How To: Tips and Tricks for Epiglottis Stiffening Operation for Epiglottis Collapse in OSAS

by Federico Leone, MD, Giulia Anna Marciante, MD, Alessandro Bianchi, MD, Michele Cerasuolo, MD, Giovanni Colombo, MD, and Fabrizio Salamanca, MD •

INTRODUCTION

Treatment of primary epiglottis collapse (EC) in patients with obstructive sleep apnea/hypopnea syndrome (OSAHS) still presents a challenge. Drug-induced sleep endoscopy (DISE) (Laryngoscope. 2015;126:515–523) has allowed assessment of the prevalence of EC in 10% to 40% of patients suffering from OSHAS. In order to treat this condition, we developed a minimally invasive technique called an epiglottis stiffening operation (ESO) (Acta Otorhinolaryngol Ital. 2019;39:404–408). ESO has been shown to be a safe and easy-to-perform procedure, with great efficacy and very short surgical training required. Herein, we propose standardization of this technique by describing the surgical procedure in detail, including some tips and tricks.

METHOD

All patients who underwent ESO between Jan. 1, 2015, and Dec. 31, 2020, at the Department of Otorhinolaryngology of Humanitas San Pio X were enrolled for the study. During the preoperative diagnostic work-up, each patient underwent a complete physical and endoscopic evaluation, polysomnographic study (PSG), and DISE. DISE was always performed by an expert otolaryngologist and recorded and later collegially discussed among the otolaryngologist surgeon, neurologist, pneumologist, and odontologist. All treatment options, including custom surgery, were proposed to the patients. Epidemiological and clinical data, surgical reports, outcomes, complications, and follow-up information were reviewed.

Surgical Technique. Exposition of the epiglottis in direct microlaryngoscopy is performed using a traditional laryngoscope after mouth guard application. In this phase, the lingual side of the epiglottis totally (or almost totally) occupies the field of the laryngoscope, and its free edge touches the lower edge of the laryngoscope itself. The working area is identified as a rectangular area extended 1/3 in the upper half and 2/3 in the lower half of the epiglottis, between the lateral glossoepiglottic folds (including the median glossoepiglottic fold). Using a Kleinsasser suction cautery (outer diameter 3 mm and working length 26 cm) with an Erbe system set in the forced coagulation mode (50 watt max.), the exuberant mucosa included in the working area is raised and so cauterized, causing an immediate and visible retraction of the epiglottis.

In this phase, it is important to reach the perichondrium in order to induce stiffening and scar retraction of the tissues as a result of healing. The cauterization stops when the epiglottis free edge is seen more or less in the middle of the surgical field. During this step, it is mandatory to preserve the free margin of the epiglottis. The procedure ends by removing the excess cauterized tissue using a Cottonoid soaked in physiological water. The laryngoscope is retracted and the mouth guard is removed.