Palate Shape, Drug-Induced Sleep Endoscopy Findings, and Obstructive Sleep Apnea Pharyngeal Surgery Outcomes.

OBJECTIVE: Pharyngeal surgery is a treatment option for patients with obstructive sleep apnea (OSA) unable to tolerate positive pressure therapy. This study aims to determine the association between palate shape as described by Woodson and pharyngeal surgical outcomes. STUDY DESIGN: Exploratory analysis of retrospective cohort. SETTING: Multicenter. METHODS: Three blinded reviewers assessed palate shape using drug-induced sleep endoscopy (DISE) videos from a previously-assembled cohort of adults undergoing pharyngeal surgery. Palate shape scores were examined for association with surgical outcomes with univariate and multivariate analyses. Multivariate analyses included adjustment for consensus DISE findings determined previously. RESULTS: Two hundred nine study subjects were included from 13 centers. Age was 53.7 ± 11.5 years, body mass index (BMI) was 30.3 ± 5.0 kg/m2, and 21% were female. In isolated soft palate surgery, greater GenuAP narrowing was associated with lesser odds of surgical response, whereas greater GenuLW narrowing was associated with greater odds of surgical response. These findings largely persisted after adjustment for key DISE findings, age, gender, OSA severity, BMI, and tonsil size. Other palate-shape findings were not clearly associated with surgical outcomes, although some palate-shape findings demonstrated trends toward an association with outcomes (P < .10). CONCLUSION: Greater GenuAP narrowing and GenuLW narrowing were associated with lesser and greater, respectively, odds of surgical response after isolated soft palate surgery. Palate shape and other palate shape level scores were not clearly associated with surgical outcomes. Larger studies may determine more precisely the association between palate shape and pharyngeal surgery outcomes.

Palate shape is associated with Unilateral Hypoglossal Nerve Stimulation Outcomes.

OBJECTIVE: The aim was to determine the potential association between palate shape and unilateral hypoglossal nerve stimulation (HNS) outcomes. METHODS: Preoperative drug-induced sleep endoscopy (DISE) videos were reviewed and scored by 3 blinded reviewers to determine airway narrowing at the hard-soft palate junction (HP), soft palate genu, and inferior velum, as described by Woodson (2014). Scoring was as follows: 1-open airway, 2-narrow, 3-severe narrowing. Overall palate shape (oblique, intermediate, or vertical) was determined based on prior criteria. Successful surgical treatment was defined by the HNS titration polysomnogram as a reduction of ≥50% in the apnea-hypopnea index (AHI) to <15 events/h. RESULTS: Of 332 adults, the majority was male (77%) with an average BMI of 29.2 ± 3.6 kg/m2 . Overall success rate was 73%. Success rate was lower in patients with vertical palate shape compared with the other shapes (56% vs. 75%, p = 0.029). HP score 3 compared with scores 2 and 1 was associated with lower success rates (60% vs. 76%, p = 0.028), but genu and velum scores were not associated with outcomes. Patients with both HP score 3 and complete oropharyngeal lateral wall-related obstruction had notably worse outcomes (22% vs. 74%, p = 0.026). HP score 3 (OR 0.45, 95%CI 0.22-0.92) and vertical palate shape (OR 0.33, 95%CI 0.15-0.78) were independently associated with lower odds of surgical response after adjustment for DISE findings, age, gender, and BMI. CONCLUSION: Vertical palate shape and narrowing at the hard-soft palate junction are independently associated with lower HNS surgical success rates. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:981-986, 2024.

Virtual otolaryngologic management of sleep apnea patients: Lessons learned from COVID-19 pandemic.

OBJECTIVE: To discuss the virtual management options and strategies learned during the COVID-19 pandemic for treatment of patients with sleep complaints and sleep disordered breathing presenting to the otolaryngologist. METHODS/RESULTS: The addition of a virtual evaluation can be beneficial in assessing the patient presenting to the otolaryngologist with sleep complaints. With the implementation of telemedicine, validated subjective assessment tools, and a limited physical exam, patients can be triaged for the need for treatment implementation, further evaluation or testing, and counseled regarding various management options.In this article, we discuss the lessons learned from the authors' collective experience on how to effectively use telemedicine as a tool in the management repertoire for patients with sleep disorders. CONCLUSION: The otolaryngologist will commonly see patients with sleep complaints, particularly patients diagnosed with obstructive sleep apnea not able to tolerate conservative therapies. These patients are well suited for virtual evaluation utilizing telemedicine. The technology and workflows which have been developed during the COVID-19 pandemic can be carried forward for select patients to improve access and efficiency of care.Level of evidence: 5.

Drug-Induced Sleep Endoscopy and Hypoglossal Nerve Stimulation Outcomes: A Multicenter Cohort Study.

OBJECTIVES/HYPOTHESIS: To determine the association between findings of blinded reviews of preoperative drug-induced sleep endoscopy (DISE) and outcomes of hypoglossal nerve stimulation (HNS) for obstructive sleep apnea (OSA). STUDY DESIGN: Cohort study. METHODS: A retrospective, multicenter cohort study of 343 adults who underwent treatment of OSA with HNS from 10 academic medical centers was performed. Preoperative DISE videos were scored by four blinded reviewers using the VOTE Classification and evaluation of a possible primary structure contributing to airway obstruction. Consensus DISE findings were examined for an association with surgical outcomes based on therapy titration polysomnogram (tPSG). Treatment response was defined by a decrease of ≥50% in the apnea-hypopnea index (AHI) to <15 events/hour. RESULTS: Study participants (76% male, 60.4 ± 11.0 years old) had a body mass index of 29.2 ± 3.6 kg/m2 . AHI decreased (35.6 ± 15.2 to 11.0 ± 14.1 events/hour; P < .001) on the tPSG, with a 72.6% response rate. Complete palate obstruction (vs. none) was associated with the greatest difference in AHI improvement (-26.8 ± 14.9 vs. -19.2 ± 12.8, P = .02). Complete (vs. partial/none) tongue-related obstruction was associated with increased odds of treatment response (78% vs. 68%, P = .043). Complete (vs. partial/none) oropharyngeal lateral wall-related obstruction was associated with lower odds of surgical response (58% vs. 74%, P = .042). CONCLUSIONS: The DISE finding of primary tongue contribution to airway obstruction was associated with better outcomes, whereas the opposite was true for the oropharyngeal lateral walls. This study suggests that the role for DISE in counseling candidates for HNS extends beyond solely for excluding complete concentric collapse related to the velum. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:1676-1682, 2021.

Drug-Induced Sleep Endoscopy and Surgical Outcomes: A Multicenter Cohort Study.

OBJECTIVE: To evaluate the association between findings of blinded reviews of preoperative drug-induced sleep endoscopy (DISE) examinations using the VOTE Classification and obstructive sleep apnea (OSA) surgical outcomes in a large multicenter, international cohort. METHODS: Retrospective, multi-center cohort study of adults without tonsillar hypertrophy who underwent pharyngeal surgery for OSA. The study included only participants without enlarged tonsils. Four independent reviewers performed blinded review of preoperative DISE videos using the VOTE Classification system and scoring of a primary structure contributing to airway obstruction. DISE findings were examined for an association with surgical outcomes with univariate analyses and multiple regression. RESULTS: Two hundred seventy-five study participants were included from 14 centers. Mean age was 51.4 ± 11.8 years, and body mass index was 30.1 ± 5.2 kg/m2 . There was moderate interrater reliability (kappa = 0.40-0.60) for DISE findings. Oropharyngeal lateral wall-related obstruction was associated with poorer surgical outcomes (adjusted odds ratio (AOR) 0.51; 95% CI 0.27, 0.93). Complete tongue-related obstruction was associated with a lower odds of surgical response in moderate to severe OSA (AOR 0.52; 95% CI 0.28, 0.98), with findings that were similar but not statistically significant in other analyses. Surgical outcomes were not clearly associated with the degree and configuration of velum-related obstruction or the degree of epiglottis-related obstruction. Surgical response was associated with tonsil size and body mass index (inversely). CONCLUSION: DISE findings concerning the oropharyngeal lateral walls and tongue may be the most important findings of this evaluation technique. LEVEL OF EVIDENCE: 2B Laryngoscope, 129:761-770, 2019.

Transoral Robotic Partial Glossectomy and Supraglottoplasty for Obstructive Sleep Apnea.

The standard treatment for patients with obstructive sleep apnea syndrome is positive airway pressure (PAP) therapy. However, when PAP therapy fails, surgery may be an option to alleviate the obstruction. The base of tongue plays an important role in this obstruction, and addressing the tongue base surgically can be a challenge for the head and neck surgeon. Transoral robotic surgery (TORS) using the da Vinci Surgical System provides a safe and effective way to approach and manage the base of tongue and supraglottis. Advantages of TORS include wide-field high-definition 3-D visualization, precise instrumentation, and when compared with open procedures, less operative time, quicker recovery, no external scars, and comparable tissue resection.

Transoral robotic surgery in benign diseases including obstructive sleep apnea: Safety and feasibility.

OBJECTIVES/HYPOTHESIS: To evaluate the safety and feasibility of the da Vinci Surgical System in transoral robotic-assisted surgery for benign indications. STUDY DESIGN: A multicenter, single-arm, retrospective case series. METHODS: Perioperative outcomes were recorded for patients presenting with obstructive sleep apnea, airway obstruction, lingual tonsillar/tonsillar/tongue base hypertrophy, or dysphagia who underwent one or more transoral procedures, including lingual tonsillectomy and tongue base resection (partial glossectomy) at one of three US institutions. RESULTS: Between January 2010 and October 2013, 285 patients (age 51.5 years, body mass index 30.5 kg/m(2) ) underwent 293 procedures. No conversions or blood transfusions were needed. The average operative time was 86.7 minutes, and the average volume of tissue resected (lingual tonsil and tongue base) was 8.3 mL. Hospital stays averaged 1.8 days, and the postoperative complication rate was 20.7%. There were no complications specifically related to the use the da Vinci Surgical System, and none of the complications were life threatening. CONCLUSIONS: These results demonstrate that it is safe and feasible to use the da Vinci Surgical System to perform lingual tonsillectomy and base of tongue resection (partial glossectomy) procedures for benign indications. LEVEL OF EVIDENCE: 4