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Surgical correction of lateral pharyngeal wall collapse in sleep-related disordered breathing: Functional expansion pharyngoplasty
Author's Accepted Manuscript
Surgical Correction of Lateral Pharyngeal Wall Collapse in Sleep Related Disordered Breathing: Functional Expansion Pharyngoplasty Ottavio Piccin MD-MSc, Valentina Pinto MD, Giovanni Sorrenti MD
www.techgiendoscopy.com
PII: DOI: Reference:
S1043-1810(15)00110-4 http://dx.doi.org/10.1016/j.otot.2015.10.002 YOTOT692
To appear in:
Operative Techniques in Otolaryngology
Cite this article as: Ottavio Piccin MD-MSc, Valentina Pinto MD, Giovanni Sorrenti MD, Surgical Correction of Lateral Pharyngeal Wall Collapse in Sleep Related Disordered Breathing: Functional Expansion Pharyngoplasty, Operative Techniques in Otolaryngology, http://dx.doi.org/10.1016/j.otot.2015.10.002 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
SURGICAL CORRECTION OF LATERAL PHARYNGEAL WALL COLLAPSE IN SLEEP RELATED DISORDERED BREATHING: FUNCTIONAL EXPANSION PHARYNGOPLASTY
Ottavio Piccin MD-MSc, Valentina Pinto MD*, Giovanni Sorrenti MD Department of Otolaryngology, * Plastic and Reconstructive Surgery Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy Corresponding author: Ottavio Piccin MD, Department of Otolaryngology, S. Orsola-Malpighi University Hospital, Via Massarenti 9, 40138, Bologna, Italy e-mail: [email protected] phone: +393391184045 fax: +390516363525 Key words: obstructive sleep apnea, uvulopalatopharyngoplasty, expansion pharyngoplasty No financial disclosure Conflict of interest: none Short running title: Functional expansion pharyngoplasty for OSA treatment
ABSTRACT
The recent evolution regarding the techniques of pharyngoplasty has been focused on the concept of obtaining the expansion and stabilization of the pharyngeal airspace through the treatment of lateral pharyngeal wall (LPW) collapse rather than through ablation of the redundant pharyngeal soft tissue. The role of LPW in the pathogenesis of OSAS has been
1
demonstrated by radiologic and sleep endoscopy studies and
the narrowing of the LPW
appears to be the sole independent risk factor for OSAS. The Functional Expansion Pharyngoplasty represents a conservative modification of Expansion Sphincter Pharyngoplasty and can be utilized in patients with obstruction of the upper airway due to the lateral pharyngeal walls collapse without altering physiologic functions of the upper airway, including smell, taste, swallowing, and speech.
INTRODUCTION
Among the variety of surgical procedures described to expand the pharyngeal lumen in obstructive sleep apnea syndrome (OSAS), uvulopalatopharyngoplasty (UPPP) remains the most frequently performed technique for the treatment of retropalatal obstruction. UPPP first described by Fujita in 1981 1, basically consists of a tonsillectomy, trimming of the soft palate and uvula and suturing of the tonsillar pillars. Due to its low success rate and the considerable morbidities involved 2 the role of this technique has been questioned since the 1990s and, in the last two decades, many modifications of UPPP have been proposed. The recent evolution regarding the techniques of pharyngoplasty has been focused on the concept of obtaining the expansion and stabilization of the pharyngeal airspace through the treatment of lateral pharyngeal wall (LPW) collapse rather than through ablation of the redundant pharyngeal soft tissue. The role of LPW in the pathogenesis of OSAS has been demonstrated by Schwab 3
. The narrowing of the LPW appears to be the sole independent risk factor for OSAS. We present a new
surgical technique called “ Functional Expansion Pharyngoplasty” (FEP) which represents a conservative modification of Expansion Sphincter Pharyngoplasty as described by K. Pang and T. Woodson 4. The FEP technique involves the splinting of the LPW and advancement of the soft palate obtained by means of supero-lateral repositioning of the palatopharyngeus muscle with a less aggressive and more “physiologic” approach to the LPW and soft palate, to fulfill both increase of pharyngeal airspace and decrease of pharyngeal collapse, without undermining velum muscles so avoiding scarring of the velum.
2
INDICATIONS This surgical technique is indicated in the treatment of retropalatal obstruction in OSAS patients as an isolated technique or in combination with other nasal and hypopharyngeal techniques in a multilevel protocol. In our protocol, the surgery originates from a diagnostic work up completed by drug induced sleep endoscopy (DISE). In case of retropalatal obstruction and lateral pharyngeal wall collapse, we carry out this procedure in order to treat the retropalatal segment; in case of the coexistence of retrolingualhypopharyngeal obstruction, FEP was combined with hyoid suspension or tongue base reduction.
SURGICAL TECHNIQUE The surgery is performed while the patients are under general anesthesia and in supine position with their head extended. The authors perform the procedure with orally endotracheal intubation and a mouth gag is then used to adequately expose the oropharynx. The operation was initiated with a bilateral tonsillectomy performed with a cold instrument to spare the palatopharyngeus muscle (PPM) and the mucosa of the tonsillar pillars (figure 1). The key point of the surgical procedure is the identification and careful dissection of the PPM in the midpoint of the tonsillar fossa (figure 2). Using a dissection forceps and pulling up the muscular faciculus with a 2.0 vicryl , the Authors separated the superior 2/3s of the PPM from the superior pharyngeal constrictor (SPC) muscle; medially, a muscular rim of the PPM is preserved to avoid damage to the pillar mucosa and consequent retracting scar tissue. Using an angulate scissor (Long Fomon type), the PPM is transected, creating a superior flap medially based on the palatine musculature; the inferior third of the PPM is laterally sutured to the SPC (figure 3). With a gentle blunt dissection using curved haemostatic forceps, a tunnel is then obtained through the palatal musculature from the apex of the tonsillar fossa to the hamulus of the pterygoid process (figure 4). The PPM flap is then elevated with a superolateral rotation through the palatine tunnel and fixed to the palatine musculature, close to the pterygoid hamulus, using a 2-0 MH vicryl “figure-eight suture” (figures 5-6). The PPM flap is anchored, stitching 3 times (with different angulations) into the muscle before its relocation in order to obtain a steady anterolateral fixation of the flap which moves the soft palate in a forward direction and creates an immediate
widening of the antero-posterior and lateral oropharyngeal diameters (figure 7). The
3
procedure ends with suturing the superior 2/3s of the tonsillar pillars; the uvula is trimmed only when abnormally elongated (figure 8).
COMPLICATIONS No dysphagia or swallowing disturbances were referred.
DISCUSSION The recent evolution regarding the techniques of pharyngoplasty has been focused on the concept of obtaining the expansion and stabilization of the pharyngeal airspace through the treatment of lateral pharyngeal wall (LPW) collapse rather than through ablation of the redundant pharyngeal soft tissue. The role of LPW in the pathogenesis of OSAS has been demonstrated by Schwab 3. The narrowing of the LPW appears to be the sole independent risk factor for OSAS. The first surgical technique aimed at stabilizing the lateral wall was lateral pharyngoplasty described by Cahali in 2003 5, a technique which was not widely used. In fact, this procedure involves a notable modification of the lateral wall with sectioning of the superior pharyngeal constrictor (SPC) muscle and the risk of significant complications, including postoperative dysphagia. Instead, the Expansion Sphincter Pharyngoplasty (ESP), described by Pang and Woodson in 2007 4 has had much greater acceptance; it originated from the technique of sphincter pharyngoplasty described for the correction of palatal incompetence using medial rotation of the palatal pharyngeal muscle in such as way as to narrow the velopharyngeal isthmus. In the case of OSAS patients, the muscle is instead superolaterally rotated and sutured to the palatine musculature after incision of the muco-palatal plane; the surgery ends with resection of the uvula. The FEP technique does not involve sensitivity and swallowing disturbances. Infact, the complete preservation of the soft palate and uvula involves less invasivity than the other techniques. In this respect it is worth to remember that the palatoglossus muscles (anterior part of the soft palate) muscle spindles play a role in inducing unconstrained swallowing. Therefore, this anterior palatine arch,
4
together with the paired muscularis uvulae, must be protected when performing soft palate surgery. On the other hand, the palatopharyngeal muscle (posterior part of the soft palate) has no muscle spindles6; therefore, it can be partially separated without impeding swallowing or the possibility of future nasally applied continuous positive airway pressure therapy.
CONCLUSIONS The FEP represents a technique that improves form and function without altering other physiologic functions of the upper airway, including smell, taste, swallowing, and speech. This technique can be utilized in patients with documented retropalatal obstruction and obstruction of the upper airway due to the lateral pharyngeal walls collapse .
REFERENCES
1) Fujita S, Cinway W, Zorik F, et al: Surgical correction of anatomic abnormalities in obstructive sleep apnea syndrome: uvulopalatopharyngoplasty. Otolaryngol Head Neck Surg. 1981;89:923-934.
2) Sher AE, Schechtman KB, Piccirillo JF: The efficacy of surgical modifications of the upper airway in adults with obstructive sleep apnea syndrome. Sleep. 1996;19:156-177.
3) Schwab RJ, Pack A, Gupta HB, et al. Upper airway and soft tissue structural changes induced by CPAP in normal subjects. Am J Respir Crit Care Med. 1996;154:1106-1116.
4) Pang KP, Tucker Woodson B. Expansion Sphincter Pharyngoplasty in the Treatment of Obstructive Sleep Apnea. Operative Techniques in Otolaryngology. 2006; 17: 223-225.
5
5) Cahali MB. Lateral pharyngoplasty: a New Treatment for Obstructive Sleep Apnea Hypopnea Syndrome. Laryngoscope. 2003;113:1961-1968.
6) Gross Anatomical study of the palatopharyngeus muscle throughout its entire course from origin to insertion. Sumida K, Yamashita K, Kitamura S. Clinical Anatomy 2012; 25:314-323.
LEGEND FOR FIGURES
Figure 1: tonsillectomy. Figure 2: identification and careful dissection of the PPM. Figure 3: the PPM is transected, creating a superior flap medially based on the palatine musculature; the inferior third of the PPM is laterally sutured to the SPC. Figure 4: a tunnel is obtained through the palatal musculature from the apex of the tonsillar fossa to the hamulus of the pterygoid process. Figures 5-6: the PPM flap is elevated with a superolateral rotation through the palatine tunnel and fixed to the palatine musculature, close to the pterygoid hamulus, using a 2-0 MH vicryl figure-8 suture. Figure 7: the PPM flap is anchored, stitching 3 times into the muscle before its relocation in order to obtain a steady anterolateral fixation of the flap which moves the soft palate in a forward direction and creates an immediate widening of the antero-posterior and lateral oropharyngeal diameters. Figure 8: suture of the superior 2/3s of the tonsillar pillars.
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Surgical Correction of Lateral Pharyngeal Wall Collapse in Sleep Related Disordered Breathing: Functional Expansion Pharyngoplasty Ottavio Piccin MD-MSc, Valentina Pinto MD, Giovanni Sorrenti MD
www.techgiendoscopy.com
PII: DOI: Reference:
S1043-1810(15)00110-4 http://dx.doi.org/10.1016/j.otot.2015.10.002 YOTOT692
To appear in:
Operative Techniques in Otolaryngology
Cite this article as: Ottavio Piccin MD-MSc, Valentina Pinto MD, Giovanni Sorrenti MD, Surgical Correction of Lateral Pharyngeal Wall Collapse in Sleep Related Disordered Breathing: Functional Expansion Pharyngoplasty, Operative Techniques in Otolaryngology, http://dx.doi.org/10.1016/j.otot.2015.10.002 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
SURGICAL CORRECTION OF LATERAL PHARYNGEAL WALL COLLAPSE IN SLEEP RELATED DISORDERED BREATHING: FUNCTIONAL EXPANSION PHARYNGOPLASTY
Ottavio Piccin MD-MSc, Valentina Pinto MD*, Giovanni Sorrenti MD Department of Otolaryngology, * Plastic and Reconstructive Surgery Unit, S. Orsola-Malpighi University Hospital, Bologna, Italy Corresponding author: Ottavio Piccin MD, Department of Otolaryngology, S. Orsola-Malpighi University Hospital, Via Massarenti 9, 40138, Bologna, Italy e-mail: [email protected] phone: +393391184045 fax: +390516363525 Key words: obstructive sleep apnea, uvulopalatopharyngoplasty, expansion pharyngoplasty No financial disclosure Conflict of interest: none Short running title: Functional expansion pharyngoplasty for OSA treatment
ABSTRACT
The recent evolution regarding the techniques of pharyngoplasty has been focused on the concept of obtaining the expansion and stabilization of the pharyngeal airspace through the treatment of lateral pharyngeal wall (LPW) collapse rather than through ablation of the redundant pharyngeal soft tissue. The role of LPW in the pathogenesis of OSAS has been
1
demonstrated by radiologic and sleep endoscopy studies and
the narrowing of the LPW
appears to be the sole independent risk factor for OSAS. The Functional Expansion Pharyngoplasty represents a conservative modification of Expansion Sphincter Pharyngoplasty and can be utilized in patients with obstruction of the upper airway due to the lateral pharyngeal walls collapse without altering physiologic functions of the upper airway, including smell, taste, swallowing, and speech.
INTRODUCTION
Among the variety of surgical procedures described to expand the pharyngeal lumen in obstructive sleep apnea syndrome (OSAS), uvulopalatopharyngoplasty (UPPP) remains the most frequently performed technique for the treatment of retropalatal obstruction. UPPP first described by Fujita in 1981 1, basically consists of a tonsillectomy, trimming of the soft palate and uvula and suturing of the tonsillar pillars. Due to its low success rate and the considerable morbidities involved 2 the role of this technique has been questioned since the 1990s and, in the last two decades, many modifications of UPPP have been proposed. The recent evolution regarding the techniques of pharyngoplasty has been focused on the concept of obtaining the expansion and stabilization of the pharyngeal airspace through the treatment of lateral pharyngeal wall (LPW) collapse rather than through ablation of the redundant pharyngeal soft tissue. The role of LPW in the pathogenesis of OSAS has been demonstrated by Schwab 3
. The narrowing of the LPW appears to be the sole independent risk factor for OSAS. We present a new
surgical technique called “ Functional Expansion Pharyngoplasty” (FEP) which represents a conservative modification of Expansion Sphincter Pharyngoplasty as described by K. Pang and T. Woodson 4. The FEP technique involves the splinting of the LPW and advancement of the soft palate obtained by means of supero-lateral repositioning of the palatopharyngeus muscle with a less aggressive and more “physiologic” approach to the LPW and soft palate, to fulfill both increase of pharyngeal airspace and decrease of pharyngeal collapse, without undermining velum muscles so avoiding scarring of the velum.
2
INDICATIONS This surgical technique is indicated in the treatment of retropalatal obstruction in OSAS patients as an isolated technique or in combination with other nasal and hypopharyngeal techniques in a multilevel protocol. In our protocol, the surgery originates from a diagnostic work up completed by drug induced sleep endoscopy (DISE). In case of retropalatal obstruction and lateral pharyngeal wall collapse, we carry out this procedure in order to treat the retropalatal segment; in case of the coexistence of retrolingualhypopharyngeal obstruction, FEP was combined with hyoid suspension or tongue base reduction.
SURGICAL TECHNIQUE The surgery is performed while the patients are under general anesthesia and in supine position with their head extended. The authors perform the procedure with orally endotracheal intubation and a mouth gag is then used to adequately expose the oropharynx. The operation was initiated with a bilateral tonsillectomy performed with a cold instrument to spare the palatopharyngeus muscle (PPM) and the mucosa of the tonsillar pillars (figure 1). The key point of the surgical procedure is the identification and careful dissection of the PPM in the midpoint of the tonsillar fossa (figure 2). Using a dissection forceps and pulling up the muscular faciculus with a 2.0 vicryl , the Authors separated the superior 2/3s of the PPM from the superior pharyngeal constrictor (SPC) muscle; medially, a muscular rim of the PPM is preserved to avoid damage to the pillar mucosa and consequent retracting scar tissue. Using an angulate scissor (Long Fomon type), the PPM is transected, creating a superior flap medially based on the palatine musculature; the inferior third of the PPM is laterally sutured to the SPC (figure 3). With a gentle blunt dissection using curved haemostatic forceps, a tunnel is then obtained through the palatal musculature from the apex of the tonsillar fossa to the hamulus of the pterygoid process (figure 4). The PPM flap is then elevated with a superolateral rotation through the palatine tunnel and fixed to the palatine musculature, close to the pterygoid hamulus, using a 2-0 MH vicryl “figure-eight suture” (figures 5-6). The PPM flap is anchored, stitching 3 times (with different angulations) into the muscle before its relocation in order to obtain a steady anterolateral fixation of the flap which moves the soft palate in a forward direction and creates an immediate
widening of the antero-posterior and lateral oropharyngeal diameters (figure 7). The
3
procedure ends with suturing the superior 2/3s of the tonsillar pillars; the uvula is trimmed only when abnormally elongated (figure 8).
COMPLICATIONS No dysphagia or swallowing disturbances were referred.
DISCUSSION The recent evolution regarding the techniques of pharyngoplasty has been focused on the concept of obtaining the expansion and stabilization of the pharyngeal airspace through the treatment of lateral pharyngeal wall (LPW) collapse rather than through ablation of the redundant pharyngeal soft tissue. The role of LPW in the pathogenesis of OSAS has been demonstrated by Schwab 3. The narrowing of the LPW appears to be the sole independent risk factor for OSAS. The first surgical technique aimed at stabilizing the lateral wall was lateral pharyngoplasty described by Cahali in 2003 5, a technique which was not widely used. In fact, this procedure involves a notable modification of the lateral wall with sectioning of the superior pharyngeal constrictor (SPC) muscle and the risk of significant complications, including postoperative dysphagia. Instead, the Expansion Sphincter Pharyngoplasty (ESP), described by Pang and Woodson in 2007 4 has had much greater acceptance; it originated from the technique of sphincter pharyngoplasty described for the correction of palatal incompetence using medial rotation of the palatal pharyngeal muscle in such as way as to narrow the velopharyngeal isthmus. In the case of OSAS patients, the muscle is instead superolaterally rotated and sutured to the palatine musculature after incision of the muco-palatal plane; the surgery ends with resection of the uvula. The FEP technique does not involve sensitivity and swallowing disturbances. Infact, the complete preservation of the soft palate and uvula involves less invasivity than the other techniques. In this respect it is worth to remember that the palatoglossus muscles (anterior part of the soft palate) muscle spindles play a role in inducing unconstrained swallowing. Therefore, this anterior palatine arch,
4
together with the paired muscularis uvulae, must be protected when performing soft palate surgery. On the other hand, the palatopharyngeal muscle (posterior part of the soft palate) has no muscle spindles6; therefore, it can be partially separated without impeding swallowing or the possibility of future nasally applied continuous positive airway pressure therapy.
CONCLUSIONS The FEP represents a technique that improves form and function without altering other physiologic functions of the upper airway, including smell, taste, swallowing, and speech. This technique can be utilized in patients with documented retropalatal obstruction and obstruction of the upper airway due to the lateral pharyngeal walls collapse .
REFERENCES
1) Fujita S, Cinway W, Zorik F, et al: Surgical correction of anatomic abnormalities in obstructive sleep apnea syndrome: uvulopalatopharyngoplasty. Otolaryngol Head Neck Surg. 1981;89:923-934.
2) Sher AE, Schechtman KB, Piccirillo JF: The efficacy of surgical modifications of the upper airway in adults with obstructive sleep apnea syndrome. Sleep. 1996;19:156-177.
3) Schwab RJ, Pack A, Gupta HB, et al. Upper airway and soft tissue structural changes induced by CPAP in normal subjects. Am J Respir Crit Care Med. 1996;154:1106-1116.
4) Pang KP, Tucker Woodson B. Expansion Sphincter Pharyngoplasty in the Treatment of Obstructive Sleep Apnea. Operative Techniques in Otolaryngology. 2006; 17: 223-225.
5
5) Cahali MB. Lateral pharyngoplasty: a New Treatment for Obstructive Sleep Apnea Hypopnea Syndrome. Laryngoscope. 2003;113:1961-1968.
6) Gross Anatomical study of the palatopharyngeus muscle throughout its entire course from origin to insertion. Sumida K, Yamashita K, Kitamura S. Clinical Anatomy 2012; 25:314-323.
LEGEND FOR FIGURES
Figure 1: tonsillectomy. Figure 2: identification and careful dissection of the PPM. Figure 3: the PPM is transected, creating a superior flap medially based on the palatine musculature; the inferior third of the PPM is laterally sutured to the SPC. Figure 4: a tunnel is obtained through the palatal musculature from the apex of the tonsillar fossa to the hamulus of the pterygoid process. Figures 5-6: the PPM flap is elevated with a superolateral rotation through the palatine tunnel and fixed to the palatine musculature, close to the pterygoid hamulus, using a 2-0 MH vicryl figure-8 suture. Figure 7: the PPM flap is anchored, stitching 3 times into the muscle before its relocation in order to obtain a steady anterolateral fixation of the flap which moves the soft palate in a forward direction and creates an immediate widening of the antero-posterior and lateral oropharyngeal diameters. Figure 8: suture of the superior 2/3s of the tonsillar pillars.
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10
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