Effectiveness of barbed repositioning pharyngoplasty for the treatment of obstructive sleep apnea (OSA): a prospective randomized trial

Barbed Pharyngoplasty simulation using a 3D-printed model: design and validation study

PURPOSE

Learning how to use barbed sutures and perform Barbed Pharyngoplasty (BP) is challenging due to limited surgical training opportunities. This work aims to design, develop, and validate a new 3D surgical simulator to train ENT residents and specialists in performing BP.

METHODS

The Barbed Pharyngoplasty Simulator (BPS) was designed using diagnostic images of the facial mass and testing different materials to replicate the mucosal and bony tissues. ENT specialists with experience in BP and ENT residents were included in the validation study and were asked to perform the Alianza BP. After the simulation, they compiled the Face and Content Validity Questionnaires.

RESULTS

The BPS consists of a reusable cranial structure that contains the disposable palatopharyngeal structure, replicating the palatal structures and the tongue. Fifteen experienced ENT specialists and nine residents were included in the study. Findings demonstrated that the BPS faithfully replicated the muscular and fibrous-bony palatopharyngeal structures, with only 11% of residents having a negative opinion of the mucosal tissue. All the participants positively rated the sensation of using surgical instruments on the simulator. Also, ENT residents rated all aspects of the content validity test from normal to excellent, while specialists rated the BPS as a general training tool from normal to excellent; for lateral pharyngoplasty, BP, and Alianza, only 6.7% of participants disagreed with its usefulness, and 13.3% disagreed with it for anterior pharyngoplasty.

CONCLUSION

The BPS proposed in this preliminary study can potentially be a valuable tool in BP surgical training for residents and young otolaryngologists.

Eustachian Tube Function Symptoms in Palatal Surgeries for OSA: 3-Month Postoperative Analysis

OBJECTIVES

To assess the influence of different soft palate surgeries for obstructive sleep apnea (OSA) on eustachian tube function symptoms, considering various potential factors.

METHODS

A prospective, cohort study was conducted on patients who underwent isolated palatal surgeries for OSA at a single academic medical center between 2017 and 2022. Eustachian Tube Dysfunction Questionnaire (ETDQ-7) were assessed at baseline, 1-month, 2-month, and 3-month time points. Patients with retropalatal obstruction underwent tailored surgeries: anterior palatoplasty (AP), expansion sphincter palatoplasty (ESP), or barbed palatoplasty (BP). Baseline OSA severity between baseline and follow-up time points were also examined.

RESULTS

In this study, 96 patients with OSA were enrolled and allocated to three surgical groups: AP (n = 30), ESP (n = 32), and BP (n = 34). The mean age was 44.3 ± 10.2 years, with 86% male participants. No significant differences were found between the groups in terms of age, sex, and BMI. A two-way repeated measures ANOVA revealed a significant main effect of time on ETDQ-7 scores (p < 0.001), but no significant main effect of groups (p = 0.109) or interaction between time and groups (p = 0.082). Subgroup analysis showed a significant interaction for the 3-month change in ETDQ-7 scores by OSA severity (p = 0.046). In post hoc analysis, the BP group exhibited a higher mean ETDQ-7 score compared with the AP group at the 3-month follow-up.

CONCLUSION

This study highlights the importance of considering individual patient factors, such as OSA severity and eustachian tube function symptoms, when selecting the most appropriate surgical treatment to optimize outcomes.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:2471-2477, 2024.

Barbed Repositioning Pharyngoplasty: Tips and Tricks

The barbed repositioning pharyngoplasty surgical technique is becoming more widely used for patients with obstructive sleep apnea due to its safety, effectiveness, and rapidity, as evidenced by multicenter studies and Meta-analyses. In order to achieve uniform surgical outcomes, avoid errors that could worsen outcomes, and enable adequate data comparison, a standardized procedure is required to overcome surgeon-related variability. The aim of this paper is to provide practical tips and tricks based on our surgical practice that can make the surgeon's work easier and aid in achieving desired outcomes.

Barbed palatal surgery: single stage or multilevel setting-a systematic review by the Young Otolaryngologists of the Italian Society of Otolaryngology

PURPOSE

This systematic review aims to compare the efficacy and safety of multilevel and single level surgery, including barbed pharyngoplasties, in the treatment of obstructive sleep apnea (OSA).

METHODS

The study followed PRISMA guidelines and searched PubMed/MEDLINE, Google Scholar, and Ovid databases for studies evaluating the effect of barbed pharyngoplasties on adults with OSA. Prospective and retrospective cohort studies were included with pre- and post-treatment comparisons of sleep tests and self-reported clinical outcomes. Exclusion criteria were non-English studies, case reports, reviews, conference abstracts, letters, and pediatric studies. Successful surgery was classified using Sher's criteria.

RESULTS

The study selected a total of 1014 patients from 26 studies, 24 of which were longitudinal studies with 10 retrospective trials and 14 prospective studies. The average age of the patients was 46.9 years, with an average Body Mass Index (BMI) of 25.6 kg/m2. Most of the patients were male (84.6%). The study included only palatal surgical techniques with barbed sutures, and patients who underwent cardio-respiratory monitoring and Drug Induced Sleep Endoscopy (DISE) before surgery. Mean Apnea Hypopnea Index (AHI) preoperative was 32.9/h, AHI postoperative was 11.9/h, and mean reduction of AHI was 62.3%. The most commonly adopted palatoplasty was Barbed Repositioning Pharyngoplasty (BRP) in 16 out of 26 studies, followed by its subsequent modifications in 3 studies.

CONCLUSIONS

Barbed pharyngoplasties appear to be effective both on objective measurement and subjective scores. DISE represents a fundamental tool to assess uni-level or multilevel obstruction. When retro-palatal collapse is present, barbed pharyngoplasty appears to be effective. Barbed pharyngoplasties maintain their good results both in single level or multilevel surgery. Randomized clinical controlled trials with multi-center cooperation and long-term study are necessary.

A New Lighting System for Surgical Vision Optimization in Barbed Pharyngoplasty for OSA

Obstructive sleep apnea (OSA) surgery is now a viable solution in selected patients and the "remodeling" palatopharyngeal surgery is the most common one. Recently, it has become less invasive with the introduction of barbed sutures (BS). An optimization of surgical techniques is represented by barbed pharyngoplasty (BP), which requires surgical precision and needs efficient and precise oropharyngeal visualization. Consequently, the lighting system is of pivotal importance in BP. The aim of this work is to describe the first experience on the use of a new lighting system, called KLAROTM in BP for OSA. We evaluated the KLARO™ system in 15 consecutives BP for OSA in comparison with conventional headlamp illumination. The visualization of palatopharyngeal muscle in the bottom of the tonsillar fossa, entry and exit needle, such as needle tip, were statistically better with KLAROTM than headlamp illumination for both the surgeon and resident (p < 0.05). No significant differences for the visualization of the posterior pharyngeal wall and uvula were reported. The KLAROTM lighting system allows a satisfied illumination of oral cavity and oropharynx in the majority of cases. We encourage the use of KLAROTM not only in BP for OSA, but in all oral and pharyngeal surgeries, including tonsillectomy and oncological surgery.

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.

The Effects of Barbed Repositioning Pharyngoplasty in Positional and Non-Positional OSA Patients: A Retrospective Analysis

PURPOSE

The aim of our retrospective study is evaluating the effectiveness of barbed repositioning pharyngoplasty (BRP) in a consecutive cohort of patients and assessing its impact on positional indexes in order to potentially identify specific obstructive sleep apnea (OSA) phenotypes for patients who might benefit more significantly from this intervention.

METHODS

A single-center retrospective study with baseline and follow-up type III sleep tests evaluating the Apnea Hypopnea Index (AHI), supine AHI, non-supine AHI, oxygen desaturation index (ODI), mean SaO2, percentage of time spent at SaO2 below 90% (CT90), and lowest oxygen saturation (LOS) were performed. The patients were then divided into groups according to Sher's criteria and Amsterdam Positional OSA Classification (APOC). Parametric and non-parametric tests and univariate and multivariate analyses were conducted.

RESULTS

The study finally included 47 patients. The statistical analysis showed significant improvement in AHI, supine AHI, non-supine AHI, and ODI after surgery. The linear regression showed that high values of baseline AHI, AHI supine, and AHI non supine predict more significant postoperative reductions in AHI, AHI supine, and AHI non supine, respectively. Therapeutic success was achieved in 22 patients out of 47. The logistic regression did not find any independent risk factors for success. The most significant reduction in AHI, supine AHI, and non-supine AHI was observed in the APOC 3 group while the APOC 1 patients experience a substantially lower improvement.

CONCLUSIONS

BRP appears to be an effective surgical procedure for the treatment of OSA. The non-positional patients might benefit more from BRP in comparison with positional patients. Moreover, OSA severity should not be considered an absolute contra-indication for this surgical procedure.

Anxiety, depression and sleepiness in OSA patients treated with barbed reposition pharyngoplasty: a prospective study

PURPOSE

To evaluate the efficacy of barbed reposition pharyngoplasty (BRP) on sleepiness, anxiety, and depression o adult patients with obstructive sleep apnea (OSA).

METHODS

We performed a prospective multicentric study to assess functional outcomes in 20 OSA patients treated with BRP and compare the results with an observational group of 20 subjects. All recruited subjects performed at baseline and 6-months postoperative follow-up Polysomnography (PSG), daytime sleepiness scoring using the Epworth Sleepiness Scale (ESS), and anxiety and depression evaluation via the Beck Anxiety Inventory (BAI) and the Beck Depression Inventory-II (BDI-II) questionnaires.

RESULTS

At follow-up the BRP demonstrated greater improvements in AHI (8.92 ± 2.29 vs. 30.66 ± 2.56; p < 0.001) and ODI (7.65 ± 2.39 vs. 24.55 ± 3.20; p < 0.001) than control at intergroup analysis. Surgical group reported significant data in daytime sleepiness (5.15 ± 1.19 vs. 13.15 ± 1.35; p < 0.001), anxiety (12.65 ± 3.11 vs. 24.2 ± 2.37; p < 0.001), and depression domains (5.85 ± 1.19 vs. 17.55 ± 3.24; p < 0.001). AHI, ODI, and advanced age have been shown to multiple regression as independent predictors of treatment response for mood domains (p < 0.001; p = 0.02; p = 0.041, respectively).

CONCLUSIONS

Patients with OSA may benefit from palate surgery, reducing not only the apnea and hypopnea index, daytime sleepiness but also associated mood comorbidities. However, further studies are needed to confirm our preliminary results to validate the evidence to date reported.

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.

Long-term outcomes of pharyngoplasty for Obstructive Sleep Apnea Syndrome

<b>Introduction: </b> Pharyngoplasty techniques for the treatment of obstructive sleep apnea syndrome (OSAS) have evolved, which improved the understanding of the anatomy, patient selection, and adoption of functional approaches. </br></br> <b>Aim:</b> To analyze long-term results of pharyngoplasty in OSAS patients. </br></br> <b>Material and methods:</b> Between 2007 and 2021, a total of 234 adult patients with OSAS who had previously failed positive airway pressure (PAP) therapy underwent sleep surgery. Of this group, 75 patients met the criteria of a minimum 5-year follow-up. To date, 25 patients completed the follow-up study protocol, including the medical history, visual analog scale (VAS) for snoring loudness, body mass index (BMI), endoscopy of the upper airways, type III sleep study, and standardized questionnaires including Epworth Sleepiness Scale (ESS) and EQ-5D-5L Euro – Quality of Life Questionnaire. </br></br> <b>Results:</b> The average period of follow-up was 96.80 ± 30.20 months. The mean age of participants was 54.6 ± 14.02 and the mean BMI 30.28 ± 2.74. Patients underwent uvulopalatopharyngoplasty (n = 21) and expansion sphincterpharyngoplasty (n = 4) between 2008–2015. A long-term improvement in sleep parameters was observed for the mean AHI (29.84 ± 20.06before and 19.45 ± 18.53 after surgery, p = 0.0294), and the median VAS (8.13 before and 3.78 after surgery), mean oxygen saturation during sleep 94,5% (IQR 93.0–95.25), and the median ESS score was 6.17 ± 4.57. The majority of patients reported subjective long-term improvement in sleep quality and a reduction of snoring. </br></br> <b>Conclusions:</b> In OSAS patients who failed PAP therapy, pharyngoplasty may provide a long-term improvement in upper airway obstruction during sleep.

Obstructive Sleep Apnea Syndrome: From Symptoms to Treatment

Obstructive sleep apnea (OSA) syndrome is a respiratory sleep disorder characterized by partial or complete recurrent episodes of upper airway collapse that occur during the night. The OSA manifests with a reduction (hypopnea) or complete cessation (apnea) of airflow in the upper airways, associated with breathing effort. OSA is a frequent and often underestimated pathology affecting between 2 and 5% of the middle-aged population. Typical nocturnal symptoms are the persistent snoring and awakenings with dyspnea sensation. On the other hand, diurnal symptoms could be sleepiness, headaches, asthenia, neurological disorders, and impaired personal relationships. Surgery of the velo-pharyngeal region had a huge evolution going from ablative techniques (UP3 and LAUP) to remodeling techniques of the pharyngeal lateral walls.

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.

Obstructive sleep apnoea/hypopnoea syndrome: relationship with obesity and management in obese patients

Obstructive sleep apnoea/hypopnoea syndrome (OSAHS) is a disease characterised by upper airway obstruction during sleep, quite frequent in the general population, even if underestimated. Snoring, sleep apnoea and diurnal hypersomnia are common in these patients. Central obesity plays a key role: it reduces the size and changes the conformation of the upper airways, besides preventing lung expansion, with consequent reduction of lung volumes. Furthermore, obese people are also resistant to leptin, which physiologically stimulates ventilation; as a result, this causes scarce awakening during apnoea. OSAHS diagnosis is based on the combination of clinical parameters, such as apnoea/hypopnoea index (AHI), medical history, physical examination and Mallampati score. The first objective reference method to identify OSAHS is polysomnography followed by sleep endoscopy. Therapy provides in the first instance reduction of body weight, followed by continuous positive airway pressure (CPAP), which still remains the treatment of choice in most patients, mandibular advancement devices (MAD) and finally otolaryngology or maxillofacial surgery. Among surgical techniques, central is barbed reposition pharyngoplasty (BRP), used in the field of multilevel surgery.

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.

OSA Upper Airways Surgery: A Targeted Approach

Obstructive sleep apnea syndrome (OSA) is a multi-factorial disorder, with quite complex endotypes, consisting of anatomical and non-anatomical pathophysiological factors. Continuous positive airway pressure (CPAP) is recognized as the first-line standard treatment for OSA, whereas upper airway (UA) surgery is often recommended for treating OSA patients who have refused or cannot tolerate CPAP. The main results achievable by the surgery are UA expansion, and/or stabilization, and/or removal of the obstructive tissue to different UA levels. The site and pattern of UA collapse identification is of upmost importance in selecting the customized surgical procedure to perform, as well as the identification of the relation between anatomical and non-anatomical factors in each patient. Medical history, sleep studies, clinical examination, UA endoscopy in awake and drug-induced sedation, and imaging help the otorhinolaryngologist in selecting the surgical candidate, identifying OSA patients with mild UA collapsibility or tissue UA obstruction, which allow achievement of the best surgical outcomes. Literature data reported that the latest palatal surgical procedures, such as expansion sphincter palatoplasty or barbed reposition palatoplasty, which achieve soft palatal and lateral pharyngeal wall remodeling and stiffening, improved the Apnea Hypopnea Index, but the outcome analyses are still limited by methodological bias and the limited number of patients' in each study. Otherwise, the latest literature data have also demonstrated the role of UA surgery in the improvement of non-anatomical factors, confirming that a multidisciplinary and multimodality diagnostic and therapeutical approach to OSA patients could allow the best selection of customized treatment options and outcomes.

Barbed suture Extrusion and Exposure in palatoplasty for OSA: What does it mean?

PURPOSE

Analyze Extrusion&Exposion (E&E), its implications in the functional, anatomical results and subjective discomfort in OSA patients treated with Barbed Reposition Pharyngoplasty (BRP).

MATERIALS AND METHODS

488 patients treated with BRP or multilevel TORS. Stratafix wire was used in 230 patients, V-Loc in 258. E&E, timing and localization evaluated at follow-up. Polygraphy used to assess the impact of E&E on functional results, PPOPS questionnaire used for subjective discomfort.

RESULTS

E&E in the entire group was 18,4%, with significant difference between Stratafix and V-Loc wire (p = 0,002), but not between BRP alone and multilevel surgery (p = 0,68). 28,9% of extrusion happened within the first seven days, 76,7% between seven days and two months, 5,5% after two months. Symptomatic clinical profile has been seen in 62,2%, asymptomatic one in 37,8% of patients. 35,5% of E&E were localized in tonsillar bed, 46,7% in soft palate and 20% in other sites. Mean delta-AHI of E&E patients was -15,87 ± 16.82 compared with one of those who did not have E&E was -16.34 ± 22,77 (p = 0,38). Mean PPOPS of 183 patients analyzed was 12,32 ± 4,96. Mean PPOPS of extruded group was 12,94 ± 4,68 and 11,92 ± 5,11 in not extruded one (p = 0,166).

CONCLUSIONS

E&E are suture-type sensitive (V-Loc > Stratafix), reported more frequent when BRP is performed alone than BRP-TORS with no statistical significance. 76,7% of the E&E occur after patient discharge and within 2 months. About half of the E&E were localized in soft palate. There is no need to fear Extrusion&Exposition because it does not affect in a negative way subjective and PSG outcome.

Long-term stability of results following surgery for obstructive sleep apnea (OSA)

PURPOSE

Although upper airway surgery in selected patients with obstructive sleep apnea (OSA) has been shown to be beneficial, its long-term effects have been questioned. The main objective was to evaluate whether results following surgery remain stable over time, both in objective and subjective terms. As a secondary aim, such stability was also measured in relation with the type of surgery performed.

METHODS

This work constitutes a retrospective study of OSA adult patients subjected to the following surgical procedures: different types of pharyngoplasties, tongue-base surgery, partial epiglottectomy or hyoid suspension. Those who exclusively underwent tonsillectomy or nasal surgery were excluded. Before surgery, a sleep study, and an assessment of the patients' sleepiness and quality of life were performed, which were repeated at 8, 34, and 48 months after surgery. A total of 153 patients was included.

RESULTS

Following surgery, the apnea-hypopnea index decreased from 34.84/h to 14.54/h and did not vary more than one point in subsequent controls (p = 0.01). The oxygen desaturation index changed from 31.02/h to 14.0/h and remained stable in the second (15.34/h) and third (11.43/h) controls (p = 0.01). Parameters measuring sleepiness and well-being demonstrated the maintenance of long-term benefits. New pharyngoplasties were observed to be more stable than classic pharyngoplasties in the long term (p = 0.04). Single-level surgeries were found to be more stable than multilevel surgeries, although a statistically significant difference was not observed (p = 0.07).

CONCLUSION

The benefits obtained remained stable in the long term. In our sample, modern pharyngoplasty techniques showed superiority over the classic ones regarding long-term stability.

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.

Sleep medicine in otolaryngology units: an international survey

PURPOSE

No study to date has described the overall landscape of sleep disorders management and training in otolaryngology departments of different countries. The aim of our study was to investigate and compare settings, diagnostic and therapeutic approaches and training programmes.

METHODS

An international online survey was developed with the collaboration of the YO-IFOS (Young Otolaryngologists-International Federation of Otorhinolaryngological Societies) to assess the current practice of otolaryngologists in the management of sleep disorders. The survey also included a session dedicated to training.

RESULTS

A total of 126 otolaryngologists completed the survey. The larger part of responses was collected from Central/South America and Europe. The majority of responders from South/Central America (97%) declared to be certified as sleep specialist while 49% of Europeans stated the opposite. Of responders 83% perform a drug-induced sleep endoscopy (DISE) before planning a possible surgical intervention. Soft palate and base of tongue interventions were the most common procedure, respectively performed in 94% and 79% of the cases. Residents were allowed to perform soft palate surgery in 77% of the cases. Upper airway stimulation (26% vs 10%), trans-oral robotic surgery (36% vs 11%) and radiofrequency of the base of the tongue (58% vs 25%) were preferred more frequently by European responders. The highest caseloads of soft palate surgery and bi-maxillary advancement were registered in the academic institutions.

CONCLUSION

Significant concordance and few interesting divergences in diagnosis and treatment of sleep disorders were observed between nationalities and types of institution. Economic resources might have played a significant role in the therapeutic choice. Trainees' lack of exposure to certain interventions and to a sufficient caseload appeared to be the main burden to overcome.

Effect of Multilevel Upper Airway Surgery vs Medical Management on the Apnea-Hypopnea Index and Patient-Reported Daytime Sleepiness Among Patients With Moderate or Severe Obstructive Sleep Apnea: The SAMS Randomized Clinical Trial

IMPORTANCE

Many adults with obstructive sleep apnea (OSA) use device treatments inadequately and remain untreated.

OBJECTIVE

To determine whether combined palatal and tongue surgery to enlarge or stabilize the upper airway is an effective treatment for patients with OSA when conventional device treatment failed.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, parallel-group, open-label randomized clinical trial of upper airway surgery vs ongoing medical management. Adults with symptomatic moderate or severe OSA in whom conventional treatments had failed were enrolled between November 2014 and October 2017, with follow-up until August 2018.

INTERVENTIONS

Multilevel surgery (modified uvulopalatopharyngoplasty and minimally invasive tongue volume reduction; n = 51) or ongoing medical management (eg, advice on sleep positioning, weight loss; n = 51).

MAIN OUTCOMES AND MEASURES

Primary outcome measures were the apnea-hypopnea index (AHI; ie, the number of apnea and hypopnea events/h; 15-30 indicates moderate and >30 indicates severe OSA) and the Epworth Sleepiness Scale (ESS; range, 0-24; >10 indicates pathological sleepiness). Baseline-adjusted differences between groups at 6 months were assessed. Minimal clinically important differences are 15 events per hour for AHI and 2 units for ESS.

RESULTS

Among 102 participants who were randomized (mean [SD] age, 44.6 [12.8] years; 18 [18%] women), 91 (89%) completed the trial. The mean AHI was 47.9 at baseline and 20.8 at 6 months for the surgery group and 45.3 at baseline and 34.5 at 6 months for the medical management group (mean baseline-adjusted between-group difference at 6 mo, -17.6 events/h [95% CI, -26.8 to -8.4]; P < .001). The mean ESS was 12.4 at baseline and 5.3 at 6 months in the surgery group and 11.1 at baseline and 10.5 at 6 months in the medical management group (mean baseline-adjusted between-group difference at 6 mo, -6.7 [95% CI, -8.2 to -5.2]; P < .001). Two participants (4%) in the surgery group had serious adverse events (1 had a myocardial infarction on postoperative day 5 and 1 was hospitalized for observation following hematemesis of old blood).

CONCLUSIONS AND RELEVANCE

In this preliminary study of adults with moderate or severe OSA in whom conventional therapy had failed, combined palatal and tongue surgery, compared with medical management, reduced the number of apnea and hypopnea events and patient-reported sleepiness at 6 months. Further research is needed to confirm these findings in additional populations and to understand clinical utility, long-term efficacy, and safety of multilevel upper airway surgery for treatment of patients with OSA.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12614000338662.

Modified reposition pharyngoplasty for OSAS treatment: How we do it and our results

INTRODUCTION AND PURPOSES

The relevance of the lateral pharyngeal walls in the collapse of the upper airway in obstructive sleep apnea patients has been revealed in the last 20years. New surgical techniques that address this collapse have been published. The aim of this study is to show the technique that we are currently using to treat the collapse and its results.

MATERIALS AND METHODS

This is a retrospective study of surgically treated OSAS patients who did not tolerate conventional positive airway pressure (CPAP) or for whom it was not indicated. After a complete physical examination either awake or under drug-induced sleep endoscopy, tonsillectomy with reposition pharyngoplasty was performed using barbed bidirectional suture and removing the supratonsillar fat. Three to 6months after surgery the subjective parameters were evaluated and a sleep study was performed.

RESULTS

Twenty-six patients were enrolled with a significative decrease in the AHI and also significative improvement in all the rest parameters studied. In 65.4% of the patients the AHI decreased 50% and was lower than 20/h, in 42.3% postoperative AHI was lower than 10/h. The most frequent complication was the partial extrusion of the suture.

CONCLUSIONS

This surgical procedure obtains statistically significant results in objective and subjective parameters of sleep apnoea without major associated complications.

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.

Long-Term Subjective Outcomes of Barbed Reposition Pharyngoplasty for Obstructive Sleep Apnea Syndrome Treatment

Background: The purpose of this study was to evaluate long-term subjective outcomes of barbed reposition pharyngoplasty for obstructive sleep apnea syndrome (OSAS) treatment using a specific questionnaire, the Palate Postoperative Problem Score (PPOPS). Methods: 140 patients who underwent barbed reposition pharyngoplasty (BRP) surgery in the Morgagni Pierantoni Hospital of Forlì, Italy were enrolled in the study. Postoperative outcomes were evaluated in a short- and long-term follow-up using the PPOPS questionnaire. The average period of follow-up was 26 months. All patients received the PPOPS questionnaire by telephone in a period between April and August 2019. Results: 51% of patients complained of swallowing problems after surgery. In 91% of cases, the problem cleared up spontaneously. At the time of the interview, only 9% of patients had a residual swallowing difficult. At the time of PPOPS evaluation, rhinolalia was observed in 8% of patients, whereas nose regurgitation was present in 2% of patients. In 20% of patients, the foreign body sensation was present during follow-up. The value of apnea–hypopnea index (AHI) reduced from the preoperative value of 31.5 to the postoperative value of 11.4. Conclusions: BRP surgery proved to be an effective technique, appreciated by the majority of patients. Use of the PPOPS questionnaire has demonstrated that the BRP technique seems to ensure efficacy and lower morbidity, with few complications after surgery.