Clin Exp Otorhinolaryngol.  2020 Aug;13(3):215-224. 10.21053/ceo.2020.01053.

Surgical Algorithm for Obstructive Sleep Apnea: An Update

• Liu SYC
• Riley RW
• Yu MS

• KMID: 2504915
• DOI: http://doi.org/10.21053/ceo.2020.01053

Abstract

Sleep surgery is part of a continuum of care for obstructive sleep apnea (OSA) that involves medical, pharmacologic, and behavioral therapy. Upper airway surgery for OSA can significantly improve stability by way of modulating the critical negative closing pressure. This is the same mechanism of action as positive airway pressure or oral appliance therapy. The updated surgical algorithm in this review adds precision in three areas: patient selection, identification of previously unaddressed anatomic phenotypes with associated treatment modality, and improved techniques of previously established procedures. While the original Riley and Powell phase 1 and 2 approach to sleep surgery has focused on individual surgical success rate, this algorithm strives for an overall treatment success with multi-modal and patient-centric treatments.

Keyword

Obstructive Sleep Apnea; Sleep Surgery; Palatopharyngoplasty; Algorithm; Maxillomandibular Advancement; Hypoglossal Nerve Stimulation; Upper Airway Stimulation

Figure

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  Fig. 1. Obstructive sleep apnea patient with high-arched palate (A) and narrow nasal floor (B). Narrow and high-arched hard palate indicates a disproportion between the volume of tongue and the size of the oral cavity.

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  Fig. 2. Distraction Osteogenesis Maxillary Expansion: maxillary expansion results in widening of nasal floor and internal nasal valve.

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  Fig. 3. Virtual surgical planning of genioglossus advancement: the osteotomy guide is designed to capture the genial tubercle.

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  Fig. 4. Upper airway stimulation (UAS): the medial branch of hypoglossal nerve is identified (A), sensing lead is placed between internal and external intercostal muscles (B).

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  Fig. 5. Counterclockwise maxillomandibular advancement allows a greater advancement of mandible than maxilla, to maximize airway and facial esthetics.

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  Fig. 6. Updated Stanford sleep surgery algorithm. PE, physical examination; PSG, polysomnography; BMI, body mass index; PAP, positive airway pressure; OAT, oral appliance therapy; NP, nasopharyngoscopy; DISE, drug-induced sedation (sleep) endoscopy; CCC, complete concentric collapse; LPW, lateral pharyngeal wall; DOME, distraction osteogenesis maxillary expansion; TBR, tongue base reduction; TORS, transoral robotic surgery; GGA, genioglossus advancement; UAS, upper airway stimulation.

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