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17
Hypopharyngeal Surgery for OSA Patients
PratyushaYalamanchi andPaulT.Hoff
Contents
18.1 Introduction – 270
18.2 Historical Perspective – 270
18.3 Patient Selection – 271
18.4 Physical Exam – 271
18.5 Imaging I – 272
18.5.1 Imaging – 272
269
18
18.6 Drug-Induced Sedated Endoscopy – 272
18.7 Treatment Algorithm – 274
18.8 Procedures – 274
18.8.1 Transoral Robotic Surgery – 274
18.8.2 Radiofrequency Ablation (RFA) – 275
18.8.3 Genioglossus Advancement – 277
18.8.4 Tongue Base Suspension – 277
18.8.5 Hyoid Suspension – 277
18.8.6 Maxillomandibular Advancement (MMA) – 278
18.8.7 Hypoglossal Nerve Stimulators – 279
18.9 Future Directions – 279
References – 280
© Springer Nature Switzerland AG 2021
K. B. Kim et al. (eds.), Management of Obstructive Sleep Apnea, https://doi.org/10.1007/978-3-030-54146-0_18
270
P. Yalamanchi and P. T. Hoff
18.1 Introduction
Hypopharyngeal airway obstruction in obstructive
sleep apnea (OSA) is caused by the prominence of
the base of the tongue, lateral pharyngeal wall, and
less commonly the aryepiglottic folds or epiglottis.
Abnormal bony anatomy such as narrow maxillomandibular arch or maxillomandibular deciency can signicantly contribute to hypopharyngeal obstruction.
While continuous positive airway pressure (CPAP)
remains the gold standard for treatment for obstructive
sleep apnea, surgery is an effective therapeutic option
for patients who are intolerant of positive pressure
therapy.
Successful obstructive sleep apnea surgery has
been traditionally dened as a reduction in apnea–
hypopnea index (AHI) to 50% and an AHI less than
20 in the surgical literature. Stuck and Maurer have
described an adjusted AHI which also accounts for
the percentage of time patients wear CPAP during the
night [1]. The adjusted AHI success rate has demonstrated a similar reduction in AHI in a subset of
highly selected surgical patients compared to those
treated with CPAP.
This chapter presents the current role of hypopharyngeal surgery for sleep apnea. The evolution of hypopharynx surgery over the last several decades,
preoperative airway evaluation and patient selection,
overview of procedures to address hypopharyngeal
obstruction, and the future of the eld of hypopharyngeal surgery to address OSA, are discussed.
18.2 Historical Perspective
The complexity of the soft tissues and bony anatomy
that contribute to hypopharyngeal obstruction, as well
as the importance of the hypopharynx to speech and
swallowing have presented signicant challenges over
the last several decades in the surgical management of
hypopharyngeal obstruction.
Fujita etal. [2] were the rst to present a classication system of the upper airway based on different levels
of obstruction, specically retropalatal, retrolingual, or
combined retropalatal and retroglossal obstruction,
. Fig.18.1. Surgical treatment of OSA dates back to
Fujita’s introduction of the uvulopalatopharyngoplasty
(UPPP) in the early 1980s. Based on these different levels of obstruction, the concept of multilevel surgery was
dened by Riley etal. [3]. Thorough understanding of
the complexity of airway obstruction by upper airway
endoscopy demonstrated that the hypopharynx and
base of tongue, in addition to the soft palate, are important anatomic components of obstruction in OSA [4]. In
addition, lateral collapse of the airway has been noted
to be of particular signicance in recalcitrant cases [5].
Over the past 30 years, numerous techniques have
been introduced to address base of tongue obstruction
including CO
laser resection, radiofrequency ablation
2
(RFA), suture suspension, skeletal framework surgery,
and radiofrequency coblation. Success has been variable, and the gold standard surgical technique, beyond
tracheotomy, remains bimaxillary advancement with a
success rate greater than 80% [5].
18
Type 1
. Fig. 18.1 Fujita classication
Fujita classification
Type 2
Type 3
Hypophar yngeal Surgery forOSA Patients
271
18
The application of transoral robotic surgery
(TORS) for safe, effective access to the base of tongue
in treatment of OSA was rst introduced in 2010 by
Vicini et al. [6, 8]. For patients with retrolingual
obstruction, TORS gained increasing acceptance
among sleep surgeons, given its ability to provide
excellent surgical exposure for safely resecting large
volumes of tissue via transoral approach. While effective, the previously established transcervical tongue
base reduction with hyoepiglottoplasty (TBRHE) procedure presented signicant risk of morbidity, including need for both tracheostomy and feeding tube
placement, as well as the possibility of tongue weakness and stula. The comparatively limited morbidity
of TORS for OSA resulted in acceptance among sleep
surgeons as a part of a multilevel approach in highly
selected patients. In 2014, the Federal Drug
Administration gave its approval for removal of benign
tissue from the base of tongue but stopped short of
approving TORS for the clinical indication of
OSA. More recently, increased attention has been
given to upper airway neuromuscular activity during
sleep, as neurostimulation has been utilized as an
intervention for patients with OSA.Given that loss of
compensatory neuromuscular responses has been
shown to play a critical role in airway obstruction during sleep, electrical stimulation of pharyngeal dilator
muscles such as the genioglossus have been designed to
overcome decits in airway neuromuscular control
and augment airway patency during sleep. The rst
successful use of hypoglossal nerve stimulation (HNS)
to reduce OSA severity in a small cohort of patients
was reported in 2001. Apnex Medical then developed
the rst commercially available implantable HNS
device for OSA but ultimately closed in 2013 due to
disappointing results from the associated randomized
control trial. Currently, Inspire Medical Systems manufactures the only FDA- approved HNS device for
OSA, which is an implantable, pacemaker-like pulse
generator with a sensing lead and stimulation lead.
The sensing lead is implanted between the external
and internal intercostal muscles for ventilator effort
detection. The stimulator lead is implanted in the submental space to stimulate select branches of the hypoglossal nerve responsible for stimulation of the
genioglossus muscle. In 2016, Inspire published
36-month outcomes data for its pivotal STAR trial,
which demonstrated signicant improvement in outcomes for patients with OSA after HGS implantation.
This study was a multicenter, single-arm intervention
followed by a randomized controlled, therapywithdrawal design with study participants serving as
their own controls. In total, 126 patients underwent
implantation after extensive workup with polysom-
nography, clinical assessment, and drug-induced sleep
endoscopy (DISE). Exclusion criteria included
BMI>32kg/m2, AHI>50 events per hour, central or
positional sleep apnea, and concentric palatal collapse. Resolution or signicant improvement in sleep
apnea was demonstrated in 66% of participants with
responses in sleep apnea improvement and quality of
life sustained in long-term follow-up at 36 and subsequently at 60months. With the success of the Inspire
system and increasing adoption, the eld of neurostimulation for treatment of OSA continues to grow.
18.3 Patient Selection
A number of important factors must be taken into consideration to determine surgical candidacy and choice
of intervention, including detailed sleep history, inofce physical exam including evaluation of base of
tongue, endoscopy, preoperative contraindications, and
predictors of success. Successful surgical outcome in
hypopharyngeal surgery for the treatment of OSA is
thought to depend on proper patient selection and
choice of surgical procedure.
18.4 Physical Exam
Body habitus including body mass index (BMI) and
neck circumference should be noted as this has been
shown to inuence surgical outcomes. A detailed head
and neck examination is necessary to identify sites of
upper airway obstruction, including the nose, soft palate, lateral pharyngeal walls, and tongue base.
Specically, examination of the nose should include
identication of any external deformity, septal position,
turbinate size, and the presence of polyps. Oral cavity
assessment includes tongue size and position, palate and
uvula elongation, tonsil size, Friedman tongue position,
dentition, and crowding of the oropharynx. Additionally,
evaluation of bony maxillofacial anatomy such as the
size and position of the maxilla and mandible (Angle
class) must also be considered, .
In addition to direct visual examination, beroptic
nasopharyngoscopy is critical for complete assessment
of the hypopharyngeal airway. With this examination
technique, the dimensions of upper airway can be fully
assessed including the prominence of the tongue base
(Moore classication and Friedman lingual tonsil size)
and the lateral pharyngeal wall. . Figure18.3 demonstrates different classication systems for assessment of
upper airway obstruction.
Evaluation of the supraglottic structures may identify a retro-displaced epiglottis that may contribute to
Fig.18.2.
272
P. Yalamanchi and P. T. Hoff
Dental occlusion-angle class
18
Normal occlusion
Class II malocclusion Class III malocclusion
. Fig. 18.2 Dental occlusion– Angle class: Class 2 occlusion often associated with signicant posterior airway space narrowing due to
retro-displacement of tongue
airway obstruction. Dynamic evaluation of the airway
18.6 Drug-Induced Sedated Endoscopy
Class I malocclusion
under sedation is the best way to identify collapse in the
region of the velum, lateral pharyngeal walls, tongue
base, and supraglottis. The Mueller maneuver for assessment of airway collapsibility, performed with the patient
awake, has been reported to have poor inter-rater reliability and predictive value.
In 1991, Croft and Pringle introduced drug-induced
sedated endoscopy (DISE). This technique has gained
wide acceptance in Europe and is rapidly gaining popularity in North America as surgeons have recognized its
utility in identifying both sites of obstruction and in
planning site-specic surgery. DISE is performed with
the patient supine and sedated in the operating room,
18.5 Imaging I
. Fig.18.5. Kezirian etal. popularized the VOTE clas-
sication which characterizes both the direction and
18.5.1 Imaging
degree of collapse at the level of the velum (V), oropharynx (O), tongue base (T), and epiglottis (E), . Fig.18.6.
Lateral radiographs can be used to assess facial skeletal
anatomy that may contribute to upper airway obstruction. Cephalometric radiography is a widely available
low cost two-dimensional representation of the airway
that can aid in evaluation of both the bony skeleton and
the associated soft tissues, . Fig. 18.4. Inferior displacement of the hyoid (>25mm below the hyoid mandibular plane), narrowed posterior airway (11mm), and
an elongated soft palate (35mm) are common ndings
in OSA patients. CT imaging may also be used and has
the advantage of allowing for three dimensional reconstruction measurements of the upper airway. At this
time, use of dynamic MRI is typically limited to research
The operating room setup for DISE exam is shown
in . Fig.18.6 [7].
The indications for DISE include revision upper airway surgery, in cases where there is no obvious site of
anatomic obstruction, and for all patients being considered for HNS.DISE has been shown to identify additional sites of obstruction, not identied on awake
examination in the clinic, particularly at the tongue base
and supraglottis that can alter the surgical plan in up to
one-third of cases. Concentric (sphincter like) collapse
at the soft palate is an absolute contraindication for
HNS as it has been associated with decreased success
rates, . Fig.18.7.
settings.
Hypophar yngeal Surgery forOSA Patients
273
18
a
Proximal Proximal and retroepiglottic
b
Moore classification
Retroepiglottic
Brodsky tonsil grading scale
0
3 4
. Fig. 18.3 Phenotypic characterization of the soft tissue components of the oropharynx and hypopharynx can be documented during the
obstructive sleep apnea directed phyiscal examination using the Moore classication, Brodsky tonsil grading system, Friedman staging and
Friedman lingual tonsil classication. The data obtained in the awake patient, combined with knowledge of the skeletal frame work, complements drug induced sleep endoscopy and optimizes surgical planning
1 2
274
ab
3G
P. Yalamanchi and P. T. Hoff
c
Visualize the
entire uvula
and tonsils
d
Grade I
Friedman tongue position
cd
Grade IIa Grade IIbGrade III
Visualize the
entire uvula
and partial
tonsils
Visualize soft
palate down to
base of uvula
Visualize soft
palate
Friedman grading system for lingual tonsil hypertrophy
Visualize hard
palate only
Grade 0Grade 1Grade 2Grade
Complete absence of
lymphold tissue
. Fig. 18.3 (continued)
Lymphold tissue
scattered over tongue
18
18.7 Treatment Algorithm
Surgical treatment of the hypopharynx consists of procedures designed to prevent sleep-related tongue
obstruction. The majority of patients choose surgery
due to intolerance of nonsurgical treatments such as
CPAP. Goals of surgery and anticipated surgical outcomes should be discussed prior to surgical intervention. Informed consent must be obtained, and patients
should be educated regarding the potential risks and
benets of hypopharyngeal surgery.
base
Lymphoid tissue
covering entirety of
tongue base with
limited vertical
thickness
18.8 Procedures
18.8.1 Transoral Robotic Surgery
Transoral robotic surgery (TORS) for OSA has rapidly
gained acceptance among sleep surgeons as a part of a
multilevel approach in highly selected patients. Since
the rst publication of TORS for OSA in 2009, numerous publications representing over 800 patients have
been reported. However, due to procedure morbidity
and advent of hypoglossal nerve stimulation, the num-
rade 4
Signicantly raised
lymphoid tissue
covering entirety of
the tongue base,
approximtely 5–10
mm in thickness
Lymphoid tissue rising
above the tip of the
epiglottis, 1 cm in
thickness
Drug-induced sleep endoscopy: VOTE classication
Degree of obstruction: 0 – No obstruction, 1 – partial obstruction, 2 – complex obstruction, X – not observed
Hypophar yngeal Surgery forOSA Patients
275
18
ber of TORS procedures for OSA has more recently
declined [13].
Candidates for TORS are patients who have been
diagnosed with moderate-to-severe OSA and have failed
conservative therapy with weight loss and CPAP. The
typical patient has a body mass index (BMI) <30. As
part of the clinical exam, the surgeon will have assessed
the airway and selected patients with a Friedman tongue
position of 3 or less without signicant retrognathia
[12]. TORS requires organization and efciency from a
multispecialty team. The team includes the surgeon,
anesthesiologist, and a surgical technician who has dedicated time to train for robotics cases and a bedside assistant familiar with TORS.As shown in . Fig.18.8, there
is a basic instrument setup that is standard for TORS,
and familiarity of the team with this set is essential.
18.8.2 Radiofrequency Ablation (RFA)
Radiofrequency (RF) tongue reduction is an outpatient
procedure often performed under local anesthesia for
volumetric reduction in tongue base tissue. It is particularly helpful for patients without lymphoid hypertrophy
who present with a muscular tongue base. An insulated
probe is used to deliver radiofrequency energy at
465 KHz. The resultant frictional heat causes tissue
injury and results in tongue volume reduction via coagulation necrosis and healing by scar. RFA is often an
adjunctive procedure, performed along with other hypopharyngeal airway surgical procedures.
Prospective studies of RF tongue reduction have
demonstrated a signicant improvement in respiratory
disturbance index without a change in speech or swallowing [9]. Surgical risks include supercial tongue
ulceration, persistent odynophagia, and infection
[10, 11].
PAS
HMP
. Fig. 18.4 Cephalometric characteristics on lateral radiograph:
Posterior airway space (PAS), hyoid to mandibular plane distance
(HMP)
. Fig. 18.5 VOTE classica-
tion which characterizes both the
direction and degree of collapse
at the level of the velum (V),
oropharynx (O), tongue base
(T), and epiglottis (E)
LEVEL
Velum
Oropharynx
Tongue Base
Epiglottis
DIRECTION
AP LATERAL CONCENTRIC
. Fig. 18.6 DISE operating room setup
276
P. Yalamanchi and P. T. Hoff
18
. Fig. 18.7 Circumferential collapse at velum identied on DISE
a
b
d
. Fig. 18.8 Transoral robotic surgery (TORS): a TORS lingual tonsillectomy, b DaVinci robot, c CELL operating room setup, d CELL
technique
c
Hypophar yngeal Surgery forOSA Patients
Genioglossus advancement
277
18
Pre-operative
. Fig. 18.9 Genioglossus advancement involves movement of the genial tubercle with genioglossus insertion forward, to place tension on
the tongue musculature and limit posterior displacement during sleep
18.8.3 Genioglossus Advancement
The genioglossus advancement procedure involves a bicortical osteotomy inclusive of the genial tubercle with its genioglossus muscle insertion anteriorly to place tension on the
tongue musculature and limit posterior displacement during
sleep, .
Fig.18.9. A rectangular osteotomy along the sym-
physis of the mandible is made intraorally. The rectangular
segment is then advanced and either rotated or secured with
titanium microplates to prevent retraction. Typically, genioglossus advancement is performed in conjunction with other
sleep apnea surgical procedures such as palatal repositioning
procedures and hyoid advancement to maximize success.
Like RFA, genioglossus advancement is helpful for patients
18.8.4 Tongue Base Suspension
Like genioglossus advancement, tongue base suspension
seeks to reduce tongue collapsibility during sleep,
. Fig.18.10. Via either an intra-oral or submental inci-
sion, a suspension suture is brought from an anchor
screw on the inner surface of the mandible to the base of
the tongue. This is then tightened such that a hammock
effect for the tongue is created. This short, relatively
simple procedure is often performed in conjunction with
palatal repositioning procedures. Variable success rates
ranging from 20% to 82% have been noted. Risks of the
procedure include infection, injury to tooth roots, and
possible detachment of the anchor screw.
Post-operative
with a large muscular tongue. Variable surgical success with
genioglossus advancement procedures, ranging from 20% to
70%, highlights the difculty in accurately predicting suc-
18.8.5 Hyoid Suspension
cess. Anatomic factors, body habitus, and OSA severity have
been demonstrated to inuence surgical success. Potential
risks associated with genioglossus advancement include
infection, hematoma, mandibular fracture, and paresthesia
of the lower teeth.
Hyoid advancement is performed by either advancing
the hyoid bone in an anterior-inferior (thyrohyoidpexy)
or anterior-superior direction (hyoidmandibulopexy),
and is often performed in conjunction with genioglossus