Authored by Ahmed Mohamed Mohye El Din Elbassiouny*
Abstract
Objective: To investigate the overall efficacy of a single-stage surgical procedure based on localizing the site of anatomic obstruction with simultaneous combined nasal-palatopharyngeal surgery for the treatment of OSA.
Methods: A total of 35 consecutive OSA patients were enrolled in the study. All patients had OSA, were type I Fujita classification, stage 1 or 2 Friedman classification and had nasal septal deviation and inferior turbinate hypertrophy. Intraoperative drug-induced sleep endoscopy (DISE) was performed in all patients. Modified barbed palatopharyngoplasty with septoplasty and reduction of the size of inferior turbinate were used to correct the upper airway abnormalities. Baseline and 6 months postoperative overnight portable polysomnography was performed. Surgical results (Subjective symptoms improvement, reduction of OSA), patient satisfaction, complications were recorded. Surgical success was defined as a reduction of at least 50% in the preoperative apnea-hypopnea index (AHI) and a final AHI of less than 20 per hour.
Results: The Surgical success was 89% (31/35) of patients, 26 males, and 9 females. Snoring was improved with a snoring scale reduced from 9.4±2.8 to 1.07±0.3 (p<0.0001). The nasal blockage was improved with the nasal Obstruction Visual Analog Scale from 8.6±1.3 to 0.57±0.2 (p<0.0001). The Epworth Sleepiness score (ESS) was decreased from 8.9±1.3 to 1.11±0.2(p< 0.0001). The pre-operative to post-operative AHI statistically improved from 38.4±23.3 to 12.3±21.1 (p <0.0001) and lowest O2 saturation from 73.9±12.6% to 87.8±9.4%(p<0.001). There were no significant complications. All patients were satisfied with the single-stage treatment.
Conclusion: Our data indicate that Single-staged modified barbed soft palatal posterior pillar flap palatopharyngoplasty with nasal surgery is a safe, effective. It has the potential to serve as an effective alternative for the staged surgery without adding to the cost-effectiveness in terms of total hospitalization.
Keywords: Single stage; Nasal surgery; Palatopharyngeal surgery; Drug induced sleep endoscopy; OSA
Introduction
Obstructive sleep apnea (OSA) is a disorder caused by the repetitive collapse of the upper airway during sleep that may occur at any level including the nasal cavity, nasopharynx, oropharynx, and hypopharynx, and may be either single-level or multilevel. Data from observational studies suggest that nasal obstruction contributes to the pathogenesis of snoring and OSA [1]. In most studies, nasal obstruction is partially related to the development | or aggravation of OSA [2,3]. Nasal obstruction is related to OSA in several ways:
1. Increasing upper airway resistance as nasal obstruction can cause an increase in negative pressure in the upper airway and induces an inspiratory collapse at the pharyngeal level.
2. Patients become mouth breathers during sleep, which destabilizes the upper airway and aggravates sleep-related breathing disorder.
3. Interferes with the nasal reflexes that stimulate ventilation [4].
Data on OSA patients treated for nasal obstruction alone has shown consistent improvement in subjective symptoms such as daytime somnolence and snoring despite a minimal change in their sleep study results [5]. However, in other words, the effect of nasal surgery alone in sleep-disordered breathing (SDB) with nasal obstruction is controversial [6,7]. Nasal surgery alone has also been shown to significantly improve CPAP tolerance and adherence [8].
Obstruction at the level of the soft palate, pharynx, and tonsillar pillars is a more common finding in patients with snoring and OSA. These sites are the focus of many of the surgical procedures traditionally labeled phase I therapies. Soft palatal procedures serve to reduce or reconstruct the collapsible portions of the soft palate. Recently, there has been a paradigm shift within the field of sleep surgery in recent years with an emphasis on mucosalsparing reconstruction of the soft palate rather than ablation [9]. Surgical management of retropalatal airspace obstruction now focuses on the concept of lateral pharyngeal port opening [10- 12]. The complete lateral oropharyngeal collapse was significantly associated with increased severity of OSA. The complete concentric collapse of the velum and complete lateral oropharyngeal collapse were associated with higher BMI values [13].
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