Lateral-Expansion Pharyngoplasty: Combined Technique for the Treatment of Obstructive Sleep Apnea Syndrome

THIEME Original Research Lateral-Expansion Pharyngoplasty: Combined Technique for the Treatment of Obstructive Sleep Apnea Syndrome José Antonio Pinto1 Luciana Balester Mello de Godoy2 Heloisa dos Santos Sobreira Nunes2,3 2,3 Kelly Elia Abdo Gabriella Spinola Jahic2,3 André Freitas Cavallini2,3 Gabriel Santos Freitas2,3 Davi Knoll Ribeiro2,3 Caue Duarte2,3 1 Director of Department of Otolaryngology, Núcleo de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço de São Paulo, São Paulo, SP, Brazil 2 Department of Otolaryngology, Núcleo de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço de São Paulo, São Paulo, SP, Brazil 3 Department of Otorhinolaryngology, Hospital Sao Camilo Pompeia, São Paulo, SP, Brazil Address for correspondence José Antonio Pinto, Director of Department of Otolaryngology, Núcleo de Otorrinolaringologia e Cirurgia de Cabeça e Pescoço de São Paulo, São Paulo, SP, Brazil (e-mail: ). Int Arch Otorhinolaryngol 2020;24(1):e107–e111. Abstract Keywords ► obstructive sleep apnea ► polysomnography ► upper airway surgery ► surgical technique ► pharyngeal muscles ► pharynx/surgery received February 24, 2019 accepted June 19, 2019 Introduction Obstructive sleep apnea syndrome (OSAS) is a multifactorial disease characterized by episodes of partial or complete collapse during sleep of different regions of the upper airway. Surgery for OSAS evolved with the introduction of different techniques, considering new surgical concept of reconstruction of the upper airway. Objective To retrospectively evaluate the effectiveness of a new approach aimed at reducing pharyngeal collapse by combining two surgical techniques: lateral and expansion pharyngoplasty. Methods We reviewed the medical records of 38 patients with OSAS undergoing lateral/expansion pharyngoplasty from January 2012 to December 2016. The following data were collected: patient age, gender, and pre- and postoperative body mass index (BMI), Epworth sleepiness scale (ESS) scores, snoring visual analogue scale (VAS) scores, and polysomnography (PSG) results. Results The PSG results showed a significant reduction in the apnea/hypopnea index (AHI) from 22.4
27.3 events/h preoperatively to 13.6
17.9 events/h postoperatively (p ¼ 0.009), with postoperative AHI reduction greater than 50% in 63.2% of the patients. There was also a significant reduction in the microarousal index (19.5
22.6 vs 11.0
13.4 events/h; p ¼ 0.001) and in the minimum oxygen saturation (82.6
10.3 vs 86.9
11.1; p ¼ 0.007). Conclusions Lateral-expansion pharyngoplasty represents a new surgical strategy for the treatment of OSAS in patients with palatal collapse by combining two different techniques: lateral and expansion pharyngoplasty. The two techniques, performed as a one-stage procedure, led to improvements in excessive daytime sleepiness, snoring, and PSG respiratory parameters by acting on lateral and retropalatal collapse, producing favorable results with good applicability in otolaryngology clinical practice. DOI https://doi.org/ 10.1055/s-0039-1695026. ISSN 1809-9777. Copyright © 2020 by Thieme Revinter Publicações Ltda, Rio de Janeiro, Brazil e107 e108 Lateral-Expansion Pharyngoplasty Pinto et al. Introduction Methods Obstructive sleep apnea syndrome (OSAS) is a complex and multifactorial disease characterized by episodes of partial or complete collapse during sleep of different regions of the upper airway, such as nasal cavities, palate, uvula, tonsils, base of the tongue, lateral pharyngeal walls, and epiglottis.1 Continuous positive airway pressure (CPAP) has been long considered the first-line therapy for OSAS, being effective when used properly and in accordance with the standards of the American Academy of Sleep Medicine (AASM).2 However, due to difficult adherence of some patients to this treatment modality, the actual effectiveness of CPAP is low, with a large number of users abandoning it within 1 year of prescription. Conversely, surgery for OSAS does not depend on patient adherence, and when topodiagnosis is combined with the right pharyngeal procedure, effective long-term results have been observed.3 Surgical OSAS treatment has evolved over the years with the introduction of different techniques. In 1964, Ikematsu developed a surgical procedure to reduce snoring by shortening the palate and uvula.4,5 In 1977, Quesada et al introduced the concept of partial palate resection, a technique that was considered the first uvulopalatopharyngoplasty (UPPP).5,6 In 1981, Fujita et al published the UPPP technique by modifying the original procedure described by Ikematsu and generating great enthusiasm in the otolaryngology community.5,7 Several variations of the UPPP technique have been described since then, leading to a conceptual shift from aggressive palate resection to reconstructive surgery and improving pharyngeal function by changing its shape. In 2003, Cahali described lateral pharyngoplasty, a surgical technique designed to splint the lateral pharyngeal walls via a microdissection of the superior pharyngeal constrictor muscle, thus giving support to these walls and reducing lateral collapse in patients with OSAS.5,8 In 2007, Pang and Woodson described expansion sphincter pharyngoplasty, which consists of a tonsillectomy followed by rotation of the palatopharyngeus muscle, partial uvulectomy, and closure of the anterior and posterior tonsillar pillars.1,5 The purpose of this procedure is to create lateral wall tension and remove the bulk of the lateral pharyngeal walls. In 2012, Sorrenti and Piccin improved the technique by stabilizing the palatopharyngeus muscle with a less aggressive and more physiologic surgery.5,9 Considering this new surgical concept of reconstruction of the upper airway, we combined two techniques, lateral and expansion pharyngoplasty, in a single procedure to both increase the pharyngeal space and address retropalatal and lateral collapse. This was a retrospective longitudinal study. The study was approved by the research ethics committee the institution, CAAE: 72825617.7.0000.0062–Comissão Nacional de Ética em Pesquisa (CONEP, in the Portuguese acronym). We retrospectively reviewed the medical records of all patients with OSAS undergoing lateral-expansion pharyngoplasty at the department of otolaryngology of our institution from January 2012 to December 2016. The following data were collected from the medical records: patient age, gender, and pre- and postoperative body mass index (BMI), Epworth sleepiness scale (ESS) scores, snoring visual analogue scale (VAS) scores, and polysomnography (PSG) results. The eligible participants were all patients aged 18 to 60 years old with a diagnosis of OSAS according to the International Classification of Sleep Disorders2 who were classified as Friedman stage I or II on physical examination and had retropalatal obstruction of the oropharynx and/or hypopharynx (Fujita type I and II) as seen with awake flexible endoscopy. Exclusion criteri (...truncated)