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Barbed Reposition Pharyngoplasty as Surgical Management of Obstructive Sleep Apnea

Background:

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.

Case Overview:

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.

First a partial uvulectomy is performed.  Next a Bovie is used to perform an extracapsular tonsillectomy, taking care to preserve the anterior and posterior pillar.  The palatopharyngeus (PP) muscle is then divided horizontally with a needlepoint Bovie halfway down the tonsillar fossa.  Dissection proceeded deep until the constrictor muscle was identified.     The needle point Bovie is then used to open the mucosa at three points--horizontally midline at the junction of the hard and soft palate, horizontally approximately 1cm above each mid point of the tonsillar fossae, and vertically over each pterygomandibular raphe. Two 3-0 V-Loc 180 Coviden sutures on a G-21 needle are used. The needle of one suture is passed through the loop of the other then back through its own loop to create a single bi-directional suture. Each suture is passed from the midline, to the spot above the tonsillar fossa and then to the raphe so that the knot sits within the central mucosal incision.   Next each side proceeded as follows: --Stitch passed from raphe through inferior aspect of PP muscle the back through/lateral to the raphe --Stitch passed submucosally from raphe into tonsillar fossa and then through the inferior muscle coming out through the mucosa --Two oppositely oriented stiches moving superiorly through the muscle with the second stitch oriented in a direction towards the raphe and then the stitch was passed through the raphe. The initial tension was then set pulling the lateral walls in nicely and also pulling the soft palate anteriorly. --The stitch is passed submucosally from the raphe through the uvular muscle and mucosa then back through the raphe setting the final tension. --Finally, the stitch is passed submucosally from the raphe to the previously made paramedian incision above the tonsillar fossa and cut   The same process is performed on the contralateral side and incisions are closed with 3-0 vicryl sutures.
- Moderate OSA poorly controlled with conservative management (ie. CPAP, oral appliance therapy, positional therapy, lifestyle modifications) - OSA centered around retropalatal collapse
- Pre-operative evidence of velopharyngeal insufficiency or soft palate deformity - OSA centered around retrolingual collapse - Severe OSA - BMI >40
General anesthesia is induced and orotracheal intubation is performed with oral right angle endotracheal tube (RAE). The patient is then turned 90 degrees and a shoulder roll is placed. The patient is then draped and a mouthgag is used to visualize patient's oropharynx and suspended onto a mayo stand.
- Polysomnogram to evaluate AHI and assess for central apneas - Drug induced sleep endoscopy to evaluate patterns of collapse at velum, oropharynx, tongue base, and epiglottis
- Tonsil/Tonsillar Fossa - Pterygomandibular raphe - Crucial to identify as the raphe maintains the anterolateral tension once the velopharynx is suspended by the tension of the V-Loc sutures - Palatopharyngeus muscle - Along the posterior pillar of the tonsillar fossa. Plays a crucial role as this muscle is what is suspended to the pterygomandibular raphe, resulting in the anterolateral displacement of the velopharynx.
Advantages: - Shorter operative time compared to other techniques of pharyngoplasty - Less anatomical dissection required Disadvantages: - risk of barbed suture extrusion causing discomfort - Once under suspension, barbed sutures are not easily removed or repositioned
- Post-operative hemorrhage - Dehydration/poor P.O. intake secondary to post-operative pain - Velopharyngeal insufficiency - Extrusion of barbed sutures causing discomfort - Failure to improve symptoms of OSA
No conflicts of interest to disclose
N/A
Yaremchuk K, Garcia-Rodriguez L. The History of Sleep Surgery. Adv Otorhinolaryngol. 2017;80:17-21. doi: 10.1159/000470683. Epub 2017 Jul 17. PMID: 28738337. Friedman M, Ibrahim H, Bass L. Clinical staging for sleep-disordered breathing. Otolaryngol Head Neck Surg. 2002 Jul;127(1):13-21. doi: 10.1067/mhn.2002.126477. PMID: 12161725. Neruntarat C, Khuancharee K, Saengthong P. Barbed Reposition Pharyngoplasty versus Expansion Sphincter Pharyngoplasty: A Meta-Analysis. Laryngoscope. 2021 Jun;131(6):1420-1428. doi: 10.1002/lary.29357. Epub 2020 Dec 25. PMID: 33368308. Iannella G, Vallicelli B, Magliulo G, Cammaroto G, Meccariello G, De Vito A, Greco A, Pelucchi S, Sgarzani R, Corso RM, Napoli G, Bianchi G, Cocuzza S, Maniaci A, Vicini C. Long-Term Subjective Outcomes of Barbed Reposition Pharyngoplasty for Obstructive Sleep Apnea Syndrome Treatment. Int J Environ Res Public Health. 2020 Feb 27;17(5):1542. doi: 10.3390/ijerph17051542. PMID: 32121007; PMCID: PMC7084807. Iannella G, Magliulo G, Cammaroto G, Meccariello G, De Vito A, Pelucchi S, Ciorba A, Maniaci A, Cocuzza S, Gulotta G, Pace A, Corso RM, Bahgat A, Vicini C. Effectiveness of drug-induced sleep endoscopy in improving outcomes of barbed pharyngoplasty for obstructive sleep apnea surgery: a prospective randomized trial. Sleep Breath. 2022 Dec;26(4):1621-1632. doi: 10.1007/s11325-021-02528-4. Epub 2021 Nov 20. PMID: 34802107.

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