Raol N, Hartnick CJ (eds): Surgery for Pediatric Velopharyngeal Insufficiency. Adv Otorhinolaryngol. Basel, Karger, 2015, vol 76, pp 86–88 (DOI: 10.1159/000368033)
Obstructive Sleep Apnea J. Paul Willging a, b a
Division of Pediatric Otolaryngology – Head and Neck Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, b Department of Otolaryngology – Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
Abstract This chapter outlines the surgical management of children who experience symptoms of airway obstruction after undergoing pharyngeal flap surgery or sphincter pharyngoplasty for the correction of velopharyngeal insufficiency. It also describes the management of children with hyponasality fol© 2015 S. Karger AG, Basel lowing these corrective surgical interventions.
Following the surgical correction of velopharyngeal insufficiency by pharyngeal flap surgery or sphincter pharyngoplasty, the ports that were created may become stenotic. If this occurs, airway obstruction may ensue. By 6 weeks postoperatively, postsurgical edema will have resolved, thereby allowing accurate assessment of the effect of the ports on breathing. If symptoms of airway obstruction are evident at this time, spontaneous improvement is unlikely to occur. Flexible endoscopy should be performed to assess the ports. Questions pertaining to the significance of sleep-related airway symptoms should be addressed by having the patient undergo overnight polysomnography. If obstructive sleep apnea (OSA) is documented, continuous positive airway pressure may be used as a temporizing measure. Although obstructive airway symptoms may gradually improve over time as a child grows, it is the author’s opinion that surgical intervention is preferable to having the child remain technology dependent for a long and indefinite period of time.
Downloaded by: Siriraj Medical Library, Mahidol University 202.28.191.34 - 3/13/2015 2:32:16 PM
Background
Additionally, children with OSA generally have significant hyponasality. In this setting, enlarging the velopharyngeal ports will not only correct the OSA but also normalize resonance.
Indications for Surgical Correction of Obstructive Sleep Apnea
• Significant increase in the work of breathing while asleep • Documentation of OSA by polysomnography Increasing the Size of the Ports After flexible endoscopy documents the presence of stenotic port(s), surgical enlargement of the port should be undertaken. The aim of surgical intervention is to open the problematic port. Port Enlargement: Online supplementary video (for online supplementary material, see http://www.karger.com/Article/ FullText/368033). Procedure • A mouth gag is inserted, and the patient is placed in suspension. • A suction catheter is passed transnasally through the stenotic port. If the catheter is difficult to pass, a dilator can be passed through the eye of the catheter and into its lumen, and the dilator can be manipulated through the port. Traction on the catheter(s) will tense the port, allowing better visualization. • With the port under tension, a beaver blade is used to make a V-shaped wedge in the scar tissue that is obstructing the port. • If necessary, the revision is carried out bilaterally. • The resulting defect is left to granulate.
Procedure • A mouth gag is inserted, and the patient is placed in suspension. • The pharyngeal flap is visualized with a mirror. • A right-angle beaver blade is used to separate the pharyngeal flap from the posterior pharyngeal wall. Residual flap tissue is left attached to the free edge of the soft
Obstructive Sleep Apnea
Raol N, Hartnick CJ (eds): Surgery for Pediatric Velopharyngeal Insufficiency. Adv Otorhinolaryngol. Basel, Karger, 2015, vol 76, pp 86–88 (DOI: 10.1159/000368033)
87
Downloaded by: Siriraj Medical Library, Mahidol University 202.28.191.34 - 3/13/2015 2:32:16 PM
Flap Takedown If the pharyngeal flap is totally obstructing the nasopharyngeal inlet and the velopharyngeal ports cannot be opened satisfactorily by other methods, it may be necessary to release the pharyngeal flap; this procedure restores the child’s ability to breathe well at night. It is prudent to obtain a ‘sleep MRI’ (i.e. sagittal MRI of the head and neck performed under sedation) prior to undertaking this procedure to ensure that the flap is the primary cause of the OSA, as tongue base obstruction may also present with similar symptoms.
palate; this retains bulk on the soft palate, which maximizes the ability to maintain velopharyngeal closure while improving the airway. • The resulting defect on the posterior pharyngeal wall is left open to granulate.
Pearls and Pitfalls
Increasing the Size of the Ports • There is usually a specific site within the port that causes the obstruction. Attention to that specific area will allow the port to spring open when it is divided. • Minimal modification to the flap itself is required to open the port. • Enlarging the velopharyngeal port(s) may cause abnormal resonance or the development of nasal air emission if the moving lateral wall cannot make contact with the flap during connected speech.
J. Paul Willging, MD Division of Pediatric Otolaryngology – Head and Neck Surgery Cincinnati Children’s Hospital Medical Center 3333 Burnet Avenue, MLC 2018, Cincinnati, OH 45229 (USA)
88
Willging
Raol N, Hartnick CJ (eds): Surgery for Pediatric Velopharyngeal Insufficiency. Adv Otorhinolaryngol. Basel, Karger, 2015, vol 76, pp 86–88 (DOI: 10.1159/000368033)
Downloaded by: Siriraj Medical Library, Mahidol University 202.28.191.34 - 3/13/2015 2:32:16 PM
Flap Takedown • If a flap has been in position for a long period of time prior to takedown, resonance often remains normal. • Flap takedown does not always normalize the airway, as tongue base obstruction or hypopharyngeal collapse may also lead to OSA.
Obstructive Sleep Apnea J. Paul Willging a, b a
Division of Pediatric Otolaryngology – Head and Neck Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, b Department of Otolaryngology – Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
Abstract This chapter outlines the surgical management of children who experience symptoms of airway obstruction after undergoing pharyngeal flap surgery or sphincter pharyngoplasty for the correction of velopharyngeal insufficiency. It also describes the management of children with hyponasality fol© 2015 S. Karger AG, Basel lowing these corrective surgical interventions.
Following the surgical correction of velopharyngeal insufficiency by pharyngeal flap surgery or sphincter pharyngoplasty, the ports that were created may become stenotic. If this occurs, airway obstruction may ensue. By 6 weeks postoperatively, postsurgical edema will have resolved, thereby allowing accurate assessment of the effect of the ports on breathing. If symptoms of airway obstruction are evident at this time, spontaneous improvement is unlikely to occur. Flexible endoscopy should be performed to assess the ports. Questions pertaining to the significance of sleep-related airway symptoms should be addressed by having the patient undergo overnight polysomnography. If obstructive sleep apnea (OSA) is documented, continuous positive airway pressure may be used as a temporizing measure. Although obstructive airway symptoms may gradually improve over time as a child grows, it is the author’s opinion that surgical intervention is preferable to having the child remain technology dependent for a long and indefinite period of time.
Downloaded by: Siriraj Medical Library, Mahidol University 202.28.191.34 - 3/13/2015 2:32:16 PM
Background
Additionally, children with OSA generally have significant hyponasality. In this setting, enlarging the velopharyngeal ports will not only correct the OSA but also normalize resonance.
Indications for Surgical Correction of Obstructive Sleep Apnea
• Significant increase in the work of breathing while asleep • Documentation of OSA by polysomnography Increasing the Size of the Ports After flexible endoscopy documents the presence of stenotic port(s), surgical enlargement of the port should be undertaken. The aim of surgical intervention is to open the problematic port. Port Enlargement: Online supplementary video (for online supplementary material, see http://www.karger.com/Article/ FullText/368033). Procedure • A mouth gag is inserted, and the patient is placed in suspension. • A suction catheter is passed transnasally through the stenotic port. If the catheter is difficult to pass, a dilator can be passed through the eye of the catheter and into its lumen, and the dilator can be manipulated through the port. Traction on the catheter(s) will tense the port, allowing better visualization. • With the port under tension, a beaver blade is used to make a V-shaped wedge in the scar tissue that is obstructing the port. • If necessary, the revision is carried out bilaterally. • The resulting defect is left to granulate.
Procedure • A mouth gag is inserted, and the patient is placed in suspension. • The pharyngeal flap is visualized with a mirror. • A right-angle beaver blade is used to separate the pharyngeal flap from the posterior pharyngeal wall. Residual flap tissue is left attached to the free edge of the soft
Obstructive Sleep Apnea
Raol N, Hartnick CJ (eds): Surgery for Pediatric Velopharyngeal Insufficiency. Adv Otorhinolaryngol. Basel, Karger, 2015, vol 76, pp 86–88 (DOI: 10.1159/000368033)
87
Downloaded by: Siriraj Medical Library, Mahidol University 202.28.191.34 - 3/13/2015 2:32:16 PM
Flap Takedown If the pharyngeal flap is totally obstructing the nasopharyngeal inlet and the velopharyngeal ports cannot be opened satisfactorily by other methods, it may be necessary to release the pharyngeal flap; this procedure restores the child’s ability to breathe well at night. It is prudent to obtain a ‘sleep MRI’ (i.e. sagittal MRI of the head and neck performed under sedation) prior to undertaking this procedure to ensure that the flap is the primary cause of the OSA, as tongue base obstruction may also present with similar symptoms.
palate; this retains bulk on the soft palate, which maximizes the ability to maintain velopharyngeal closure while improving the airway. • The resulting defect on the posterior pharyngeal wall is left open to granulate.
Pearls and Pitfalls
Increasing the Size of the Ports • There is usually a specific site within the port that causes the obstruction. Attention to that specific area will allow the port to spring open when it is divided. • Minimal modification to the flap itself is required to open the port. • Enlarging the velopharyngeal port(s) may cause abnormal resonance or the development of nasal air emission if the moving lateral wall cannot make contact with the flap during connected speech.
J. Paul Willging, MD Division of Pediatric Otolaryngology – Head and Neck Surgery Cincinnati Children’s Hospital Medical Center 3333 Burnet Avenue, MLC 2018, Cincinnati, OH 45229 (USA)
88
Willging
Raol N, Hartnick CJ (eds): Surgery for Pediatric Velopharyngeal Insufficiency. Adv Otorhinolaryngol. Basel, Karger, 2015, vol 76, pp 86–88 (DOI: 10.1159/000368033)
Downloaded by: Siriraj Medical Library, Mahidol University 202.28.191.34 - 3/13/2015 2:32:16 PM
Flap Takedown • If a flap has been in position for a long period of time prior to takedown, resonance often remains normal. • Flap takedown does not always normalize the airway, as tongue base obstruction or hypopharyngeal collapse may also lead to OSA.
