International Journal of Head and Neck Surgery

Register      Login

VOLUME 10 , ISSUE 3 ( July-September, 2019 ) > List of Articles

Special Issue 3: Invited Article

Selecting Different Surgical Approaches for Hypopharyngeal Obstruction

PHUA Chu Qin, LOH Shaun Ray Han, TOH Song Tar

Keywords : Hypopharyngeal obstruction, Hypopharyngeal surgery, Patient selection, Surgical approach, Obstructive sleep apnea

Citation Information : Chu Qin P, Shaun Ray Han L, Song Tar T. Selecting Different Surgical Approaches for Hypopharyngeal Obstruction. Int J Head Neck Surg 2019; 10 (3):67-76.

DOI: 10.5005/jp-journals-10001-1375

License: CC BY-NC 4.0

Published Online: 00-09-2019

Copyright Statement:  Copyright © 2019; Jaypee Brothers Medical Publishers (P) Ltd.


Abstract

Introduction: Surgery for obstructive sleep apnea (OSA) has evolved significantly over the last few decades owing to lessons learned from prior failures and increased understanding of this condition. Analysis of single-level palatal surgery failures and the advent of sleep endoscopy showed the presence of a concomitant hypopharyngeal obstruction, highlighting the importance of hypopharyngeal obstruction in the treatment of OSA. Objective: This article aims to delineate the concepts behind optimal patient selection for hypopharyngeal OSA surgery. Results: Understanding the various factors contributing to hypopharyngeal obstruction allows the treating surgeon to build a framework in the thought process. This allows customization in selecting proper surgical techniques for individual patients in the setting of treating this multifactorial condition. These concepts include understanding the significance of hypopharyngeal obstruction, the concept of volume reduction versus tension enhancement in upper airway surgery, synchronization of major airway dilator with respiration during sleep, the notion of multilevel surgery and significance of holistic management in OSA. It is also important to understand multiple surgeries or different types of surgery may be applicable at the different timeline, for the same patients. Optimal treatment outcome relies on accurate assessment. Assessment methods of particular relevance to hypopharyngeal surgery for OSA include drug-induced sleep endoscopy, Friedman Tongue Position and tongue base lymphoid tissue grading. Types of hypopharyngeal surgery, their indication and efficacy are also discussed in this article. Conclusion: Hypopharyngeal obstruction is prevalent, and its presence is associated with increased OSA severity. In the context of hypopharyngeal surgery for OSA, the key achieving optimal outcome is integration of targeted treatment, clinical expertise, patient preference, and understanding potential positive and negative predictive clinical findings.


PDF Share
  1. Fujita S, Conway W, et al: Surgical correction of anatomic abnormalities of obstructive sleep apnea syndrome: uvulopalatopharyngoplasty. Otolaryngol Head Neck Surg. 1981;89:923–934.
  2. Riley RW, Powell NB, et al. Obstructive sleep apnea syndrome: a surgical protocol for dynamic upper airway reconstruction. J Oral Maxillofac Surg. 1993;51(7):742–747.
  3. Vroegop VA, Vanderveken OM, et al. Drug-induced sleep endoscopy in sleep-disordered breathing: report on 1,249 cases. Laryngoscope. 2014;124(3):797–802.
  4. Phua CQ, Yeo WX, et al. Multi-level obstruction in obstructive sleep apnoea: prevalence, severity and predictive factors. J Laryngol Otol. 2017;131(11):982–986.
  5. Sher AE, Schechtman KB, et al. The efficacy of surgical modifications of the upper airway in adults with obstructive sleep apnea syndrome. Sleep. 1996;19(2):156–177.
  6. KK Li. Hypopharyngeal airway surgery. Otolaryngol Clin N Am. 2007;40:845–853.
  7. Kezirian EK, Goldberg AN. Hypopharyngeal surgery in obstructive sleep apnea: An evidence-based medicine review. Arch Otolarygol Head Neck Surg. 2006;132:206–213.
  8. Lin HC, Friedman M, et al. The efficacy of multilevel surgery of the upper airway in adults with obstructive sleep apnea/hypopnea syndrome. Laryngoscope. 2008;118(5):902–908.
  9. Guimaraes KC, Drager LF, et al. Effects of oropharyngeal exercises on patients with moderate obstructive sleep apnea syndrome. Am J Respir Crit Care Med. 2009;179:962–966.
  10. Camacho M, Certal V, et al. Myofunctional Therapy to Treat Obstructive Sleep Apnea: A Systematic Review and Meta-analysis. Sleep. 2015;38(5):669–675.
  11. Li Y, Lin N, et al. Upper airway fat tissue distribution in subjects with obstructive sleep apnea and its effect on retropalatal mechanical loads. Respir Care. 2012;57(7):1098–1105.
  12. Kim AM, Keenan BT, et al. Tongue Fat and its Relationship to Obstructive Sleep Apnea. Sleep. 2014;37(10):1639–1648.
  13. Peppard PE, Young T, et al. Longitudinal study of moderate weight change and sleep- disordered breathing. JAMA. 2000;284(23):3015–3021.
  14. Subramani Y, Singh M, et al. Understanding Phenotypes of Obstructive Sleep Apnea: Applications in Anesthesia, Surgery, and Perioperative Medicine. Anesth Analg. 2017;124(1):179–191.
  15. Blumen M, Bequignon E, et al. Drug-induced sleep endoscopy: A new gold standard for evaluating OSAS? Part I: Technique. Eur Ann Otorhinolaryngol Head Neck Dis. 2017;134(2):101–107.
  16. De Vito A, Carrasco Llatas M, et al. European position paper on drug-induced sedation endoscopy (DISE). Sleep and Breathing. 2014;18(3):453–465.
  17. Kezirian EJ, Hohenhorst W, et al. Drug-induced sleep endoscopy: the VOTE classification. Eur Arch Otorhinolaryngol. 2011;268:1233–1236.
  18. Vicini C, De Vito A, et al. The nose oropharynx hypopharynx and larynx (NOHL) classification: a new system of diagnostic standardized examination for OSAHS patients. Eur Arch Otorhinolaryngol. 2012;269:1297–1300.
  19. Certal VF, Pratas R, et al. Awake examination versus DISE for surgical decision making in patients with OSA: A systematic review. Laryngoscope. 2016;126(3):768–774.
  20. Huntley C, Chou D, et al. Preoperative Drug Induced Sleep Endoscopy Improves the Surgical Approach to Treatment of Obstructive Sleep Apnea. Ann Otol Rhinol Laryngol. 2017;126(6):478–482.
  21. Friedman M, Ibrahim H, et al. Clinical staging for sleep-disordered breathing. Otolaryngol Head Neck Surg. 2002;127:13–21.
  22. Harvey R, O'Brien L, et al. Friedman tongue position and cone beam computed tomography in patients with obstructive sleep apnea. Laryngoscope Investig Otolaryngol. 2017;2(5):320–324.
  23. Friedman M, Salapatas AM, et al. Updated Friedman Staging System for Obstructive Sleep Apnea. Sleep-Related Breathing Disorders. Adv Otorhinolaryngol. Basel, Karger. 2017;80:41–48.
  24. Friedman M, Yalamanchali S, et al. A Standardized Lingual Tonsil Grading System: Interexaminer Agreement. Otolaryngology-Head and Neck Surgery. 2014;151(1_suppl):47–48.
  25. Wee JH, Tan K, et al. Evaluation of coblation lingual tonsil removal technique for obstructive sleep apnea in Asians: preliminary results of surgical morbidity and prognosticators. Eur Arch Otorhinolaryngol. 2015;272(9):2327–2333.
  26. Leitzbach SU, Bodlaj R, et al. Safety of cold ablation (coblation) in the treatment of tonsillar hypertrophy of the tongue base. Eur Arch Otorhinolaryngol. 2014;271(6):1635–1639.
  27. Zhang Q, Zhou W, et al. Preliminary study on treatment of lingual tonsil hypertrophy by endoscopic assisted coblation. Lin Chung Er Bi Yan HouTou Jing WaiKeZaZhi. 2013;27(14):787–789.
  28. Rangabashyam M, Huang W, et al. State of the art transoral robotic surgery for obstructive sleep apnea-hypopnea syndrome. Robotic Surgery: Research and Reviews. 2016;3:13–28.
  29. Miller SC, Nguyen SA, et al. Transoral robotic base of tongue reduction for obstructive sleep apnea: A systematic review and meta-analysis. Laryngoscope. 2017;127(1):258–265.
  30. Vicini C, Montevecchi F, et al. Clinical outcomes and complications associated with TORS for OSAHS: A benchmark for evaluating an emerging surgical technology in a targeted application for benign disease. ORL. 2014;76:63–69.
  31. Torre C, Camacho M, et al. Epiglottis collapse in adult obstructive sleep apnea: A systematic review. Laryngoscope. 2016;126(2):515–523.
  32. Catalfumo FJ, Golz A, et al. The epiglottis and obstructive sleep apnoea syndrome. J Laryngol Otol. 1998;112:940–943.
  33. Toh ST, Han HJ, et al. Transoral robotic surgery for obstructive sleep apnea in Asian patients: a Singapore sleep centre experience. JAMA Otolaryngol Head Neck Surg. 2014;140:624–629.
  34. Song SA, Chang ET, et al. Genial Tubercle Advancement and Genioplasty for Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis. Laryngoscope. 2017;127:984–992.
  35. Mackay SG, Carney AS, et al. Modified Uvulopalato-pharyngoplasty and Coblation Channeling of the Tongue for Obstructive Sleep Apnea: A Multi-Centre Australian Trial. J Clin Sleep Med. 2013;9(2):117–124.
  36. Woodson BT, Steward DL, et al. A randomized trial of temperature-controlled radiofrequency, continuous positive airway pressure, and placebo for obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg. 2003;128:848–861.
  37. Steward DL, Weaver EM, et al. Multilevel temperature- controlled radiofrequency for obstructive sleep apnea: extended follow-up. Otolaryngol Head Neck Surg. 2005;132(4):630–635.
  38. Zaghi S, Holty JE, et al. Maxillomandibular Advancement for Treatment of Obstructive Sleep Apnea: A Meta-analysis. JAMA Otolaryngol Head Neck Surg. 2016;142(1):58–66.
  39. Riley RW, Powell NB, et al. Obstructive sleep apnea and the hyoid: a revised surgical procedure. Otolaryngol Head Neck Surg. 1994;111:717–721.
  40. Stuck BA, Neff W, et al. Anatomic changes after hyoid suspension for obstructive sleep apnea: an MRI study. Otolaryngol Head Neck Surg. 2005;133(3):397–402.
  41. Baisch A, Maurer JT, et al. The effect of hyoid suspension in a multilevel surgery concept for obstructive sleep apnea. Otolaryngol Head Neck Surg. 2006;134:856–861.
  42. Verse T, Baisch A, et al. Multilevel surgery for obstructive sleep apnea: short-term results. Otolaryngol Head Neck Surg. 2006;134:571–577.
  43. Ha JG, Min HJ, et al. The Dimension of Hyoid Bone Is Independently Associated with the Severity of Obstructive Sleep Apnea. PLos ONE. 2013;8(12):e81590.
  44. Hamans E, Stuck BA, et al. Hyoid expansion as a treat- ment for obstructive sleep apnea: a pilot study. Sleep Breath. 2013;17(1): 195–201.
  45. Toh ST, Hsu PP, et al. Hyoid Expansion With Titanium Plate and Screw A Human Cadaveric Study Using Computer-Assisted Airway Measurement. JAMA Otolaryngol Head Neck Surg. 2013;139(8): 817–821.
  46. Heiser C, Edenharter G, et al. Palatoglossus coupling in selective upper airway stimulation. Laryngoscope. 2017;127(10):E378–E383.
  47. Strollo PJ Jr, Soose RJ, et al. Upper-airway stimulation for obstructive sleep apnea. N Engl J Med. 2014;370:139–149.
  48. Woodson BT, Soose RJ, et al. Three-Year Outcomes of Cranial Nerve Stimulation for Obstructive Sleep Apnea: The STAR Trial. Otolaryngol Head Neck Surg. 2016;154(1):181–188.
  49. Gillespie MB, Soose RJ, et al. Upper airway stimulation for obstructive sleep apnea: Patient reported outcomes after 48 months of follow-up. Otolaryngology - Head and Neck Surgery. 2017;156(4):765–771.
  50. McMillan A, Bratton DJ, et al. Continous positive airway pressure in older people with obstructive sleep apnoea syndrome (PREDICT): a 12 month multicenter randomized trial. Lancet Respir Med. 2014;2:804–812.
  51. Harvold EP, Tomer BS, et al. Primate experiments on oral respiration. Am. J. Orthod. 1981;79:359–372. doi: 10.1016/0002-9416(81)90379-1.
  52. Guilleminault C, Huseni S, et al. A frequent phenotype for paediatric sleep apnoea: short lingual frenulum. ERJ Open Res. 2016;2(3):00043-2016.
  53. Caples SM, Rowley JA, et al. Surgical Modifications of the Upper Airway for Obstructive Sleep Apnea in Adults: A Systematic Review and Meta-Analysis. Sleep. 2010;33(10):1396–1407.
  54. Benoist LBL, Verhagen M, et al. Positional therapy in patients with residual positional obstructive sleep apnea after upper airway surgery. Sleep Breath. 2017;21(2):279–288.
  55. Ishman SL, Ishii LE, et al. Temporal trends in sleep apneasuregry: 1993-2010. Laryngoscope. 2014;124(5):1251–1258.
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.