aa409fafb0","order_by":1,"name":"Asmaa El-Dessouky Rashad","email":"","orcid":"","institution":"Menoufia University, Faculty of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Asmaa","middleName":"El-Dessouky","lastName":"Rashad","suffix":""},{"id":599926527,"identity":"82dddcb7-b381-478b-91c3-ead68bdfe239","order_by":2,"name":"Ahmad Mahmoud Hamdan","email":"data:image/png;base64,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","orcid":"","institution":"Menoufia University, Faculty of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Ahmad","middleName":"Mahmoud","lastName":"Hamdan","suffix":""}],"badges":[],"createdAt":"2026-01-16 11:03:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8617320/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8617320/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104204486,"identity":"01afe73b-4bf4-46d2-b40c-46369d2cbe20","added_by":"auto","created_at":"2026-03-09 06:34:35","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":791752,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative views of a 42-year-old female patient with moderate obstructive sleep apnea showing: A) Preoperative view of the soft palate and lateral pharyngeal wall, B) Immediate postoperative view showing anterior palatoplasty and lateral expansion pharyngoplasty.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8617320/v1/ef903cf196b95617ca288de8.png"},{"id":104204487,"identity":"3cfeb163-fad4-412e-a663-0cf457e15be4","added_by":"auto","created_at":"2026-03-09 06:34:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2240428,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8617320/v1/dc4e323d-bc58-4650-9847-7e7db5b947b5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessment of clinical and phoniatric outcomes of combined lateral expansion pharyngoplasty and anterior palatoplasty in obstructive sleep apnea patients","fulltext":[{"header":"Background","content":"\u003cp\u003eObstructive sleep apnea syndrome (OSAS) is defined by recurrent, periodic episodes of breathing cessation during sleep, resulting from upper airway obstruction. Continuous positive airway pressure (CPAP) is the established first-line therapy for OSAS and is effective when applied consistently according to American Academy of Sleep Medicine (AASM) standards (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In practice, however, suboptimal patient adherence frequently limits its effectiveness, leading to a high rate of treatment discontinuation within the first year. In contrast, surgical intervention for OSAS offers a treatment outcome that is independent of patient adherence. Studies indicate that combining precise topodiagnosis with an appropriate pharyngeal procedure can achieve effective, long-term results (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe fundamental objective of OSAS surgery is to address airway collapse at various anatomical levels, including the nasal, retropalatal, and retroglossal regions. Selecting the optimal treatment remains a clinical challenge. Recent innovations in surgical techniques focus on remodeling the narrow pharynx by advancing the soft palate and reinforcing the lateral pharyngeal wall, thereby enlarging the airway lumen and mitigating collapse (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). While palatal surgery demonstrates efficacy when structural anomalies are present, outcomes can be less predictable in cases driven primarily by neuromuscular collapsibility (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Consequently, the primary aim of contemporary surgical innovation is to reduce this pharyngeal collapsibility. To address both palatal and pharyngeal components of collapse simultaneously, the present study proposes a combined procedure of anterior palatoplasty with lateral expansion pharyngoplasty, with subsequent evaluation of its clinical and phoniatric outcomes.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cp\u003eThe current study was a prospective cohort study conducted on patients with obstructive sleep apnea syndrome subjected to lateral expansion pharyngoplasty combined with anterior palatoplasty approach. The operations were performed between May 2024 and August 2025 at a tertiary university hospital. The study was approved by the institutional review board of the affiliated university with an approval number 4/2024 ENT5. Informed written consent was obtained from all patients before participating in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe sample size was calculated using statistics and sample size pro program version 6, the least sample size was 25. The power of study is 80% and confidence level is 95%, Based on review of past literature \u003cstrong\u003e(5).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study included 25 patients aged between 18 and 60 years old, having moderate or severe OSAS as detected by polysomnography, and having retropalatal /oropharyngeal obstruction collapse with concentric collapse having a combination of lateral and AP collapse as detected by Muller\u0026rsquo;s maneuver. Patients with upper airway tumors and/or polyps, craniofacial anomalies, and hypertrophy of the base of the tongue, nasal obstruction, and any other general contraindication against elective surgery were excluded from the study. Patients of the study were subjected to the following assessment protocol.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePreoperative Assessment:\u003c/strong\u003e All patients were subjected to history taking and complete otorhinolaryngology examination. Polysomnography (PSG) was performed for every patient to confirm the diagnosis of obstructive sleep apnea by having an apnea/hypopnea index (AHI) more than 5 apnea events per hour with grading of the severity of OSAS according to the AHI as mild (\u0026ge;5 to\u0026lt;15 events/hour),moderate (\u0026ge;15 to\u0026lt;30 events/hour), and severe (\u0026ge;30 events/hour). Other variables were assessed by PSG including snoring duratiom relative to sleep time and oxygen saturation.\u003c/p\u003e\n\u003cp\u003eTo ensure consistency and eliminate inter-rater variability, a single author of the study performed all evaluations using flexible nasopharyngolaryngoscopy during the Muller\u0026rsquo;s maneuver. The assessment followed the NOHL classification by Vicini et al. \u003cstrong\u003e(6)\u003c/strong\u003e, examining the nasal cavity, retropalatal oropharynx, and retrolingual base of the tongue for the degree and pattern of upper airway collapse. Collapse of the pharyngeal walls was graded on a scale from 0 to 4: grade 4 (complete collapse), grade 3 (collapse \u0026lt;75%), grade 2 (collapse \u0026lt;50%), and grade 0 (no collapse). Nasal obstruction due to conditions like turbinate hypertrophy or septal deviation was similarly graded from 4 to 0. Patterns of pharyngeal collapse were categorized as: anterior-posterior (AP), concentric (C\u0026mdash;a combination of lateral and AP collapse), or transversal (T\u0026mdash;lateral walls moving inward). Laryngeal blockage at the supraglottic or glottic level was recorded as positive or negative. Additionally, significant palatine tonsillar hypertrophy (grade 3 or 4) was documented during grading.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical technique\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe procedure was performed under general anesthesia with orotracheal intubation. local injection of lidocaine was performed to the soft palate. After tonsillectomy, if no previous tonsillectomy was present, the palatopharyngeus muscle was identified and it\u0026apos;s inferior end was transected and elevated then fixed with 2/0 vicryl suture around pterygomandibular ligament of the same side through a palatal tunnel. The palatal mucosa was then closed with 3/0 vicryl sutures. Approximation of the anterior and posterior pillars was done to give more tension to the lateral pharyngeal walls. A horizontal rectangular strip of mucosa and submucosa (about 4 cm in length and 7-10 mm in width) was removed from the soft palate with diathermy. Resection boundaries were 4 mm above the junction of the hard and soft palate, 4 mm below the uvula base and laterally from a line extending from the anterior tonsillar pillar to the soft palate. The stripped area of the palate was sutured with 4/0 vicryl resulting in anterior displacement of the palate. Partial uvulectomy was done using a diathermy and the raw area of the uvula was covered by suturing of the mucosa \u003cstrong\u003e(Figure 1)\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostoperative Assessment:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients had a weekly clinical examination for the first month postoperative. Polysomnography and flexible nasopharyngolaryngoscopy with muller maneuver were performed for every patient at 3 months postoperatively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcome measures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOutcome parameters included a comparison between preoperative and postoperative AHI, lowest oxygen saturation (LOS), snoring duration from sleep time, Epworth sleepiness scale (ESS), and degree of collapse at retropalatal and\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eoropharyngeal levels.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Data were collected, tabulated and statistically analyzed using an IBM compatible personal computer with Statistical Package for the Social Sciences (SPSS) version 26 \u003cstrong\u003e(IBM Corp., Armnok, NY, US). Descriptive statistics\u003c/strong\u003e included number (N) and percentage (%) for qualitative data, while quantitative data were expressed as mean (\u003cstrong\u003ex̅\u003c/strong\u003e), standard deviation (SD). \u003cstrong\u003eAnalytic statistics\u003c/strong\u003e included p\u003cu\u003eaired t-test (t)\u003c/u\u003e for comparison of paired quantitative data of normally distributed variables of the same group. In contrast, the \u003cu\u003eWilcoxon Signed Ranks Test\u0026nbsp;\u003c/u\u003ewas used for comparison of paired quantitative data of not normally distributed variables of the same group. \u003cstrong\u003e\u003cu\u003eMarginal Homogeneity Test\u003c/u\u003e\u003c/strong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003ewas used for the comparison of paired qualitative data. A p value less than 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe study sample included 16 (64.0%) male and 9 (36.0%) female. The ages of the patients ranged from 39 to59 years, with a mean age of 46.4\u0026plusmn;32.8 years. The mean preoperative BMI was 32.8\u0026plusmn;3.2 \u0026nbsp;kg/m2 \u003cstrong\u003e(Table 1)\u003c/strong\u003e. The mean Epworth sleepiness scale score significantly improved from 15.8\u003cstrong\u003e\u0026plusmn;4.9\u0026nbsp;\u003c/strong\u003epreoperatively to 5.52\u003cstrong\u003e\u0026plusmn; 2.9\u0026nbsp;\u003c/strong\u003epostoperatively (p\u0026lt;0.001). The results of pre- and postoperative PSG showed significant reductions in mean AHI from 33.8\u0026plusmn; 13.5 to 12.2 \u0026plusmn;11.1 (p\u0026lt;0.001) and snoring duration relative to sleep time from 4.3\u0026plusmn; 7.8% to 0.6 \u0026plusmn;1.1% (p \u0026lt;0.001). There was a significant improvement in minimum oxygen saturation from 82.5 \u0026plusmn; 4.2% to 91.4\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026plusmn;\u0026nbsp;\u003c/strong\u003e3.4% (p\u0026lt;0.001) \u003cstrong\u003e(Table 2)\u003c/strong\u003e. A significant improvement in retropalatal (oropharyngeal) space was observed in postoperative flexible nasopharyngoscopic examination (p\u0026lt;0.001) \u003cstrong\u003e(Table 3).\u0026nbsp;\u003c/strong\u003eTwenty one patients (84%) showed more than 50% reduction in AHI while 4 patients (16%) showed less than 50% reduction in AHI.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Demographic characteristics of the studied group\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"2\" valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u003cstrong\u003estudied group (n=25)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMale\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e16\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e64.0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e9\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e36.0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn;SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e46.4\u0026plusmn;32.8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRange\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e39-59\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePreoperative BMI\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(kg/m2)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn;SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e32.8\u0026plusmn;3.2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 37px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRange\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e29-41\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Results of Pre- and Postoperative Polysomnography\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"99%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-operative\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(n=25)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eoperative\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(n=25)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTest of significance\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eRange\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eRange\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEpworth sleepiness\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003escale\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e15.8\u003cstrong\u003e\u0026plusmn;4.9\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e8-24\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e5.52\u003cstrong\u003e\u0026plusmn; 2.9\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e2-15\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003eW=4.380\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eapnea/hypopnea\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eA/H index /h sleep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e33.8\u003cstrong\u003e\u0026plusmn; 13.5\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e21.7 \u0026ndash; 79.8\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e11.1\u003cstrong\u003e\u0026plusmn; 12.2\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e4 - 50\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003eW=4.374\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLowest SpO2(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e82.5\u003cstrong\u003e\u0026plusmn; 4.2\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e73 \u0026ndash; 88\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e91.4\u003cstrong\u003e\u0026plusmn; 3.4\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e83-96\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003eW=4.391\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 30px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSnoring\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eduration from\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003esleep time (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 17px;\"\u003e\n \u003cp\u003e4.3\u003cstrong\u003e\u0026plusmn; 7.8\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0.01-35.2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e0.6\u003cstrong\u003e\u0026plusmn; 1.1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e0 \u0026ndash; 4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003eW=4.377\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e*P value of \u0026lt; 0.05 statistically significant\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e`Table 3: Results of Pre- and Postoperative Flexible nasopharyngolaryngoscopy with Muller maneuver.\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"110%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-operative\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(n=25)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-operative\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(n=25)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarginal Homogeneity Test\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRetropalatal \u0026nbsp;collapse\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 1\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 2\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 3\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eGrade 4\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 9px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.0\u003c/p\u003e\n \u003cp\u003e8.0\u003c/p\u003e\n \u003cp\u003e52.0\u003c/p\u003e\n \u003cp\u003e40.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e40.0\u003c/p\u003e\n \u003cp\u003e36.0\u003c/p\u003e\n \u003cp\u003e4.0\u003c/p\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e4.064\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026lt;0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003e*P value of \u0026lt; 0.05 statistically significant\u0026nbsp;\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNo life-threatening postoperative complications were observed. Postoperative pain persisted for about 2 weeks. Velopharyngeal insufficiency or nasal regurgitation were not observed in any of the patients. Postoperative uvula edema was detected in all the patients with variable degrees with no respiratory distress. There was no dehiscence of the palatal sutures in any of the patients. Dehiscence of the sutures between anterior and posterior tonsillar pillar was detected in 15 patients without any problem. Only one patient suffered from secondary post tonsillectomy hemorrhage which was managed medically.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eObstructive sleep apnea syndrome (OSAS) has garnered substantial attention within the medical community in recent years, owing to its strong associations with numerous systemic conditions, including cardiovascular disease, hypertension, obesity, depression, dyslipidemia, gastroesophageal reflux disease, and diabetes mellitus. These comorbidities contribute to a significant potential increase in healthcare expenditures. Furthermore, the characteristic sleep fragmentation and chronic intermittent hypoxia associated with OSAS adversely affect cognitive function and diminish overall quality of life (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The pathophysiology of obstructive sleep apnea is fundamentally understood through the model of multifactorial airway obstruction, which implicates both the soft palate and lateral pharyngeal walls. This paradigm acknowledges that airway patency is compromised not by an isolated anatomical feature, but by a dynamic interaction of structural and neuromuscular factors. The soft palate, especially the uvular region, is frequently implicated in anteroposterior collapse. Concurrently, the lateral pharyngeal walls\u0026mdash;comprising mucosa, submucosal tissues, and the pharyngeal constrictor muscles\u0026mdash;constitute a primary site for lateral airway narrowing. The confluence of these collapse patterns results in a more severe, concentric reduction of the airway lumen. Therefore, effective therapeutic intervention frequently necessitates a multimodal strategy designed to concurrently address palatal redundancy and lateral wall collapsibility, such as surgical procedures that stiffen the palate and expand the lateral pharyngeal dimensions. The present study proposed anterior palatoplasty with lateral expansion pharyngoplasty at the same time to reduce both palatal and pharyngeal collapse. The study showed a significant reduction in apnea/hypopnea index and snoring time, and a significant improvement in lowest oxygen saturation postoperatively along with a significant reduction in the degree of oropharyngeal collapse as detected by Muller\u0026rsquo;s maneuver.\u003c/p\u003e \u003cp\u003eAnterior palatoplasty is a minimally invasive surgical procedure designed to address retropalatal obstruction in patients with obstructive sleep apnea (OSA). Its rationale is based on stiffening and shortening the soft palate by removing a strip of mucosa and underlying tissue from its anterior surface. This tightening reduces both the vibratory tissue responsible for snoring and the dynamic collapse of the palate during sleep, thereby improving airway patency. It is often considered for patients with mild-to-moderate OSA who have failed CPAP, particularly those with palatal-level collapse, as it offers a less morbid alternative to traditional uvulopalatopharyngoplasty (UPPP) with a focus on preserving velopharyngeal function (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe efficacy of anterior palatoplasty (AP) in the management of obstructive sleep apnea (OSA) has been evaluated in multiple studies. Research by Selcuk et al. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), which utilized computerized tomography scans, examined upper airway volumetric changes in patients undergoing AP for pure snoring and mild-to-moderate OSA. Their findings indicated a significant post-operative increase in total upper airway volume and cross-sectional area, although lateral airway dimensions were not notably affected. This anatomical outcome is corroborated by clinical data; a systematic review by Pang et al. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) reported a significant improvement in the apnea-hypopnea index following AP for mild-to-moderate OSA, with an overall pooled success rate of 72.5%. Further synthesizing the evidence, a systematic review and meta-analysis by Binar and Karakoc (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) determined a general surgical success rate for AP of 60.6%, noting an absence of serious complications in the literature. Comparative studies have also been conducted. Marzetti et al. (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), in preliminary results, compared AP to the uvulopalatal flap (UPF) technique, suggesting that the subjective and objective improvements observed might position AP as a superior method for inducing a fibrotic palatal scar. The importance of patient selection is highlighted by Gallino et al. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), who assessed AP success rates using different diagnostic tools. Their results showed an improvement rate of 66.67% for patients selected via the M\u0026uuml;ller maneuver, which increased to 83.30% for those selected using drug-induced sleep endoscopy.\u003c/p\u003e \u003cp\u003eThe rationale for lateral expansion pharyngoplasty in OSA patients is to address collapse of the lateral pharyngeal walls, a primary site of obstruction in many individuals. Unlike procedures that solely stiffen the palate, this technique physically enlarges the retropalatal airway by surgically modifying the palatopharyngeus muscles and using sutures to reposition tissues laterally. This creates a more patent, \"box-shaped\" airway that is less prone to dynamic collapse during inspiration. It is particularly indicated for patients with concentric or lateral wall collapse at the velopharynx, as identified during drug-induced sleep endoscopy, and is often combined with other procedures to treat multi-level obstruction (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe effectiveness of lateral pharyngoplasty techniques in addressing retropalatal and lateral pharyngeal wall collapse has been documented in several studies. Research by Pinto et al. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) on lateral expansion pharyngoplasty reported significant post-operative improvements, including a reduction in the apnea-hypopnea index (AHI) and microarousal index, alongside an increase in minimum oxygen saturation. Similarly, Hong et al. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) found that expansion sphincter pharyngoplasty (ESP), often performed concomitantly with other procedures, successfully corrected lateral collapse. Their results demonstrated a significant decrease in the mean AHI and an improvement in the lowest oxygen saturation at a six-month follow-up. The authors noted that postoperative complications such as pain and bleeding were minimal, although some patients reported transient abnormal sensations in the soft palate or mild dysphagia. They further identified severe circumferential palatal narrowing and bulky lateral pharyngeal tissue as favorable surgical indications for ESP. When compared to traditional techniques, lateral pharyngoplasty shows comparable efficacy. A systematic review by Maniaci et al. (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) comparing lateral pharyngoplasty (LP) to uvulopalatopharyngoplasty (UPPP) found that both procedures yielded statistically significant improvements in AHI, Epworth Sleepiness Scale (ESS) scores, and lowest oxygen saturation (LOS). Although lateral pharyngoplasty trends suggested better outcomes, the differences compared to UPPP did not reach statistical significance.\u003c/p\u003e \u003cp\u003eThe strength point of the current study is the combination of the two techniques addressing multifactorial obstruction in cases of OSA combining their positive outcomes on airway collapse. The limitations of this study include the small sample size due to no compliance of the patients to surgical indications. Another limitation is the dependance on awake endoscopy for assessment of the level of obstruction with its restrictions regarding its limited accuracy compared with Drug induced sleep endoscopy due its assessment of the patient while awake not during sleep with some difference in the underlying pathophysiology in the two conditions. However, the authors used this technique, being the most available, cost effective, and anesthesia free.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eLateral expansion pharyngoplasty and Anterior palatoplasty represent an effective surgical combination for the treatment of OSAS in patients with palatal and lateral collapse. These techniques, performed as a one-stage procedure, led to improvements in apnea hypopnea index, snoring, and PSG respiratory parameters in patients with OSAS by acting on lateral and retropalatal collapse.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eConsent to participate:\u003c/h2\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003ch2\u003eConsent to publish:\u003c/h2\u003e\n\u003cp\u003eThe authors affirm that human research participants provided informed consent for publication of the images in Fig. 1\u003c/p\u003e\n\u003ch2\u003eFunding:\u003c/h2\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Clinical assessment, and surgical procedures were performed by [Sohair Aboshady], and [Ahmad Hamdan]. Phoniatric Assessment was performed by [Asmaa Rashad]. Data collection and analysis were performed by all authors. Manuscript writing was performed by [Ahmad Hamdan]. All authors commented on previous versions of the manuscript. All authors read and approved of the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli dir=\"LTR\"\u003eSateia MJ. International classification of sleep disorders-third edition: highlights andmodifications. Chest 2014;146(05):1387\u0026ndash;1394.\u003c/li\u003e\n \u003cli dir=\"LTR\"\u003eRotenberg BW, Vicini C, Pang EB, Pang KP. Reconsidering first-line treatment for obstructive sleep apnea: a systematic review of the literature. J Otolaryngol Head Neck Surg 2016;45(01):23. \u003c/li\u003e\n \u003cli dir=\"LTR\"\u003ePinto JA. Lessons from 50 Years of Uvulopalatopharyngoplasty. J Sleep Disord Ther 2016;5(03):3\u0026ndash;5.\u003c/li\u003e\n \u003cli dir=\"LTR\"\u003eWhite DP. Advanced Concepts in the Pathophysiology of Obstructive Sleep Apnea. Adv Otorhinolaryngol 2017;80:7\u0026ndash;16.\u003c/li\u003e\n \u003cli dir=\"LTR\"\u003ePinto JA, Godoy LBM, Nunes HDSS, Abdo KE, Jahic GS, Cavallini AF, et al. Lateral-Expansion Pharyngoplasty: Combined Technique for the Treatment of Obstructive Sleep Apnea Syndrome. Int Arch Otorhinolaryngol. 2020 Jan;24(1):e107-e111.\u003c/li\u003e\n \u003cli dir=\"LTR\"\u003eVicini C, De Vito A, Benazzo M, Frassineti S, Campanini A, Frasconi P, Mira E. The nose oropharynx hypopharynx and larynx (NOHL) classification: a new system of diagnostic standardized examination for OSAHS patients. Eur Arch Otorhinolaryngol. 2012 Apr;269(4):1297-300. \u003c/li\u003e\n \u003cli dir=\"LTR\"\u003eLichtblau M, Bratton D, Giroud P,Weiler T, Bloch KE, Brack T. Risk of Sleepiness-Related Accidents in Switzerland: Results of an Online Sleep Apnea Risk Questionnaire and Awareness Campaigns.Front Med (Lausanne) 2017;4(April):34\u003c/li\u003e\n \u003cli dir=\"LTR\"\u003eBinar M, Karakoc O. Anterior Palatoplasty for Obstructive Sleep Apnea: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg. 2018 Mar;158(3):443-449. \u003c/li\u003e\n \u003cli dir=\"LTR\"\u003eSelcuk A, Ozer T, Esen E, Ozdogan F, Ozel HE, Yuce T, Caliskan S, Dasli S, Bilal N, Genc G, Genc S. Evaluation of effects of anterior palatoplasty operation on upper airway parameters in computed tomography in patients with pure snoring and obstructive sleep apnea syndrome. Eur Arch Otorhinolaryngol. 2017 May;274(5):2183-2188. \u003c/li\u003e\n \u003cli dir=\"LTR\"\u003e Pang KP, Pang EB, Pang KA, Rotenberg B. Anterior palatoplasty in the treatment of obstructive sleep apnoea - a systemic review. Acta Otorhinolaryngol Ital. 2018 Feb;38(1):1-6. \u003c/li\u003e\n \u003cli dir=\"LTR\"\u003e Marzetti A, Tedaldi M, Passali FM. Preliminary findings from our experience in anterior palatoplasty for the treatment of obstructive sleep apnea. Clin Exp Otorhinolaryngol. 2013 Mar;6(1):18-22. \u003c/li\u003e\n \u003cli dir=\"LTR\"\u003e Gallino N, Herranz F, Redivo M, Marinelli S, Ruggeri CS. Results of Anterior Palatoplasty to Treat Snoring and Obstructive Sleep Apnea. J Sleep Disord Manag. 2024; 9:045. \u003c/li\u003e\n \u003cli dir=\"LTR\"\u003e Cahali MB. Lateral pharyngoplasty: a new treatment for obstructive sleep apnea hypopnea syndrome. Laryngoscope 2003;113 (11):1961\u0026ndash;1968.\u003c/li\u003e\n \u003cli dir=\"LTR\"\u003e Hong SN, Kim HG, Han SY, Ji JY, Kim MK, Han DH, et al. Indications for and Outcomes of Expansion Sphincter Pharyngoplasty to Treat Lateral Pharyngeal Collapse in Patients With Obstructive Sleep Apnea. JAMA Otolaryngol Head Neck Surg. 2019 May 1;145(5):405-412. \u003c/li\u003e\n \u003cli dir=\"LTR\"\u003e Maniaci A, Di Luca M, Lechien JR, Iannella G, Grillo C, Grillo CM, et al. Lateral pharyngoplasty vs. traditional uvulopalatopharyngoplasty for patients with OSA: systematic review and meta-analysis. Sleep Breath. 2022 Dec;26(4):1539-1550. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-journal-of-otolaryngology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [The Egyptian Journal of Otolaryngology](https://ejo.springeropen.com/)","snPcode":"43163","submissionUrl":"https://submission.springernature.com/new-submission/43163/3","title":"The Egyptian Journal of Otolaryngology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Anterior palatoplasty, Apnea Hypopnea Index, Lateral expansion pharyngoplasty, Obstructive sleep apnea patients","lastPublishedDoi":"10.21203/rs.3.rs-8617320/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8617320/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSurgical techniques for managing obstructive sleep apnea syndrome (OSAS) focus on remodeling the narrow pharynx by advancing the soft palate and reinforcing the lateral pharyngeal wall, thereby enlarging the airway lumen and mitigating collapse. While palatal surgery demonstrates efficacy when structural anomalies are present, outcomes can be less predictable in cases driven primarily by neuromuscular collapsibility. Consequently, the primary aim of contemporary surgical innovation is to reduce this pharyngeal collapsibility. To address both palatal and pharyngeal components of collapse simultaneously, the present study proposes a combined procedure of anterior palatoplasty with lateral expansion pharyngoplasty, with subsequent evaluation of its clinical and phoniatric outcomes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSignificant reductions were observed in postoperative apnea hypopnea index (AHI), and snoring duration relative to sleep time with 84% of patients showing more than 50% in AHI. There was a significant improvement in minimum oxygen saturation (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for all). A significant improvement in retropalatal/oropharyngeal space collapse was observed in postoperative flexible nasopharyngoscopic examination (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No life-threatening postoperative complications were observed. Dehiscence of the sutures between anterior and posterior tonsillar pillar was detected in 15 patients without any problem. Only one patient suffered from secondary post tonsillectomy hemorrhage which was managed medically.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eLateral expansion pharyngoplasty and Anterior palatoplasty represent an effective surgical combination for the treatment of OSAS in patients with palatal and lateral collapse. These techniques, performed as a one-stage procedure, led to improvements in apnea hypopnea index, snoring, and respiratory parameters in patients with OSAS by acting on lateral and retropalatal collapse.\u003c/p\u003e","manuscriptTitle":"Assessment of clinical and phoniatric outcomes of combined lateral expansion pharyngoplasty and anterior palatoplasty in obstructive sleep apnea patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-09 06:34:30","doi":"10.21203/rs.3.rs-8617320/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-03-03T10:55:55+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-19T05:47:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-19T05:44:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"The Egyptian Journal of Otolaryngology","date":"2026-01-16T09:02:28+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-journal-of-otolaryngology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [The Egyptian Journal of Otolaryngology](https://ejo.springeropen.com/)","snPcode":"43163","submissionUrl":"https://submission.springernature.com/new-submission/43163/3","title":"The Egyptian Journal of Otolaryngology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d08296f4-a8e6-4479-87b8-b07dcbecbd21","owner":[],"postedDate":"March 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-09T06:34:30+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-09 06:34:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8617320","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8617320","identity":"rs-8617320","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}