While continuous positive airway pressure (CPAP) remains the gold standard for management of obstructive sleep apnea (OSA), surgical management is nonetheless a good alternative for patients that are unable to tolerate CPAP therapy. Pharyngoplasty is one such option. First described in 1976 by Dr. Ikematsu and popularized in the US by Dr. Fujita in 1981, the goal of the surgery is to suspend the velopharynx anterolaterally to improve patency of the airway for patients with collapse at the level of the velopharynx. Since its inception, it has undergone many iterations. This video demonstrates the steps to performing barbed reposition pharyngoplasty, a technique that has gained in popularity due to its short operative time and decreased post-operative morbidities. It utilizes the unique properties of V-loc sutures to evenly distribute tension when suspending the soft palate. Pharyngoplasty are best suited for patients with collapse at the level of the velopharynx and are not recommended for patients with significant posterior collapse at the level of the base of tongue.
45-year-old male with BMI of 33.1 and past medical history of OSA with poor sleep quality secondary to CPAP intolerance. Updated polysomnogram demonstrated moderate OSA with AHI of 15.7 with 1 central apnea. Physical examination demonstrated 1+ bilateral tonsil size and Friedman 3 palate position.
Pre-operative drug induced sleep endoscopy demonstrated mixed anteroposterior collapse of the velopharynx, partial lateral wall oropharyngeal collapse, with no significant collapse at the level of the base of tongue, hypopharynx, and epiglottis.
Hypoglossal Nerve Stimulator Implantation: 2-Incision Technique Authors: Cheryl Yu, MD1; Nilan Vaghjiani, BS1; Ryan Nord, MD1 1Virginia Commonwealth University School of Medicine, Department of Otolaryngology/ Head and Neck Surgery, Richmond, VA
Obstructive sleep apnea is a worldwide health problem that affects all groups. Given its systemic associations with comorbid diseases, it ultimately increases lifetime risk of mortality and thus, should not be a disorder taken lightly. Although continuous positive airway pressure is thoroughly acknowledged as the gold standard for treating OSA with studied efficacy, adherence remains challenge. Given such, hypoglossal nerve stimulation therapy presents a revolutionary alternative for those with moderate to severe degrees of OSA who are unable to tolerate standard CPAP therapy. It has been studied to be very efficacious in treating the disorder, with reductions in apneas up to 70-80%. The surgery itself is less invasive, now even more so with the 2-incision technique, when compared to other surgical options such as mandibular advancement or other upper airway surgery, with decreased post-operative pain and healing times. Adherence to therapy is generally superior as the majority prefer it over traditional positive airway pressure therapy. Overall, hypoglossal nerve stimulator implantation is an effective, tolerable long-term alternative treatment option for those with OSA.
Case Overview: 84-year-old female with BMI of 31 with past medical history significant for hypertension, atrial fibrillation, and obstructive sleep apnea and inability to tolerate CPAP. Polysomnography revealed severe OSA with an AHI of 33 and minimal central or mixed apneas. Preoperative drug induced sleep endoscopy was performed noting complete anterior-posterior collapse of the velum, no collapse at the oropharynx, complete anterior-posterior collapse of the tongue base, and no collapse at the epiglottis. Patient was subsequently deemed an appropriate candidate for hypoglossal nerve stimulator implantation and elected to proceed with the procedure. The following video demonstrates her hypoglossal nerve stimulator implantation via the 2-incision technique detailing the procedure’s anatomic landmarks and corresponding steps.