Expansion sphincter pharyngoplasty: Usefulness of DISE

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.

Effectiveness of drug-induced sleep endoscopy in improving outcomes of barbed pharyngoplasty for obstructive sleep apnea surgery: a prospective randomized trial

PURPOSE

To observe the effectiveness of preoperative drug-induced sleep endoscopy in improving surgical results of patients undergoing single-level barbed pharyngoplasty surgery for OSA, using a prospective randomized model.

METHODS

A single-center randomized controlled trial with two prospective arms was carried out to compare functional results in patients treated with barbed reposition pharyngoplasty (BRP) surgery without a preoperative drug-induced sleep endoscopy (DISE) evaluation vs patients treated with BRP surgery performed after DISE evaluation of sites/patterns of collapse.

RESULTS

We compared 50 patients who underwent BRP without a preoperative DISE evaluation (Group A) and 42 patients (Group B) treated with BRP surgery but preoperatively selected by means of a preoperative DISE. In this second group of patients, after DISE evaluation, 70% of patients were selected for single-level BRP surgery because they showed an isolated velopharyngeal collapse at the DISE evaluation, without obstruction at other upper airway levels evaluated. Both groups of patients showed a statistically significant difference between preoperative and postoperative values of AHI, ODI, and LOS (p<0.05 in all cases). Comparing Group A and Group B patients, the therapeutic success rate was found to be 60% in patients treated without preoperative DISE evaluation and 83% in patients treated with preoperative DISE (p = 0.02).

CONCLUSION

DISE appears to improve the surgical results of single-level velopharyngeal surgery due to the possibility of excluding patients with obstruction of the base of the tongue, the hypopharynx, and the epiglottis/larynx.

One-Stage Multilevel Surgery for Treatment of Obstructive Sleep Apnea Syndrome

We report the results of one-stage multilevel upper airway surgery for patients who could not tolerate continuous positive airway pressure (CPAP). Patients treated with multilevel surgery at a University Hospital in 2015–2019 were identified from a prospectively maintained database. The inclusion criteria were aged 18–70 years, body mass index (BMI) < 35 kg/m², apnea–hypopnea index (AHI) > 20, and lingual tonsil hypertrophy grade 3 or 4. Drug-induced sleep endoscopy was performed before surgery in all patients. Multilevel surgery was performed in one stage and included expansion sphincter pharyngoplasty (ESP), coblation tongue base reduction (CTBR), and partial epiglottectomy (PE) as required. The outcome measures were postoperative AHI, time percentage oxygen saturation < 90%, and Epworth Sleepiness Scale (ESS) score. A total of 24 patients were included: median age 49.1 years, average BMI 27.26 kg/m², and 90% men. Ten patients received ESP plus CTBR plus PE, eight received ESP plus CTBR, and six received ESP plus PE. The mean preoperative AHI was 33.01 at baseline and improved to 17.7 ± 13 after surgery (p < 0.05). The ESS score decreased from 11 ± 5.11 to 7.9 ± 4.94 (p < 0.05). The surgical success rate according to Sher’s criteria was 82.3%. The median follow-up was 23.3 months (range 12–36). These findings suggest that multilevel surgery is a safe and successful treatment of OSAHS.

Effect of Modified Uvulopalatopharyngoplasty without Tonsillectomy on Obstructive Sleep Apnea: Polysomnographic Outcome and Correlation with Drug-Induced Sleep Endoscopy

OBJECTIVE

Uvulopalatopharyngoplasty (UPPP) is a common procedure for the treatment of obstructive sleep apnea (OSA) and is usually initiated with the resection of palatine tonsils. Because tonsillectomy potentially contributes to complications, minimally invasive upper airway surgeries have been proposed for OSA therapy. Whether tonsillectomy is always essential for UPPP remains unclear, particularly for patients with small tonsils. The purpose of this study was to present the effect of modified UPPP without tonsillectomy (UPsT) on patients with OSA and attempt to select the candidates for this procedure.

METHODS

This is a retrospective cohort study of patients with OSA, with tonsil size of grade 0-2, and with only retropalatal obstruction in drug-induced sleep endoscopy (DISE). The patients underwent UPsT at a tertiary center from November 2017 to December 2019. The sleep study was performed before and at least 3 months after surgery. The demographics, surgical outcomes, and staging patterns of preoperative DISE were recorded. The correlation between surgical outcome and DISE was also established.

RESULTS

A total of 22 adults with an average age of 46.5 years [interquartile range: 40 to 60 years] completed the follow-up study. Their apnea-hypopnea index (AHI) and Epworth sleepiness scale values improved significantly after surgery. Of the 17 patients with partial collapse and complete anteroposterior collapse (APC) at the velum, 16 presented good responses to UPsT. However, among the five patients with complete concentric collapse (CCC), only two (2/5, 40%) satisfied the criteria for surgical success. Furthermore, their follow-up AHI values were significantly higher than those of patients without CCC in DISE.

CONCLUSION

UPsT was demonstrated to be an effective therapy for patients with OSA who had small tonsils and retropalatal obstruction in DISE. CCC in sleep endoscopy indicates a poorer surgical outcome than does complete APC and partial collapse at the velum.

Expansion sphincter pharyngoplasty: analyzing the technique based on anatomy

PURPOSE

The purpose of this study is to evaluate the effect of the different surgical techniques of expansion sphincter pharyngoplasty (ESP) on the dimensions of the oropharyngeal airway.

METHODS

The techniques that were evaluated included the preservation and transection of the palatopharyngeus (PP) and superior pharyngeal constrictor (SPC) muscle attachment and transposition of the PP muscle to the hamulus of the medial pterygoid plate and the palatal musculature. Surgical techniques were applied in twenty half heads.

RESULTS

The preservation of the PP-SPC attachment inhibited the transposition of the PP muscle to the hamulus and resulted in comparable enlargement in the medial-lateral dimension in the oropharyngeal airway when the PP muscle was transposed to the palatal musculature. After transection of the PP-SPC attachment, significant enlargement was observed in anterior-posterior and medial-lateral directions in the oropharyngeal airway when the PP muscle was transposed both to the hamulus and the palatal musculature. The distances measured after both the transposition techniques were similar.

CONCLUSION

The present study is a basic study demonstrating how different techniques of ESP affect the position of the soft palate. The PP-SPC attachment can be transected in the patients with anterior-posterior palatal and lateral wall collapse to pull the soft palate anteriorly in addition to prevent the lateral wall collapse. The PP-SPC attachment can be preserved in the patients with only lateral wall collapse. Nevertheless, the clinical consequences of these static changes need to be evaluated in clinical studies.