Palatopharyngoplasty Resolves Concentric Collapse in Patients, Enables Eligibility for Upper Airway Stimulation

Can a modified tissue-preserving uvulopalatopharyngoplasty (UPPP) convert retropalatal concentric collapse to anteroposterior or lateral patterns of collapse on drug-induced sleep endoscopy (DISE) in patients who are not candidates for upper airway stimulation (UAS) due to complete circumferential collapse at the velum?

BOTTOM LINE

A modified UPPP can successfully convert collapse patterns in patients with complete circumferential collapse (CCC).

BACKGROUND: Upper airway stimulation is a successful treatment for select patients with obstructive sleep apnea (OSA) but often fails in patients with CCC at the level of the palate on preoperative DISE. The clinical phenotyping of which patients can best be treated by UAS is ongoing.

COMMENT: Approximately 25% of patients are excluded from hypoglossal nerve stimulator implantation due to the demonstration of complete circumferential collapse (CCC) at the level of the velum on preoperative drug-induced sleep endoscopy. Within this prospective, single-blinded cohort study, a tissue-preserving modified uvulopalatopharyngoplasty was able to convert 12/12 patients from CCC to anterior-posterior collapse or no collapse at the level of the velum, thus allowing these patients to become candidates for upper airway simulation. The authors indicate that longterm outcomes for these patients that were able to convert to candidacy is already underway. —Boyd Gillespie, MD

STUDY DESIGN: Prospective cohort study.

SETTING: Department of Otolaryngology–Head and Neck Surgery, Division of Sleep Surgery, Stanford Hospital and Clinics, Stanford, Calif.

SYNOPSIS: Researchers identified 12 patients with an OSA diagnosis and documented failure with continuous positive airway pressure (CPAP) treatment who presented to a single institution for UAS evaluation, had a body mass index (BMI) <32, 25% central apneas, and an apnea hypopnea index (AHI) >15 demonstrated on polysomnography. All were noted to have CCC at the level of the velum, excluding them from UAS criteria. The patients were offered tonsillectomy and tissue-preserving modified UPPP. At a mean interval of 17 weeks following UPPP, a repeat polysomnography was performed. Mean AHI in the cohort was reduced from 54.0 to 33.1 events per hour. All 12 patients converted from a pattern of CCC at the level of the velum: three with no collapse at the level of the velum, seven with complete anteroposterior collapse, and two with partial collapse. Moreover, all patients now met AHI and DISE criteria for UAS implantation. Study limitations included the nonconsecutive, small sample size.

CITATION: Liu SYC, Hutz MJ, Poomkonsarn S, et al. Palatopharyngoplasty resolves concentric collapse in patients ineligible for upper airway stimulation. Laryngoscope. 2020;130:E958-E962.