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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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Fig. 20.3 Preoperative DISE with primary epiglottis collapse (a); postoperative DISE with out-
come after ESO (b)
F. Salamanca and F. Leone
20.7 Contraindications
Body mass index (BMI) >35 and factors making laryngeal exposure difcult (e.g.,
presence of trismus, mandibular prognatism, etc.) [11] should be considered as
restrictions precluding the use of our technique.
20.8 Complications
In our experience, this procedure is devoid of major complications. No patient had
dysphagia, aspiration, or dysphonia. Some minor complications are mainly due to
postoperative infections which can be managed with oral antibiotics.
20.9 Our Experience
Between 1 January 2016 and 31 December 2020, we have performed 536 surgical
procedures for OSAHS and a total of 87 patients who underwent ESO exclusively.
A strong predominance of male was found, since only 10 patients were female
(11,5%), while 77 were male (88,5%); the mean age was 53,1years (SD±11,1).
The mean BMI was 26.8kg/m2 (SD±3,1). Fourteen (16,1%) patients were affected
by simple snoring; 73 (83,9%) patients were affected by OSAHS with a mean AHI
of 30/h (SD± 20,3). The postoperative course of all patients was uneventful substantially without pain (vNRS-11 range from 0 to 3) with discharge in the rst post op day. Moreover, no patient had dysphagia, aspiration (I-EAT 10 range from 0 to
2), or dysphonia. Two patients affected by diabetes mellitus had postoperative epiglottitis treated with oral antibiotics and subsided within 6 days. Postoperative
bronasolaryngoscopy on seventh and 30th postoperative day showed good results
in terms of retraction of epiglottis in all patients. Follow-up ranged between 6 and
68months (mean, 18months; SD±13,4).
20 Epiglottis Stiening Operation (ESO)
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20.10 Summary
The epiglottis is an important anatomical structure that was largely ignored and/or
underestimated in the early research on obstructive breathing disorders [12]. Recent
studies, however, have shown that it plays an important role, either on its own or in
combination with other pharyngeal structures. [13, 14] Primary collapse of the epiglottis represents a challenging situation because CPAP treatment may sometimes
aggravate airway obstruction by further pushing the epiglottis down into the laryngeal aditus. [7, 15] Furthermore, an epiglottis collapse can in some cases persist
even while performing a mandibular protrusion during the DISE, making it difcult
to treat exclusively with an oral appliance application. [6, 16] For all these reasons,
surgical treatment could represent a good option when dealing with EC, though up
to now no standardized surgical protocol has been described.
It’s important to remember that the epiglottis plays a role in preventing aspirations thanks to its sensitive receptors (distributed on the laryngeal surface, ariepiglottic folds, arytenoids, and posterior commissure) that stimulate the so-called
“glottis closure reex”.[16] For this reason, we stopped to perform “partial epiglottectomy”[17] for the treatment of primary epiglottis collapse, developing the surgical procedure we are actually reporting about.
Since its advent as a tool for the treatment of OSAHS, the scope of surgery has
evolved to address multiple areas of obstruction simultaneously [18, 19]. The treat-
ment of EC is generally part of multi-site procedures, explaining why we currently
lack enough scientic evidence to support any surgical treatment that is intended to
address this specic site of obstruction. To date, different surgical approaches [16,
17, 20] were described with the aim of treating this peculiar region, but some of
these are technically complex and eventually associated with complications, such as
bleeding, edema, persistent dysphagia, dysgeusia, etc. [20].
Our experience allows us to afrm that our ESO is a safe procedure, devoid of
complications, easy to perform, and effective to treat EC that presents itself as a
single or coexistent site of UA obstruction without altering epiglottis fundamental
functions. The short healing time and the lack of discomfort for the patients allow
surgeons to approach this surgery alone or in association with other techniques in a
multimodal approach or multilevel surgical treatment.
References
1. Delakorda M, Ovsenik N.Epiglottis shape as a predictor of obstruction level in patients with
sleep apnea. Sleep Breath. 2018;149:1–7. https://doi.org/10.1007/s11325- 018- 1763- y.
2. Azarbarzin A, Marques M, Sands SA, etal. Predicting epiglottic collapse in patients with
obstructive sleep apnoea. Eur Respir J. 2017;50:1700345–20. https://doi.org/10.1183/1399300
3.00345- 2017.
3. Campanini A, Canzi P, De Vito A, etal. Awake versus sleep endoscopy: personal experience in
250 OSAHS patients. Acta Otorhinolaryngol Ital. 2010;30:73–7.
4. Salamanca F, Costantini F, Bianchi A, etal. Identication of obstructive sites and patterns in
obstructive sleep apnoea syndrome by sleep endoscopy in 614 patients. Acta Otorhinolaryngol
Ital. 2013;33:261–6.
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5. Giarda M, Brucoli M, Arcuri F, etal. Efcacy and safety of maxillomandibular advancement
in treatment of obstructive sleep apnoea syndrome. Acta Otorhinolaryngol Ital. 2013;33:43–6.
6. Kent DT, Rogers R, Soose RJ.Drug-induced sedation endoscopy in the evaluation of OSA
patients with incomplete Oral appliance therapy response. Otolaryngol Head Neck Surg.
2015;153:302–7. https://doi.org/10.1177/0194599815586978.
7. Verse T, Pirsig W. Age-related changes in the epiglottis causing failure of nasal continuous
positive airway pressure therapy. J Laryngol Otol. 2007;113:1022. https://doi.org/10.1017/
S0022215100145888.
8. Pang KP, Terris DJ.Modied cautery-assisted palatal stiffening operation: new method for treating snoring and mild obstructive sleep apnea. Otolaryngol Head Neck Surg. 2016;136:823–6.
https://doi.org/10.1016/j.otohns.2006.11.014.
9. Salamanca F, Leone F, Bianchi A, etal. Surgical treatment of epiglottis collapse in obstructive sleep apnoea syndrome: epiglottis stiffening operation. Acta Otorhinolaryngol Ital.
2019;39:404–8. https://doi.org/10.14639/0392- 100X- N0287.
10. Schindler A, Mozzanica F, Monzani A, et al. Reliability and validity of the Italian
eating assessment tool. Ann Otol Rhinol Laryngol. 2013;122:717–24. https://doi.
org/10.1177/000348941312201109.
11. Incandela F, Paderno A, Missale F, et al. Glottic exposure for transoral laser microsurgery:
proposal of a mini-version of the laryngoscore. Laryngoscope. 2018;24:135–7. https://doi.
org/10.1002/lary.27525.
12. Catalfumo FJ, Golz A, Westerman ST, etal. The epiglottis and obstructive sleep apnoea syndrome. J Laryngol Otol. 2007;112:940. https://doi.org/10.1017/S0022215100142136.
13. Kwon OE, Jung SY, Al-Dilaijan K, etal. Is epiglottis surgery necessary for obstructive sleep
apnea patients with epiglottis obstruction? Laryngoscope. 2019;115:538–6. https://doi.
org/10.1002/lary.27808.
14. Torre C, Camacho M, Liu SY-C, etal. Epiglottis collapse in adult obstructive sleep apnea: a
systematic review. Laryngoscope. 2015;126:515–23. https://doi.org/10.1002/lary.25589.
15. Dedhia RC, Rosen CA, Soose RJ.What is the role of the larynx in adult obstructive sleep
apnea? Laryngoscope. 2013;124:1029–34. https://doi.org/10.1002/lary.24494.
16. Roustan V, Barbieri M, Incandela F, etal. Transoral glossoepiglottopexy in the treatment of
adult obstructive sleep apnoea: a surgical approach. Acta Otorhinolaryngol Ital. 2018;38:38–44.
https://doi.org/10.14639/0392- 100X- 1857.
17. Oluwasanmi AF, Mal RK.Diathermy epiglottectomy: endoscopic technique. J Laryngol Otol.
2006;115:289–92. https://doi.org/10.1258/0022215011907479.
18. Lin H-C, Friedman M, Chang H-W, Gurpinar B.The efcacy of multilevel surgery of the
upper airway in adults with obstructive sleep apnea/hypopnea syndrome. Laryngoscope.
2008;118:902–8. https://doi.org/10.1097/MLG.0b013e31816422ea.
19. Montevecchi F, Meccariello G, Firinu E, etal. Prospective multicentre study on barbed reposition pharyngoplasty standing alone or as a part of multilevel surgery for sleep apnoea. Clin
Otolaryngol. 2017;43:483–8. https://doi.org/10.1111/coa.13001.
20. Bourolias C, Hajiioannou J, Sobol E, etal. Epiglottis reshaping using CO2 laser: a minimally
invasive technique and its potent applications. Head Face Med. 2008;4:539–4. https://doi.org/1
0.1186/1746- 160X- 4- 15.
F. Salamanca and F. Leone
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MarcoBarbieri, MarcoFragale, andDavideMocellin
21.1 Introduction
The role of the epiglottis collapse regarding the hypopharyngeal obstruction in OSA
patients is become more relevant in the last years. Although it is well known that the
gold standard’s treatment of OSA syndrome is the CPAP therapy, some patients
show a non-responsiveness or even a worsening of the apnea-hypopnea index during administration of CPAP. In fact, in case of primary epiglottis collapse, it is
believed that continuous positive pressure may further push the epiglottis down in
the laryngeal aditus. The importance of epiglottis is also underlined by the evidence
that many patients who are adult affected by sleep apnea syndrome are affected by
multilevel obstruction in upper airways and among these, the epiglottis collapse
shows a prevalence of 15% [1].
Primary epiglottis collapse is not properly evaluable during ofce-based endoscopy. Consequently, it is strongly suggested to perform Drug Induced Sleep
Endoscopy (DISE) in patients that are intolerant to CPAP or have an incomplete
response to medical device therapy. Nevertheless, the sleep endoscopy is possible to
evaluate anatomical changes after previous surgical treatment.
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978-3-031-34992-8_21. 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.
M. Barbieri (*)
ENT Dept., IRCCS Ospedale Policlinico San Martino, Genoa, Italy
M. Fragale
Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”,
ENT Section, University of Catania, Catania, Italy
D. Mocellin
ENT Dept., Ospedale S.Paolo, Savona, 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_21
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In the year 2018, Roustan and colleagues developed a surgical technique called
glossoepiglottopexy (GEP) [2]. This procedure was borrowed from that conceived
by Monnier for children affected by laryngomalacia [3] and modied to ensure a
stabilization of the epiglottis in adult patients. This surgical technique is performed
by a transoral approach to perform a scarication of lingual surface of epiglottis and
part of the tongue base to afford a scarring between these two structures helped by
a transcervical suture that forties the adhesion; the suture has to be maintained for
about 3weeks.
When approaching to this surgical technique, it deserves to remember the importance of glottic closure reex mediated by stimulation of the superior laryngeal
nerve. The correct function of this reex guarantees a successful sphincteric protection of laryngeal inlet. To afford this, performing the GEP is mandatory to spare the
free margin of the epiglottis and to avoid injury of the numerous sensitive receptors
that are represented. Therefore, this procedure provides a stable support to the epiglottis without inuencing its function during swallowing while preserving laryngeal anatomy and physiology.
Roustan etal. analysed a group of 20 patients who underwent GEP and pharyngoplasty between January 2015 and September 2016 [2]. ESS scores, AHI, ODI and
T90 values showed a signicant decrease after 6months from surgery, and the mean
oxygen saturation showed a signicant increase of its value at the polysomnographic study. Those ndings demonstrated the safety and effectiveness of the GEP
and allow us to consider this technique as a valid and safe choice to treat adults who
suffer from sleep apnoeas with primary epiglottis collapse.
M. Barbieri et al.
21.2 Indications andContraindications
The main indication for this surgical technique is the primary epiglottis collapse that
can be seen and better detected during drug-induced sleep endoscopy. Every patient
with a suspicion of epiglottis collapse needs to be scheduled for a DISE to conrm
the correct indication of the surgical procedure. The retrodisplacement can principally be due to the laxity of the glossoepiglottic ligament, but recent studies have
underlined the importance of the shape of the epiglottis. Delakorda and colleagues
described three different shapes of the epiglottis: type 1, omega-shaped epiglottis;
type 2, normal concave epiglottis shape; type 3, at epiglottis. Among these three
types, the latter appears to be the most associated with obstruction [4]. The GEP
affords to reduce the retrodisplacement stitching together the epiglottis and the base
of the tongue; additionally, the suture embracing the suprahyoid epiglottis provides
a more signicative convexity to the epiglottis itself.
Individual parameters of the patient could make the laryngeal exposure harder;
among them, a low grade of extension of the neck, trismus, macroglossia, high BMI
index, or others can be found. To help to better stratify the different types of patients
during operative microlaryngoscopy, a clinical predictor score for difcult laryngeal
exposure (DLE) as the Laryngoscore described by Piazza etal. can be used [5].
Contraindication of primary importance is the presence of major comorbidities
as cardiovascular, pulmonary, or neurologic disease. Moreover, the presence of
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cranio- facial malformations either isolated or syndromic could be avoid to execution of this surgical procedure properly. For example, the presence of micrognathia
can make very challenging the microlaryngoscopic exposition of the larynx; moreover, these patients often present an epiglottis collapse secondary to a severe retroposition of the tongue base, the hyoid bone or the mandible itself and take more
advantage from mandibular advancement devices, mandibular distraction or maxillomandibular advancement surgery.
Finally, among the contraindications deserve to be mentioned those patients
affected by neurological dysfunction which determine dysphagia where the swallowing function is already impaired preoperatively.
21.3 Surgical Technique
The surgery is performed under general anesthesia. The patient lies supine in the
Boyce-Jackson’s position. The eyes are protected with wet gauze and the superior
teeth with a silicone mouthguard.
For the transoral intubation, a smallest endotracheal tube is needed to be chosen to
provide the adequate ventilation for the patient (Laser Shield II Endotracheal Tube,
Medtronic Xomed, Jacksonville, FL, USA). The rst goal for the surgeon is to expose
the base of the tongue, the epiglottic vallecula, and the epiglottis with a Sataloff laryngoscope (MicroFrance Sataloff Laryngoscopes 124, Medtronic ENT, Jacksonville,
FL, USA) (Fig.21.1). The hyoid bone is identied and marked on the skin as a reference point. The CO2 laser is set on the ultra-pulse mode and 3W of power are delivered, working with the microscope at 400mm of distance from the surgical eld.
Fig. 21.1 The setting of the surgical procedure of glossoepiglottopexy. The patient can be seen in
the Boyce-Jackson’s position after intubation and the positioning of the laryngoscope
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Fig. 21.2 The
microlaryngoscopic view
of the lingual surface of
epiglottis before starting
the vaporization of its
mucosa where the red spot
of the CO2 laser can be
seen. The mucosa of the
tongue base had been
already vaporizated
Fig. 21.3 The
microlaryngoscopic view
during the vaporization of
the mucosa. Out of focus,
it can be seen the surgical
aspirator used to pull the
epiglottis to expose the
entire mucosa of the
lingual surface
M. Barbieri et al.
The next step requires the switch to a microscopic vision of the pharynx and the
larynx through the laryngoscope (Fig.21.2). With the CO2 laser (Ultrapulse Dualpro
Laser CO2, Lumenis, Yokneam, Israel), paired to the microscope, the mucosa overlying the vallecula and the tongue base are vaporized by the operator (Fig.21.3).
The surgical eld is always blood-free, thanks to the ability of the CO2 laser to coagulate vessels with a diameter less than 0.5mm. For the vessels with a higher diameter, it
needs to be used as an electrocautery monopolar and, if necessary, surgical clips. If present a moderate to severe degree of hypertrophy of the tongue base, the resection of the
lymphatic tissue may be combined as an additional step of this technique.
Surgical tip: Even when the epiglottis represents a cause of obstruction, its function in protecting the upper airway must be taken into account. To maintain the glottic closure reex coordinated by the superior laryngeal branch of the vagal nerve, it
is necessary to leave a 3–4mm rim of healthy cartilage and mucosa along the entire
prole of the epiglottis with the aim of address food to the piriform sinuses.
From the outside side of the neck, two 16-gauge needles are inserted through the
skin, the tongue base and the vallecula to pierce the epiglottis (Figs.21.4 and 21.5).
The transcervical needles are used as a guide to run into them as two Premilene®
sutures: number 1 (Premilene, Braun, Melsungen, Germany): the rst wire is
inserted in the rst needle (Fig.21.6); then, the second wire is inserted in the second
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Fig. 21.4 The insertion of
the needle through the skin
above the hyoid bone. The
wire of Premilene® running
inside the needle can
be seen
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Fig. 21.5
Microlaryngoscopic view
of the rst needle piercing
the epiglottis after its
transcervical insertion
needle forming a loop (Fig.21.7) and subsequently the rst wire is passed through
the loop outside of the laryngoscope.
The transcervical stitch must be tied up embracing the epiglottis so to keep
together its lingual surface to the base of the tongue (Figs.21.8 and 21.9); then, it is
tied outside of the neck, anteriorly to the larynx, using a silicone surgical sheet to
protect the skin from local trauma (Fig.21.10).
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Fig. 21.6
Microlaryngoscopic view
of the wire of Premilene®
running inside the needle.
In the next step, the
surgeon has to catch the
wire and pull it out from
the laryngoscope
Fig. 21.7
Microlaryngoscopic view
of the second 16-gauge
needle after its
transcervical insertion. The
wire inside the needle is
folded to create a loop and
it will be pulled out from
the laryngoscope by the
operator
M. Barbieri et al.
Fig. 21.8
Microlaryngoscopic view
of the vallecula and the
wires previously inserted
because the needles had
been removed. Now the
wires can be knotted
The wires need to be placed both superiorly or inferiorly to the hyoid bone. If one
is placed superiorly and the other inferiorly, the risk of injury of the epiglottis is too
high because of the excessive tension created. Before tying the suture, a small
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Fig. 21.9 The rst wire
passing through the loop of
the second wire (this step
needs to be done outside of
the laryngoscope). The
loop of the wire is used to
take out the inner side of
the other wire outside of
the neck
Fig. 21.10 The stitch of
the transcervical wire at
the end of the surgical
procedure. A silastic sheet
is positioned to avoid the
decubitus of the knot on
the skin
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Fig. 21.11 (Video 21.1) Epiglottic vallecula during performing the GEP
(► https://doi.org/10.1007/000-bfq)
amount of Tisseel® (Baxter, Westlake Village, CA, USA) is spread in the epiglottic
vallecula using a Duplocath® (Baxter, Westlake Village, CA, USA) catheter
(Figs.21.11 and 21.12).
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