Original Expansion pharyngoplasty for treatment of

Article snoring and obstructive sleep apnea Otorhinolaryngology

Alyaa H. Dawaba1, Sayed M. Mekhemar2, Tawfik A. El Kholy2, Mohammed F. Zidan2

1
Otorhinolaryngology Department, AlRahmaniyah Central Hospital, Behara, Egypt.
2
Otorhinolaryngology Department, Faculty of Medicine for Girls, Cairo, Al-Azhar University, Egypt.

ABSTRACT
Background: Obstructive sleep apnea is defined as “five or more respiratory events (apneas, hypopneas) in combination
with severe daytime somnolence, waking with gasping, choking, or breath-holding.”
Objective: to investigate the importance of anterolateral pharyngoplasty in the management of obstructive sleep apnea by
increasing pharyngeal airspace and decreasing palatal and lateral pharyngeal wall collapse.
Methodology: A prospective interventional study included 30 patients over the age of 18 who were suffering from
symptoms suggestive of obstructive sleep apnea; each patient was assessed by history, polysomnography, and a cahali VI
lateral pharyngoplasty, with the patients being followed-up for six months after the procedure.
Results: There was statistically significant reduction of sleeping index postoperatively compared to preoperatively (51.27 ±
5.71 vs. 37.53 ± 2.64). There was statistically significant reduction of apnea hypopnea index postoperatively compared to
preoperatively (27.77 ± 9.55 vs. 21.33 ± 8.07 ). There was statistically significant reduction of Epworth sleepiness scale
postoperatively compared to preoperatively (2.40 ± 0.72 vs. 0.83 ± 0.70 ).
Conclusion: Cahali VI lateral pharyngoplasty can be used as a stand-alone treatment for all OSA patients.
JRAM 2022; 3 (1): 67-74
Keywords: Obstructive sleep apnea, polysomnography, lateral pharyngoplasty.
Submission Date: 3 August 2021 Acceptance Date: 6 October, 2021

Corresponding author: Alyaa H. Dawaba, Otorhinolaryngology department, AlRahmaniyah central hospital, Behara, Egypt. Tel:
+200109634425. E-mail. Alyaahamdy5@gmail.com
Please cite this article as: Dawaba AH, Mekhemar SM, ElKholy TA, Zidan MF. Expansion pharyngoplasty for treatment of snoring and
obstructive sleep apnea. JRAM 2022; 3 (1): 67-74. DOI: 10.21608/jram.2021.86392.1129

INTRODUCTION
Obstructive sleep apnea (OSA) is a sleep disorder in Snoring, male gender, middle age, women's menopause,
which a person repeatedly stops breathing while obesity, large neck circumference, nasal obstruction,
sleeping.Low motor tone of the tongue and/or airway enlarged tonsils, adenoids, macro-glossia, and low-lying
dilator muscles cause an obstruction of the upper airway [ ][ ]
soft palate are all risk .Increased snoring
while sleeping. Worldwide, the prevalence of OSA in index prior to surgery is a strong predictor of operation
men is estimated to be 3% to 7%, and in women it is failure. However, a high basal SpO2 level before surgery
estimated to be 2% to 5%.OSA is present in 41% of is a strong predictor of success.When the brain fails to
individuals with a BMI greater than 28, which is communicate with the muscles that control breathing,
determined as a person's weight in kilograms divided by central sleep apnea (CSA) occurs. In contrast to
[ ][ ]
the square of their height in .patient may not obstructive sleep apnea, which is a
be aware of snoring or apneic episodes.Thus, Collateral [ ]
mechanical .
sleep history and recognition of linked medical comorbid
illnesses that may imply OSA as an underlying diagnosis To diagnose OSA, various levels of nocturnal monitoring
[ ]
are .OSA has a complicated etiology, involving of respiratory, sleep, and cardiac parameters (Poly-
a complex interplay of anatomic, neuromuscular, and somnography) is used, with the goal of detecting
genetic variables, as well as an underlying hereditary obstructive events and changes in oxygen
[ ] [ ]
predisposition to the . .The aim of study is todetect the of
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 JRAM 2022;3(1):67-47 Dawaba et al. Expansion pharyngoplasty for OSA

importance anterolateral advancement pharyngoplasty in After that, we used three to four interrupted 3-0
treating obstructive sleep apnea by increasing pharyngeal monofilament absorbable, vertical mattress sutures to
airspace and decreasing palatal and lateral pharyngeal suture the palatopharyngeus flap to the anterior pillar (the
wall collapse. portion that was detached from the SPC), taking
generous bites with each stitch. The sutures were then
PATIENTS AND METHODS tied just tightly enough to oppose the edges.
It's an interventional prospective study. The research
procedure was authorized by the research ethics Statistical analysis
committee of Al-Azhar University's faculty of medicine The data were analysed using the social package for
for girls and the hospital's ethics board, and the patients statistical science (SPSS) version 17. Categorical
signed a written informed permission form. This research variables are presented as relative frequency (n.) and
was carried out at otorhinolaryngology department of Al- percentages, while quantitative data is presented as
Zahraa University hospital. The patients were operated arithmetic mean and standard deviation (SD)The
upon between December 2017 and May 2019. This study statistical difference between two points in time was
involved 30 patients over the age of 18 complaining of investigated using the paired (t) test. To interpret the
obstructive sleep apnea. The patients were followed up results, a P value of less than 0.05 was used as the margin
for six months after operation. We asked for of significance.
postoperative symptoms and satisfactions one month
after operation. Polysomnography was done at kobry el RESULTS
koppa military hospital. Table (1) shows that the studied patients were 18 males
(60%) and 12 females (40%) with mean age of (45.10 ±
Inclusion criteria: 9.06).
The following patients were included into the study;
adults more than 18 years, BMI less than 30 kg\ m2, Table (2) There was statistically significant decrease of
suitable for general anesthesia, have sleep study and sleeping index postoperatively compared to preoperatively
diagnosed as OSA syndrome, Patients who are unable to (37.53 ± 2.64 vs51.27 ± 5.71)(p< 0.001). The percentage of
use continuous positive airway pressure (CPAP) or who reduction of SI was (26.27±6.37) There was statistically
are non-compliant, with no previous history of sleep significant decrease of apnea hypopnea index (AHI)
surgery. postoperatively compared topreoperatively (21.33 ± 8.07 vs
27.77 ± 9.55 ) (p< 0.001). The percentage of reduction of
Exclusion criteria: AHI was (24.21±8.01). There was statistically significant
Patients with the following criteria were excluded from decrease of Epworth sleepiness scale (ESS)
the study; patients less than 18 years, BMI more than 30 postoperatively compared topreoperatively (0.83 ± 0.7 vs
kg\ m2, those who aren't candidates for general 2.40 ± 0.72 ) (p < 0.001). The percentage of reduction of
anesthesia, patients who have had previous palatal ESS was (68.89±25.04). There was statistically significant
surgery, such as uvulopalatopharyngoplasty (UPPP), and increase of base line Spo2 postoperatively compared
severe craniofacial abnormalities. topreoperatively (94.40 ± 2.42 vs 84.97 ± 3.21) (p <
0.001). The percentage of increase of Spo2 was (9.43 ±
The Stop Bang score and the Epworth score 2.79)
questionnaire were used to examine each patient based
on their medical history, with special attention devoted to Table (3) demonstrated that the postoperative pain
their sleep history. BMI, Neck circumference, and blood collected from patient on day by visual analogue scale
pressure are all part of a general systemic checkup. ENT (VAS) it was mild in 12 patient (40%) patient and it was
evaluation, polysomnography, and lateral pharyngoplasty moderate in 10 patient (33.3%), and severe in 8 patient
were performed. (26.7%). As regard to intraoperative bleeding according
to aspirated blood intraoperatively in suction containers
Surgical procedure there was no bleeding in 2 patient (6.7%) and small
A bilateral tonsillectomy preceded the lateral amount 15 patient (50%), moderate amount in 5 patient
pharyngoplasty procedure if it hasn't been (16.7%), and large amount in 8 patient (26.7%). As
donepreviously. The palatoglossus and palatopharyngeus regard to postoperative dysphagia (two weeks
muscles are identified by removing the tonsillar fossa postoperative) it was mild 15 patient (50%) and moderate
mucosa. Next, we remove a triangle of mucosa and 10 patient (33.3%), and severe 5 patient (16.7%)
muscle (palatoglossus) from the lateral oral free margin
Table (4) revealed that as regard to satisfaction of
of the soft palate and anterior pillar using an upside-
patients after operation the patients who was completely
down „V-shape' incision. Then, using both monopolar
satisfied was 10 patient (33.3%), very satisfied was 10
cautery and blunt dissection, elevate the cranial half of
patient (33.3%), somewhat satisfied 5 patient(16.7%),
the palatopharyngeus muscle from the superior
and not at all 5 patient (13.3%).
pharyngeal constrictor muscle (SPC).

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 JRAM 2022;3(1):67-47 Dawaba et al. Expansion pharyngoplasty for OSA

Table (1): Distribution of the studied cases according to demographic data

Studied group Patients with OSA
Characteristics (n = 30)
Age \ years
Range 28– 61
Mean ± SD 45.10 ± 9.06
Age groups \ years n (%)
<50 20 (66.7)
≥50 10 (33.3)
Sex n (%)
Male 20 (66.7)
Female 12 (40.0)
Table (2): Comparison between pre and post according to Apnea-hypopnea index - sleeping index Epworth sleeping
scale

Preoperative Postoperative
Item Decrease % decrease t p value
(n=30) (n=30)
AHI Min. – Max. 6.0 – 40.0 5.0 – 30.0
Mean ± SD 27.77 ± 9.55 21.33 ± 8.07 6.43 ± 2.22 24.21 ± 8.01 1.99 0.001
ESS Min. – Max. 1.0 – 3.0 0.0 – 2.0
Mean ± S 2.40 ± 0.72 0.83 ± 0.70 1.57 ± 0.63 68.89 ± 25.04 6.05 0.001
SI Min. – Max. 40.0 – 65.0 33.0 – 42.0 13.73 ± 4.52 26.27 ± 6.37
Mean ± SD 51.27 ± 5.71 37.53 ± 2.64 8.45 0.001
Preoperative Postoperative
Increase % Increase t p value
(n=30) (n=30)
SpO2 Min. – Max. 80.0 – 94.0 91.0 – 98.0
Mean ± SD 84.97 ± 3.21 94.40 ± 2.42 9.43 ± 2.79 11.20 ± 3.56 18.53 0.001
Apnea-hypopnea index (AHI), Sleeping index (SI), Epworth sleeping scale (ESS), SpO2: oxygen saturation, paired t-test (t)

Table (3): Distribution of the studied cases according to postoperative symptoms

Studied group Patients with OSA (n = 30)
Postoperative symptoms no. (%)
Pain
Mild 12 (40.0)
Moderate 10 (33.3)
Severe 8 (26.7)
Bleeding
No 2 (6.7)
Small amount 15 (50.0)
Moderate amount 5 (16.7)
Large amount 8 (26.7)
Dysphagia
Mild 15 (50.0)
Moderate 10 (33.3)
Severe 5 (16.7)

Table (4): Distribution of the studied cases according to satisfaction

Studied group Patients with OSA (n. = 30)
Satisfaction no. (%)
Not at all 5 (16.7)
Somewhat satisfied 5 (16.7)
Very satisfied 10 (33.3)
Completely satisfied 10 (33.3)

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JRAM 2022;3(1):67-47 Dawaba et al. Expansion pharyngoplasty for OSA

A)

B)

C)

Figure (1) :Steps of lateral pharyngoplasty

(A) Beginning of the division of the palatopharyngeus from the superior pharyngeal constrictor muscle
(SPC),(B)Cut off the right superior pharyngeal constrictor muscle releasing the arch of the palatopharyngeus flap
and exposing the buccopharyngeal fascia. (C) Vertical mattress sutures of the palatopharyngeus flap to the lateral
pharyngeal wall and anterior pillar

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 JRAM 2022;3(1):67-47 Dawaba et al. Expansion pharyngoplasty for OSA

Figure (2a): PSG of patient with OSA before LPP shows the respiratory analysis and related position changes during sleep
cycle

Figure (2b): PSG of the same patient 6 month after LPP shows the marked improvement of respiratory events and
related position changes during sleep cycle.

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 JRAM 2022;3(1):67-47 Dawaba et al. Expansion pharyngoplasty for OSA

DISCUSSION
Obstructive sleep apnea is a serious medical condition normal swallowing after 33 days, with a return to normal
that affects up to 4% of adults in their forties. The most diet after 10.9 days, with a range of 5 to 17 days.
common complaints include loud snoring, sleep
disruption, and excessive daytime tiredness. Patients with As regard to postoperative bleeding there was no
apnea have fragmented sleep and may develop bleeding in (6.7%) and small amount (50%), moderate
cardiovascular problems as a result of the repeated cycles amount in (16.7%), and large amount in (26.7). Our
of snoring, airway collapse, and arousal. The majority of result agrees with Park et al [15] Postoperative bleeding
[ ][ ] was noted in four patients (9.8%), and it stopped
individuals are obese and have a short, thick .
Obstructive sleep apnea Its classified into 3 degrees spontaneously in all four cases without the need for
according to the apnea -hypopnea index (AHI) which is emergency surgery, with just one incidence of VPI (2.4
[ ] %).
the number of apnea and hypopneas per hour of .

The current study revealed that there was male As regard to postoperative pain collected from patient on
predominance (60%). Our result agreed with Khan et al day by VAS, it was mild in (40%) patient and it was
[10]
where men made up 81% of the population with moderate in (33.3%), and severe in (26.7%). Our result
OSA. This suggests that OSA is more common in men. agrees with Cahali [11] who conducted a study on 10
patients whom Lateral pharyngoplasty giving a median
In present study there was significant reduction of AHI value of 4.5 (4.0). After 10 days of the procedure,
postoperatively (21.33 ± 8.07) compared to preoperative analgesics were usually no longer required. The median
value (27.77 ± 9.55). Our result agrees with Cahali [11] time it took for patients to return to normal nourishing
who found that the median AHI decreased from 41.2 was 14.5 (10) days.
(34.0) to 9.5 (17.7). Sixty percent of patients had a
postoperative AHI of less than 20. Also our results agree CONCLUSION
with The mean AHI of lateral In selected patients, splinting the lateral pharyngeal wall
pharyngoplasty patients before surgery was 23.4, and the (by extended lateral pharyngoplasty ) obtains significant
mean AHI after surgery was 11.3 (P < 0.05). improvement in subjective snoring and daytime
sleepiness, as well as objective adverse sleep respiratory
In the present study there was statistically significant events and sleep architecture, while retaining normal
decrease of sleeping index postoperatively compared to pharyngeal function. There is great improvement in
preoperatively (37.53±2.64 vs. 51.27±5.71) (p< 0.001). snoring index and baseline SpO2 level postoperative so it
Our result agreed with Cahali [11] who discovered that ten ensure the success of operation. As a stand-alone
persons with OSAHS who were first selected for treatment, Cahali VI lateral pharyngoplasty can help all
treatment with the Lateral pharyngoplasty operation had OSA patients.
a statistically significant difference (p=0.005) in their
snoring index from 10 IQR preoperatively to 3.5 IQR Conflict of interest: there is no conflict of interest.
postoperatively. Financial support: There is no financial support.

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7. Sama A. Snoring and obstructive sleep apnea. Ear, S2-S199, 2015.
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8. Ramar K and Guilleminault C. Obstructive sleep swallowing in lateral pharyngoplasty with
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consequences: pathophysiology, comorbidities, and journal of otorhinolaryngology.78(6): 51-5, 2012.
consequences. CRC Press.197, 2007. 15. Park DY, Chung HJ, Park SC, Kim JW, Yoon
9. Olson EJ, Moore WR, Morgenthaler TI, Gay PC, JH, Lee JG, et al. Surgical outcomes of
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syndrome. Mayo ClinProc. 78:1545-1552, 2003. coblator tongue base resection for obstructive sleep
10. Khan A, Ramar K, Maddirala S, Friedman O, apnea. European Archives of OtoRhino-
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 ‫‪JRAM 2022;3(1):67-47‬‬ ‫‪Dawaba et al. Expansion pharyngoplasty for OSA‬‬

‫الملخص العربي‬
‫الجراحة الىظُفُة لتىسُع البلعىم لعالج الشخُر وانقطاع النفس االنسذادٌ أثناء النىم‬
‫‪2‬‬
‫علُاء حوذي دوابة‪ ,1‬سُذ هحوىد هخُور‪ ,2‬تىفُك عبذالعاطٍ الخىلً‪ ,2‬هحوذ فتحٍ زَذاى‬
‫‪1‬لطى األَف واألرٌ وانحُجرج‪ ,‬يطرشفً انرحًاَُح انًركسٌ‪ ,‬انثحُرج‪ ,‬جًهىرَح يصر انعرتُح‪.‬‬
‫‪2‬لطى األَف واألرٌ وانحُجرج‪ ,‬كهُح طة انثُاخ‪ ,‬انماهرج‪ ,‬جايعح األزهر‪ ,‬جًهىرَح يصر انعرتُح‪.‬‬
‫هلخص البحث‬
‫الخلفُة‪َُ :‬عرَّف اَمطاع انُفص االَطذاد انُىيٍ تأَه "خًطح أحذاز ذُفطُح أو أكثر اَمطاع انُفص‪ ,‬ولهح انرُفص‬
‫تااللرراٌ يع انُعاش انًفرط أثُاء انُهار‪ ,‬أو االضرُماظ يع انههاز‪ ,‬أو االخرُاق‪ ,‬أو حثص انُفص‪.‬‬
‫الهذف‪ :‬ذهذف انذراضح إنً انرحمك يٍ فاعهُح عًهُح ذجًُم انثهعىو انرمذيٍ األيايٍ نرىضُع انًجال انثهعىيٍ وذمهُم‬
‫اَهُار جذار انحهك وانثهعىو انالحك فٍ عالج اَمطاع انُفص االَطذادٌ انُىيٍ‪.‬‬
‫الطرق‪ :‬ذضًُد انذراضح انًطرمثهُح ‪ 33‬يرَضًا ذسَذ أعًارهى عٍ ‪ 18‬عا ًيا َشكىٌ يٍ اَمطاع انُفص االَطذادٌ‬
‫انُىيٍ ‪ ,‬ولذ ذى ذمُُى كم يرَض يٍ خالل انرارَخ ‪ ,‬وذمُُى انُىو‪ ,‬وَمىو تئجراء عًهُح رأب انثهعىو انجاَثٍ (كاهانٍ‬
‫انطادش)‪ ,‬وذى يراتعح انًرضً نًذج ضد أشهر تعذ انعًهُح‪.‬‬
‫النتائج ‪ :‬فًُا َرعهك تًؤشر انُىو كاٌ يرىضظ لثم انجراحح (‪ )5.71 ± 51.27‬وكاٌ يرىضظ تعذ انجراحح (‪37.53‬‬
‫‪ ,)2.64 ±‬كاَد راخ دالنح إحصائُح عانُح‪.‬‬
‫فًُا َرعهك تًؤشر ذىلف انرُفص أثُاء انرُفص كاٌ يرىضظ لثم انجراحح (‪ )9.55 ± 27.77‬ويرىضظ تعذ انجراحح‬
‫(‪ )8.37 ± 21.33‬وكاٌ رو دالنح إحصائُح عانُح‪ .‬فًُا َرعهك تًمُاش إتىورز نهُعاش‪ ,‬كاٌ يرىضظ لثم انجراحح‬
‫(‪ )3.72 ± 2.43‬ويرىضظ تعذ انجراحح (‪ )3.73 ± 3.83‬وكاٌ رو دالنح إحصائُح عانُح‪.‬‬
‫االستنتاجات ‪ :‬ذى إثثاخ أهًُح لاتهُح اَهُار انجذار انثهعىيٍ انجاَثٍ فٍ انرطثة فٍ يرالزيح ذىلف انرُفص أثُاء انُىو‪.‬‬
‫ًَكٍ اضرخذاو عًهُح رأب انثهعىو انجاَثٍ (كاهانٍ انطادش) كئجراء يطرمم فٍ جًُع انًرضً‪ .‬دراضح انُىو كأداج‬
‫ذشخُصُح أضاضُح نهرشخُص انذلُك لثم انجراحح نحذوز يرالزيح ذىلف انرُفص أثُاء انُىو‪.‬‬
‫الكلوات الوفتاحُة ‪ :‬اَمطاع انُفص االَطذادٌ انُىيٍ‪ ,‬ذخطُظ انُىو‪ ,‬رأب انثهعىو انجاَثٍ‪.‬‬
‫الباحث الرئُسً‬
‫األسن ‪ :‬عهُاء حًذي دواتح‪ ,‬لطى األَف واألرٌ وانحُجرج‪ ,‬يطرشفً انرحًاَُح انًركسٌ‪ ,‬انثحُرج‪ ,‬جًهىرَح يصر انعرتُح‪.‬‬
‫الهاتف‪+231396344257 :‬‬
‫البرَذ اإللكترونٍ‪Alyaahamdy5@gmail.com :‬‬

‫‪74‬‬