Preoperative Evaluation

As part of the preoperative evaluation the surgeon should do the following.

Polysomnography is appropriate in patients with sleep-disordered breathing, including mild to moderate or severe obstructive sleep apnea syndrome undergoing airway reconstruction. Since successful clinical outcomes of surgery cannot be guaranteed, maximal attempts at more conservative treatments are appropriate. Additionally, the sleep study provides information on the severity of disease and the nadir of oxygen desaturation and helps to identify those who warrant postoperative care and observation. Individuals at higher general surgical risk also include those with severe obesity, severe sleepiness, difficult intubation, or severe pharyngeal tissue redundancy. Individuals with preexisting speech or swallowing disorder should be identified and warned that pharyngeal surgery may worsen symptoms or problems with dysphagia, muco-ciliary function, mouth dryness, and aspiration.

Cephalometric upper-airway evaluation is optional. No specific measures are available that select surgical patients for this procedure. The main method of evaluation is endoscopy. Endoscopy is performed in a sitting and supine body position. Size, shape, areas of collapse, and pharyngeal swallow are evaluated. During endoscopy when the nasopharynx is visualized, close attention is focused on the size of the proximal pharyngeal isthmus. Narrowing of the airway proximal to any level of palatal excision with traditional palatopharyngoplasty should be noted. The position of the levator muscle in the soft palate and the size of the associated airway should be assessed. The le-vator muscle can be identified by visualizing the torus tubarius. The position of the anterior fold is the torus levatorious, with the posterior fold the salpin-gopharyngeus muscle. A more posteriorly placed le-vator muscle in close approximation to the posterior pharyngeal wall cannot be addressed by traditional palatopharyngoplasty without aggressive excision of the levator muscle. During endoscopy, swallow is performed and lateral wall motion assessed. Finally, the oral cavity and oropalatal airway is assessed. An oropalatal airway that allows oral ventilation without deformation of the tongue may not require treatment. Evidence of oropalatal collapse manifested by "tongue grooving" or a midline deformation of the posterior tongue indicates relative macroglossia and the need for treatment of this segment.

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