10.14639/0392-100X-N1871
Objective. This study reports our experience in a selected cohort of patients affected by mild-moderate OSAS, without tonsillar obstruction, and treated with pharyngoplasty. Methods. In a case-control retrospective study, we compared modified expansion sphincter pharyngoplasty (MESP) to modified barbed reposition pharyngoplasty (MBRP) in adult patients with oropharyngeal transversal collapse with a BMI ≤ 30 kg/m2, and mild-moderate obstructive sleep apnoea syndrome (OSAS). A clinical evaluation, including collection of anthropometric data and sleep endoscopy, was performed. Six months after surgery, symptoms recording, clinical evaluation and polysomnography (PSG) were repeated. Results. We enrolled 20 patients: 10 treated with MESP and 10 treated with MBRP. Mean apnoea-hypoapnoea index (AHI) was 22.8 (± 5.63). We observed in both groups a significant reduction of AHI and oropharyngeal obstruction (p = 0.01), with a success rate, according with Sher’s criteria, of 90% for MESP and 80% for MBRP, respectively. Post-surgical pain and snoring reduction were significantly lower with MBRP. Conclusions. We recorded similar success rates for both techniques. MBRP may be considered better than MESP due to less surgical time, no potential mucosal damage, absence of knots, and faster recovery with less pain.
text/xml
1827-675X
1871
en
Salvatore Gallina
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
sleep-disordered breathing
Management of pharyngeal collapse in patients affected by moderate obstructive sleep apnoea syndrome
Text.Serial.Journal
https://www.actaitalica.it/
42
OSAHS
2022-06-30
2021-10-19
2022-07-26
2022-07-26
273-280
1
Salvatore Gallina
2022/06/30
10.14639/0392-100X-N1871
273
Department of Biomedicine, Neuroscience and Advanced Diagnostics (BIND), Unit of Otolaryngology, Policlinico Universitario Paolo Giaccone, Palermo, Italy
1827-675X
sleep-disordered breathing
en
280
Management of pharyngeal collapse in patients affected by moderate obstructive sleep apnoea syndrome
https://www.actaitalica.it/article/download/1871/830
42
ACTA OTORHINOLARYNGOLOGICA ITALICA 2022;42:273-280; doi: 10.14639/0392-100X-N1871




OSAHS


Management of pharyngeal collapse in patients
affected by moderate obstructive sleep apnoea
syndrome
Gestione del collasso faringeo in pazienti affetti da sindrome delle apnee ostruttive
di grado moderato
Francesco Lorusso1, Francesco Dispenza1, Federico Sireci1, Angelo Immordino1, Palmira Immordino2, Salvatore Gallina1
1
 Department of Biomedicine, Neuroscience and Advanced Diagnostics (BIND), Unit of Otolaryngology, Policlinico Universitario Paolo
Giaccone, Palermo, Italy; 2 Department of Health Promotion, Maternal and Infant Care, Internal Medicine and Medical Specialties
(POMISE), University of Palermo, Hygiene and Preventive Medicine Section, Policlinico Universitario Paolo Giaccone, Palermo, Italy


SUMMARY
Objective. This study reports our experience in a selected cohort of patients affected by
mild-moderate OSAS, without tonsillar obstruction, and treated with pharyngoplasty.
Methods. In a case-control retrospective study, we compared modified expansion sphincter
pharyngoplasty (MESP) to modified barbed reposition pharyngoplasty (MBRP) in adult
patients with oropharyngeal transversal collapse with a BMI ≤ 30 kg/m2, and mild-moderate
obstructive sleep apnoea syndrome (OSAS). A clinical evaluation, including collection of
anthropometric data and sleep endoscopy, was performed. Six months after surgery, symp-
toms recording, clinical evaluation and polysomnography (PSG) were repeated.
Results. We enrolled 20 patients: 10 treated with MESP and 10 treated with MBRP. Mean
apnoea-hypoapnoea index (AHI) was 22.8 (± 5.63). We observed in both groups a sig-
nificant reduction of AHI and oropharyngeal obstruction (p = 0.01), with a success rate,
according with Sher’s criteria, of 90% for MESP and 80% for MBRP, respectively. Post-
surgical pain and snoring reduction were significantly lower with MBRP.
                                                                                                   Received: October 27, 2021
Conclusions. We recorded similar success rates for both techniques. MBRP may be con-
                                                                                                   Accepted: February 21, 2022
sidered better than MESP due to less surgical time, no potential mucosal damage, absence
of knots, and faster recovery with less pain.
                                                                                                   Correspondence
KEY WORDS: soft palate, obstructive sleep apnoea hypopnoea syndrome, sleep-                        Angelo Immordino
disordered breathing                                                                               Department of Biomedicina, Neuroscienze e
                                                                                                   Diagnostica Avanzata, Unit of Otolaryngology,
                                                                                                   Policlinico Universitario Paolo Giaccone, via del
RIASSUNTO                                                                                          Vespro 129, 90100 Palermo, Italy
Obiettivo. Riportare la nostra esperienza in una coorte selezionata di pazienti affetti da         E-mail: angelo.immordino182@gmail.com
sindrome da apnee ostruttive del sonno (OSAS) lieve-moderata, senza ipertrofia tonsillare,
trattati con faringoplastica.                                                                        How to cite this article: Lorusso F, Dispenza
Metodi. Confrontare in uno studio retrospettivo caso-controllo la Expansion Sphincter Pha-           F, Sireci F, et al. Management of pharyngeal
ryngoplasty modificata (MESP) e la Barbed Reposition Pharingoplasty modificata (MBRP) in             collapse in patients affected by moderate ob-
pazienti adulti con collasso trasversale orofaringeo con BMI ≤ 30 e OSAS lieve-moderata. È           structive sleep apnoea syndrome. Acta Otorhi-
stata effettuata una valutazione clinica, con raccolta di dati antropometrici e sleep endoscopy.     nolaryngol Ital 2022;42:273-280. https://doi.
Sei mesi dopo l’intervento sono stati rivalutati i sintomi e ripetuta la polisonnografia (PSG).      org/10.14639/0392-100X-N1871
Risultati. 20 pazienti, dieci trattati con MESP e dieci trattati con MBRP. Indice di apnea-
ipopnea (AHI) medio di 22,8 (± 5,63). Abbiamo osservato in entrambi i gruppi una riduzio-          © Società Italiana di Otorinolaringoiatria
                                                                                                   e Chirurgia Cervico-Facciale
ne significativa dell’AHI e dell’ostruzione orofaringea (p = 0,01), con un tasso di successo
secondo i criteri di Sher del 90% per MESP e 80% per MBRP. Il dolore post-operatorio e
                                                                                                                  OPEN ACCESS
la riduzione del russamento erano significativamente più bassi nella MBRP.
Conclusioni. Abbiamo registrato percentuali di successo simili per entrambe le tecniche.           This is an open access article distributed in accordance with
                                                                                                   the CC-BY-NC-ND (Creative Commons Attribution-Non-
L’MBRP può essere considerata superiore alla MESP per minor tempo chirurgico, assenza              Commercial-NoDerivatives 4.0 International) license. The
di potenziali danni alla mucosa, assenza di nodi e un recupero più rapido con meno dolore.         article can be used by giving appropriate credit and mentio-
                                                                                                   ning the license, but only for non-commercial purposes and
PAROLE CHIAVE: palato molle, sindrome delle apnee-ipopnee ostruttive nel sonno,                    only in the original version. For further information: https://
disturbi respiratori nel sonno                                                                     creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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F. Lorusso et al.




Introduction                                                      We included adult patients with body mass index (BMI)
                                                                  ≤ 30 kg/m2, who had snoring and OSAS symptoms with
Obstructive sleep apnoea syndrome (OSAS) is a sleep dis-
                                                                  apnoea-hypopnea index (AHI) > 5 and < 30 on polysom-
order caused by an excessive narrowing of the pharyngeal
                                                                  nography (PSG) examination, and transverse oropharyn-
wall that collapses during inspiration, resulting in increased
                                                                  geal obstruction pattern. All enrolled patients refused ven-
negative intrathoracic pressure, which further exacerbates
                                                                  tilatory therapy with continuous positive airway pressure
the condition 1.
                                                                  (CPAP). We excluded patients with upper airway obstruc-
The prevalence of the disease is 3-7%, and many factors
                                                                  tion other than oropharyngeal obstruction such as those
are involved in the development of this disorder, such as
                                                                  caused by the anatomical features of the tongue assessed
aging, male gender, obesity, family history, menopausal,
                                                                  as Friedman score higher than grade 1, tonsil hypertrophy
craniofacial abnormalities and habits such as smoking and
                                                                  higher than grade 1 11, craniofacial abnormalities, evidence
alcohol abuse 2.
                                                                  of multilevel airway obstruction. The selection process is
Although nasal pathologies are not a direct cause of phar-
                                                                  shown in Figure 1. In the patients with nasal obstruction 12
yngeal collapse, a close correlation exists between OSAS
                                                                  such as significant deviation of the nasal septum or polypo-
and non-allergic rhinitis (NAR), particularly in non-allergic
                                                                  sis, we preferred to anticipate the nasal surgery, followed
rhinitis with eosinophilia syndrome (NARES). Probably
                                                                  by the repetition of the PSG six months later and finally
this condition is due to nasal congestion, chronic eosino-
                                                                  oropharyngeal surgery.
philic inflammation, or nervous reflexes. However, the role
                                                                  All patients underwent anamnestic data collection, with a
of these mechanisms is still debated 3.
                                                                  subjective assessment of the daytime sleepiness with the
OSAS also affects children, and in most of cases it is related
                                                                  Epworth Sleepiness Scale (ESS), and a snoring assessment
to adenotonsillar hypertrophy 4. In this particular group of
                                                                  with a 0-10 visual analogue scale (VAS snoring: 0 = no
patients, there is a relationship between sleep breathing dis-
                                                                  snoring; 10 = maximum loudness of snoring) administered
orders and negative effects on mental health, cognitive and
                                                                  to their bed partners.
behavioural abilities. However, these conditions improve
                                                                  The patients underwent to a clinical evaluation, which in-
when the patient is treated with adenotonsillectomy 5. In the
                                                                  cluded the collection of anthropometric data (neck circum-
last 15 years, several conservative surgical techniques have
                                                                  ference, BMI) and preoperative endoscopic examination of
been developed to treat retropalatal obstruction, including
                                                                  the nose and upper airway to locate and grade the obstruc-
anterior palatoplasty 6, lateral pharyngoplasty 7, expansion
                                                                  tion with drug induced sleep endoscopy (DISE) according
sphincter pharyngoplasty 8, relocation pharyngoplasty 9 and
                                                                  to the European position paper 13. We used the NOHL grad-
barbed reposition pharyngoplasty 10.
                                                                  ing proposed by Vicini et al. 14 to evaluate the obstruction.
It is now clear that determining the sites and patterns of col-
                                                                  This grading consists of the evaluation of the obstruction at
lapse of the upper airway (UA) in OSAS patients is pivotal
                                                                  the nasal level (N), oropharyngeal level (O), hypopharyn-
for selection of the appropriate surgical intervention. In our
                                                                  geal level (H) and laryngeal level (L). It is a quantitative
study, we focused attention on retropalatal transversal col-
lapse.
The purpose of the present study is to report our surgical
experience in a selected cohort of patients affected by mild-
moderate OSAS, without tonsillar obstruction, treated with
a pharyngoplasty technique. The presence of some tonsillar
obstruction at oropharyngeal level may cause, in our opin-
ion, a bias in the evaluation of a palatal surgical technique.
We compared modified expansion sphincter pharyngoplas-
ty (MESP) and the modified barbed reposition pharyngo-
plasty (MBRP) in a single stage of treatment in patients
with transversal collapse at the oropharyngeal level.

Materials and methods
A case-control retrospective study was conducted from
September 2012 to February 2019 at the Department of
Otolaryngology, Policlinico Universitario Paolo Giaccone,
Palermo, Italy.                                                   Figure 1. Flow diagram describing the selection process.



274
                                                   Modified expansion sphincter pharyngoplasty versus modified barbed reposition pharyngoplasty




evaluation of the obstruction, in which 1 corresponds to a           preserving the fibres of the upper pharyngeal constrictor. At
collapse lower than 25%; 2, from 25 to 50%; 3, from 50 to            this point, two ligatures are placed at the level of the distal
75%; and 4, more than 75% of collapse. With the aim to               margin of the muscle to keep the muscle fibres together and
select only cases with transverse pharyngeal collapse, we            to ensure better haemostasis, since the muscle is sectioned
evaluated also the dynamic pattern of pharyngeal wall col-           downwards creating a superior hinged muscle flap, in part
lapse: circular (c), transverse (t) and antero-posterior (a-p).      connected to the upper constrictor of the pharynx.
All patients underwent a single-step oropharyngeal surgery,          At this point, the original technique 8 involves an incision of
and we defined two groups based on surgical procedure                the palato-glossus muscle fibres at the palatine arch plane,
performed: Group A modified expansion sphincter pharyn-              the suture of the distal portion of the flap at this level, and
goplasty (MESP), and Group B modified barbed reposition              the subsequent suturing of the superficial mucous planes.
pharyngoplasty (MBRP).                                               In our experience, this passage was modified by creating
Post-operative pain was evaluated with a 0-10 visual ana-            a tunnel in the context of the soft palate with a 45° angle
logue scale (VAS pain; 0 = no pain; 10 = maximum pain                in the direction of the pterygoid hamulus, tipping the mus-
you’ve ever experienced). Daily pain was evaluated as the            cular flap inside the tunnel and fixing it with two resorb-
average of three values taken each day, three times a day,           able stitches in position to obtain an antero-lateral palate
for 10 post-operative days.                                          stretching. At this point, the palatine pillars are joined with
Post-operative complications were recorded, divided into:            a resorbable suture. A partial uvulectomy is performed de-
mild complications (bleeding that stops spontaneously and            pending on the laxity of the uvular mucosa.
does not require recourse to the operating room, transient           In MBRP, the first step consists in tonsillectomy with care-
dysphagia and sense of foreign body); and serious compli-            ful preservation of the mucosa of the anterior and posterior
cations (bleeding that requires surgical treatment, persis-          pillars, therefore the lower portion of the palate-pharyngeal
tent dysphagia).                                                     muscle is partially incised to weaken it. Next, unlike BRP
Six months after surgery, we recorded symptoms, with Ep-             proposed by Vicini et al. 10, we do not perform a removal
worth sleepiness scale (ESS) and VAS snoring assessment              of full-thickness mucosa and muscle triangle at the upper
administered to the bed partner.                                     lateral edge of the tonsillar loggia. The needle is then in-
Clinical evaluation was also repeated, with collection of an-        troduced at the level of the posterior palatal spine, made
thropometric data (neck circumference, BMI), endoscopic              to pass completely through the palate in a lateral direction,
upper airways examination with DISE and PSG.                         then around the pterigo-mandibular raphe, and is taken out
All PSGs were performed at our sleep laboratory, and the re-         of the bed of the tonsillectomy and then passed through
sults were interpreted by certified sleep medicine physicians.       the upper part of the palate muscle pharyngeal making it
Both groups of patients had a mean follow-up longer than             come out near the mucosa of the posterior pillar, but not
one year.                                                            crossing it. Then, the needle is passed again through the
The results were expressed as absolute and relative fre-             palatopharyngeal muscle and through the raphe by sus-
quencies for the categorical variables, or as the mean with          pending the posterior pillar. By allowing the posterior pillar
standard deviation (SD) for the continuous variables. A              to be positioned in a more lateral and anterior position, this
comparison of the quantitative variables between pre- and            passage is repeated several times up to the most distal part
postoperative was performed using the Student’s t-test. All          of the palate-pharyngeal muscle and therefore the thread is
tests were two-sided, and values of p < 0.05 were consid-            passed through the soft palate to block it.
ered statistically significant. Statistical analyses were per-
formed using Microsoft Excel 2003 (Microsoft Corpora-
tion, Redmond, WA, US) software and imported into the
                                                                     Results
R-project (R Foundation for Statistical Computing, Vienna,           A total of 20 patients with moderate OSAS were selected
Austria) software, version 2.15.2.                                   as suitable for the study, 10 in group A and 10 in group B.
                                                                     There were no significant preoperative differences between
Surgical procedure                                                   the two groups (Tab. I).
Each surgical procedure was performed under general an-              The sample consisted of 20 men, with an average age of 45
aesthesia by the same surgeon. In MESP 14 the first step of          years (± 9.42), mean BMI of 28.55 (± 3.04) and mean neck
the surgery consists of bilateral tonsillectomy with identi-         circumference of 40.75 cm (± 1.9). All patients had a his-
fication of the palato-glossal and palato-pharyngeal muscle          tory of snoring associated with mild to moderate apnoea,
and preservation of the covering mucosa. The palato-phar-            and, in most cases, also with frequent arousal and sudden
yngeal muscle is then isolated from the surrounding tissues,         awakening. The patients had a mean AHI of 22.8 (± 5.63).



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F. Lorusso et al.




Table I. Preoperative clinical data comparation between group A and B: there were no differences between groups in baseline characteristics.
 PRE-OP                                                MESP                                   MBRP                                   t-test
 Age                                                    48.4 (sd 4.8)                            41.6 (sd 11.77)                                P = 0.16
 BMI                                                 28.4 kg/m2(sd 3.06)                       28.7 kg/m2 (sd 3.02)                             P = 0.07
 Neck                                                 40.2 cm (sd 1.8)                           41.3 cm (sd 2.1)                               P = 0.06
 AHI                                                    23.9 (sd.61)                             22.03 (sd 5.05)                                P = 0.12
 Grade N                                                1.3 (sd 0.48)                             1.2 (sd 0.35)                                 P = 0.06
 Grade O                                                3.4 (sd 0.51)                             3.6 (sd 0.51)                                 P = 0.07
 Grade H                                                 1.8 (sd 0.9)                             1.6 (sd 0.69)                                 P = 0.07
 ESS                                                    10.4 (sd 3.1)                             9.1 (sd 2.07)                                 P = 0.08
 Snoring                                                 9.1 (sd 1.8)                             9.1 (sd 1.37)                                 P = 0.07
BMI: Body Mass Index; AHI: Apnoea-Hypopnea Index; ESS: Epworth Sleepiness Scale; Grade N: nasopharyngeal collapse at Mueller’s maneuver; Grade O: oropharyngeal collapse at
Mueller’s maneuver Grade H: hypopharyngeal collapse at Mueller’s maneuver.



In Group A, one patient had previous tonsillectomy, and for                             As expected, we did observe modification in the nasal ob-
that reason had tonsillar grade 0; nine patients had tonsil-                            struction that was 1.3 (± 0.48) in group A and 1.2 (± 0.35)
lar grade I. In Group B, two patients had previous tonsil-                              in group during DISE in the pre- and post-operative evalu-
lectomy with tonsillar grade 0; eight patients had tonsillar                            ations. We observed (Tab. II) a reduction in oropharyn-
grade I.                                                                                geal obstruction that was predominantly transverse in all
All patients had prolapsed soft palate, with hypertrophy of                             patients according to the selection criteria, and decreased
the uvula and posterior palatine pillars.                                               postoperatively from a mean of 3.4 (± 0.51) to 1.3 (± 0.48)
Seven patients were taking pharmacological treatment for                                (p = 0.01) in group A. In group B, it decreased from a mean
hypertension in group A, and six in group B. Two patients                               of 3.6 (± 0.51) to 1.2 (± 0.42) (p = 0.01).
of group B had a history of mild depressive disorder with                               Regarding hypopharyngeal obstruction, we observed a
anxiety; three patients were smokers in group A and four in                             preoperative reduction from a mean of 1.8 (± 0.9) to 1.1
group B. None of them usually drank alcohol. Respiratory                                (± 0.31) (p = 0.01) in group A, and in group B from 1.6
allergies were reported by three patients in group A and                                (± 0.69) to 1.5 (± 0.7) (p = 0.07). No laryngeal modifica-
five in group B.                                                                        tions were observed.
Daytime sleepiness was evaluated with the ESS; a patho-                                 Comparison between pre- and postoperative PSG data con-
logic score was achieved by nine patients, with an aver-                                firmed the success rates according to Sher criteria (AHI re-
age value of 10.4 (± 3.1) in group A, and five patients in                              duction > 50% and AHI value < 20) 15.
group B with a main value of 9.1 (± 2.07).                                              In group A, we noted a reduction of 40.9% in mean
After surgery (Tab. II), postoperative assessment revealed                              AHI, which from a mean of 23.9 (± 6.61) decreased to
a reduction in daytime sleepiness in all patients, with the                             11 (± 3.31) postoperatively (p = 0.01), with a success
persistence of a pathological score in two patients belong-                             rate, according to the Sher’s criteria of 90%; similar re-
ing to group A. The postoperative ESS mean score results                                sults was obtained in group B with reduction of 38.07%
was of 5.1 (± 3.17) (p = 0.02) in group A and 4.5 (± 2.5)                               of AHI, which from 22.03 (± 5.05) decreased to 12.47
(p = 0.04) in group B.                                                                  (± 5.03) (p = 0.01), with a success rate according to the
The preoperative mean snoring score was 9.1 (± 1.8) in                                  Sher’s criteria of 80%.
group A and postoperatively was reduced to 3.5 (± 2.1)                                  Comparing the results obtained in the post-operative phase
(p = 0.03). In group B, the preoperative mean snoring score                             between the two techniques, we highlighted a significant
was 9.1 (± 1.37) and was post-operatively reduced to 1.4                                difference in the reduction of hypopharyngeal obstruction
(± 1.25) (p = 0.02).                                                                    and snoring (Tab. II).
Considering anthropometric data, the mean BMI was of 28.4                               Postoperative pain was treated with paracetamol 1 g every
kg/m2 (± 3.06) in group A and 28.7 kg/m2 (± 3.02) in group B.                           8 hours for the first 3 post-operative days, and then admin-
In the postoperative evaluation, six months after surgery, the                          istered as needed the following days. In group B, we re-
BMI remained substantially unchanged in all patients. The                               corded a significant decrease in post-operative pain com-
mean preoperative neck circumference was 40.2 cm (± 1.8)                                pared to group A (p = 0.02).
in group A and 41.3 cm (± 2.1) in group B, and no changes                               After the fifth postoperative day, none of the patients of
were recorded in the postoperative evaluation in either group.                          group B needed analgesic therapy; on the contrary, in group



276
                                                                   Modified expansion sphincter pharyngoplasty versus modified barbed reposition pharyngoplasty




Table II. Comparation of results between MESP and MBRP.
                 Pre-op MESP          Post-op MESP                   t-test          Pre – op MBRP         Post- op MBRP               t-test          Post-op A vs B
                                                                                                                                                           t-test
 Age                      48.4                   48.4              P = 0.11                  41.6                 41.6               P = 0.18              P = 0.16
                        (SD 4.8)               (SD 4.8)                                 (SD 11.77)            (SD 11.77)
 BMI                  28.4 kg/m2            28.4 kg/m2             P = 0.06             28.7 kg/m2            28.7 kg/m2             P = 0.07              P = 0.07
                       (SD 3.06)             (SD 3.06)                                    (SD 3.02)            (SD 3.02)
 Neck                   40.2 cm               40.2 cm              P = 0.06                41.3 cm             41.3 cm (             P = 0.07              P = 0.06
                        (SD 1.8)               (SD 1.8)                                    (SD 2.1)             SD 2.1)
 AHI                      23.9                    11               P = 0.01                 22.03                12.47               P = 0.01              P = 0.01
                       (SD 6.61)             (SD 3.31)                                    (SD 5.05)            (SD 5.03)
 Grade N                  1.3                     1.3               P=0.07                    1.2                 1.2                P = 0.06              P = 0.06
                       (SD 0.48)             (SD 0.48)                                    (SD 0.35)            (SD 0.35)
 Grade O                  3.4                     1.3               P=0.04                    3.6                 1.2                P = 0.02              P = 0.07
                       (SD 0.51)             (SD 0.48)                                    (SD 0.51)            (SD 0.42)
 Grade H                  1.8                     1.1               P=0.01                    1.6                 1.5                P = 0.08              P = 0.07
                        (SD 0.9)              (SD 031)                                    (SD 0.69)             (SD 0.7)
 ESS                      10.4                    5.1               P=0.02                    9.1                 4.5                P = 0.04              P = 0.08
                        (SD 3.1)             (SD 3.17)                                    (SD 2.07)             (SD 2.5)
 Snoring                  9.1                     3.5               P=0.03                    9.1                 1.4                P = 0.02              P = 0.03
                        (SD 1.8)               (SD 2.1)                                  (SD 1,.37)            (SD 1.25)
BMI: Body Mass Index; AHI: Apnoea-Hypopnea Index; ESS: Epworth Sleepiness Scale; Grade N: nasopharyngeal collapse at Mueller’s maneuver; Grade O: oropharyngeal collapse at
Mueller’s maneuver; Grade H: hypopharyngeal collapse at Mueller’s maneuver.



A the patients required some analgesic treatment until the                              ered with a 4% ODI of ≥ 15 events/hour; further evalua-
10th post-operative day.                                                                tion is instead required with a 4% ODI ≥ 10 events/hour.
In group A, we reported 2 cases of serious complications                                Screening is recommended for the detection of OSAS
with early bleeding on the first postoperative day. No case                             associated with cardiovascular risk in middle-aged men
of fluid reflux into the nose was noted. In group B, no seri-                           without comorbidities 17. In fact, untreated OSAS, in ad-
ous complications were reported. In both groups, two pa-                                dition to causing depressive symptoms and reduced qual-
tients presented a feeling of a persistent foreign body in the                          ity of social, economic and family life, can cause sudden
throat for a few months after the intervention; however, this                           death, uncontrolled hypertension, coronary heart disease
symptom spontaneously resolved.                                                         and congestive heart failure 18. As suggested by the litera-
                                                                                        ture, many snoring and obstructive episodes seem to be
Discussion                                                                              related to anatomical features of the soft palate and, for
                                                                                        this reason, OSAS surgery is often focused on widening
OSAS is a relatively common sleep disorder, affecting an                                the retropalatal space 13.
estimated 3-7% of adults 3.                                                             In 1963, Ikematsu introduced uvulopalatopharyngoplasty
This disease also affects children, with a prevalence of                                (UPPP) as a single step procedure. This technique was then
1.8% 16 and in most of cases is related to adenotonsillar                               adopted and disseminated by Fujita et al. in 1981, and, in
hypertrophy; about 80% of children benefit from surgery 4.                              the following two decades, was widely performed and ex-
The consequence of the collapse of the upper airway is a                                tensively investigated despite low success rates and many
reduction in blood oxygenation; for this reason, OSAS is                                complications 15.
considered a systemic disease, and over the last decades,                               In the last 15 years, researchers shifted to more conserva-
attention to persistent snoring, particularly when associated                           tive surgical options to treat palatal obstruction.
with apnoea syndrome, has increased greatly 6.                                          In 2003, Cahali 7 was the first to focus attention on the lat-
It can be considered a multisystem disease because poor                                 eral pharyngeal wall in the development of OSAS by using
oxygenation of the body at night leads to important reper-                              lateral pharyngoplasty (LP). The main purpose of this tech-
cussions on the entire organism.                                                        nique is the stiffening and enlargement of the lateral walls,
Rashid et al. evaluated in a recent systematic review the                               unlike uvulopalatopharyngoplasty, in which the surgical
desaturation index (ODI) for diagnosis of OSAS. Accord-                                 goal is to shorten and stiffen the soft palate.
ing to this review, a diagnosis of OSAS should be consid-                               Expansion sphincter pharyngoplasty (ESP), developed by



                                                                                                                                                                      277
F. Lorusso et al.




Pang and Woodson in 2007 8, is based on the fundamen-              specting and preserving the anatomical and physiological
tal concept that at pharyngeal level the obstruction linked        components of the velopharyngeal sphincter.
to the collapse of the lateral walls of the pharynx plays a        Despite the numerous techniques proposed for the treat-
fundamental role. This technique is much more conserva-            ment of retropalatal collapse there are a limited number of
tive and respectful of the palatal anatomy than the previous       studies evaluating the success of recent techniques in the
approaches. Increasing the transverse space at the level of        literature. Studies comparing the results of ESP and barbed
the pharynx allows the dislocation of the palate-pharyngeal        pharyngoplasty are also scarce.
muscle, which is not completely isolated from the upper            From the limited number of studies evaluating the success
pharyngeal constrictor and creates sufficient tension on the       of recent techniques in the literature, Pang et al. 24 showed
side walls. ESP also tends to widen further, in the antero-        a success rate of 82.6% based on Sher’s criteria 13 for ESP
lateral sense, the space at the level of the oropharyngeal         in their randomised controlled clinical trial.
vestibule during the healing phases. This is due to the cica-      In another study analysing 77 mild-moderate OSAS pa-
tricial retraction of the palate-pharyngeal muscle flap that       tients, a success rate for anterior palatoplasty (AP) of
stretches the palate and lateral walls of the pharynx by cre-      71.8% was reported 25.
ating centrifugal healing vectors 19.                              However, Pang reported that a combination of ESP and AP
In 2009, Pang et al. 6 described anterior palatoplasty as a        gives better results for patients with all grades of AHI with
minimally invasive technique for OSA, based on the con-            a success rate of 83.2% 26.
cept of obtaining expansion and stabilisation of the collaps-      Vicini et al. 10 reported a success rate of 90% for BRP for
ible pharyngeal soft tissues via tissue preservation.              patients with all grades of AHI, although in a multicentre
Functional expansion pharyngoplasty (FEP) 20 was sug-              prospective study performed on 111 patients, Montevecchi
gested by Sorrenti for the treatment of lateral pharyngeal         et al. reported that the success rate was 73% in the group
wall collapse; physiological correction can be obtained by         with a mean AHI of 33.4 27.
taking advantage of the anatomical characteristics of the          Karakoc et al. reported outcomes of patients with mild to
palatal pharyngeal muscle. However, similar to ESP, the            moderate OSAS treated with AP, LP and ESP in their pro-
technique requires dissection and relocation of mucosa-            spective study with success rates of 45, 64 and 74%, re-
deprived muscles that are not devoid of mucosal tear and           spectively 28.
muscle trauma, weakness and/or fibrosis.                           Babademez et al. 29 compared the outcomes of ESP com-
Barbed reposition pharyngoplasty (BRP) proposed by Vi-             bined to AP and BRP in patients with mild to moderate
cini et al. 10, arises from the idea of using self-locking wires   OSAS, obtaining, respectively, a success rate of 84.9 and
applied to a technique similar to relocation pharyngoplas-         86.6%.
ty 9, but being more conservative with respect to palatal          In our case series, we adopted modifications to both the
anatomy. It is based on the principle that the palatine pillars    original ESP and BRB techniques with the aim of being
and palate are considered as a tripod and therefore, weak-         more respectful of the anatomical structures involved in the
ening the posterior palatine pillar and moving it forward          surgical incisions. We are not aware of any literature stud-
tends to unbalance the entire system forward by increasing         ies comparing ESP and BRP in the treatment of mild-mod-
the transversal mesopharynx space. Recently, Babademez             erate OSAS in selected subjects with 0 or I tonsil grading.
et al. 21 proposed a modification of barbed pharyngoplas-          Our goal was to evaluate the impact of the two techniques
ty, using a single continuous suture technique in patients         on improving OSAS regardless of the action of the tonsils
with retropalatal collapse. Our study compared the results         that have an important role at the oropharyngeal level in
obtained between BRP and MBRP with this new suturing               reduction of the respiratory space and in worsening of the
technique concluding that there are no significant differ-         collapse. In fact, it is known that patients with more volu-
ences in terms of outcomes. Although in the literature there       minous tonsils have greater post-operative improvement 30.
are several studies that have shown good anatomical and            By comparing the two groups that were homogeneous with
functional results with the use of barbed sutures, some au-        regards to the pre-operative characteristics, we did not ob-
thors have reported a possible extrusion in both the me-           serve significant differences in patients treated with MESP
dium and long term. However, a recent study concluded              compared to those treated with MBRP considering daytime
that barbed wire extrusion did not lead to any significant         sleepiness evaluated with ESS, BMI and anthropometric
worsening of the long-term outcomes of OSAS surgery 22.            data.
In 2018, Askar and El-Anwar 23 proposed double suspen-             Regarding the data of DISE, we observed a comparable
sion sutures, a simple and easy technique for the single step      reduction of oropharyngeal obstruction that was predomi-
treatment of palatal obstruction with the objective of re-         nantly transverse, but we noted a significantly higher reduc-



278
                                                  Modified expansion sphincter pharyngoplasty versus modified barbed reposition pharyngoplasty




tion (p = 0.01) at the hypopharyngeal level in patients sub-        damage, absence of knots and probably faster recovery with
jected to MESP compared to those treated with MBRP. This            less pain, further prospective studies of larger case series are
is probably due to the greater action at the hypopharyngeal         needed to establish its superiority over MESP.
level due to the low resection of the palatopharyngeal mus-
cle, which increases the transverse space more at this level.       Conflict of interest statement
No modifications were observed at the laryngeal level.              The authors declare no conflict of interest.
The success rates were similar to those according to Sher’s
criteria of 80% for MESP and 70% for MBRP.                          Funding
We observed a significant difference in reduction of snoring        This research did not receive any specific grant from fund-
in patients subjected to MBRP compared to those subjected           ing agencies in the public, commercial, or not-for-profit
to MESP, probably due to the greater stabilisation and stiff-       sectors.
ness at the palatal level obtained with multiple passages of
the barbed wires anchored to the fibrous points of hamulus,         Authors’ contributions
raphe and posterior nasal spine. In addition, the multiple          Conceptualisation: FL, SG and FD; methodology: FL and
lateral sustaining suture loops performing by barbed suture         FD; validation: SG; investigation: FS and AI; resources: FS
provides more stable soft palate suspension than the single         and AI; formal analysis: PI; writing – original draft prepa-
pulling tip suture of ESP, with no risk of tearing the muscle       ration: FL; writing – review and editing: AI and PI; project
fibres, respecting the mucosa and muscular structure.               administration: SG.
This allows to obtain a greater palatal rigidity, without
causing side effects such as rhinolalia and oral-nasal reflux,      Ethical consideration
but considerably reducing snoring.                                  This study was approved by the Comitato Etico of Poli-
It is known that ESP is a more invasive technique compared          clinico “Paolo Giaccone” of Palermo (Ref n° 27/06). All
to BRP, since the palatopharyngeal muscle is dissected              procedures performed in this study involving human partic-
while performing ESP. We did not perform muscle-mucosal             ipants were in accordance with the ethical standards of the
incisions on the palate in either MESP or MBRP, but we              institutional and/or national research committee (and with
have also observed a significant decrease in post-operative         the 1964 Helsinki declaration and its later amendments or
pain (p = 0.02) and dysphagia in the MBRP group, with               comparable ethical standards. Written informed consent
less use of analgesics in the post-operative period.                was obtained from each participant/patient for study par-
As previous studies have reported, the operation time for
                                                                    ticipation and data publication.
MBRP is shorter than MESP as a result of using a barbed
suture and a minor surgical dissection.
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