Is there a relationship between tonsil volume and the success of pharyngeal surgery among adult patients with obstructive sleep apnea?

Surgical failure guided by DISE in patients with obstructive sleep apnea: a systematic review and meta-analysis

OBJECTIVES

The failure rate and risk factors of upper airway surgery with drug induced sleep endoscopy (DISE) remain unknown in the treatment of obstructive sleep apnea (OSA). This review aims to analyze the failure rate of upper airway surgery with DISE and identify obstruction sites for surgical failure.

METHODS

A systematic review was conducted using PubMed, Embase, Web of Science, and Google Scholar until May 20th, 2023. We included studies that used DISE to assess obstructive sites before upper airway surgery and reported surgical failure rates and outcomes in patients with OSA.

RESULTS

25 studies with a total of 1522 patients were included in the systematic review and meta-analysis. Upper airway surgery guided by DISE had a relatively low failure rate of 37% (95% CI 0.31-0.44) in the random effects model (I2 = 85.97%, P < 0.001). According to the velum, oropharynx, tongue base, and epiglottis (VOTE) scoring system, major risk factors for surgical failure included circumferential collapse at the velum, lateral wall collapse and small tonsils at the oropharynx, anterior-posterior lingual collapse and complete collapse at the tongue base. High body mass index and large preoperative apnea hypopnea index were also risk factors for OSA surgical failure.

CONCLUSIONS

Upper airway surgery guided by DISE in patients with OSA had a low failure rate of 37%. DISE can identify obstruction sites associated with surgical failure and guide single-level and multi-level surgeries.

Predictors of Success of Pharyngeal Surgery in the Treatment of Obstructive Sleep Apnea: A Narrative Review

(1) Background: This narrative review aims to explore the predictors of success for pharyngeal surgery in the treatment of obstructive sleep apnea (OSA). An extensive literature search was conducted, identifying relevant studies published up to June 2023, utilizing various databases and key search terms related to OSA, surgical interventions, and predictors of success. The review encompasses both retrospective and prospective studies, case series, and cohort studies to provide a broad understanding of the topic; (2) Methods: Review of English scientific literature on phenotypes of OSA related to predictors of success of pharyngeal surgery; (3) Results: Of 75 articles, 21 were included, in these the following were determined to be factors for surgical success: body mass index (BMI) (8 articles), apnea/hypopnea index (AHI) (8 articles), cephalometry (8 articles), palatine tonsil size (7 articles), Modified Mallampati score (2 articles), genioglossus electromyography (2 articles), Friedman score or upper airway anatomy (3 articles), nasopharyngolaryngoscopy (2 articles), drug-induced sleep endoscopy (DISE) (1 article), oral cavity anatomy (1 article) and oxygen desaturation index (ODI) (1 article); (4) Conclusions: The lack of standardized protocols for the indication of pharyngeal surgery is a reality, however identifying known predictors of surgical success may facilitate homogenizing indications.

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.

Insights into the Use of Point-of-Care Ultrasound for Diagnosing Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a sleeping disorder caused by complete or partial disturbance of breathing during the night. Existing screening methods include questionnaire-based evaluations which are time-consuming, vary in specificity, and are not globally adopted. Point-of-care ultrasound (PoCUS), on the other hand, is a painless, inexpensive, portable, and useful tool that has already been introduced for the evaluation of upper airways by anesthetists. PoCUS could also serve as a potential screening tool for the diagnosis of OSA by measuring different airway parameters, including retropalatal pharynx transverse diameter, tongue base thickness, distance between lingual arteries, lateral parapharyngeal wall thickness, palatine tonsil volume, and some non-airway parameters like carotid intima-media thickness, mesenteric fat thickness, and diaphragm characteristics. This study reviewed previously reported studies to highlight the importance of PoCUS as a potential screening tool for OSA.

Treatment of sleep disordered breathing relapse after surgery

This narrative review provides a general overview of the management of relapses after surgery for the treatment of sleep disordered breathing. This clinical scenario represents a challenging field, but fortunately several therapeutic options are included in sleep surgeons’ armamentarium. Each therapeutic modality is described in detail in a dedicated section.

Tonsil volume and outcome of radiofrequency uvulopalatoplasty with or without tonsillectomy in adults with sleep-disordered breathing

PURPOSE

Predictors for the outcome of uvulopalatopharyngoplasty with and without tonsillectomy (UPPP ± TE) in sleep-disordered breathing have not been fully established. This study investigates tonsil grade, volume, and preoperative examination in predicting radiofrequency UPP ± TE outcomes.

METHODS

All patients undergoing radiofrequency UPP with tonsillectomy if tonsils were present between 2015 and 2021 were retrospectively analyzed. Patients underwent a standardized clinical examination, including Brodsky palatine tonsil grade from 0 to 4. Preoperatively and 3 months after surgery, sleep apnea testing was performed using respiratory polygraphy. Questionnaires were administered assessing daytime sleepiness using the Epworth Sleepiness Scale (ESS) and snoring intensity on a visual analog scale. Tonsil volume was measured intraoperatively using water displacement.

RESULTS

The baseline characteristics of 307 patients and the follow-up data of 228 patients were analyzed. Tonsil volume increased by 2.5 ml (95% CI 2.1-2.9 ml; P < 0.001) per tonsil grade. Higher tonsil volumes were measured in men, younger patients, and patients with higher body mass indices. The preoperative apnea-hypopnea index (AHI) and AHI reduction strongly correlated with tonsil volume and grade, whereas postoperative AHI did not. The responder rate increased from 14% to 83% from tonsil grade 0 to 4 (P < 0.01). ESS and snoring were significantly reduced after surgery (P < 0.01), but the reduction was not influenced by tonsil grade or volume. No other preoperative factor other than tonsil size could predict surgical outcomes.

CONCLUSIONS

Tonsil grade and intraoperatively measured volume correlate well and predict the reduction of AHI, while they are not predictive of ESS and snoring response after radiofrequency UPP ± TE.