1
Introduction
Severe obstructive sleep apnea syndrome (OSAS) is preferably treated by nasal continuous positive airway pressure (NCPAP). Unfortunately, 30% to 50% of patients refuse or cannot accept NCPAP for a variety of reasons. Approximately 25% of patients refuse it up front or cannot pass the test period; others cannot accept it or refuse it in the long run, or use it for only a few hours per night and/or fewer than 5 nights per week. It is our experience that increasingly, many patients, in particular the young, refuse NCPAP therapy up front and ask how realistic surgical alternatives are. Whatever the reason for not using NCPAP, treatment remains indicated in patients with moderate-to-severe OSAS and NCPAP refusal/failure.
Various surgical interventions are available, such as uvulopalatopharyngoplasty (UPPP), Z-palatoplasty (ZPP), uvula flap, and other variations in cases of palatal obstruction, and hyoid suspension (HS) and genioglossal advancement (GA) cases of in retrolingual obstruction. Maxillomandibular advancement (MMA) and tracheostomy are usually very effective, but the morbidity of these two modalities limits their application in the first line of surgery. In addition to surgical modalities, minimally invasive interventions exist, such as radiofrequency thermotherapy of palate and/or tongue base (RFTB). Surgery can be divided into unilevel (at palatal or tongue base level only) and multilevel (surgery at both these levels), and can be performed either staged or in one surgical event. For this chapter, multilevel surgery excludes MMA, single tongue base surgery, nasal surgery, or such combinations. A variety of interventions, both minimally invasive (RF of palate and tongue base) and surgical (UPPP, Z-P, uvular flap, expansion sphincter pharyngoplasty [ESP], barbed-suture reposition pharyngoplasty [BRP], laser and Coblation glossectomy, HS, GA) are currently being performed and have been reported as part of multilevel treatment in severe OSAS and NCPAP failure or nonacceptance. Treatment is sometimes performed staged, but we prefer to perform multilevel surgery in one session. Our approach relies on drug-induced sleep endoscopy (DISE) findings, and all obstruction sites identified are treated. We prefer to perform all procedures concurrently, as otherwise some patients may not return for second-stage surgery and thus will not be completely treated.
We focus in this chapter on literature concerning past and present forms of palatopharyngoplasty and HS with/without RFTB and with or without GA.
2
Patient Selection
2.1
Indications
In severe OSAS, the likelihood that obstruction is present on both a palatal and a retrolingual level is high; in fact, obstruction at both levels might be responsible for the high Apnea/Hypopnea Index (AHI). A therapeutic dilemma is whether these patients should undergo intervention (and what form of surgery) and whether at different levels staged (and in which sequence) or simultaneously. Performing multilevel surgery in a staged sequence will in the case of multilevel obstruction often lead to a prolonged path to success. DISE reveals information about the sites, severity, and level(s) of obstruction and is commonly classified into four levels: velum, oropharynx, tongue, and epiglottis. Combinations of surgery at the level of the velum or oropharynx in combination with surgery of the tongue base or epiglottis include multilevel surgery ( Table 56.1 ). The large variation of types of surgeries and different inclusion criteria result in a wide range of success rates in the literature. We consider multilevel surgery in patients with an AHI of 15 to 55 with a body mass index (BMI) <32. Shared decision making is important in these cases; other options such as MMA, hypoglossal nerve stimulation, and another NCPAP attempt should also be discussed with patients.
| Obstruction Level | Types of Surgery |
|---|---|
| Velum | Variations of palatopharyngoplasty, such as UPPP, uvula flap, Z-plasty, ESP, lateral pharyngoplasty, BRP, palatal stiffening, palatal advancement |
| Oropharynx | Tonsillectomy |
| Tongue | Radiofrequency ablation of tongue base, hyoid suspension, genioglossal advancement, lingual tonsillectomy, midline glossectomy |
| Epiglottis | Partial epiglottectomy, epiglottopexy, hyoid suspension |
2.2
Contraindications
In our experience, the effect of unilevel surgery is often inadequate in moderate to severe OSAS. Patients with an AHI >55 to 60 are more likely to fail after multilevel surgery.1. Caution is needed in patients with obesity, as OSAS is not often adequately treated by surgery. It is known that 56% of patients with sleep apnea syndrome are position dependent, and this factor should be taken into account during DISE and before offering multilevel surgery.2 Complete concentric collapse at the palatal level during DISE is a negative prognostic factor for multilevel surgery.2 How well newer palatal techniques that address the lateral pharyngeal wall solve this problem remains to be proven.
2.3
Alternative Treatment Options
Since the beginning of 2017 upper airway stimulation is reimbursed in the Netherlands, and its introduction has had a great effect on the palette of surgeries that can be considered. For a patient who fulfills the strict criteria regarding AHI, BMI, central and mixed apnea, complete concentric palatal collapse, CPAP failure, or nonacceptance, we usually offer upper airway stimulation first.
In our department, in patients with AHI of 55 and higher, MMA is offered up front, with tracheotomy in reserve as the last option, as it is rarely accepted. The invasiveness and morbidity of these procedures relegate them for patients with very severe OSA (AHI >55) and for nonresponders to multilevel surgery with an AHI <55. However, the cutoff point of AHI of 55 as an indication for multilevel surgery or MMA is situated in a grey area; it is a continuous point of discussion in our multidisciplinary meetings where the indication for MMA starts and multilevel surgery should no longer be offered as first-line surgery.
The BMI is also used as a cutoff point; we are cautious in offering multilevel surgery in patients with a BMI >32. Bariatric surgery can be considered in patients with obstructive sleep apnea (OSA) with morbid obesity (BMI >35).
3
Anesthesia and Positioning
The patient is positioned supine with a slight hyperextension of the neck. The main considerations are the different positions of the intubation tube during multilevel surgery. The position of the tube differs for the separate surgical procedures: the tube should be placed in the corner of the mouth during radiofrequency ablation of the tongue base, then shifted to the midline and angled downward during palatopharyngoplasty, and in case of consecutive HS, the tube needs to be angled away from the neck.
4
Surgical Techniques
Different surgical techniques are described for multilevel surgery as shown in Table 56.1 . Here we present the surgical techniques.
4.1
Palatopharyngoplasty
UPPP is performed according to the Fujita technique; the anterior and posterior tonsillar pillars are trimmed and reoriented and the uvula is excised to create more retropalatinal space ( Fig. 56.1 ).
Newer variations of palatopharyngoplasty are now more commonly used in our institute, such as ESP and BRP, leaving the uvula in situ or with limited reduction while targeting lateral expansion. Readers are referred to the relevant chapters on these specific techniques. Tonsillectomy is performed if it had not been done previously. In patients who had tonsillectomy previously with a short anteroposterior diameter at the retropalatinal level, ZPP can be performed, but BRP is also a viable option and is the technique we most commonly perform at present in combination with tonsillectomy (see Chapter 33 ).
4.2
Radiofrequency Ablation of the Tongue Base
RFTB (bipolar, Celon) is used for stiffening the base of the tongue. Energy is delivered with a needle tip handpiece through the dorsal surface of the tongue. Evidence-based criteria for technical adjustment and optimal energy dosage according to relevant increase in lesion size are used. If indicated, an additional radiofrequency ablation can be performed after the initial surgery ( Fig. 56.2 ).
4.3
Hyoid Suspension
After exposure via an external horizontal incision at the level of the membrana thyrohyoidea, the strap muscles (M. sternohyoideus, M. omohyoideus, and M. thyrohyoideus) are divided just below the hyoid, and superior to the hyoid, the tendon of the stylohyoideus is divided from the hyoid bone ( Fig. 56.3 ) The hyoid bone is mobilized in an anterocaudal direction and connected to the thyroid cartilage with four nonabsorbable braided stitches, which creates more space retrolingually (for details see Chapter 49 ).
