Surgery of the Hypopharynx So Many Choices Medical Advisory Board - PDF document

1/10/2018 Disclosures Surgery of the Hypopharynx – So Many Choices Medical Advisory Board ReVENT Medical Medical Advisory Board Pillar Palatal Eric J. Kezirian, MD, MPH Medical Advisory Board Cognition Life Science Professor, Otolaryngology – Head & Neck Surgery Research Funding Inspire Medical Systems President, International Surgical Sleep Society Consultant Nyxoah Consultant Split Rock Scientific Sleep-Doctor.com Intellectual Property Rights Magnap Eric.Kezirian@med.usc.edu Consultant, IP Rights Berendo Scientific Consultant Gerard Scientific 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 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 (%) 5% Fujita Types II and III 100 Conclusion: failure to identify site(s) of obstruction 75 80 is principal factor in poor results for surgery Palate Obstruction 60 Tongue Obstruction Friedman Stage (Friedman OtoHNS 2002) 33 40 25 23 Success of UPPP/T: Stage I 81% 13 20 7 Stage II 38% 0 Stage III 8% AI RDI LSAT Unfortunately, few patients Stage I Sher et al. SLEEP 1996;19:156-177 Adapted from Table 7 http://sleep-doctor.com/blog http://sleep-doctor.com/blog 1

1/10/2018 Expansion Sphincter Pharyngoplasty Lateral Pharyngoplasty http://sleep-doctor.com/blog http://sleep-doctor.com/blog Body Mass Index Site of Obstruction and Surgical Options Not really an eval technique Past/Current Current/Future? Easy, low cost, and Crude measure of obesity associated with outcomes Underweight <18.5 May affect structures involved Palate/Tonsils Velum/Palate Normal 18.5 - <25 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 2

1/10/2018 Difference for Tongue Fat and Its Relationship to OSA tongue total (Kim Schwab SLEEP 2014) volume and tongue fat but not Case-control of BMI ≥ 28.7: OSA (90), non (31) for masseter Subgroup analysis: 18 matched pairs (BMI, age, sex, race) Tongue and masseter muscle volume and fat (Dixon) Difference between matched pairs was 12 mL for tongue volume and 8 mL for tongue fat http://sleep-doctor.com/blog http://sleep-doctor.com/blog 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 3

1/10/2018 Tongue GA and MG Results Many areas of the body Radiofrequency Heart, prostate, oncology Turbinates, palate, tonsils, tongue Most have overweight BMI but not obese (highest mean BMI 32) Energy delivered to create Wide range mean baseline AHI injury, then fibrosis Success rates 39-87% in different series Multiple technologies Monopolar (Gyrus/TCRF) vs. Factors associated with outcomes Bipolar (ArthroCare and Celon) AHI (not universal) BMI 29 or 30 Less invasive Can be done in clinic— titratable, snoring http://sleep-doctor.com/blog http://sleep-doctor.com/blog 8-Week Outcomes: Active RF vs. Sham Tongue Radiofrequency Randomized Trial 1.2 Woodson et al., Oto—HNS 2003 1 0.89 Level 1: randomized, placebo-controlled trial 0.8 0.59 0.6 Mild to Effect Size 0.45 0.43 0.41 0.39 0.39 0.39 Moderate OSA 0.4 0.25 0.23 (AHI 5-40) 0.2 0 Palate/Tongue Tot Vol 1/SRT FOSQ SNORE RT FRT AHI AI LSAT ESS MCS PCS Placebo “RF” CPAP RF -0.2 -0.13 (n=30) (n=30) (n=30) -0.26 -0.4 Oto-HNS 2003;128:848-61 Adapted from Table 6 Outcomes http://sleep-doctor.com/blog http://sleep-doctor.com/blog 2-Year Outcomes: Final vs. Baseline Tongue Radiofrequency Improves UPPP/T outcomes 1.2 1.11 Palate surgery alone 1 0.87 UPPP/T provides improvement 0.81 0.81 UPPP/T 0.8 FS + RF Only Tongue Addition of tongue RF 0.6 Effect Size improves outcomes for 0.41 0.4 I 80% patient subgroups that 0.28 0.25 would not be expected to 0.16 0.2 have ideal outcomes after II 38% 55% palate surgery 0 1/SRT RT FRT LSAT Tot Vol FOSQ SNORE AHI AI ESS MCS PCS -0.2 Friedman Oto—HNS 2003 III 8% 33% Friedman Oto—HNS 2004 -0.4 Adapted from Figure 1 Oto-HNS 2005;132:630-35 Outcomes http://sleep-doctor.com/blog http://sleep-doctor.com/blog 4

1/10/2018 Tongue Stabilization Tongue Radiofrequency Case Series Repose/AIRvance (Medtronic) Most have overweight BMI but not obese (highest AirLift (Siesta Medical) mean BMI 32) Wide range mean baseline AHI Technique Success rates 20-80% in different series Bone screw in mandible Pre-attached suture passed Factors associated with outcomes through tongue base and AHI (not universal) secured to stabilize tongue BMI 29 or 30 base Friedman Stage (II better than III) http://sleep-doctor.com/blog http://sleep-doctor.com/blog Tongue Stabilization Case Series TS: Handler 2013 EBM Review Most have overweight BMI TS alone: 36% success (highest mean 31) UPPP + TS: success 62% Wide range mean AHI Success: UPPP/TS = UPPP/GA = UPPP/GA/HS 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 Li Eur Arch Oto 2013: Glossoptosis Midline Glossectomy Cohort study: UPPP vs. UPPP/TS (pt preferences) Morbid procedure with CO2 laser, cautery Modified Mallampati 1/2 Robinson technique: Coblation (not FDA indication) OSA on PSG with NP trumpet (AHI >15) TORS No lingual T hyp; CT with retrolingual airway >12 mm http://sleep-doctor.com/blog http://sleep-doctor.com/blog 5

1/10/2018 Robotic-Assisted Surgery Vicini Head Neck 2012 AHI 36 to 16; ESS 12.6 to 7.7 da Vinci System Resection: 13.5 ± 8.2 ml (< 7 ml poor) Intuitive Surgical Urology, GYN, CT, and General Surgery Minimally invasive, improved access, decreased morbidity OSA: lingual T FDA-approved with little data (Vicini) http://sleep-doctor.com/blog http://sleep-doctor.com/blog http://sleep-doctor.com/blog http://sleep-doctor.com/blog Friedman Oto-HNS 2012 Tongue Resection: Midline Glossectomy, SMILE, Hyoepiglottoplasty, and Lingual Tonsillectomy Baseline AHI mid-50s; ZPPP + TORS Resection 2.3±0.4 g (no corr with outcome) Most series have mean BMI in obese range (29-36) Mean baseline AHI wide range but higher than RF/TS Success rates 25-100% in different series Factors associated with outcomes AHI BMI (Vicini: better outcomes in BMI < 30) Amount of tissue resected (Vicini) ? Lingual tonsil vs. muscle only http://sleep-doctor.com/blog http://sleep-doctor.com/blog 6