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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4586_Библиотеки_им_академика_М_И_Перельмана
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B. T. Kotecha
19.2 Indications/Rationale
As with any other surgical intervention, careful patient selection is of utmost importance. Clinical evaluation of the upper airway particularly in patients who have
failed CPAP therapy may reveal the problem to be at the level of the epiglottis and
this could be identied by awake endoscopy, DISE or indeed by MRI studies. Awake
endoscopy for example may demonstrate a very retractile epiglottis almost impinging on the posterior pharyngeal wall and likewise DISE could reveal a trapdoor
phenomenon whereby the laryngeal lumen is almost completely occluded. The trapdoor phenomenon seen during DISE is due to the high negative intra-luminal pressure sucking the oppy epiglottis inwards towards the laryngeal inlet (Fig.19.1). In
this case, the glosso-epiglottic fold is quite long and the vallecula appears somewhat
deeper and very easily visible. In addition, the anatomy and shape of epiglottis such
as omega shaped, normally curved, at will determine the type of specic obstruction and hence the surgical procedure deemed necessary [8]. However, at times one
may see that the base of tongue is rather bulky and that may be pushing the epiglottis posteriorly and inferiorly to occlude the larynx. In these cases, the glossoepiglottic fold is fairly short and the vallecula rather narrow. Imaging techniques
such as MRI scans are useful for soft tissue analysis and could potentially pick up
compromised retro-glossal component due to prominence of tongue base and/or
epiglottis. Laryngomalacia is not uncommonly seen in the paediatric population and
is occasionally encountered in adults with sleep disordered breathing where there is
redundant soft tissue around the ary-epiglottic folds and some in-curling of the epiglottis which compromises the airway during inspiration.
It is prudent that the patient is fully informed and consented prior to undergoing
surgery and during this process, it is important to discuss risks such as bleeding,
infections and swallowing difculties in the earlier phase and possibility of laryngeal penetration or aspiration. In some cases, if the airway gets signicantly compromised from bleeding and/or swelling, then it may be necessary to perform a
Fig. 19.1 (Video 19.1) DISE demonstrating epiglottic trap door phenomenon
(► https://doi.org/10.1007/000-bfm)
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temporary tracheotomy and the patient ought to be made aware of this. This may
particularly be the case if surgery to the epiglottis is combined with procedure on
the tongue at the same time.
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19.3 Contraindications
Patient selection is crucial for all surgical procedures and the case in epiglottectomy
is no exception. In patients with co-existing neurological conditions, the risks of
aspiration may be greater, so this would need to be taken into consideration. General
co-morbidities of the individual patient should also be considered and factors such
as obesity would make the outcome from surgery less favourable.
19.4 Surgical Technique
Pre-operative assessment should also include a full and thorough evaluation by the
anaesthetist and the discussion between the surgeon and the anaesthetist should
include the type of endotracheal intubation tube to be used. From a safety perspective, a metallic laser tube is recommended for laser surgery and furthermore, the
insertion of the tube may have to be via the naso-tracheal approach if combined
surgery of the tongue and epiglottis is being considered. If laser tubes are unavailable, then it may be possible to use a rubber endotracheal tube with a protective foil,
but in terms of safety this is not as good as the metallic laser tube.
For surgery on epiglottis solely, an oro-tracheal intubation may sufce and the
standard endo-laryngeal surgery using suspension microlaryngoscopy is the preferred option. The patient is placed in the supine position with the head in the “sniffing the morning air” position with the head extended and the neck exed. This could
be attained with an appropriate positioning of a pillow half under the shoulders with
or without the use of a head-ring depending on the size and exibility of the neck.
While draping the patient, if laser is to be used then the standard laser safety precautionary measures should be taken including applying wet gauze swabs around
the face.
A variety of rigid laryngoscopes are available and include Dedo, Lindholm,
Holinger and Sataloff. The choice of scope would be determined by the anatomy
and of course the personal preference. Surgical exposure is of utmost importance
and hence the use of the appropriate laryngoscope to accommodate the anatomy is
equally important. Illumination of the surgical eld is initially attained with a good
light source and cable followed by the light from the microscope or rigid endoscope
if that is preferred. While inserting the laryngoscope, great care should be taken to
protect the dentition with a plastic guard and unnecessary aggressive levering of the
laryngoscope on the teeth should be avoided in order to prevent dental trauma. The
beak of the laryngoscope is placed in the vallecula to expose the epiglottis adequately. A micro-laryngoscopy Lewy suspension system is utilised to allow bimanual surgery and a Mayo stand may be used to support the surgeon’s arms. While
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Fig. 19.2 Epiglottis
exposed and the undersurface covered by wet
swab. The excision margin
of inverted “V” is marked
out with the microscope
mounted laser
B. T. Kotecha
some surgeons may choose to use a rigid endoscope to be inserted via the rigid
laryngoscope, the author prefers the use of a microscope with a 400mm lens and a
micromanipulator for attachment of the CO2 laser to it and this technique will be
described rst.
Once the epiglottis has been exposed, the choice of excision is dependent on how
the epiglottis is obstructing the upper airway. In most cases of the trapdoor phenomenon, a laser wedge resection in the shape of an inverted “V” would appropriately
resolve the problem. This is the author’s preferred practice and is demonstrated by
Fig. 19.2. Inadvertent lasering of the posterior pharyngeal surface is avoided by
inserting a wet swab or surgical patties underneath the epiglottis. The CO2 laser is
set on 5–10W power in the continuous mode and using the micromanipulator to
control the ne laser beam and pushing the foot pedal to deliver the laser energy, the
outline is rst marked as shown in Fig.19.2. Smoke aspirator is connected alongside the shaft of the laryngoscope which aids in sucking the smoke and thus providing a constantly satisfactory view. Further careful lasering is continued to resect the
wedge alongside one of the edges of the triangle (Fig.19.3) and then the other edge
likewise. Hardly any bleeding is encountered, but should this become an issue then
de-focussing the laser beam and addressing the bleeding point with this should rectify the problem. Alternatively, adrenaline-soaked surgical patties would also be
helpful. Figure 19.4 demonstrates the clear view of the larynx after resection.
Figure19.5 demonstrates the six-week post-operative view with a exible nasendoscope illustrating the patent laryngeal inlet. However, the surgical technique may
need modication if in-curling of the epiglottis is noted during DISE [9]. In these
cases, the lateral borders of the omega-shaped epiglottis are trimmed from the
pharyngo- epiglottic fold with preservation of mucosa using the transoral robotic
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Fig. 19.3 Some of the
epiglottis resected, but
vocal cords still not seen
clearly
Fig. 19.4 Clear view of
the larynx following laser
wedge resection
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approach. Robotic approach is also usefully applied in cases where both the tongue
and the epiglottis need addressing [7].
Alternative techniques using different surgical tools if laser is unavailable and
endoscopes rather than the operating microscope have been described. Endoscopic
diathermy epiglottectomy has been reported in four cases of sleep disordered breathing [10]. They used a microdissection monopolar scissors to excise most of the
epiglottis leaving behind approximately 3mm of the suprahyoid epiglottis. They
reported that the view was satisfactory without the microscope and in any case, if
the microscope was to be used then it was more difcult to manoeuvre the scissors.
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Fig. 19.5 Six-week
post-operative view of the
larynx demonstrating the
epiglottic remnant and a
very clear view of the
larynx
B. T. Kotecha
Fig. 19.6 (Video 19.2) TORS epiglottic resection with thulium laser
(► https://doi.org/10.1007/000-bfk)
Similarly, endoscopic coblator-assisted epiglottic surgery has been reported [11].
This describes the use of a 300 rigid laryngeal 5mm endoscope, inserted via a broad
lumen laryngoscope suspended with Lewy laryngoscope holder and xed to a Mayo
table. A PROcise™ Plasma wand connected to the Coblator II surgical system is
utilised, but an epiglottoplasty rather than epiglottectomy is performed. However,
there is no reason why the excision of the epiglottis cannot be carried out with this
technique.
If base of tongue surgery is also required in addition to the epiglottic resection,
then the author modies the approach and utilises the trans-oral robotic surgery [7].
In this case, the microscope is no longer required and da Vinci robotic system is
used. The laser used here is the thulium laser available in the bre mode and hence
very easy to use through one of the robotic ports via an introducer. The excision of
the epiglottis is carried out with thulium laser set at 15W (Fig.19.6). The setup is
somewhat different; as there is no microscope, a Boyle-Davis gag is used to keep
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the mouth open and wet swabs are used as a protective measure on the pharyngeal
wall and also underneath the epiglottis to prevent inadvertent lasering. During the
procedure with any of the above, it is prudent to give the patient intravenous prophylactic antibiotics (500/125mg of amoxicillin-clavulonic acid if not allergic to penicillin) and 8mg of intravenous dexamethasone to prevent swelling.
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19.5 Post-Operative Care andComplications
Post-operatively, one would look out for bleeding or breathing difculty with close
monitoring. The patient would be kept in for a minimum of 24h observation and it
is useful to have high dependency unit available for nursing care if necessary.
Appropriate analgesic agents and oxygen supplementation are given as and when
necessary. In general, a soft diet is recommended for the rst couple of days. The
patient is advised to swallow slightly slower than normal as in the earlier postoperative phase, they may experience laryngeal penetration or mild aspiration. Once
patients have made adequate post-operative recovery, they are discharged on oral
antibiotics for a week and a small dose of dexamethasone (2mg twice or thrice daily
for three further days). Analgesic agents (usually codeine and/or non-steroidal antiinammatory agents such as diclofenac) and mouth wash are also recommended for
a few days. Most of our patients recover fully after 2–3weeks with normal swallowing without any problems with aspiration.
19.6 Discussion
DISE has enabled more accurate evaluation of the upper airway collapse and the
role of the epiglottis collapse has been better recognised [5, 12]. Epiglottic surgery
may be conducted as a sole procedure or as part of multi-level surgery [7, 13, 14]
with favourable outcomes reported by all. Golz etal. [15] reported good objective
improvement in the sleep study parameters in 27 patients who underwent laser epiglottectomy. In their group, the improvement in overall oxygen saturation was signicant from the preoperative levels recorded at 66% +/−17.6% to postoperative
levels of 95% +/− 13.2%. Similarly, they found the RDI (respiratory distress index)
reduced from 45 +/−14.6 per hour to 14 +/− 5.1 per hour. Babademez etal. [9]
reported a statistically signicant improvement in the mean apnea-hypopnea index
(AHI) from 27.89/h preoperatively to 10.58/h postoperatively in their group of 21
patients with inward curling of the epiglottis. An important point made in this study
was regarding stabilisation of the epiglottis remnant in that excessive medial trimming should be avoided and they suggest to use an imaginary line through the arytenoid cartilage as a possible landmark. Catalfumo etal. [16] reported an improved
cure rate in their group of OSA patients from 50% to 65% when partial epiglottectomy was performed with other surgical procedures such as palatal surgery.
Literature on epiglottic surgery is somewhat sparse compared to that of palatal
surgery and based on this, the complications encountered following epiglottic
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B. T. Kotecha
surgery do not appear to be frequently listed. However, surgeons have to be
extremely aware of the potential serious complications of epiglottic surgery. This
being said, our own experience in terms of persistent dysphagia or any aspiration
has been negligible [7]. Recognising that the epiglottis is causing the issue in upper
airway obstruction and understanding the nature of the problem is crucial before
embarking on any specic surgical epiglottic resection and further research is
needed to better appreciate this [17].
References
1. De Vito A, Carrasco-Llatas M, Ravesloot MJ, Kotecha B, de Vries N, etal. European position
paper on drug-induced sleep endoscopy: 2017 update. Clin Otolaryngol. 2018;43:1541–52.
2. Lechner M, Wilkins D, Kotecha B.A review on drug induced sedation endoscopy– technique,
grading systems and controversies. Sleep Med Rev. 2018;41:141–8.
3. Virk JS, Kotecha BT.When continuous positive airway pressure (CPAP) fails. J Thoracic Dis.
2016;8(10):E1112–21.
4. Lan MC, Liu SY, Lan MY, Modi R, Capasso R.Lateral pharyngeal wall collapse associated
with hypoxaemia in obstructive sleep apnea. Laryngoscope. 2015;125:2408–12.
5. Koutsourelakis I, Saruddin F, Ravesloot M, Zakynthinos S, de Vries N.Surgery for obstructive
sleep apnea: sleep endoscopy determinants of outcome. Laryngoscope. 2012;122:2587–91.
6. Leder SB, Burrell MI, Van Daele DJ.Epiglottis is not essential for successful swallowing in
humans. Ann of Otol Rhinol Laryngol. 2010;119(12):795–8.
7. Arora A, Chaidas K, Garas G, etal. Outcome of TORS to tongue base and epiglottis in patients
with OSA intolerant of conventional treatment. Sleep Breath. 2016;20(2):739–47.
8. Delakorda M, Ovsenik N.Epiglottis shape as a predictor of obstructive level in patients with
sleep apnea. Sleep Breath. 2019;23(1):311–7.
9. Babademez MA, Gul F, Bulut KS, Sancak M, Atalay SK.Robotic modication of epiglottis
trimming in the treatment of obstructive sleep apnea. Otolaryngol head neck Surg; 2021. p.1–7.
10. Oluwasanmi AF, Mal RK.Diathermy epiglottectomy: endoscopic technique. J Laryngol Otol.
2001;115:289–92.
11. Cassano M. Endoscopic coblator-assisted epiglottoplasty in “obstructive sleep apnoea syndrome” patients. Clin Otolaryngol. 2015;42:1112–4.
12. Bosco G, Morato M, Perez-Martin N, Navarro A, Racionero MA, etal. One-stage multilevel
surgery for treatment of obstructive sleep apnea syndrome. J Clin Med. 2021;10(4822):1–9.
13. Mickelson SA, Rosenthal L.Midline glossectomy and epiglotticdectomy for obstructive sleep
apnea syndrome. Laryngoscope. 1997;107:614–9.
14. Toh ST, Han HJ, Tay HN, Kiong KL.Transoral robotic surgery for obstructive sleep apnea
in Asian patients: a Singapore sleep Centre experience. JAMA Otolaryngol Head Neck Surg.
2014;140:624–9.
15. Golz A, Goldenberg D, Westerman ST, etal. Laser partial epiglotticdectomy as a treatment
for obstructive sleep apnea and laryngomalacia. Ann Otol Rhinol Laryngol. 2000;109:1140–5.
16. Catalfumo FJ, Golz A, Westerman ST, Gilbert LM, Joachims HZ, Goldenberg D.The epiglottis and obstructive sleep apnoea syndrome. J Laryngol Otol. 1998;112:940–3.
17. Torre C, Camacho M, Liu SY-C, Huon L-K, Capasso R.Epiglottis collapse in adult obstructive
sleep apnea: a systematic review. Laryngoscope. 2016;126:515–23.
Epiglottis Stiffening Operation (ESO)
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20
FabrizioSalamanca andFedericoLeone
20.1 Introduction
The identication of upper respiratory tract obstruction site(s) in obstructive sleep
apnea/hypopnea syndrome (OSAHS) patients is important in order to select the best
therapeutic strategy. Nowadays, among different diagnostic tools, drug-induced
sleep endoscopy (DISE), although not ideal, plays a key role in the decision making
process [1]. The introduction of routinely use of DISE studies in OSAHS patients
demonstrated that the upper airway (UA) obstruction results from the collapse of
one or more pharyngeal and/or laryngeal structures [2–4].
In the large majority of patients, laryngeal involvement consists of epiglottis collapse; this may be primary (in which case it is described as “oppy epiglottis”) or
secondary, when a bulky tongue base pushes the epiglottis backwards. Primary epiglottis collapse (EC) in patients with obstructive sleep apnea/hypopnea syndrome
(OSAHS) still represents a challenge in terms of conservative treatments, such as
oral appliances [5, 6] and CPAP [7]; therefore, its identication has important implications for surgical treatment. In order to approach EC, we got inspired by the
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978-3-031-34992-8_20. The videos can be accessed individually by click-
ing the DOI link in the accompanying gure caption or by scanning this link with the SN More
Media App.
F. Salamanca
Unit of Otorhinolaryngology– Head and Neck Surgery– Snoring and OSA Research Centre,
Humanitas San Pio X, Milan, Italy
Department of Biomedical Sciences, Humanitas University, Milan, Italy
F. Leone (*)
Unit of Otorhinolaryngology– Head and Neck Surgery– Snoring and OSA Research Centre,
Humanitas San Pio X, Milan, Italy
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
M. Delakorda, N. de Vries (eds.), The Role of Epiglottis in Obstructive Sleep
Apnea, https://doi.org/10.1007/978-3-031-34992-8_20
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CAPSO (Cautery Assisted Palate Stiffening Operation) described by Pang etal. [8]
It consists of the removal of an area of palatal mucosa with an electric scalpel inducing scar retraction without sutures, so that stiffening of the soft palate is obtained,
decreasing snoring and palatal prolapse. Similarly, we applied this principle at the
lingual surface of the epiglottis, naming our procedure “Epiglottis Stiffening
Operation” (ESO) [9].
F. Salamanca and F. Leone
20.2 Indications
The presence of a primary epiglottic collapse at DISE evaluation is the main indication for this type of procedure.
20.3 Preoperative Work-Up
The preoperative diagnostic work-up includes complete physical examination,
endoscopic evaluation, polysomnographic study (PSG), and DISE.Treatment was
planned taking into account clinical features and preferences of every single patient.
20.4 Surgical Technique
Exposition of the epiglottis in direct microlaryngoscopy is performed. The working
area is identied as a rectangular area extended 1/3in the upper half and 2/3in the
lower half of the epiglottis, between the lateral glosso-epiglottic folds (including the
median glosso-epiglottic fold) (Fig.20.1).
The lingual side of the epiglottis within the working area is cauterized using a suction cautery avoiding reaching the free margin of the epiglottis itself (Fig.20.2a–d). In
this phase, it’s important to reach the perichondrium in order to induce stiffening and
scar retraction of the tissues as a result of healing by secondary intention (Fig.20.2e).
Fig. 20.1 (Video 20.1) ESO working area: a rectangular area extended 1/3in the upper half and
2/3in the lower half of the epiglottis (► https://doi.org/10.1007/000-bfn)
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a
d
Fig. 20.2 Step by step procedure. The excessive mucosa of the lingual side of the epiglottis within
the work area is raised (a) and cauterized (b–d) using a suction cautery causing an immediate and
visible retraction of the epiglottis (e)
b
e
c
20.5 Tips andTricks
Some tips and tricks must be taken into account performing ESO: a) the scarication is made using a suction cautery in order to cauterize and at the same time
removing the excess of lax tissues; b) it’s important to reach the perichondrium of
the lingual side of epiglottis, especially on the midline, in order to induce an effective stiffening in the direction of median tiroepiglottic ligament; c) it is necessary to
leave a rim of healthy tissue along the free border of the epiglottis to preserve sensitive receptors allowing the activation of reexes; d) using a small endotracheal tube
allows a good and complete visualization of the epiglottis; e) very low cauterization
power avoids heat transmission, reducing the chance of healing problems or even
loss of substance of the epiglottis; f) postoperative antibiotic administration is
strongly recommended.
20.6 Postoperative Management
After surgery, at the rst postoperative day, a verbal Numerical Rating Scale 11
(vNRS-11) and an Eating Assessment Tool 10 (Italian version)(I-EAT-10) [10] is
administered; patients are discharged afterwards. Patients are followed for at
least 3 months postoperatively according to our protocol that includes endoscopic evaluation on seventh and 30th postoperative day and PSG at about
3months (Fig.20.3).
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