The patient should next have a flexible laryngoscopic exam, usually a continuation of the nasal endoscopy. The nasopharynx is inspected for adenoid hypertrophy, polyps, cysts, and tumors. The palate is inspected from above. The exam proceeds to the level of the pharynx and hypopharynx with attention paid to the pharyngeal and lingual tonsils and the base of tongue position. Finally, the larynx is inspected for position of the epiglottis, laryngeal masses, vocal fold immobility, laryngomalacia, and arytenoid redundancy and prolapse with inspiration. A drug-induced sleep endoscopy (DISE) should be performed at a later date to assess these same structures dynamically in a state mimicking sleep to help guide appropriate surgical technique. DISE was reviewed in a previous issue and will not be discussed in detail.
Finally, the neck should be examined. Masses, tracheal deviation, evidence of prior tracheotomy, hyoid position, circumference, and lymphadenopathy should all be noted. Masses, especially goiters, can compress the internal jugular veins leading to laryngeal and pharyngeal edema. Surgical removal of the mass is the treatment of choice.
Treatment
Nasopharyngeal lesions are treated with surgical excision. The velopharynx is usually addressed with uvulopalatopharyngoplasty which often, but not always, includes the tonsils. Various techniques have been developed to address circumferential vs anteroposterior(AP) collapse of the palate and uvula. Present practices favor soft tissue/muscle rearrangement over soft tissue ablation. One such technique preferred by the author is expansion sphincter pharyngoplasty. Lingual tonsillectomy addresses large lingual tonsils, if present.
Many operations exist to address the tongue base, and consensus as to best practice is yet to be reached. Generally, two broad categories exist: suspensory or ablative. Suspension can be accomplished with sutures along the base of tongue, hyoid fixation to the anterior mandible or thyroid cartilage, and genioglossus advancement. A novel technology recently FDA-approved shows immense promise. Upper-airway stimulation uses electrodes on the hypoglossal nerve to protrude the tongue, timing it with each respiration through an intercostal muscle sensor lead (Strollo Jr et al. STAR Trial Group. N Engl J Med. 2014;370[2]:139).
Ablation can be accomplished by reducing the base of tongue through the delivery of energy, such as use of radiofrequency or excising tissue through techniques like midline glossectomy. This can be accomplished both directly and with robot-assisted techniques using the daVinci system transorally (TORS).
Laryngeal techniques include epiglottopexy or epiglottectomy in cases where the epiglottis retroflexes and obstructs the airway on inspiration. Laryngeal lesions are generally addressed with excision. Vocal fold paralysis in the midline can be addressed with cordotomy or arytenoidectomy. Prolapsing redundant tissue can be tightened using a laser. Laryngomalacia can be addressed surgically, as well.
In summary, OSAS is a complex disease that often requires multiple therapeutic modalities. Proper patient selection and a thorough physical exam are crucial to proper treatment choice. Surgery can be both adjunctive and curative. Patients often have multiple levels of airway obstruction that can be treated simultaneously or staged. Careful follow-up and involvement of a multidisciplinary care team will result in the highest success rates for these patients with complex disease.
Dr. Chernobilsky is Director of Sleep and Airway Surgery, Mount Sinai Beth Israel, Assistant Professor of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York.
Editor’s comments
Although positive airway pressure is the gold standard treatment for obstructive sleep apnea, poor compliance with this modality provides the impetus for alternative treatments that are both effective and acceptable to patients. Upper airway surgery is a viable alternative for select patients, either as a primary treatment modality or as adjunctive therapy. In this installment of sleep strategies, Dr. Boris Chernobilsky discusses and clarifies, from a surgical perspective, the surgical techniques available, as well as the systematic approach, in the evaluation of the patient with sleep apnea.
Dr. Jeremy Weingarten, FCCP