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Hypopharyngeal airway surgery for obstructive sleep apnea: morbidity in the early postoperative period.

INTRODUCTION

Obstructive sleep apnea (OSA) affects approximately 2 percent of women and 4 percent of men in the middle-aged population of the US. This prevalence rate has been found to be higher in certain population subsets, such as individuals who are obese, elderly, male, those who have significant medical comorbidities (coronary artery disease and hypertension), and in individuals of African-American or Asian ethnicity. (1-3) OSA is caused by an excess of soft tissue that occludes the upper airway during sleep. Repeated episodes of airway collapse during sleep result in periods of apneas and hypopneas followed by respiratory arousals that impede the natural restorative benefits of sleep. (4) The effects of OSA include snoring, headaches, insomnia, irritability, depression, and daytime somnolence. Long-term consequences vary, and may include pulmonary hypertension, cor pulmonale, and sudden death. Because of the significant morbidity and mortality associated with OSA, risk reduction and therapeutic intervention for refractory cases is medically necessary. For patients with sleep apnea due to an obstruction involving the tongue base or hypopharynx, individualized hypopharyngeal surgery can expand the airway to improve the quality of sleep. (5)

A number of surgeries are utilized to treat patients with OSA due to hypopharyngeal obstructions, including: partial glossectomy, genioglossus advancement, lingual tonsillectomy, and submucosal minimally-invasive lingual excision (SMILE). Hypopharyngeal surgery has been shown by a number of studies to improve airway volume and flow, reduce the apnea-hypopnea index (AHI), decrease daytime somnolence, and improve patients' quality of life. (6-9) However, based on our experience, many patients and medical professionals alike believe that hypopharyngeal surgery causes significant morbidity and may be relatively unsafe in the early postoperative period given the risk for airway obstruction after surgical manipulation of the hypopharyngeal airway.

We aimed to examine our cohort of patients who underwent hypopharyngeal surgery for OSA to assess short-term post-operative complications and patient tolerance of the procedures in relation to subjective speech, swallowing and pain outcomes. This assessment was performed to help our group determine if it was safe to begin performing hypopharyngeal surgery on an outpatient basis in appropriately selected patients.

PATIENTS AND METHODS

Institutional review board approval was obtained to analyze patient medical records and to conduct a telephone survey. Patients with a diagnosis of OSA who underwent hypopharyngeal surgeries (partial glossectomy, lingual tonsillectomy, SMILE, and genioglossus advancement) between November 2012 and September 2013 were included in this study. Medical records were reviewed to determine age, gender, race, duration of hospitalization, and pre-operative body mass index (BMI) and the AHI. Operative procedures performed, including adjunct procedures, were analyzed (Table 1) and the incidences of various surgical outcomes (Table 2) were reviewed. Surgical outcomes concerning safety were analyzed which specifically included post-operative oxygen desaturations less than 90 percent, hemorrhage, prolonged admission for inadequate pain control, infection, dehydration, pulmonary edema, airway compromise requiring re-intubation, and any other complication was recorded.

Patients were contacted via telephone and asked to respond to a 14 question survey designed to subjectively assess surgical outcomes in terms of speech and swallowing impairment, pain, satisfaction with surgery, and functional improvement in snoring and daytime energy (Figure). The senior author performed all of the surgical procedures at a tertiary care facility. Comparative data analysis of subjective patient reported outcomes was performed using Fischer's exact test.

RESULTS

A total of 22 patients (14 male, 8 female) met the inclusion criteria. Medical records were reviewed to determine our objective surgical outcomes, and 16 (12 male, 4 female) of the patients were reached to complete the subjective telephone survey. The average age was 52.7 years (range 23-74). Of these patients, 54.5% were Caucasian, 40.9% were African-American, and 4.5% were Asian. Hypopharyngeal surgeries performed included 7 lingual tonsillectomies, 11 partial glossectomies, 2 SMILE procedures, and 2 genioglossus advancements. The average pre-operative BMI was 37.2 (33.0 - 46.5) and the average pre-operative AHI was 45.9 (8.1 - 94.0). All patients underwent multilevel surgeries, receiving a variety of adjunct procedures for the indication of OSA (Table 1). Surgical selection was arrived at utilizing information gained from the Friedman staging system, in office awake supine endoscopy with Muller maneuver, and in certain cases drug-induced sleep endoscopy.

Objective Surgical Outcomes:

None of the patients experienced intra-operative complications, or post-operative O2 desaturation <90%, hemorrhage, prolonged admission for inadequate pain control, pulmonary edema, and airway compromise requiring reintubation (Table 2). 20 (90.9%) patients were discharged after 23 hours of observation and 2 (9.09%) patients were discharged the same day of surgery.

A 59-year-old man experienced post-operative hemorrhage manifesting as epistaxis. This patient returned to the emergency department on post-operative day 2, received intra-nasal oxymetazoline and intravenous steroids, and was discharged home the same day once hemostasis was achieved.

A 62-year-old female developed an infection at a surgical incision site and was re-admitted to the hospital on post-operative day 10. This patient required IV antibiotics, steroids and one wound washout before discharge on hospital day 5.

Lastly, a 72-year-old man presented to the ED on postoperative day 7 with dehydration due to odynophagia. This patient received IV fluids and hydrocodone bitartrate (Lortab Elixir) and was discharged home the same day.

Subjective Telephone Survey:

Twelve of 16 (75%) patients reported no problems with speech following hypopharyngeal surgery (p=0.01). Of those 4 patients who did experience speech difficulties, 2 patients found it difficult to form words due to pharyngeal pain, 1 patient had dysphonia due to tongue swelling, and 1 patient had dysphonia due to tongue weakness. These patients experienced speech difficulties for an average of 5 (range 3-8) days. Fourteen of 16 patients (87.5%) reported difficulty swallowing after hypopharyngeal surgery (p<0.001). Seven (50%) of these patients had problems swallowing solids and liquids, 6 (42.9%) patients indicated dysphagia for solids alone, and 1 (7.1%) patient reported dysphagia for liquids alone. These patients experienced dysphagia for an average of 4.36 (range 1-10) days.

The Numeric Rating Scale was used to subjectively assess post-operative pain for each of the first four weeks following hypopharyngeal surgery. Patients were asked to rate their pain on a scale of 0 to 10 with 0 representing no pain and 10 representing the worst possible pain. Patients reported the following averages and ranges for pain throughout post-operative weeks 1 to 4: 7.9 (range 3-10) during week 1, 6.7 (range 0-10) during week 2, 3.5 (range 0-9) during week 3, and 1.75 (range 0-8) during week 4.

Following hypopharyngeal surgery, patients recovered for an average of 2.4 (range 1-4) weeks before returning to work or resuming normal activity (retired patients). Twelve of 16 patients (75%) felt an improvement in their overall health (p=0.01), 3 patients (18.75%) described no improvement in their health, and 1 patient (6.25%) felt unsure of any improvement. Fifteen of 16 patients (93.75%) felt an improvement in their snoring while 1 patient (6.25%) indicated no improvement (p<0.001). Ten of 16 patients (62.5%) described improved daytime energy following surgery for OSA while 6 patients (37.5%) felt no improvement (p=0.29).

DISCUSSION

The gold standard for treatment of obstructive sleep apnea is continuous positive airway pressure (CPAP). This pneumatic stent has well documented efficacy; (10) however, it has also been shown to be far less effective in the noncompliant patient. (11) Furthermore, in those patients with severe sleep apnea, the device must be worn 100 percent of the night to effectively reduce the patient's AHI. (12) Many patients can't tolerate wearing the device secondary to high pressures and claustrophobia, or they refuse to wear it for social or sexual reasons. (13) If these patients have soft tissue hypertrophy causing airway obstruction at the tongue base or hypopharynx, hypopharyngeal surgery offers drastic improvement in functional outcomes. (6) The goal of surgery in these patients is often not to avoid the use of CPAP, but to reduce the pressure settings so the device can be worn at a comfortable level.

Multiple surgical procedures exist for the treatment of hypopharyngeal and tongue base obstructions. In our group, partial glossectomy, lingual tonsillectomy, SMILE, and genioglossus advancement were used in combination with other surgeries such as septoplasty, submucosal resection of turbinates, tonsillectomy and/or pharyngoplasty when multilevel obstruction existed. Historically, those patients undergoing hypopharyngeal surgery have been admitted to the intensive care unit or general floor to monitor for conditions that would create life threatening airway obstruction in the early post-operative period. (14) No patients experienced post-operative pulmonary edema or airway obstruction requiring intubation. Three patients experienced a postoperative complication, but only one required readmission to the hospital for treatment. Additionally, post-operative pain causing dehydration is often listed as a reason to admit patients for intravenous pain control. However, in our group no patients required an extended hospital stay to achieve adequate pain control in order to tolerate a soft diet. One patient did require readmission for pain causing dehydration, however, this occurred one week after surgery and prolonged admission would not have prevented this issue. Furthermore, we found that no patient undergoing hypopharyngeal surgery experienced any type of complication that would have benefited from airway monitoring in an intensive care unit setting or even admission to a general hospital floor.

Another major concern of hypopharyngeal surgery is the patient's ability to tolerate the procedure due to pain, dysphonia, and/or dysphagia in the early postoperative period. (15) In our cohort, no patient reported lasting, disabling effects from these issues. Only 25 percent of patients experienced dysphonia, and in all reported cases, symptoms lasted less than a week. While most patients did report dysphagia following hypopharyngeal surgery, the average duration was less than five days. Overall, average pain by week 3 had decreased to 3.5 and 1.75 by post-operative week 4. The majority of patients felt that hypopharyngeal surgery had reduced snoring, improved daytime energy, and provided an overall benefit to daily health.

As a result of these findings regarding safety and subjective functional outcomes after hypopharyngeal surgery for OSA, our group has begun to send patients home the same day of surgery, except when signs of significant airway swelling or obstruction are present prior to discharge. One can postulate that the recovery from hypopharyngeal procedures can be successfully managed with traditional oral pain medication regimens on an outpatient basis with successful resolution of symptoms in the early postoperative period. We believe our data supports the notion that hypopharyngeal surgery is a safe treatment course for OSA, and in most circumstances can be performed utilizing an outpatient model. In addition, we believe same day surgery is sufficient and overnight observation may be considered in cases of post-operative edema or when pain management is difficult to achieve with oral pain medicines alone.

Our results are limited by the small patient population and by the retrospective nature of the study design. The study addresses the safety of hypopharyngeal surgery. More comprehensive results regarding the efficacy of this surgery for improvement of AHI, respiratory disturbance index (RDI), and other sleep parameters will be determined after a longer period of follow-up with patients.

Ryan E. Nelson, BA; John M. Carter, MD; Akash G. Anand, MD

REFERENCES

(1.) Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993; 328:1230-1235.

(2.) Bixler EO, Vgontzas AN, Lin HM, Ten Have T, Rein J, Vela-Bueno A, Kales A. Prevalence of sleep-disordered breathing in women: effects of gender. Am J Respir Crit Care Med 2001;163:608-613.

(3.) Al Lawati NM, Patel SR, Ayas NT. Epidemiology, risk factors, and consequences of obstructive sleep apnea and short sleep duration. Prog Cardiovasc Dis 2009;51(4):285-293.

(4.) White, DP. The pathogenesis of obstructive and central sleep apnea. Am J Respir Crit Care Med 2005;172:1363-1370.

(5.) Li, K. Hypopharyngeal airway surgery. Otolaryngol Clin North Am 2007;40: 845-853.

(6.) Kezirian, E. and Goldberg, A. Hypopharyngeal surgery in obstructive sleep apnea; Arch Otolaryngol Head Neck Surg 2006;132:206-212.

(7.) Jacobowitz, O. Palatal and tongue base surgery for surgical treatment of obstructive sleep apnea: a prospective study. Otolaryngol Head Neck Surg 2006;135:258-264.

(8.) Li, KK. et al. Morbidly obese patients with severe obstructive sleep apnea: is airway reconstructive surgery a viable treatment option? Laryngoscope 2000;110:982-987.

(9.) Fletcher, A. et al. The effect of genioglossal advancement on airway flow using a computational flow dynamics model. Laryngoscope 2013;123:3227-3232.

(10.) Sullivan, C. et al. Reversal of obstructive sleep apnea by continuous positive airway pressure applied through the nares. Lancet 1981;1:862-865.

(11.) Ballard, R. et al. Interventions to improve compliance in sleep apnea patients previously non-compliant with continuous positive airway pressure; J Clin Sleep Med 2007;3:706-712.

(12.) Ravesloot, M and de Vries, N. Reliable calculation of the efficacy of non-surgical and surgical treatment of obstructive sleep apnea revisited. Sleep 2011;34:105-110.

(13.) Wolkove, N. et al. Long-term compliance with continuous positive airway pressure in patients with obstructive sleep apnea. Can Respir J 2008;15:365-369.

(14.) Terris, DJ et al. Conservation of resources: indications for intensive care monitoring after upper airway surgery on patients with obstructive sleep apnea. Laryngoscope 1998; 108:784-788.

(15.) Franklin, K et al. Effects and side-effects of surgery for snoring and obstructive sleep apnea--a systematic review. Sleep 2009; 32:27-36.

Mr. Nelson is a medical student and Dr. Carter are associated with the Tulane University School of Medicine in the Department of Otolaryngology- Head & Neck surgery in New Orleans, LA; Dr. Anand, MD is associated with the Ochsner Medical Center, Department of Otolaryngology-Head & Neck Surgery in Jefferson, LA.
Table 1: Hypopharyngeal, nasal, oropharyngeal, and multilevel
surgeries performed

                Surgical Procedure                   Incidence (#/22)

Hypopharyngeal
  Partial glossectomy                                11
  Lingual tonsillectomy                              7
  SMILE                                              2
  Genioglossus advancement                           2
Nasal
  Septoplasty                                        17
  Submucosal resection of turbinates                 19
Oropharyngeal
  Pharyngoplasty (Lateral, Uvulopalato, Sphincter)   20
  Tonsillectomy                                      11
Multilevel
  Two Levels                                         4
  Three Levels                                       18

Table 2: Incidence of complications following hypopharyngeal surgery

                Surgical Outcome                    Incidence (#/22)

Intra-operative complications                       0
Post-operative [O.sub.2] desaturation <90%          0
Post-operative hemorrhage                           1
Prolonged post-operative admission for inadequate   0
  pain control
Post-operative infection                            1
Post-operative dehydration                          1
Post-operative pulmonary edema                      0
Post-operative airway compromise requiring re-      0
  intubation

Figure: Safety of hypopharyngeal surgery for OSA telephone survey

1a.     Did you experience any problems with speech
        following surgery? (YES/NO)

1b.     If so, was it difficult to form words because of:
        tongue weakness, swelling, or pain?

1c.     If so, for how many weeks did you experience
        problems with speech?

2a.     Did you have any problems with swallowing following
        surgery? (YES/NO)

2b.     If so, did you have difficulties swallowing: solids,
        liquids, or both?

2c.     If so, for how many weeks did you experience
        problems with swallowing?

3a-d.   Please rate your level of pain on a scale of 0-10
        with 0 representing no pain and 10 representing the
        worst possible pain for each of the following weeks:

        (a) week 1
        (b) week 2
        (c) week 3
        (d) week 4

4.      How many weeks were you out of work following
        surgery (working patients)? If you do not work, how
        many weeks passed until you resumed normal activity?

5.      Do you feel that this surgery was beneficial to your
        health? (YES/NO)

6.      Do you feel that your snoring has improved? (YES/NO)

7.      Do you feel that you have more energy during the
        daytime compared to before surgery? (YES/NO)
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Author:Nelson, Ryan E.; Carter, John M.; Anand, Akash G.
Publication:The Journal of the Louisiana State Medical Society
Article Type:Report
Date:Jan 1, 2015
Words:2567
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