10.14639/0392-100X-suppl.1-43-2023-13
This narrative review provides a general overview of the management of relapses after surgery for the treatment of sleep disordered breathing. This clinical scenario represents a challenging field, but fortunately several therapeutic options are included in sleep surgeons’ armamentarium. Each therapeutic modality is described in detail in a dedicated section.
text/xml
1827-675X
2615
en
Giovanni Cammaroto
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
surgery
Treatment of sleep disordered breathing relapse after surgery
Text.Serial.Journal
https://www.actaitalica.it/
43
Annual congress report
2023-04-21
2023-04-21
2023-04-28
2023-04-28
S103-S110
1
Giovanni Cammaroto
2023/04/21
10.14639/0392-100X-suppl.1-43-2023-13
S103
ENT Unit, Morgagni Pierantoni Hospital, Forlì, Italy
1827-675X
surgery
S110
Treatment of sleep disordered breathing relapse after surgery
https://www.actaitalica.it/article/download/2615/950
43
ACTA OTORHINOLARYNGOLOGICA ITALICA 2023;43(SUPPL.1):S103-S110; doi: 10.14639/0392-100X-suppl.1-43-2023-13




Head and Neck section


Treatment of sleep disordered breathing relapse
after surgery
Il trattamento delle recidive chirurgiche dei disturbi respiratori del sonno
Claudio Vicini1,2, Giovanni Cammaroto2
1
    University of Ferrara, University of Bologna; 2 ENT Unit, Morgagni Pierantoni Hospital, Forlì, Italy


SUMMARY
This narrative review provides a general overview of the management of relapses after
surgery for the treatment of sleep disordered breathing. This clinical scenario represents a
challenging field, but fortunately several therapeutic options are included in sleep surgeons’
armamentarium. Each therapeutic modality is described in detail in a dedicated section.
KEY WORDS: OSA, snoring, relapse, treatment, surgery

RIASSUNTO
Questa review narrativa presenta una visione generale della gestione delle recidive suc-
cessive al trattamento dei disturbi respiratori del sonno. Questo scenario clinico rappre-
senta una vera sfida ma fortunatamente diverse opzioni terapeutiche sono a disposizione
del roncochirurgo. Ogni modalità terapeutica viene descritta nel dettaglio in ogni sezione
dedicata.
PAROLE CHIAVE: OSA, russamento, recidiva, trattamento, chirurgia



Introduction

Never give up                                                                                    Received: December 12, 2022
Sleep Disordered Breathing (SDB) encompasses a wide range of different clini-                    Accepted: January 8, 2023
cal conditions including the most common prevalent as Simple Snoring (SS)
and Obstructive Sleep Apnoea (OSA) 1.                                                            Correspondence
                                                                                                 Claudio Vicini
OSA treatment is one of the most difficult challenges of modern medicine for                     ENT Unit, Morgagni Pierantoni Hospital, via Carlo
many and unrelated reasons. First of all, OSA is by nature a worsening disease                   Forlanini, 47100 Forlì, Italy
with a natural trend to become more and more severe over time 2.                                 Tel. +39 0543 735651
                                                                                                 E-mail: claudio@claudiovicini.com
In essence, dealing with OSA is like swimming against the current. Any possible
treatment has to reckon with this natural trend of OSA to become more severe as
                                                                                                   How to cite this article: Vicini C, Cammaroto
time passes, and relapse if treated. Among the reasons for this natural history of                 G. Treatment of sleep disordered breathing
OSA is the natural tendency for the muscles and soft tissues of the upper airways                  relapse after surgery. Acta Otorhinolaryngol
to become less effective and laxer with age and the frequent increase in body                      Ital 2023;43(SUPPL.1):S103-S110. https://doi.
                                                                                                   org/10.14639/0392-100X-suppl.1-43-2023-13
mass index (BMI) throughout life. Ageing is in itself associated with a decrease
in sleep quality; SDB may further alter sleep architecture in elderly subjects 3.                © Società Italiana di Otorinolaringoiatria
                                                                                                 e Chirurgia Cervico-Facciale

SDB treatment goals                                                                                             OPEN ACCESS
The goals of any OSA treatment are multiple: to normalise the cardio-respir-                     This is an open access article distributed in accordance with
                                                                                                 the CC-BY-NC-ND (Creative Commons Attribution-Non-
atory index of sleep registration and prevent cardiovascular complications, to                   Commercial-NoDerivatives 4.0 International) license. The
treat neuropsychological impairments, to eliminate or improve snoring, and, in                   article can be used by giving appropriate credit and mentio-
                                                                                                 ning the license, but only for non-commercial purposes and
a more holistic perspective, to improve the quality of life, as measured by dif-                 only in the original version. For further information: https://
ferent scales or scoring systems 4.                                                              creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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Different long term surgery failures                               Bariatric surgery is a possibility for obese patients. Even
                                                                   more complex is the spectrum of non-surgical options.
Unfortunately, the effects of surgery as well of any alternative
                                                                   Continuous Positive Airway Pressure (CPAP), oral appli-
treatment options on the above-mentioned different goals are
                                                                   ances, positional devices, weight loss, and myofunctional
not equal, and not stable in the same way over time 5.
                                                                   therapy are among the most popular treatments. The more
From the practical point of view, it implies that our in-
                                                                   recent conceptualisation of OSA endotypes and pheno-
tervention may be very effective in reducing snoring and
                                                                   types has made it possible to stratify the different therapeu-
Apnoea Hypopnea Index (AHI), but quite ineffective in
                                                                   tical actions for OSA and to differentiate anatomical from
controlling excessive daytime sleepiness, producing a dis-
                                                                   functional patterns 13-15.
sociated outcome profile. A second and not unusual situ-
                                                                   Anatomical trait means upper airway obstruction and/or
ation is a transient positive effect on snoring, and snoring
                                                                   collapse, and may be counteracted by CPAP, Mandibular
relapse after a few months, with a relatively stable control
                                                                   Advancement Devices (MAD), weight loss and positional
of cardiorespiratory index 6.
                                                                   therapy, i.e. the so-called anatomical treatments. Function-
                                                                   al traits include insufficient muscle reaction to collapse, in-
How to measure multi-dimensional                                   creased loop gain and lowered arousal threshold 16.
outcomes                                                           The set of possible treatment options includes drugs, myo-
Probably the best way to describe OSA treatment outcomes           functional training and a special type of surgery, namely
is to define a multi-dimensional profile including different       hypoglossal nerve stimulation. In the time domain, the
axes, possibly independent 7:                                      different treatment options may be devised as single
1. relational axis: snoring;                                       stand-alone treatment (e.g.: CPAP as first line, or surgery
2. cardio-respiratory axis: Apnoea Index (AI), AHI, Res-           as unique selected therapy), or ab initio multistep staged
   piratory Disturbance Index (RDI), Lowest Oxygen Satu-           surgical strategy (e.g.: Stanford phase one and phase two).
   ration (LOS), Blood Pressure (BP) etc.;                         The concept of multimodal therapy implies a pre-planned
3. neuropsychological axis: Epworth Sleepines Scale                strategy which offers the patient a logical association or se-
   (EPSS), Multiple Sleep Latency Test (MLST) etc.;                quence of different options in order to increase the possibil-
4. quality of life axis: Functional Outcomes of Sleep Ques-        ity for final success. Some examples include palate surgery
   tionnaire (FOSQ), Sleep Apnoea Quality of Life Index            supported by the post-operative adoption of MAD, surgical
   (SAQLI);                                                        reduction of nose resistance in order to increase CPAP ac-
5. comprehensive axis: Pang Sleep Goal (PSG).                      ceptance and compliance, and association of palate and/or
A work-up consisting of questionnaires, polygraphy/poly-           tongue surgery with myofunctional therapy.
somnography, clinical examination and Drug-Induced
Sleep Endoscopy (DISE) is needed in order to record all            Rescue options
the above-mentioned outcomes. It is quite common to reg-
ister a different degree of improvement along the different        Several options for the primary treatment of SDB may also
outcome axes after a planned post-operative check. How-            be offered as rescue options. We will discuss separately the
ever, it is probably much more frequent to disclose variable       non-surgical and surgical ones (Fig. 1).
evolutions of the different outcomes over time, producing a
complex combination of poorly controlled parameters co-            Non-surgical
existing with well controlled ones. We will discuss in detail      The main criterium of choice in this group of solutions
and in a separate way the main multi-dimensional axis long         lies in the patient’s preference who must be fully informed
term failures, in a prominent rescue perspective: how to ad-       about the relative pro and cons of the different solutions.
dress the problem? 8.                                              Wait and see
                                                                   It is not considered a real option after a surgical late fail-
SDB treatments                                                     ure. However, in a very limited number of snoring relapses
                                                                   without OSA recurrence it may be discussed with the pa-
For simply practical purposes, SDB treatments may be di-
                                                                   tient, mainly as a provisional therapy while waiting to se-
vided into surgical ones and non-surgical ones 9-11.
                                                                   lect the best additional procedure.
Surgery includes a wide range of solutions to address soft tis-
sue or bone-framework abnormalities of the upper airways,          CPAP
very commonly planned as multilevel surgery (surgery tar-          Coming back to ventilation is perceived as a really frus-
geted to the nose, pharynx, tongue in the same patient) 12.        trating solution for most patients who received surgery. In



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Figure 1. Flow chart for personalised treatment of obstructive sleep apnea.


a minority of subjects, the most symptomatic ones, CPAP                       ing and OSA are included in the MAD area. Its adoption
is adopted again without significant problems. CPAP is the                    for surgical failure after CPAP drop out in our personal ex-
most effective in the anatomical treatment armamentarium,                     perience seems to be far superior to returning to ventilation.
and follows the same rules of engagement as for an untreated                  The literature on MAD back up after surgery is minimal,
patient. Recurrent OSA is its main target. Recurrent snor-                    but always supports the efficacy of oral appliances in most
ing is not routinely included. In the classic literature of the               cases 19. A matter of open discussion in Italy is the prob-
Uvulo-Palato-Pharyngoplasty (UPPP) era, a main matter                         lem that oral appliances are not reimbursed by the Public
of discussion was the difficulties in adapting to ventilation                 Health System, and the cost is not negligible.
some anecdotal case of palate over-resection (air leakage and
                                                                              Positional therapy
loss of pressure) 17. In our personal experience, taking into
                                                                              The theoretical background of this increasingly popular
account the lack of consistent evidence, after the switch to
                                                                              anatomical non-surgical option is worthy of comment:
non-resective palatoplasties (Expansion Sphincter Pharyn-
                                                                              • most cases of the surgical failed OSA became positional
goplasty, ESP; Barbed Repositioning Pharyngoplasty, BRP)
                                                                                after surgery, even if not positional before surgery 20;
this event was no longer observed. On the other hand, to rea-
                                                                              • it is possible to try to manipulate sleep position in or-
dapt CPAP to an operated patient, especially in cases of mul-
                                                                                der to maintain the patient in a position different from
tilevel surgery, besides the psychological impact, it is usually
                                                                                the most critical one as long as possible: lying on his
technically easier. The reduced nose resistance and increased
                                                                                back. The most classic and popular group of mechanical
pharynx stability allows a lower pressure setting, leading to
                                                                                or electronic devices try to stabilise patients in a lateral
increasing acceptance and compliance 18.
                                                                                lying position (tennis ball in the back, electronic vibrat-
Mandibular advancement devices                                                  ing devices). A special mattress with a hole for the face
These are one of the most popular treatments for SDB                            was proposed in order to allow to breathe in a prone face
(simple snoring and sleep apnoea) after CPAP, operating in                      down position. Last but not least, our group is collecting
the same anatomical area. When properly customised and                          an increasing amount of evidence about the use of 30°
titrated, it may affect the overall stability of the upper air-                 Fowler’s position in managing positional OSA in a more
ways in the retro-palatal and retro-lingual areas. Both snor-                   comprehensive way 21;



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• the latest generation of electronic devices offers a wide          Tonsillectomy
  range of different vibration patterns in order to prevent          In case of failed palato/pharyngoplasty, irrespective of the
  patient arousal, and allows a continuous feedback by in-           previous technique, tonsillectomy may be considered as a
  ternet to the clinician, who is informed about real use and        rescue procedure if not previously done. It is more impor-
  efficacy of the device. Unfortunately, positional therapy          tant and may be effective if tonsil score is 2 or more 26.
  is not reimbursed by the Italian Public Health System.             Sjöblom et al. recently confirmed that stand-alone tonsil-
  However, positional therapy as failed surgery back up              lectomy without concomitant pharyngoplasty may be an
  is becoming more and more popular and well accepted.               effective treatment for OSA in adults with tonsillar hyper-
                                                                     trophy 27. According to Matarredona et al. tonsil volume
Weight Loss
                                                                     was found to be linked to the success rate of tonsillectomy
In sleep surgery, the weight curve over time tends to run
                                                                     and pharyngoplasty with barbed sutures 28. For this reason,
parallel to the outcome curve after surgery. Immediately
                                                                     completion tonsillectomy must be included into the availa-
after surgery and for a few months the weight loss induced
                                                                     ble salvage tool set for recurrent OSA after pharyngoplasty
by swallowing pain and dysphagia contributes to improve
                                                                     without tonsillectomy.
the success rate. Too commonly in the following months,
the weight curve overshoots the pre-surgery values and the           Partial resection of torus tubarius
success rate decreases. Hypo-caloric diet and physical ex-           Hypertrophic torus tubarius was described as a cause of
ercise are the mainstay of this inexpensive approach 22.             recurrent symptoms after adenoidectomy in childhood by
                                                                     Kim et al. (Fig. 2) 29. Microscopic coblator-assisted par-
Myofunctional
                                                                     tial section is probably the only targeted surgical technique
“Oral and facial Muscular function Therapy (OMT) can be
                                                                     specifically devised for recurrence of sleep-disordered
used as a simple and non-invasive new technique to im-
                                                                     breathing symptoms in some children after successful ad-
prove the AHI, minimum oxygen saturation, EPSS, and
                                                                     enoidectomy. In the described series, microscopic coblator-
snoring intensity in patients with mild and moderate OSA
                                                                     assisted partial resection of torus tubarius was successful.
and the lowest oxygen saturation in patients with severe
                                                                     There were no complications related to partial resection of
OSA” 23. Furthermore “oro-facial myofunctional therapy
                                                                     the torus tubarius, such as nasopharyngeal, choanal steno-
can be considered as an effective complementary treatment
for OSA patients with oral breathing after adenotonsillecto-
my” 24. Data about the use of post-operative myofunctional
therapy in OSA relapse are not yet reported in the litera-
ture. According to our preliminary experience, OMT may
be offered during post-operative follow-up even months/
years after surgery as a salvage option. Further studies are
required to confirm this possibility.
Drugs
Different drugs are under evaluation for the targeted treatment
of the non-anatomical traits of OSA. In case of persistent or
recurrent OSA after correct upper airways surgery (one of the
main options for anatomical treatment), a negative effect of a
concomitant pathological functional trait must be considered.
High loop gain may be treated by O2 or acetazolamide, a low
arousal threshold may be modified by sedatives (e.g.: trazo-
done) 25. This is a promising field of interest, requiring further
studies to gain a sound place in clinical practice.

Surgical
The choice of surgical options to address SDB recurrence re-
quires careful global reassessment including physical exam,
biometrics, awake endoscopy and in most the cases DISE. The
surgeon must identify the best procedure and the patient is re-
quested to accept the suggested one. Many surgeries may be
considered as rescue procedures, and each will be summarised         Figure 2. Partial resection of torus tubarius.



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                                                                                                   Sleep disordered breathing relapse after surgery




sis, or Eustachian tube scarring with subsequent middle ear          it has been applied also as revision procedure in failed
problems.                                                            UPPP and failed ESP, and in a few cases, in failed laser
                                                                     assisted uvulopalatoplasty (LAUP). The basic BRP tech-
Radio-frequency volume reduction
                                                                     nique is easy to implement in an already operated palate,
Temperature-controlled radio-frequency tissue volume re-
                                                                     with significant results in reducing snoring and address-
duction of the soft palate has been introduced as a minimally
                                                                     ing residual or relapsing OSA (Figs. 4, 5). The procedure
invasive, outpatient procedure for treatment of habitual snor-
                                                                     is well accepted by the patient, and now it is open to dis-
ing and mild OSA 30,31. A relapse of palatal snoring over time
                                                                     cussion as a possibility to offer to all patients the idea of
seems to be a problem for at least some patients, although
                                                                     pre-planned repeated BRPs in case of relapse, as in face
additional treatments with the same technique may be ben-
                                                                     face-lift 36.
eficial in these cases. With regards to the fact that a relapse of
snoring is a general problem in surgical treatment, the pos-         Modified toh palatal flaps technique
sibility of repeated treatment sessions in cases of snoring re-      The technique was devised to address nasopharyngeal ste-
lapse has to be regarded as an advantage 32. Radio-frequency         nosis. It is an uncommon acquired pathological condition
technology, as an office-based minimally-invasive procedure
is an interesting tool to address relapsed snoring.
Uvulo Palatal Flap (UPF)
Introduced by Powell et al. this has been demonstrated to
be a safe and effective procedure that results in long-term
success for OSA by Neruntarat (Fig. 3) 33,34. After one year
of experience, the procedure was dismissed as primary
surgery in our institution for significant incidence of for-
eign body sensation. It nonetheless remains an interesting
option in case of residual or recurring snoring in previous
palatoplasties with very thin and long palate. Tissue dupli-
cation allows a useful stiffening effect to be produced.
Barbed reposition pharyngoplasty
Barbed reposition pharyngoplasty has proven to be an
easy to learn, quick, safe and effective new palatopharyn-
geal procedure that can be used in a single level surgery
or as a part of multilevel procedure 35. In our experience,          Figure 4. Preparation of muscular layers for barbed repositioning pharyngoplasty.




Figure 3. Result after Uvulo Palatal Flap.                           Figure 5. Pharyngeal expansion obtained with barbed repositioning phar-
                                                                     yngoplasty.



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characterised by the reduction and, sometimes, by the com-           ty (TOLE) has been applied in a couple of cases. In the
plete obstruction of the nasopharyngeal isthmus. This par-           first, before introduction of DISE a floppy epiglottis was
ticular condition is usually an iatrogenic entity following          overlooked and the patient was operated on by bi-maxil-
therapeutic procedures such as: tonsillectomy, adenoidec-            lary advancement with relapse of OSA. TOLE was carried
tomy and UPPP. Our group reported on a surgical variation            out and epiglottis collapse was addressed. In a second pa-
in a series of patients affected by OSA and nasopharyngeal           tient, after TORS removal of more than 20 cc of lingual
stenosis as a consequence of different surgeries 37.                 tonsil we registered a short term recurrence of snoring re-
In our technique, a nasopharyngeal mucosal flap of the               lated to floppy supraglottic area vibration. A staged laser
soft palate is tailored and then split vertically to obtain a        supraglottoplasty was successfully applied.
right and left palatal flap. Interrupted sutures are applied
in order to tie the muscular layer anteriorly to the oral            Free flaps
mucosal layer of the soft palate and at the same time pull           Free flap reconstruction is routinely applied to wide tis-
both lateral palatal flaps anteriorly and laterally to the oral      sue loss after cancer resection. Free flaps have also been
palatal mucosa.                                                      described to address upper airway strictures after caustic
The purpose of our technique is to reduce the incidence              ingestion, extensive burns or neck trauma. In cooperation
of post-operative complications such as velo-pharyngeal              with the ENT clinic in Pavia, we managed an obstructive
insufficiency by splitting the soft palate into two flaps and        recurrence of OSA after TORS referred us to another in-
suture the muscular layers of both flaps anteriorly and lat-         stitution. Unfortunately, this 56-year-old man operated on
erally in order to increase the retro-pharyngeal volume in           elsewhere by UPPP and tongue base TORS developed a
a replicable, less-invasive, and effective way (Fig. 6).             velo-pharyngeal incompetence as well as a progressive
                                                                     hypo-pharyngeal circular stenosis (web stenosis), that was
Trans-Oral Robotic Surgery (TORS)
                                                                     addressed by scar resection and reconstruction with fore-
TORS for OSA was devised for trans-oral reduction of
                                                                     arm free flap. To our knowledge, this is the only case of free
a large tongue base, related to lingual tonsil hyperplasia
                                                                     flap application after OSA recurrence following previous
or muscle hypertrophy/collapse. Iannella et al. in a retro-
                                                                     TORS for sleep apnoea.
spective study demonstrated a very low rate of lymphoid
tissue regrow after robotic removal 38. They never regis-            HNS
tered a functional recurrence (OSA relapse), but few ana-            Liu et al. firstly described a patient who was successfully
tomical recurrences as not significant lymphatics regrew.            treated with phase 1 and 2 operations more than a decade
In one case, revision TORS was offered for tongue base               previously 39. He returned at 65 years of age with relapse
biopsy, which proved to be negative for malignancy.                  of moderate OSA, and after workup with polysomnogra-
Epiglottoplasty                                                      phy and drug-induced sleep endoscopy underwent upper
In our experience, rescue Trans-Oral Laser Epiglottoplas-            airway stimulation of the hypoglossal nerve that resulted
                                                                     in cure of OSA (Fig. 7). This case demonstrates why up-
                                                                     per airway stimulation may be an appropriate option for
                                                                     patients with OSA relapse after previously successful
                                                                     maxillo-mandibular advancement.
                                                                     Proposal of management flow-charts (Figs. 8-9).
                                                                     Figure 8 shows how the relapse of snoring can be addressed
                                                                     primarily on the basis of patient preference. If surgery is
                                                                     not accepted, weight loss, mandibular advancement devic-
A                                                                B   es, myofunctional therapy, and positional devices may be
                                                                     differently associated.
                                                                     If local anaesthesia is preferred, palate radiofrequency is
                                                                     offered. In general anesthesia palatoplasty is still a valid
                                                                     option.
                                                                     In the event of relapse of OSA, sleep endoscopy is criti-
                                                                     cal in selecting palate, tongue, supraglottis or multilevel
                                                                     revision. Conservative approaches like weight loss, MAD
C                                                                D
                                                                     positional or myofunctional may be additional solutions
Figure 6. Surgical steps of oropharyngeal stenosis correction.       (Fig. 9).



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                                                                                                            Sleep disordered breathing relapse after surgery




Figure 7. Surgical steps of hypoglossal nerve stimulator positioning.           Figure 8. Flow chart for the management of snoring relapse.



Conclusions
OSA relapses after surgery represent a clinical challenge
for sleep surgeons. An adequate comprehension of patho-
physiological endotypes and anatomical conditions is
mandatory in order to address patients to the most appro-
priate therapeutic choice. Among treatment options, ven-
tilatory therapy, oral appliances, second look surgery and
positional therapy are certainly the most viable solutions.

Conflict of interest statement
The authors declare no conflict of interest.

Funding
This research did not receive any specific grant from fund-
ing agencies in the public, commercial, or not-for-profit
                                                                                Figure 9. Flow chart for the management of OSA relapse.
sectors.

Author contributions                                                            3
                                                                                    Feinsilver SH. Normal and abnormal sleep in the elderly. Clin Geriatr
The authors equally contributed to the draft of the manu-                           Med 2021;37:377-386. https://doi.org/10.1016/j.cger.2021.04.001
script.                                                                         4
                                                                                    Evans EC, Sulyman O, Froymovich O. The goals of treating obstruc-
                                                                                    tive sleep apnea. Otolaryngol Clin North Am 2020;53:319-328. htt-
                                                                                    ps://doi.org/10.1016/j.otc.2020.02.009
Ethical consideration
Not applicable.
                                                                                5
                                                                                    Vicini C, Marani M, Frasconi PC. Failures in snoring and OS-
                                                                                    AS surgery. Facial Plast Surg 1999;15:327-335. https://doi.
                                                                                    org/10.1055/s-2008-1064334
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