Barbed suspension pharyngoplasty for treatment of lateral pharyngeal wall and palatal collapse in patients affected by OSAHS

Does the number of loops affect the results of barbed pharyngoplasties? A retrospective comparison in two techniques

INTRODUCTION

The use of barbed sutures for pharyngoplasty techniques is a new trend in sleep apnea surgery, but little is known about its short-term results depending on the different techniques. The purpose of this study was to analyse the surgical results in two different centres using barbed sutures with different barbed pharyngoplasty techniques.

MATERIAL AND METHODS

This is a multicenter retrospective study of patients with obstructive sleep apnea (OSA) undergoing surgery, all of whom underwent pharyngoplasty with barbed suture using a classic or modified technique, which may or may not be associated with other surgical techniques. A univariate and multivariate statistical analysis were performed to assess the relationship of these surgical techniques with surgical success and with different descriptive variables.

RESULTS

The final sample size was 126 patients. A surgical success rate of 39.7% was obtained for a postoperative AHI < 10/h and a 51.6% success rate according to Sher's criteria. A greater proportion of success was observed in the modified barbed pharyngoplasty technique that was not maintained after the multivariate analysis, as with other factors such as age, ODI or the presence of nasal surgery.

CONCLUSION

Non-resective pharyngoplasty with barbed sutures is an effective technique for the treatment of OSA in selected patients, with both the classic technique and the modified alternatives having good postoperative results, with no differences observed in relation to surgical success between both. More studies are necessary to evaluate the differences between both techniques in more homogeneous groups.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Complications and side effects after barbed pharyngoplasty: a systematic review

BACKGROUND

Recently, the use of barbed pharyngoplasty (BP) has become widespread in snoring and obstructive sleep apnoea (OSA) palatal surgery, but there are no studies regarding the short- and long-term complications resulting from these different techniques. This systematic review aimed to report the complications and side effects of different BP techniques.

METHODS

An electronic search was performed on PubMed/MEDLINE, Google Scholar, and Ovid databases. The PRISMA statement was followed. Databases were searched from inception through September 2, 2021.

RESULTS

We included 14 prospective clinical studies consisting of 769 patients aged 23 to 81 years. The associated intra-operative complications of BP were as follows: partial thread extrusion (2.9%), self-limited bleeding (2.9%), broken needle (1.0%), and suture rupture (1.0%). Short-term complications were as follows: thread/knot extrusion (12.4%), dysphagia (5.6%), bleeding (1.5%), velopharyngeal insufficiency (1.5%), anterior pharyngoplasty dehiscence (1.2%), tonsillar haemorrhage (1.0%), excessive postnasal discharge (1.0%), barbed suture failure (0.5%), acute infection (0.2%), mucosal granulomas (0.2%), chipped tooth caused by mouth gag displacement (0.2%), and fibrous scar (0.2%). Long-term complications were as follows: foreign body sensation (7.8%), sticky mucus in throat (5.9%), dysphagia (3.6%), rhinolalia (3.1%), throat phlegm (1.1%), nose regurgitation (0.8%), dry throat (0.6%), and throat lump (0.3%).

CONCLUSION

BP is a safe technique free of significant side effects and major complications. However, in this review, patients undergoing BP were very heterogeneous in terms of characteristics of patients chosen and severity of diseases, surgical technique used (myoresective vs non-myoresective), time of follow-up, and mono level vs multilevel surgery. More studies on a larger scale with long-term follow-up are needed to confirm these promising results.

Oromaxillofacial Surgery: Both a Treatment and a Possible Cause of Obstructive Sleep Apnea-A Narrative Review

Obstructive sleep apnea (OSA) is a chronic, sleep-related breathing disorder. It is characterized by a nocturnal periodic decrease or complete stop in airflow due to partial or total collapse of the oropharyngeal tract. Surgical treatment of OSA is constantly evolving and improving, especially with the implementation of new technologies, and this is needed because of the very heterogeneous reasons for OSA due to the multiple sites of potential airway obstruction. Moreover, all of these surgical methods have advantages and disadvantages; hence, patients should be approached individually, and surgical therapies should be chosen carefully. Furthermore, while it is well-established that oromaxillofacial surgery (OMFS) provides various surgical modalities for treating OSA both in adults and children, a new aspect is emerging regarding the possibility that some of the surgeries from the OMFS domain are also causing OSA. The latest studies are suggesting that surgical treatment in the head and neck region for causes other than OSA could possibly have a major impact on the emergence of newly developed OSA, and this issue is still very scarcely mentioned in the literature. Both oncology, traumatology, and orthognathic surgeries could be potential risk factors for developing OSA. This is an important subject, and this review will focus on both the possibilities of OMFS treatments for OSA and on the OMFS treatments for other causes that could possibly be triggering OSA.

Treatment of primary epiglottis collapse in OSA in adults with glossoepiglottopexy: a 5-year experience

Objective

To review our 5-year experience with a modified version of glossoepiglottopexy for treatment of obstructive sleep apnoea syndrome (OSA) in two hospitals.

Methods

A retrospective analysis was carried out on a cohort of adult patients affected by OSA suffering from primary collapse of the epiglottis who underwent a modified glossoepiglottopexy. All patients underwent drug-induced sleep endoscopy, polysomnographic and swallowing evaluation, and assessment with the Epworth Sleepiness Scale (ESS).

Results

Forty-nine patients were retrospectively evaluated. Both the apnoea-hypopnoea index (AHI) (median AHI_post-AHI_pre = -22.4 events/h; p < 0.001) and oxygen desaturation index (ODI) showed a significant postoperative decrease (median ODI_post-ODI_pre = -18 events/h; p < 0.001), as did hypoxaemia index (median T_{90% post}-T_{90% pre} = -5%; p < 0.001). The ESS questionnaire revealed a significant decrease in postoperative scores (median ESS_post-ESS_pre =- 9; p < 0.001). None of the patients developed postoperative dysphagia.

Conclusions

Our 5-year experience demonstrates that modified glossoepiglottopexy is a safe and reliable surgical technique for treatment of primary epiglottic collapse in OSA patients.

Predictors of response to sleep apnea surgery addressing the lateral pharyngeal wall collapse

PURPOSE

To evaluate the predictive factors for surgical success in sleep apnea surgical techniques addressing the lateral pharyngeal wall.

MATERIALS AND METHODS

This is a retrospective review of consecutive cases treated by functional expansion pharyngoplasty for OSA. Collected data included patients demographics, ENT physical examination and somnographic data. Furthermore inter pterygoid distance was assessed by CT scans. To determine predictors of surgical success, physical examination, CT findings, polysomnographic and demographic data were compared between the success and failure group.

RESULTS

Fifty two patients were enrolled. The mean AHI decreased significantly from 44.3 to 17 (p = 0.001). A total of 33 patients (63.5%) met the surgical success criteria. An inter pterygoid distance longer than 34 mm was the only significant predictor of success.

CONCLUSIONS

Inter pterygoid distance seems to be a promising parameter associated with the surgical outcomes that should be further studied to be validated as predictor of success.

Barbed pharyngoplasty for obstructive sleep apnea: A meta-analysis

PURPOSE

The purpose of this study was to perform a meta-analysis of barbed pharyngoplasty (BP) in the treatment of obstructive sleep apnea (OSA).

METHODS

Databases included PubMed, Ovid MEDLINE, Cochrane Library, Web of Science and Scopus, and reference lists. Relevant articles were searched through August 2021, following the PRISMA guidelines.

RESULTS

Twenty articles with 762 participants were included. The mean success in BP as a single-level surgery was 85.2% (MD, 95% CI 77.6%, 92.7%). There was a significant reduction of oxygen desaturation index (ODI) of -11.7 (MD 95% CI -16, -7.4). The lowest oxygen saturation (LSAT) improved 8.9% (MD, 95% CI 1.3%, 16.7%). Epworth Sleepiness Scale (ESS) and snoring score significantly decreased -6.8 (MD 95% CI -8.3, -5.2) and -5.3 (MD 95% -7.9, -2.7), respectively. The apnea-hypopnea index (AHI) significantly decreased -23.9 events/h (MD, 95% CI -25.5, -22.9) with a 69% reduction. The mean surgical time was 23 min. A significant improvement of AHI, ODI, ESS, and LSAT was also revealed in BP as a multilevel surgery. Complications included suture extrusion (18%), dysphagia (20%), velopharyngeal insufficiency (15%), and dysgeusia (3%) without serious consequences. The median follow-up period was 6 months, ranged 1 to 26 months.

CONCLUSION

Barbed pharyngoplasty as a single-level or multilevel surgery is a safe and effective procedure with significant objective and subjective outcomes for OSA patients with palatal obstruction. However, randomized clinical controlled trials with multicenter cooperation and long-term study are necessary.

Barbed reposition pharyngoplasty (BRP) in obstructive sleep apnea treatment: State of the art

PURPOSE

In this paper, we perform a systematic review that discusses the state of the art and evolution on the barbed reposition pharyngoplasty (BRP) in the velo-pharyngeal surgery. Clinical evidence and published outcomes of this surgical technique are reported and discussed.

MATERIALS AND METHODS

We performed a systematic review of the current literature through the analysis of the last 10 years of literature on barbed palate surgery. Study design, number of patients enrolled, inclusion criteria, pre- and posttreatment outcomes (AHI, ODI), surgical success rate, follow-up time and complication has been collected and reported.

RESULTS

15 studies for a total of 1531 patients, out of which 1061 underwent barbed reposition pharyngoplasty. Five trials were uncontrolled prospective studies (215 patients, 14% of total), nine were retrospective studies (1266 patients, 82,6% of total), and one randomized prospective clinical trial (RCT) (50 patients, 3,32% of total). All analyzed studies reported good outcomes after BRP surgery. Average preoperative values of AHI and ODI reduced in all studies considered with a significative statistical difference between preoperative and postoperative values (p < 0.05 in all cases). The postoperative surgical success rate ranged between 65.4 and 93% of cases. There were no significant intra-operative or post-operative complications in all studies considered in this systematic review.

CONCLUSIONS

Barbed reposition pharyngoplasty has proven to be an easy to learn, quick, safe and effective new palatopharyngeal procedure, that can be used in a single level surgery or as a part of multilevel procedures.

Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment

INTRODUCTION

This systematic review provides supporting evidence for the accompanying clinical practice guideline on the referral of adults with obstructive sleep apnea (OSA) for surgical consultation.

METHODS

The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies that compared the use of upper airway sleep apnea surgery or bariatric surgery to no treatment as well as studies that reported on patient-important and physiologic outcomes pre- and postoperatively. Statistical analyses were performed to determine the clinical significance of using surgery to treat obstructive sleep apnea in adults. Finally, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process was used to assess the evidence for making recommendations.

RESULTS

The literature search resulted in 274 studies that provided data suitable for statistical analyses. The analyses demonstrated that surgery as a rescue therapy results in a clinically significant reduction in excessive sleepiness, snoring, blood pressure (BP), apnea-hypopnea index (AHI), respiratory disturbance index (RDI), and oxygen desaturation index (ODI); an increase in lowest oxygen saturation (LSAT) and sleep quality; and an improvement in quality of life in adults with OSA who are intolerant or unaccepting of positive airway pressure (PAP) therapy. The analyses demonstrated that surgery as an adjunctive therapy results in a clinically significant reduction in optimal PAP pressure and improvement in PAP adherence in adults with OSA who are intolerant or unaccepting of PAP due to side effects associated with high pressure requirements. The analyses also demonstrated that surgery as an initial treatment results in a clinically significant reduction in AHI/RDI, sleepiness, snoring, BP, and ODI and an increase in LSAT in adults with OSA and major anatomical obstruction. Analysis of bariatric surgery data showed a clinically significant reduction in BP, AHI/RDI, sleepiness, snoring, optimal PAP level, BMI, and ODI and an increase in LSAT in adults with OSA and obesity. Analyses of very limited evidence suggested that upper airway surgery does not result in a clinically significant increase in risk of serious persistent adverse events and suggested that bariatric surgery may result in a clinically significant risk of iron malabsorption that may be managed with iron supplements. The task force provided a detailed summary of the evidence along with the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations.

CITATION

Kent D, Stanley J, Aurora RN, et al. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med. 2021;17(12):2507-2531.

Combined Transoral Robotic Tongue Base Surgery and Palate Surgery in Obstructive Sleep Apnea Syndrome: Modified Uvulopalatopharyngoplasty versus Barbed Reposition Pharyngoplasty

Background: Successful surgery outcomes are limited to moderate to severe obstructive sleep apnea (OSA) syndrome. Multilevel collapse at retropalatal and retroglossal areas is often found during the drug-induced sleep endoscopy (DISE). Therefore, multilevel surgery is considered for these patients. The aim of our study was to survey surgical outcomes by modified uvulopalatoplasty (UPPP) plus transoral robotic surgery tongue base reduction (TORSTBR) versus barbed repositioning pharyngoplasty (BRP) plus TORSTBR. Methods: The retrospective cohort study was performed at a tertiary referral center. We collected moderate to severe OSA patients who were not tolerant to positive pressure assistant PAP from September 2016 to September 2019; pre-operative–operative Muller tests all showed retropalatal and retroglossal collapse; pre-operative Friedman Tongue Position (FTP) > III, with the tonsils grade at grade II minimum, with simultaneous velum (V > 1) and tongue base (T > 1), collapsed by drug-induced sleep endoscopy (DISE) under the VOTE grading system. The UPPP plus TORSTBR (n = 31) and BRP plus TORSTBR (n = 31) techniques were offered. We compare the outcomes using an Epworth sleepiness scale (ESS) questionnaire, and measure the patients’ apnea–hypopnea index (AHI), lowest O₂ saturation, cumulative time spent below 90% (CT90), and arousal index (AI) by polysomnography six months after surgery; we also measure their length of hospital stay and complications between these two groups. Results: Comparing BRP plus TORSTBR with UPPP plus TORSTBR, the surgical success rate is 67.74% and 38.71%, respectively. The significantly higher surgical success rate in the BRP plus TORSTBR group was noted. The surgical time is shorter in the BRP plus TORSTBR group. The complication rate is not significant in pain, bleeding, dysgeusia, dysphagia, globus sensation, and prolonged suture stay, even though the BRP plus TORSTBR rendered a higher percentage of globus sensation during swallowing and a more prevalent requirement of suture removal one month after surgery. The length of hospital stay is not significantly different between the two groups. Conclusion: In conclusion, BRP plus TORSTBR is a considerable therapy for moderate to severe OSA patients with DISE showing a multi-level collapse in velum and tongue base area. The BRP technique might offer a better anterior–posterior suspension vector for palate level obstruction.

Barbed Reposition Pharyngoplasty versus Expansion Sphincter Pharyngoplasty: A Meta-Analysis

OBJECTIVE

This study was to compare barbed reposition pharyngoplasty (BRP) and expansion sphincter pharyngoplasty (ESP) in the treatment of obstructive sleep apnea (OSA).

METHODS

Relevant 907 articles were searched from various databases until August 2020, including PubMed, MEDLINE, EMBASE, Cochrane Library, Web of Science and Scopus, and reference lists.

RESULTS

Four studies with a total of 208 participants were included. The mean reduction of apnea-hypopnea index (AHI) in the BRP group was 74.03% and the mean reduction of AHI in the ESP group was 60.17%. The mean success rate in the BRP group and the ESP group was 84.96% and 79.87%, respectively. The mean difference (MD) of the change in AHI between groups was not significantly different (MD = -1.24 event/hr, 95% CI [-11.86, 9.36], P = .82). There was no significant difference in postoperative AHI, postoperative Epworth Sleepiness Scale, pain, hospital stay, time to oral diet, and the change in oxygen desaturation index in both groups whereas the analgesic requirement was lower in the BRP group. Operative time was lower in the BRP group (MD = 21.72 minutes, 95% CI [18.85, 24.60], P < .0001).

CONCLUSION

The outcomes in both procedures are comparable in the improvement of OSA with palatal collapse. BRP is superior to ESP in term of surgical time. However, randomized clinical controlled trials with multicenter cooperation and long-term follow-up are essential to further demonstrate the efficacy of these procedures. Laryngoscope, 131:1420-1428, 2021.

Manipulation of Lateral Pharyngeal Wall Muscles in Sleep Surgery: A Review of the Literature

Background: Obstructive sleep apnea syndrome (OSAS) occurs due to upper airway obstruction resulting from anatomical and functional abnormalities. Upper airway collapsibility, particularly those involving the lateral pharyngeal wall (LPW), is known to be one of the main factors contributing to the pathogenesis of OSAS, leading the authors of the present study to propose different strategies in order to stiffen the pharyngeal walls to try to restore normal airflow. Methods: An exhaustive review of the English literature on lateral pharyngeal wall surgery for the treatment of OSAS was performed using the PubMed electronic database. Results: The research was performed in April 2020 and yielded approximately 2000 articles. However, considering the inclusion criteria, only 17 studies were included in the present study. Conclusions: The analyzed surgical techniques propose different parts of LPW on which to focus and a variable degree of invasivity. Despite the very promising results, no gold standard for the treatment of pharyngeal wall collapsibility has been proposed. However, thanks to progressive technological innovations and increasingly precise data analysis, the role of LPW surgery seems to be crucial in the treatment of OSAS patients.

Different barbed pharyngoplasty techniques for retropalatal collapse in obstructive sleep apnea patients: a systematic review

BACKGROUND

The use of barbed sutures (BS) for the treatment of retropalatal collapse and vibration in patients suffering from snoring and obstructive sleep apnea (OSA) has significantly increased in the last few years. Many surgeons have discovered the advantages and unique properties of the BS and allowed the popular surgical pharyngoplasty techniques to be updated and improved.

METHODS

A systematic review was performed to identify all the clinical studies concerning the different barbed pharyngoplasty (BP) techniques used for the treatment of palatal collapse in snoring and OSA patients. A qualitative analysis of data extracted was conducted.

RESULTS

We included 12 studies of which 10 are prospective and 2 retrospective: 9 single-arm studies on the efficacy of a specific BP technique, 1 randomized clinical trial on the comparison between BP and control groups, and 2 studies on the correlation between two different BP techniques. To date, in the literature, 5 different types of BP techniques have been described: barbed snore surgery, barbed reposition pharyngoplasty, barbed expansion sphincter pharyngoplasty, barbed suture suspension, and barbed soft palate posterior webbing flap pharyngoplasty. All the studies showed an overall improvement in the primary efficacy parameters investigated (apnea-hypopnea index, oxygen desaturation index, and Epworth sleepiness scale) in each of the surgical techniques performed without any major complications.

CONCLUSIONS

Given the extreme heterogeneity of the studies analyzed, it is necessary to perform more randomized and control studies on large samples aimed to define the best BP technique based on its effectiveness, surgical success rate, patient's compliance, and complications.

Outcome predictors for non-resective pharyngoplasty alone or as a part of multilevel surgery, in obstructive sleep apnea-hypopnea syndrome

PURPOSE

Non-resective pharyngoplasty techniques have been shown to be effective to treat oropharyngeal collapse in patients affected by obstructive sleep apnea-hypopnea syndrome (OSAHS). The aim of our study is to evaluate outcome predictors in a cohort of patients affected by OSAHS and treated with non-resective pharyngoplasty, including variation of pharyngeal measures at the end of the surgical procedure.

METHODS

A cohort of patients affected by OSAHS, with palatal or lateral pharyngeal wall collapse, who underwent non-resective pharyngoplasty, were enrolled between 2014 and 2017. Surgical procedures encompassed non-resective pharyngoplasty by expansion sphincter pharyngoplasty (ESP) or barbed antero-lateral pharyngoplasty with barbed reposition pharyngoplasty (BRP) or barbed suspension pharyngoplasty (BSP) techniques, eventually associated with nasal surgery. Pharyngeal measures were recorded intraoperatively and their variation at the end of the procedure was considered. Surgical success was evaluated at least 6 months after surgery with respiratory polygraphy and ESS questionnaire. Outcome predictors were examined by multivariable logistic regression and ROC curve analysis.

RESULTS

Seventy patients met the study inclusion criteria. ESP, BRP, and BSP in a uni-/multilevel setting led to significant improvement of all respiratory polygraphic parameters and daily sleepiness (p < 0.0001). Outcome analysis showed that greater variation of antero-posterior pharyngeal measure was associated with success (p = 0.01), with an optimal cutoff value of 8.5 mm; low AHI_pre, high ESS_pre, and antero-lateral pharyngoplasty with barbed sutures were associated with a higher rate of cure (p < 0.05).

CONCLUSIONS

Non-resective pharyngoplasty is effective in treating OSAHS patients affected by palatal or lateral pharyngeal wall collapse, and intraoperative variation of antero-posterior width may be a useful tool to predict surgical success.