Hypopharyngeal Approaches to Obstructive Sleep Apnea

At his center, significant improvement in sleepiness, snoring, AHI, and oxygen levels have been seen, Dr. Lin said. Among 234 patients, AHI fell from an average of 44.9 prior to surgery to 28.2 afterward. Scores on the visual analog scale for snoring fell from 9.87 to 4.07 (p

“Endoscopic coblator base of tongue reduction should have significant potential in the treatment of selected patients with OSA,” he said.

Epiglottal Collapse and Laryngomalacia

Epiglottal collapse and laryngomalacia, more common in children than in adults, frequently involves a neuromuscular issue, said Kathleen Yaremchuk, MD, chair of otolaryngology-head and neck surgery at Henry Ford Hospital in Detroit. “There is a degree of neuropathy in these patients that occurs, and I always say you can’t trust the sleep apnea patient to breathe,” she said. “They don’t breathe when they’re asleep, and even when they’re awake there are abnormalities present.”

Beyond obstruction, part of it is the mechanical load and the compensatory neuromuscular responses, she added. CPAP is often ineffective in these patients because as soon as the machine is turned on with positive pressure, the epiglottis is pushed inferiorly and blocks the airway. The patient feels as if she is being suffocated.

Partial epiglottectomy has been shown to be an effective treatment. Dr. Yaremchuk referred to a study in which 27 adults with OSA and 12 infants with stridor were treated with this approach. OSA improved in 85% of the cases, and all of the infants improved (Ann Otol Rhinol Laryngol. 2000;109 (12 Pt 1):1140-1145).

Skeletal Surgery

Maxillomandibular advancement (MMA) has consistently shown the highest rates of surgical success for patients with OSA who cannot tolerate CPAP, said Stanley Liu, MD, DDS, assistant professor of otolaryngology at Stanford University. The surgery involves advancement and rotation of the mandible to increase pharyngeal muscle tension (Med Clin North Am. 2010;94:479-515).

“MMA’s efficacy may be due to decreased collapsibility of the upper airway muscles, or due to reduced negative pressure with stable air flow,” Dr. Liu said. “It’s probably a little bit of both.”

“What I found via drug-induced sedation endoscopy is that MMA reliably addresses complete collapse of the lateral pharyngeal wall and the soft palate,” he said. “The effect at the tongue level is less predictable. Relapse also tends to occur at the tongue level. With the advent of upper airway stimulation [hypoglossal nerve stimulation] to help me address where the MMA falls short, the playbook is now more complete than ever for patients seeking surgical solutions for OSA.”