Selecting Hypopharyngeal The following personal financial - PowerPoint PPT Presentation

2/15/2014 Disclosures Selecting Hypopharyngeal The following personal financial relationships with Surgery in OSA commercial interests relevant to this presentation: Medical Advisory Board Apnex Medical Eric J. Kezirian, MD, MPH Medical Advisory Board ReVENT Medical Consultant Inspire Medical Systems Professor Consultant Split Rock Scientific Eric.Kezirian@med.usc.edu Intellectual Property Rights Berendo Scientific Sleep-Doctor.com Intellectual Property Rights Magnap http://sleep-doctor.com/blog http://sleep-doctor.com/blog Overview Why Hypopharyngeal Surgery? Effective surgery directed at Why hypopharyngeal surgery? site(s) of obstruction Nose Evaluation techniques for procedure Palate selection Hypopharynx Hypopharyngeal procedures and Fujita Classification outcomes Type I Palate Type II Combined Type III Hypopharynx http://sleep-doctor.com/blog http://sleep-doctor.com/blog 1

2/15/2014 Palate Surgery Outcomes: OSA surgery review (Sher et al. Sleep 1996) Palate vs. Tongue Obstruction UPPP “successful” in 41% of all OSA patients 52% Fujita Type I Improvement (%) 100 5% Fujita Types II and III 75 80 Conclusion: failure to identify site(s) of obstruction is principal factor in poor results for surgery 60 Palate Obstruction Tongue Obstruction 40 33 Friedman Stage (Friedman OtoHNS 2002) 25 23 20 13 Success of UPPP/T: Stage I 81% 7 Stage II 38% 0 Stage III 8% Unfortunately, few patients Stage I AI RDI LSAT Sher et al. SLEEP 1996;19:156-177 Adapted from Table 7 http://sleep-doctor.com/blog http://sleep-doctor.com/blog Expansion Sphincter Pharyngoplasty Lateral Pharyngoplasty http://sleep-doctor.com/blog http://sleep-doctor.com/blog 2

2/15/2014 Body Mass Index Site of Obstruction and Surgical Options Not really an eval technique Current Future? Crude measure of obesity Easy, low cost, and associated with outcomes Underweight <18.5 May affect structures involved Normal 18.5 - <25 Palate/Tonsils Velum/Palate and nature of involvement Overweight 25 - <30 Hypopharynx/ Oro LW Obesity major OSA risk factor Obese Class I 30 - <35 Retrolingual Tongue Obese Class II 35 - <40 = Weight (kg) / [Height (m)] 2 Epiglottis ≈ Weight (lb)*700/[Height (in)] 2 Obese Class III 40+ Maxillofacial Maxillofacial http://sleep-doctor.com/blog http://sleep-doctor.com/blog What Is the Link between Obesity and OSA? Correlation of Percent Tongue Fat with BMI Why Is Obesity Associated with Worse Outcomes after (Nashi et al, Laryngoscope 117:1467, 2007) Most Procedures? Fat Is Deposited in Tongue in Obese Subjects (Nashi et al, Laryngoscope 117:1467, 2007) 10-12% fat 28-32% fat 28-33% fat http://sleep-doctor.com/blog http://sleep-doctor.com/blog 3

2/15/2014 Factors and Outcomes Hypopharyngeal Procedures Examining case series studies, although some small Genioglossus advancement Most randomized trials are pilot studies (sample size) Mortised genioplasty Factors: BMI, preop AHI, cephalogram measures Tongue radiofrequency Outcomes: AHI and “success” Tongue stabilization “Success” = 50% reduction in AHI/AI to absolute level Midline glossectomy no greater than 20/15/5 Major oversimplification Hyoid suspension Goal generally to improve OSA/AHI Partial epiglottectomy Other outcomes (sleepiness, QOL) Maxillomandibular advancement However, AHI reported widely and enables comparison http://sleep-doctor.com/blog http://sleep-doctor.com/blog Mortised Genioplasty Genioglossus Advancement Rectangular osteotomy below Hendler et al., Sleep incisor roots between canines Breathing 2001 --GBAT: circular osteotomy Capture genial tubercle and Capture of genioglossus, genioglossus muscle attachments geniohyoid, mylohyoid, and digastric muscles Advance bone fragment and muscle attachment to place genioglossus on tension Risks similar to GA, although some Risks: dental numbness, injury differences http://sleep-doctor.com/blog http://sleep-doctor.com/blog 4

2/15/2014 BMI Pre AHI Post AHI Success (AHI) Factors Tongue Riley 1994 39% (9/23) Many areas of the body PAS and MP-H (not real Radiofrequency Heart, prostate, oncology Johnson 1994 59 14* 78% (7/9) statistical analysis) Turbinates, palate, tonsils, tongue Lee 1999 53 19* 69% (24/35) AHI (better with <40); Energy delivered to create Miller 2004 (GBAT) 30.5 53 16* 67% (7/11) BMI and AHI injury, then fibrosis AI < 20; low BMI (<30) in Liu 2005 28.0 62 30* 52% (23/44) sample All age < 60 years Multiple technologies 27.5 Emara 2011 41 15* 87% (20/23) (all < 30) Monopolar (Gyrus/TCRF) vs. Not BMI but lateral Bipolar (ArthroCare and Celon) Kim 2012 26.8 41% (35/85) cephalogram measures Hendler 2001 AHI, BMI <30 Less invasive (mortised 32.6 60 29* 48% (16/33) genioplasty) Can be done in clinic— ? BMI (all < 30 in dos Santos 2007 25.4 (all below titratable, snoring 12 4* 70% (7/10) sample) (genioplasty) 30) http://sleep-doctor.com/blog http://sleep-doctor.com/blog 8-Week Outcomes: Active RF vs. Sham Tongue Radiofrequency Randomized Trial 1.2 1 Woodson et al., Oto—HNS 2003 0.89 Level 1: randomized, placebo-controlled trial 0.8 0.59 0.6 0.45 Mild to Effect Size 0.43 0.41 0.39 0.39 0.39 0.4 Moderate OSA 0.25 0.23 (AHI 5-40) 0.2 0 Palate/Tongue 1/SRT RT FRT AHI AI LSAT Tot Vol FOSQ SNORE ESS MCS PCS Placebo “RF” CPAP -0.2 -0.13 RF (n=30) (n=30) -0.26 (n=30) -0.4 Oto-HNS 2003;128:848-61 Adapted from Table 6 Outcomes http://sleep-doctor.com/blog http://sleep-doctor.com/blog 5

2/15/2014 2-Year Outcomes: Final vs. Baseline Tongue Radiofrequency Improves 1.2 1.11 UPPP/T outcomes 1 Palate surgery alone 0.87 0.81 0.81 UPPP/T provides improvement UPPP/T 0.8 FS + RF Only 0.6 Tongue Addition of tongue RF Effect Size 0.41 improves outcomes for 0.4 0.28 I 80% patient subgroups that 0.25 0.16 would not be expected to 0.2 have ideal outcomes after II 38% 55% palate surgery 0 1/SRT RT FRT AHI AI LSAT Tot Vol FOSQ SNORE ESS MCS PCS -0.2 Friedman Oto—HNS 2003 III 8% 33% -0.4 Friedman Oto—HNS 2004 Adapted from Figure 1 Oto-HNS 2005;132:630-35 Outcomes http://sleep-doctor.com/blog http://sleep-doctor.com/blog Tongue Stabilization Tongue Radiofrequency Case Series Marketed as Most have overweight BMI but not obese (highest Repose/Airvance system mean BMI 32) Wide range mean baseline AHI Technique Success rates 20-80% in different series Bone screw in mandible Factors associated with outcomes Pre-attached suture AHI (not universal) passed through tongue BMI 29 or 30 base and secured to Friedman Stage (II better than III) stabilize tongue base http://sleep-doctor.com/blog http://sleep-doctor.com/blog 6

2/15/2014 Midline Glossectomy Tongue Stabilization Case Series Most have overweight BMI Morbid procedure with CO2 laser, cautery (highest mean 31) Robinson technique: Coblation (not FDA indication) Wide range mean AHI Success rates 20-80% in different series Factors associated with outcomes (limited eval) AHI BMI 29, graph ? Suture tightening Source: Vicente Laryngoscope 2006 (n=54) http://sleep-doctor.com/blog http://sleep-doctor.com/blog Tongue Resection: Midline Glossectomy, SMILE, Hyoid Suspension Rationale: Pharyngeal soft Hyoepiglottoplasty, and Lingual Tonsillectomy tissues attach to mobile hyoid bone Most series have mean BMI in obese range (29-36) Advance hyoid, limit Mean baseline AHI wide range but higher than RF/TS mobility Success rates 25-100% in different series Mandible inferior border with fascia lata or sutures Factors associated with outcomes (Repose/Airvance) AHI --suture breakage? BMI (31 in responders vs. 38 in nonresponders) Superior border of thyroid cartilage http://sleep-doctor.com/blog http://sleep-doctor.com/blog 7

2/15/2014 Pre Post Success Technique BMI Factors AHI AHI (AHI) Hyoid Suspension: Is BMI a factor? Vilaseca 2002 Thyroid 27.8 48.3 29.0* 56% (5/9) Baisch series: No? Neruntarat 2003 Thyroid 29.3 44.5 15.2* 78% (25/32) However, few BMI > 33 den Herder 2005 Thyroid 26.3 33 18* 71% (10/14) (primary) den Herder 2005 Thyroid 27.7 32 26 35% (6/17) Bowden mean BMI 34, (secondary) success 17% Not AHI or BMI (although high BMI in Bowden 2005 Thyroid 34.1 36.5 37.6 17% (5/29) sample) BMI (29.1 vs. 27.7), AHI (44 vs. 30) Success in other series lateral pharyngeal collapse only on Benazzo 2008 Thyroid 28.2 37 19* 62% (67/109) with mean BMI < 30 is MM; excluded those with abnormal cephs notably higher Source: Baisch Oto-HNS 2006 Not BMI (graph) Baisch 2006 Thyroid 28.2 38 19* 60% (40/67) Mandible Technique (less dissection of hyoid Gillespie 2011 32 41 19* 70% (16/23) (Repose) musculature) http://sleep-doctor.com/blog http://sleep-doctor.com/blog Hyoid Suspension in Combination with Partial Epiglottidectomy Other HP Procedures: Case Series Wider range of mean BMI Mean baseline AHI wide range but higher than RF/TS Success rates 20-80% in different series, for different techniques Factors associated with outcomes AHI BMI 30, 32 SNB angle on lateral cephalogram (normal 80 ± 2 degrees; >78 degrees) Age (one study; not examined much as a factor) http://sleep-doctor.com/blog http://sleep-doctor.com/blog 8