And Perioperative Management

Multilevel approach surgery is defined as a group of surgical procedures which address different levels of obstruction in the upper airways of patients with SRBD. A multilevel procedure may be performed in one stage or in multiple stages. Multilevel surgery may be associated with other nonsurgical treatment and thus it may be incorporated as a multiple modal ity approach. Minimally invasive techniques such as LAUP without transpalatal section, RFVTR or palatal implants may also be performed with multilevel airway surgery. At the retrobasilingual level, minimally invasive techniques are restricted to RFVTR or tongue-base suspension devices. UPPP, uvulopalatal flap and LAUP with transpalatal section are the invasive techniques considered for the velopharyngeal level. Techniques other than RFVTR and tongue-base suspension devices, which require an external approach, should be considered as invasive techniques

Table 48.1. Upper-airway pharyngeal surgery

Minimally invasive techniques

- Radiofrequency tissue-volume reduction or radiofrequency interstitial thermotherapy

- Laser-assisted uvulopalatoplasty without transpalatal section

- Palatal (pillar) implant Others techniques

- Laser-assisted uvulopalatoplasty with transpalatal section

- Uvulopalatopharyngoplasty

- Uvulopalatal flap

- Transpalatal advancement pharyngoplasty for the lower pharyngeal level (Table 48.1). Patients with moderate to severe apnea are usually treated with CPAP therapy and undergo invasive surgical procedures if they have poor compliance and/or are intolerant to CPAP treatment. Using a multilevel surgical approach for these patients results in higher success rate. Whether this multilevel approach should be based on radiological evaluation, such as dynamic MRI, or proposed with a "why not?" philosophy is not yet resolved in the literature.

Combinations of different surgical procedures (site-specific and multilevel) in patients with SRDB are listed in Table 48.2.

As a multilevel approach is proposed increasingly for patients with SRBD, the perioperative management is sometimes complex. If surgery is performed under general anesthesia with endotracheal intubation, the endotracheal tube may impede the ability of the surgeon to address certain anatomic areas, such as when performing RFTVR of the tongue base. A promising way to achieve better outcomes with such upper-airway procedures may be using general anesthesia without endotracheal intubation. Percutaneous transtracheal jet ventilation may be appropriate and is used in patients where difficulty in the management of their airway is anticipated [15].

Table 48.2. Combinations of different surgical procedures (site-specific or multilevel) dedicated to the sleep related breathing disorder patient

Upper

Upper

(Sinu)nasal

Lower

Lower

Maxillo-

pharyngeal

pharyngeal

surgery

pharyngeal

pharyngeal

mandibular

airway

airway

airway

airway

advance-

surgery

surgery

surgery

surgery

ment

(minimally

(minimally

invasive)

invasive)

Snoring

UARS

X

1 A T TO

Mild OSAHS

X

X

X

X

X

X

X

Moderate to severe

X

OSAHS

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

Tonsillectomy or tonsil size reduction must be performed in the case of tonsil hypertrophy. UARS upper-airway resistance syndrome, OSAHS obstructive sleep apnea-hypopnea syndrome

Tonsillectomy or tonsil size reduction must be performed in the case of tonsil hypertrophy. UARS upper-airway resistance syndrome, OSAHS obstructive sleep apnea-hypopnea syndrome

Sleep Apnea

Sleep Apnea

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Responses

  • j
    Is rfvtr surgery intrusive?
    6 months ago

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