Evaluation of Polysomnography

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Surgical Techniques for OSA

Polysomnography cannot be summarized by the AHI only. Sleep architecture, body position, and oxygen saturation should be considered. Decreased total sleep time, REM sleep, and sleep position may result in decreased AHI values. The first-night effect can also underestimate the severity of disease. Apneas are seen more frequently during stages 3 and 4 and REM sleep. In some patients apneas are strictly position related and seen mainly when the patient is in the supine sleeping position [35]. It is also very important to compare preoperative and postoperative results of polysomnography in relation to sleep position in order to avoid artificial changes. For example, a preoperative AHI of 20 in a position-dependent apnea patient is not improved when a postoperative AHI of 10 is obtained, if the postoperative sleep time in the supine position is

Surgical techniques for OSA aim to correct airway obstruction in two main sites: retropalatal and/or ret-rolingual. Success rates of UPPP alone in all patients are significantly lower than those of tracheotomy or CPAP. Early modifications of UPPP with aggressive tissue resection were suggested to achieve better results, but these were associated with increased complication rates instead of success [53]. Electrosur-gery, laser-assisted uvulopalatoplasty, radiofrequency and use of chemical agents were suggested for palate operations, as consequences of advanced technology [5, 21, 28, 39]. Instead of providing better results than UPPP, most of them tried to attain the success of UPPP, and have been recommended for snoring and mild OSAS only. It appears that multilevel and staged surgery provides the best surgical results in patients with OSA [40].

Careful dissection with respect to tissue and proper hemostasis is helpful to prevent edema, hematoma, and abscess formation. Nasopharyngeal stenosis is a rare complication of UPPP that can usually be related to the surgical technique.

Factors that might lead nasopharyngeal stenosis [9, 22] are:

■ Injury to the posterior mucosal surface of the soft palate and posterior pharyngeal mucosa

■ Excessive mucosa destruction

■ Aggressive posterior pillar resection

■ Excessive use of electrocautery

■ Infection and necrosis

Suture dehiscence is another problem that can cause unpredictable healing. In most descriptions of UPPP, suture approximation of tonsillar pillars to eliminate redundant mucosa is included in the surgical technique. Breakdown of sutures after UPPP has a potential negative effect on eliminating redundant mucosa. The incision technique, suture material, and tension at the wound edges may contribute to this complication. Electrocautery is commonly used to incise the mucosa, but the tensile strength of the mucosal wounds created by a scalpel is superior to electrocautery [46]. In one study, the incidence of tonsillar pillar dehis-cence was reported as 44.4% with electrocautery versus 33.3% with cold dissection (p=0.41) [1]. Resection of only redundant mucosa instead of aggressive tissue resection prevents the tension at the closure line. Suture materials which provide tensile strength for longer periods such as polyglactin should be used. Mattress sutures that include not only mucosa but also submucosal tissue and muscle provide for higher tensile strength.

One of the causes of persistent symptoms after UPPP is failure to obtain an enlarged lumen at the retropalatal level. Postoperative endoscopy and measurement of cross-sectional area in CT scans are helpful to confirm the pathology findings [26]. Langin et al, [26] reported that patients who failed to respond or who got worse after UPPP had persistent retropalatal narrowing. We feel that the complex relationship between the tongue and the soft palate in the pharynx might explain the reasons for failure (Fig. 45.3). In the absence of an enlarged tongue, reduction of soft-palate length by UPPP would achieve a wide lumen (Fig. 45.4). The extent of palate resection may be limited retropositioned maxilla and hard palate in some patients who are at risk for velopharyngeal insufficiency. We recommend transpalatal advancement pharyngo-plasty in these patients.

Decreasing the length of the soft palate may not be enough to widen the lumen in the presence of an

Fig. 45.3. Normal tongue volume. Excision of the soft palate will provide significant airway space

Fig. 45.4. An enenlarged tongue is present. Space superior to the vallecula narrowed (one asterisk). Long soft palate and uvula placed posteriorly to the enlarged tongue and occupied a part of the retrolingual space (three asterisks). Additionally, a more inferior segment is obstructed by an enlarged tongue (two asterisks)

Fig. 45.4. An enenlarged tongue is present. Space superior to the vallecula narrowed (one asterisk). Long soft palate and uvula placed posteriorly to the enlarged tongue and occupied a part of the retrolingual space (three asterisks). Additionally, a more inferior segment is obstructed by an enlarged tongue (two asterisks)

enlarged tongue that pushes the soft palate against posterior pharyngeal wall (Fig. 45.3, 45.5). Langin et al. [26] also remarked that if the palate tended to have its long axis parallel to the posterior pharyn-geal wall instead of there being a soft palate bulging into the pharyngeal lumen, surgical techniques to enlarge the pharyngeal lumen instead of excessive palatal resection were successful. This finding

Fig. 45.5. Soft palate partially excised and retrolingual segment interiorly obstructed by an enlarged tongue

supports our conclusion on the complex relation between an enlarged tongue and the soft palate. Narrowing of the lumen more interiorly at the tongue base would clearly add to the list of different levels of anatomic obstruction (Fig. 45.5) and in these cases, surgical techniques to enlarge the retrolingual space are needed. A solution to prevent failure in such cases would include sufficient decrease in the length of the soft palate without compromising velopharyn-geal insufficiency, transpalatal advancement pha-ryngoplasty, tongue-base reduction, or maxilloman-dibular advancement.

aggressively, it may occasionally result in an abscess of the tongue base, which can drain spontaneously or with surgery, without permanent narrowing of the airway. However, the requirement of multisession treatment was not tolerated by all patients, many of whom withdrew from the study after only symptomatic relief and before a possible cure [10]. This is an interesting cause of failure to cure, which is similar to that of CPAP.

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