Outcomes in single‐stage multilevel surgery for obstructive sleep apnea: Transoral robotic surgery, expansion sphincter pharyngoplasty and septoplasty

Abstract

Background: Many patients with obstructive sleep apnea syndrome (OSAS) have multiple obstructive sites simultaneously such as the oropharynx, hypopharynx, and larynx. Multilevel surgery is starting to be widely performed by ENT surgeons and accepted by patients.Methods: Twenty consecutive patients with moderate or severe OSAS were treated with single-stage multilevel surgery. They underwent transoral robotic surgery for tongue base reduction or epiglottoplasty, expansion sphincter pharyngoplasty, and septoplasty. Results:The average length of hospitalization was 5.2 ± 0.9 days. No serious complications were observed. At the postoperative control with polysomnography, the apnea-hypopnea index (AHI) had decreased by at least 50% in 90% of patients;improvements were observed in all sleep parameters. Conclusion:Single-stage multilevel surgery has proven to be effective in treating patients with moderate to severe OSAS, without experiencing persistent complaints.Despite multiple levels of obstruction being operated in a single stage, airway safety was maintained in all patients. K E Y W O R D S expansion sphincter pharyngoplasty, multilevel surgery, OSAS, TORS 1 | INTRODUCTION Obstructive sleep apnea syndrome (OSAS) is characterized by recurring events of partial or complete upper airway collapse during sleep.It is related to increased risk of cardiovascular diseases and causes daytime sleepiness altering the quality of life. To eliminate the collapsing points in the airway, continuous positive airway pressure (CPAP) is the first-choice treatment and the first option that is recommended to the patient. Nevertheless, a significant number of patients refuse CPAP treatment, and in this case, surgical treatment becomes an alternative along with weight loss, orthodontic, and positional therapy.Most OSAS patients have multilevel obstructions at sites including the oropharynx, hypopharynx, and larynx, so the best surgical management must be multilevel. 1

Surgical, clinical, and functional outcomes of transoral robotic surgery used in sleep surgery for obstructive sleep apnea syndrome: A systematic review and meta‐analysis

“…The majority of authors included patients with moderate to severe OSAS using various AHI thresholds 16,19,20,23,26‐33,35,36,39,41‐43,45‐47 . Three authors included patients with mild OSAS 21,22,44 .…”

“…The BOT resection was limited to the lymphoid tissue resection in two studies, 37,46 while the surgery involved both lymphoid tissue and tongue muscle resection at the surgeon's discretion in eight studies 16,18‐20,22,24,25,27,28,30,33‐35,38,41,43,44 . There were no information about the potential excision of tongue muscle in five studies 29,31,39,40,42 . Use of tracheotomy was reported in eight studies, and in these studies the percentage of patients receiving tracheotomy ranged widely from 1% to 100% 19,24,25,31,33,41,43,44 …”

“…Fourteen studies reported hospital stay details 17‐20,25,31,36,37,39,40,42,43,44,46 . The mean hospital stay time was 3.65 (SD = 2.18) days (902 patients) ranging from 1.3 to 8.5 days (Table 2).…”

“…Patients had a nasogastric feeding tube in the immediate postoperative period, which was removed as soon as the patient was able to swallow liquid or soft food without aspiration in one study 32 . The perioperative medication used in TORS was reported in 5 of 31 studies 16,17,23,42,43 . Perioperative antibiotics and steroids were administrated to all patients in three studies, 16,17,23 while others did not systematically prescribe steroids 42 or antibiotics 43 .…”

“…The epiglottoplasty is another step that is often performed at the surgeon's discretion. Some authors proposed to systematically perform epiglottoplasty because epiglottis is often significantly retroflexed after lingual tonsillectomy leading to an obstruction of the airway 20,36,42 …”