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Surgical Treatment of Obstructive Sleep Apnea

Alper Dilci, Handan Koyuncu and Vural Fidan*

Otorhinolaryngology*Corresponding author Department,: Yunus Emre Government Hospital , Turkey Vural Fidan, Otorhinolaryngology Department, Yunus Emre GovernmentPublished Date: Hospital, May 30,Eskisehir, 2017 Turkey, Email: [email protected]

SURGICAL TREATMENT OF OBSTRUCTIVE SLEEP APNEA The main problem in obstructive sleep apnea (OSA) is the vulnerability of airway to collapse. The complex interaction between respiratory control, arousal thresholds, neuromuscular tone and transmural pressure in the determine the patency of the airway through the respiration.

Stabilization of airflow in an airway compromised by OSA often requires multimodality treatment.

Factors important in making the decision to treat OSA with a surgical procedure include the and site and severity of upper airway collapse. The role of surgery is based on the reconstructive patient’s wishes, CPAP tolerance, severity of symptoms, severity of disease, patient comor-bidities, approach to improve the patency of airway tube and flow. structure is not usually the only cause of obstruction so, multiple sites of the airway often Surgical treatment often requires a combination of procedures. In adults, a single anatomic require treatment for optimal results. Understanding the pathophysiology of OSA along with the and narrowing of both retropalatal and retroglossal airways occurs in 70% to 80% of patients. airway phenotype will aid in the selection and surgical application of procedures. Obstruction primary site is uncommon [1]. Obstruction occurs in the pharynx for most events but obstruction of laryngeal tissues as a Obstructive Sleep Apnea | www.smgebooks.com 1 Copyright  Fidan V. This book chapter is open access distributed under the Creative Commons Attribution 4.0 International License, which allows users to download, copy and build upon published articles even for commercial purposes, as long as the author and publisher are properly credited. of obstruction must be determined in each patient to determine the type and extent of surgical Patients with OSA are usually managed using a staged, stepwise surgical protocol. The site for sleep apnea and snoring effectively reduces obstruction and collapse by bypassing the upper intervention. Endoscopic examination is performed to determine the site of obstruction. Surgery airway, reconstructing soft tissues, reconstructing skeletal structure, or augmenting the effects of other procedures. Successful responders are defined as having a 50% improvement in apnea or AnesthesiaAHI [2].

Sleep apnea patients may have unique preoperative, intraoperative, and postoperative care control [3]. Patients with severe obesity, poor pulmonary reserve, pharyngeal tissue redundancy, problems. Difficulty with intubation and extubation occurs related to facial structural or ventilatory hypoxemia, excessive narcotic use, multiple airway surgical procedures, and excessive sleepiness are the main risks of patients with OSA in anesthesia [4]. Patients with and pulmonary disease, and obesity. Close nursing observation is necessary in the perioperative sleep apnea are also at elevated risk due to significant comorbidities of hypertension, cardiac period. Postoperative interventions for apnea patients who have airway and nonairway surgery corticosteroids, and other nonnarcotic pain medication. may include nasal airways, nasal CPAP, patient positioning (head of bed), adequate hydration, Nasal Surgery

Nasal obstruction has been associated with poor sleep quality, snoring, and OSA. The nose contributes 70% of upper-airway resistance in adult humans and is a segment with the greatest upper-airway resistance [5]. Septoplasty, turbinate reduction, nasal valve surgery, and sinus the selection of a nasal procedure is based on pathology. surgery are procedures that have been used to treat nasal obstruction associated with OSA, and

A paradox has been described; although nasal obstruction is a risk factor for OSA, treatment of it does not necessarily affect the risk. However, even though nasal procedures are unlikely to significantly improve OSA when used alone, improving nasal patency may help restore physiologic breathing and may allow for the use of nasal CPAP in patients previously unable to tolerate it. Consideration should be made to address nasal obstruction as an initial step in OSA management so as to facilitate better CPAP adherence [6]. authors have assessed this in combination with other procedures including turbinate reduction, Most studies regarding the impact of nasal surgery on OSA have focused on septoplasty. Some

UPPP, and sinus surgeries. Interesting finding has been that for some patients there may be an improved tolerance of CPAP or a decrease in overall pressure required to treat their OSA following nasal surgery. This potentially could improve CPAP tolerance in patients where higher ObstructiveCPAP pressures Sleep Apnea are the | www.smgebooks.com suspected etiology for poor compliance. 2 Copyright  Fidan V. This book chapter is open access distributed under the Creative Commons Attribution 4.0 International License, which allows users to download, copy and build upon published articles even for commercial purposes, as long as the author and publisher are properly credited. Surgical techniques utilized included turbinectomy. Laser surgery thermal techniques with predominantly radio frequency ablation and coblation, and turbinoplasty including microdebridement. Today the thermal techniques, including radiofrequency ablation and coblation, and the sub mucosal resection techniques with micro debridement seem to be the Palatalpreferred Surgery procedures. How these surgeries impact sleep parameters is unclear. (UPPP) with was developed to eliminate palatal obstruction by resection of redundant Uvulopalatopharyngoplasty was first described in 1981 for OSA treatment [7]. UPPP palatal and pharyngeal tissue. The procedure removes distal soft , the faucial tonsils, uvula, and redundant mucosa from the anterior and posterior tonsillar pillars. The posterior pillar is then sutured anteriorly, and the mucosa is approximated. Multiple variations of the technique the retropalatal airway segment therefore the site of pharyngeal collapse has a marked effect have been described. This technique is associated with increases in pharyngeal airway size in on the probability of the success of UPPP. It is the most common of multiple palatoplasty and palatopharyngoplasty techniques used to treat OSA [8].

Using a staging system based on palate position, tonsil size, and BMI staging OSA patients for the prediction of success for UPPP was demonstrated. In this staging system, tonsil size, BMI, and palate position based on the modified Mallampati staging are used to stratify patients [9]. retropalatal obstruction also. To improve on the traditional UPPP procedure, other techniques have been suggested to address submucous cleft palate, or a nonpalatal level of obstruction and in patients whose speech or The procedure may be contraindicated in patients with velopharyngeal insufficiency, bleeding, infection, mucosal dryness, sensation of oropharyngeal tightness or phlegm, pharyngeal swallowing. Complications associated with UPPP include temporary nasal reflux, postoperative dysphagia, and severe postoperative pain and rarely altered speech [10].

Several methods of UPPP have now been described and compared to more traditional methods using evidence-based medicine. Described techniques include lateral pharyngoplasty, expansion lateral pharyngeal wall muscles and superior constrictor proxmimal to the free margin of the sphincteroplasty, and palatal advancement. Lateral pharyngoplasty exposes and plicates the muscle on the pharyngeal wall and uses this muscle as a sling to advance and open the soft palate soft palate [11]. Expansion sphincteroplasty exposes, isolates, and divides the palatopharyngeus and pharynx. Lateral pharyngeal wall collapse can play a significant role in the pathogenesis of tension of the lateral wall and reduce lateral collapse [12]. Palatal advancement removes distal OSA and should be recognized. The goal of this technique in airway reconstruction is to increase to increase the retropalatal space in a patient who has a very posterior bued hard, soft palate hard palate to advance the soft palate anteriorly and superiorly. It can be particularly useful junction [13].

Obstructive Sleep Apnea | www.smgebooks.com 3 Copyright  Fidan V. This book chapter is open access distributed under the Creative Commons Attribution 4.0 International License, which allows users to download, copy and build upon published articles even for commercial purposes, as long as the author and publisher are properly credited. The palatal implant was designed to reduce soft palate airway collapse and obstruction through placement of three woven implants, which stiffen the palate. The most common complication of this procedure is partial implant extrusion. Potential advantages include the fact that it can be done in a single office visit, has minimal morbidity, and has been noted to significantly reduce snoring [14]. Sclerotherapy agents create scar in the mucosa of the soft palate and have been used creating scar and tissue slough. to treat patients with primary snoring. Agents are injected into the submucosa of the soft palate (LAUP) using the carbon dioxide laser is hemostatic surgery

Laser assisted be resected with healing by secondary intent. Two vertical trenches in the soft palate lateral to the of the palate and can be performed under local anesthesia. 42 The palate, velum, and uvula could uvula of variable width and length at free margin of the distal part of the soft palate are created and the uvula reduced. Palatal scarring initially increases tension and

reduces snoring but long-term data (5 years) suggest recurrence of snoring is common. Airway narrowing may occur and worsen sleep apnea. Techniques using ablational radiofrequency demonstrateConceptually, less pain one offor thetreatment major causesof snoring of failurecompared of palateto the laser surgery [15]. is obstruction at other nonpalatal sites. Hypopharyngeal airway ruurowing has been implicated as a cause of surgical Oropharyngealfailure. Combining treatments Surgery of the hypopharyngeal airway may improve UPPP outcome. Tonsillectomy has been used to address the upper airway compromise caused by tonsillar been utilized to decrease resultant operative and postoperative complications associated with hypertrophy. Recently, new techniques of tonsillectomy and tonsil volume reduction have the traditional procedure. Radiofrequency tonsil reduction by intracapsular tonsillectomy has gained popularity and is being used in the treatment of OSA. In adults the outcome of simple tonsillectomy is likely limited. In a subset of patients, removing isolated palatine tonsils may be definitive; however identifying this population is difficult.

Lateral pharyngoplasty involves bilateral tonsillectomy, longitudinal incision of the superior closure of the superior aspect of the tonsillar fossa, and suturing of the anterior and posterior pharyngeal constrictor, diagonal incision through the superior palatopharyngeus, Z-plasty

Basepillars oftogether at the Procedures inferior aspect of the tonsillar fossa [16]. been used. These include partial , ablational glossectomy, mandibular advancement, Obstruction at the base of the tongue level is surgically challenging. Multiple techniques have maxillary advancement, limited mandibular osteotomies, tongue suspension, hyoid suspension, radiofrequency ablation therapies, lingual tonsillectomy, and supraglottoplasty. Obstructive Sleep Apnea | www.smgebooks.com 4 Copyright  Fidan V. This