MultiLevel Airway Surgery

1
Multi-Level Airway Surgery

• Ho-Sheng Lin, MD
• Associate Professor
• Department of Otolaryngology
• Head and Neck Surgery
• 11/14/07

2
History of Surgical Treatment

• Tracheotomy
• Sole treatment available in 1960s and 1970s
• 100 effective
• High morbidity and poorly tolerated by patients
• Uvulopharyngopalatoplasty (UPPP)
• Ikematsu in Japan in 1964
• Fujita in the US in 1981 (n12)
• 8 patients required no further treatment
• AI from 50?10
• 2 patients showed a mild decrease in AI
• AI from 76?61
• 2 patients showed an increase in AI
• AI from 48?64

Fujita et al, Otolaryngol Head Neck Surg 198189
923-934.
3
History of Surgical Treatment

• Since there is a variable response to UPPP, it
  is important to determine what subgroup of the
  sleep apnea patients would benefit from this
  procedure or whether another factor might
  influence the surgical results.
• Developed the Fujita Classification System
• Type I Palatal obstruction only Type
  II palate BOT obstruction
• Type III BOT obstruction only

Fujita et al, Otolaryngol Head Neck Surg 198189
923-934.
4
History of Surgical Treatment

• Meta-analysis by Sher et al. (1996)
• Effectiveness of 40.7
• gt 50 reduction in AHI w/ AHI lt 20
• Became discredited among many physicians as well
  as general public
• Remained the most common surgical procedure for
  Tx of OSA by otolaryngologist

5
History of Surgical Treatment

• Multi-Level Airway Surgery
• OSA involves multiple levels of airway, not
  limited to the velopharynx level
• Fujita
• Introduced laser midline glossectomy to address
  BOT in 1991
• Riley and Powell
• Introduced genioglossus advancement and hyoid
  myotomy to address the BOT in 1986
• Developed the Stanford Powell Riley Protocol that
  involves a graduated surgical approach for Tx of
  OSA
• Basis of modern surgical management of OSA

6
Powell-Riley Phase I Soft Tissue

• Selection of surgical procedures based on
  accurate localization of site of obstruction
• Surgical correction only if obstruction noted
• Nasal surgery
• Turbinate reduction
• Septoplasty
• Palatal surgery
• UPPP
• BOT surgery
• mandibular osteotomy w/ genioglossus advancement
• hyoid myotomy and suspension
• Combination of above
• Polysomnogram 4-6 months postop
• Riley, 1989 924Riley, 1993 752
• Riley, 1994 675Ramirez, 1996 573Lee,
  1999 398

7
Surgical Procedures

• Nose
• SMR
• Turbinate reduction
• Nasal valve reconstruction
• Velopharynx
• LAUP
• UPPP
• Palatal Advancement
• Z-plasty
• Pillar Palatal Implant
• Tonsillectomy Adenoidectomy
• Oropharynx
• Mandibular osteotomy w/ Genioglossus advancement
• Hyoid myotomy and advancement
• Repose tongue suspension
• Radiofrequency BOT reduction
• Partial glossectomy
• Lingual tonsillectomy
• Epiglottopexy / Epiglottectomy

8
Surgical Treatment Level of Nasal Cavity

• Septoplasty
• Turbinectomy or turbinate reduction
• Functional endoscopic surgery
• Polypectomy
• Nasal valve reconstruction
• Correction of nasal tip ptosis

9
Surgical Treatment Level of Nasal Cavity

• Improve CPAP compliance
• Nasal obstruction
• Common complaint
• PAP induced vasomotor rhinitis
• Friedman et al. (n50)
• SMR and turb on OSA patients w/ nasal obstruction
• RDI did not change
• Mean CPAP level changed from 9.3 cm H2O preop to
  6.7 cm H2O postop (plt0.01)
• Reduced CPAP level lead to increased comfort and
  increased compliance
• Powell et al. (n17, control 5)
• Radiofrequency-based inferior turbinate reduction
  
• Small improvement in sleepiness per ESS and SF-36
• Increase in CPAP use by 32 min
• Increase in CPAP adherence by 10
• Increase in CPAP tolerance by 20
• Part of multi-level surgical procedures for Tx of
  OSA

Friedman et al., Otolaryngol Head Neck Surg
200012271-4
10
Treatment Issues

• Nasal surgery
• 21 patients treated with septal/turbinate surgery
  for OSA and nasal obstruction (RDI gt 15)
• Surgery was effective in significantly reducing
  both RDI (35 to 25) and AI (19 to 16)
• OSA still present in most patients
• Surgery may be effective in treating OSA
• Kim et al., Acta Otolaryngol 2004124297-300

11
Treatment Issues

• Nasal surgery
• Results of nasal surgery for OSA are mixed
• Majority of studies show negligible efficacy
• Major review by Verse Pirsig (2003)
  demonstrates the success of nasal surgery for OSA
  to be less than 20
• Verse Pirsig, Sleep Breath 2003763-76

12
Conclusions

• Nasal surgery appears to have little direct
  effect on improving PSG indices of OSA
• Nasal surgery may be of benefit in allowing
  decreased CPAP pressures, and therefore may
  improve patient adherence and tolerance

13
Coblation-Assisted Turbinate Reduction

• Relative novel technology
• Delivery of low temperature (40-70oC)
  radiofrequency energy into the submucosa of
  inferior turbinate
• Produces a highly focused plasma field containing
  ionized particles capable of breaking organic
  molecular bonds in tissue
• Results in both immediate volumetric reduction of
  tissue and a delayed reduction due to fibrosis
  and contracture of target tissue with minimal
  damage to surrounding tissue

14
Coblation-Assisted Turbinate Reduction
15
Coblation-Assisted Turbinate Reduction
16
Nasal Valve Suspension

• Minimally invasive
• Can be performed under local anesthesia

17
Coblation-Assisted Turbinate Reduction Nasal
Valve Suspension

• Improve CPAP compliance
• OSA patients w/ nasal obstruction refractory to
  medical treatment
• No packing required, thus allowing postop use of
  nasal CPAP
• Avoid the need for general anesthesia in high
  risk patients
• High association with pulmonary and cardiac
  comorbidities
• Challenge for safe intubation
• Increased risk of postop airway obstruction (due
  to general anesthesia and postop use of pain
  meds)
• Part of multi-level surgical procedures for Tx of
  OSA
• Combined with UPPP and/or BOT procedures
• Traditionally, avoid concurrent nasal surgery w/
  UPPP/- BOT
• No packing required, thus allowing postop use of
  nasal CPAP

18
Surgical Procedures

• Nose
• SMR
• Turbinate reduction
• Nasal valve reconstruction
• Velopharynx
• LAUP
• UPPP
• Palatal Advancement
• Z-plasty
• Pillar Palatal Implant
• Tonsillectomy Adenoidectomy
• Oropharynx
• Mandibular osteotomy w/ Genioglossus advancement
• Hyoid myotomy and advancement
• Repose tongue suspension
• Radiofrequency BOT reduction
• Partial glossectomy
• Lingual tonsillectomy
• Epiglottopexy / Epiglottectomy

19
Surgical Treatment Level of Velopharynx (LAUP)

• Sher et al. Large meta-analysis
• 19 papers, n345
• Extremely variable surgical results
• 40.7 if response defined as gt50 reduction in
  RDI w/ final RDI lt 20
• Statistically significant difference in
• Preop RDI between responders (43.1) and
  nonresponders (65.7)
• Preop min 02 sat between responders (67) and
  nonresponders (60)

20
Surgical Treatment Level of Velopharynx (LAUP)

• Introduced in 1993 for snoring and OSA
• Relatively small amount of data for OSA
• Frequently used for snoring not OSA
• Procedure and PSGs may not be covered
• Success Rate reported from 0-48
• Incremental improvements with repeat procedures
  in the office
• Significant pain procedure may need repeat
• Increased risk of nasopharyngeal stenosis
• Fallen out of favor

Sher, Sleep Med Rev,6(3)195-212,2002
21
Surgical Treatment Level of Velopharynx (UPPP)

• Fujita

22
Surgical Treatment Level of Velopharynx (UPPP)

• Sher et al. Large meta-analysis
• 19 papers, n345
• Extremely variable surgical results
• 40.7 if response defined as gt50 reduction in
  RDI w/ final RDI lt 20
• Statistically significant difference in
• Preop RDI between responders (43.1) and
  nonresponders (65.7)
• Preop min 02 sat between responders (67) and
  nonresponders (60)

23
Surgical Treatment Level of Velopharynx (UPPP)

• UPPP (Uvulopalatopharyngoplasty)
• Overall response rate 40.7 (unselected pts)
• Response rate of 73-80 in selected pts w/
• Fujita type I and intact tonsils on exam
• Mild to moderate OSA w/ RDI lt 50

24
Surgical Treatment Level of Velopharynx (UPPP)

• Continual improvement and modification of UPPP
  techniques
• Decrease complications
• Increase effectiveness
• Powell et al.
• Reversible Uvulopalatal Flap
• Woodson et al.
• Palatopharyngoplsty
• Cahali et al.
• Lateral Pharyngoplasty
• Friedman et al.
• Z-plasty
• Li et al.
• Extended Uvulopalatal Flap

25
Surgical Treatment Velopharynx Lateral
Pharyngoplasty

• Randomized controlled trial (RCT) Lateral PPP vs
  modified UPPP
• AHI 41.6 to 15.5 versus 34.6 to 30 events/h
• Lsat 74.1 to 81
• Delta sleep 9.8 to 16.3 All better than
  control/comparison
• Clinical success 66 versus 33

Cahali, Laryngoscope 1131961, 2003 Cahali MB et
al Sleep 27942,2004
26
Surgical Treatment Velopharynx Palatal
Advancement

• Advance soft palate
• Modified to include incision of tensor tendon

27
Surgical Treatment Velopharynx Palatal
Advancement
28
Surgical Treatment Velopharynx Palatal
Advancement
29
Surgical Treatment Velopharynx Palatal
Advancement
Osteotomy Tendenolysis
30
Surgical Treatment Velopharynx Palatal
Advancement
Advancement and Closure
31
Surgical Treatment Velopharynx Palatal
Advancement
Woodson Robinson Otol Head Neck Surg 2005
32
Surgical Tx Velopharynx
(Z-palatoplasty-Friedman)
33
Surgical Tx Velopharynx
(Z-palatoplasty)
34
Surgical Tx Velopharynx
(Z-palatoplasty)

• ZPP (n25) vs UPPP (n25)
• Friedman Stage II III (h/o tonsillectomy)

35
Surgical Tx Velopharynx
(Z-palatoplasty)

• Changes in direction of scar contracture
• Temporary VPI to be expected

Z-Palatoplasty (ZPP)
Classical UPPP
36
Surgical Treatment Level of Velopharynx (UPPP)
Laryngoscope 1152010-2015, 2005
37
Surgical Treatment Level of Velopharynx
(Pillar)

• Pillar Palatal Implant System
• Originally designed for treatment of snoring
• Insertion of 3 implants into soft palate
• Polyethylene terephthalate or Dacron
• Used as suture, mesh, vascular grafts and valves
• Promote the ingrowth of tissue and fibrotic
  response
• Recently approved by FDA for treatment of mild to
  moderate OSA

38
Surgical Treatment Level of Velopharynx
(Pillar)
18 mm x 2 mm Polyethylene terepthalate (Dacron)
39
Surgical Technique
40
Surgical Treatment Level of Velopharynx
(Pillar)

• Prospective non-randomized multi-center clinical
  trial
• N46 pts
• Sleep study at 3 months
• Prospective non-randomized trial (German)
• N16 pts
• Sleep study at 3 months
• Results unchanged at 1 yr f/u

41
Surgical Treatment Level of Velopharynx
(Pillar)
Surgical Cure Rate 34
Friedman et al.
42
Surgical Treatment Level of Velopharynx
(Pillar)

• Huang et al. (Chest, 2005)
• Finite element model of normal pharyngeal airway
• Evaluated various anatomic manipulations on
  pharyngeal collapsibility (Pcrit)

43
Surgical Treatment Level of Velopharynx
(Pillar)

• Advantage
• Minimally invasive procedure
• Minimal pain, no narcotic required postop
• Procedure takes only 10 min
• Performed in the office setting
• Most common adverse event is implant extrusion
  (2-10)
• Disadvantage
• Most insurance does not cover
• Strict patient selection
• BMI lt 30
• AHI lt 30
• 0 or 1 Tonsils
• 1 or 2 BOT

44
Surgical Procedures

• Nose
• SMR
• Turbinate reduction
• Nasal valve reconstruction
• Velopharynx
• LAUP
• UPPP
• Palatal Advancement
• Z-plasty
• Pillar Palatal Implant
• Tonsillectomy Adenoidectomy
• Oropharynx
• Mandibular osteotomy w/ Genioglossus advancement
• Hyoid myotomy and advancement
• Repose tongue suspension
• Coblation-assisted BOT Resection
• Radiofrequency BOT reduction
• Lingual tonsillectomy
• Epiglottopexy / Epiglottectomy

45
Surgical Treatment Level of
Oropharynx
46
Surgical Treatment Level of Oropharynx

• When combined w/ UPPP, BOT surgery has been
  demonstrated to improve overall response rate
  from 40 to 56
• Cure rate dependent on severity of OSA , anatomy,
  and BMI
• Indicated in patients with Fujita type II and III
  w/ obstruction involving BOT
• Utley, 1997 515Riley, 1993 752

47
Surgical Tx OropharynxGenioglossus Advancement

• GBAT System
• Genial Bone Advancement Trephine System
• Reiley and Powell System
• horizontal mandibulotomy
• advance mentum and its attached genioglossus
  muscle 12-15mm anteriorly
• Mean surgical advancement is 13.9 mm

48
Preop Panorex Radiograph
20
10
8
49
Anatomy-Genioglossus muscle
50
Surgical Tx OropharynxGenioglossus Advancement
51
Surgical Tx OropharynxGenioglossus Advancement
52
Surgical Tx OropharynxGenioglossus Advancement
53
Surgical Tx OropharynxGenioglossus Advancement
54
Surgical Tx OropharynxGenioglossus Advancement
55
Surgical Tx OropharynxHyoid Suspension

• Riley et al.
• 1986
• Suspend hyoid bone to ant mandibular arch using
  fascia lata

56
Surgical Tx OropharynxHyoid Suspension

• Simplified in 1994
• Suspension of hyoid to thyroid cartilage
• Hyoid released from inferior attachments
• Hyoid advanced ant inf over thyroid cartilage
• apply tension to hyoepiglottic ligament, pulling
  epiglottis forward
• pull hypoglossus m and thus BOT inf ant
• Riley, 1986 1009 Riley, 1994 675

57
Surgical Tx OropharynxHyoid Suspension

• Riley et al.
• n15 w/ h/o prior surgery who still have OSA
• 11 pts had h/o UPPP and genioglossal advancement
• 3 pts had h/o genioglossal advancement alone
• 1 pt had h/o UPPP alone
• Underwent isolated hyoid suspension procedure
• 10/15 pts (67) achieved cure (RDI lt 20 and gt50
  reduction)
• Riley, 1994 675

58
Anatomy-Suprahyoid muscles
59
Anatomy-Genioglossus muscle
60
Surgical Tx OropharynxHyoid Suspension
61
Surgical Tx OropharynxHyoid Suspension
62
Surgical Tx OropharynxHyoid Suspension
63
Surgical Tx OropharynxHyoid Suspension
64
Surgical Tx Oropharynx Repose Tongue Suspension

• ReposeTM Procedure
• Suspend tongue base to mandible w/ suture
• Prevent BOT from prolapsing when supine
• Minimally invasive
• Require only 15-30 min to perform
• Caution to prevent tissue ischemia, pain, and
  edema
• Correct suture tightening should advance the
  tongue base 3-7 mm towards the mandible.
• Tightness of tongue suspension is determined by
  palpation

65
Surgical Tx Oropharynx Repose Tongue Suspension
4mm screw attached to double polypropylene 1
suture
Drill driver device
Suture passer
66
Surgical Tx Oropharynx Repose Tongue Suspension
67
Surgical Tx Oropharynx Repose Tongue Suspension
68
Surgical Tx Oropharynx Repose Tongue Suspension
69
Surgical Tx Oropharynx Repose Tongue Suspension
70
Surgical Tx OropharynxRadiofrequency
Volumetric Reduction

• Delivery of controlled thermal energy
  (radiofrequency) to BOT to reduce tissue volume
• Minimally invasive
• Powell et al. (n18 pts w/ h/o UPPP)
• Mean preop RDI39.6, O281.9
• Mean postop RDI17.8, O288.3
• required average of 5.5 treatment, delivered at 4
  week interval
• mean 1543 J x 9 min at 80oC
• complication-one abscess require ID and temp
  trach
• Powell, 1999 2570

71
Surgical Tx OropharynxRadiofrequency
Volumetric Reduction

• Woodson et al.
• N69
• 93 of patients had prior surgery (82 UPPP)
• Average of 5.4 treatments (13,394 joules)
• Complication 4 cases of BOT abscess
• Admitted all patients overnight for O2 sat
  monitor after first treatment
• 20 of patients responded to surgery
• Preop RDI 40.5 preop lowest O2 sat 80.6
• Postop RDI 32.8 postop lowest O2 sat 82.2

72
Surgical Tx OropharynxRadiofrequency
Volumetric Reduction
73
Surgical Tx OropharynxRadiofrequency
Volumetric Reduction
74
Surgical Tx Oropharynx Partial
Glossectomy/Lingual Tonsillectomy

• May require temporary trach
• Laser midline glossectomy (Fujita)
• Partial glossectomy
• Linguoplasty (Woodson)
• Involve excision of posterior lateral tongue
  tissue
• Lingual tonsillectomy for lingual tonsil
  hypertrophy
• Dundar, 1996 570

75
Surgical Tx Oropharynx Partial
Glossectomy/Lingual Tonsillectomy
76
Surgical Tx Oropharynx Partial
Glossectomy/Lingual Tonsillectomy
Woodson
77
Surgical Tx Oropharynx Epiglottopexy/Epiglotect
omy

• Laryngomalacia
• Epiglottopexy
• Epiglotectomy
• Arytenoid
• Trimming of redundant arytenoid mucosa

78
Surgical Procedures

• Nose
• SMR
• Turbinate reduction
• Nasal valve reconstruction
• Velopharynx
• LAUP
• UPPP
• Palatal Advancement
• Z-plasty
• Pillar Palatal Implant
• Tonsillectomy Adenoidectomy
• Oropharynx
• Mandibular osteotomy w/ Genioglossus advancement
• Hyoid myotomy and advancement
• Repose tongue suspension
• Coblation-assisted BOT Resection
• Radiofrequency BOT reduction
• Lingual tonsillectomy
• Epiglottopexy / Epiglottectomy

79
Surgical Tx Phase IIMaxillomandibular
Advancement (MMO)

• Indicated in pts who failed to respond to phase I
  treatment
• Should also re-consider use of CPAP or
  Tracheostomy
• Riley et al.
• Cure rate 97 (n91)
• LeFort I maxillary osteotomy w/ bil sagittal
  mandibular osteotomy
• Orthodontic work may be needed to maintain proper
  alignment of teeth
• Goal is to move both maxilla mandible as far
  forward as possible
• Hospital stay2.4 days

80
Maxillomandibular Advancement
81
Maxillomandibular Advancement
82
Tracheostomy

• Two primary indications
• Primary Tx of OSA
• Gold standard of surgical procedure
• 100 effective
• Temporary measure to secure airway
  postoperatively
• Morbidly obese / High co-morbidities
• Cannot tolerate use of PAP postoperatively