Minimally Invasive SingleStage Multilevel Surgery for OSA 1

微創性單一階段多層次上呼吸道手術 對於阻塞性睡眠呼吸中止症之治療 Minimally Invasive, Single-Stage, Multilevel Surgery for OSA 蘇 彥 燁1, 3 林 新 景 1, 2, 3 Michael Friedman 4 高雄長庚醫院 耳鼻喉科 1 睡眠中心2 達文西手術中心3 Rush University Medical Center, Illinois Masonic Medical Center, Chicago, IL 4

OSA Tx Options Treatment No Tx. Success 0% Oral Appliance ? ? ? CPAP ? ? ? Surgery +

OSA Surgery Not a substitute for CPAP Salvage procedure for those who failed CPAP and other conservative therapies Surgical success of UPPP as an isolated procedure in non-selected patients: 40. 7% ~ Sher AE. Sleep 1996.

Shiro Fujita. Ear Nose Throat J 1984; 63: 227 -235. Combined oropharyngeal and hypopharyngeal obstruction was noted in 54. 5% (36/66) of patients. Thus, it is clear that Fujita himself never intended to suggest that UPPP will cure most patients with OSA.

• Classify the obstruction levels as: - Type 1, oropharynx only - Type 2, multilevel obstruction: a combination of oro- and hypo-pharyngeal obstruction. - Type 3, hypopharynx only. • Of the 239 patients, 93. 3% (223 patients) were identified as • having multilevel obstruction, type 2. Only 16 patients (6. 7%) had single level obstruction. (10 P’t had type 1 obstruction and 6 P’ts had type 3 obstruction. ~ Riley RW, Powell NB, Guilleminault C. Obstructive sleep apnea syndrome: a review of 306 consecutively treated surgical patients. Otolaryngol Head Neck Surg 1993; 108: 117. 87% of the 893 patient population had multilevel obstruction. 154. ~ Abdullah VJ, van Hasselt CA. “Video Sleep Nasoendoscopy. ” “Surgical Management of Sleep Apnea and Snoring. ” Taylor & Francis Group; 2005: 143 -

Anatomic Basis of OSA Surgical Results ~ Multilevel Tx Concept ~ Friedman M. Staging of OSA A Guide to Appropriate Treatment. Laryngoscope 2004; 114: 454 -459.

Concept of Multilevel Disease Most OSA patients have multilevel disease Appropriate surgical treatment should be multilevel approach Since 1996 , most studies have involved multilevel surgery

Evidence of Multilevel OSA Surgery The Efficacy of Multilevel Surgery of the Upper Airway in Adults with OSA Hsin-Ching Lin. Laryngoscope 2008; 118(5): 902 -908. Pub. Med, the Cochrane database, and MEDLINE bibliographic database Inclusion criteria: 1) English-language papers 2) Surgical Tx : at least two target levels in the nose, oropharynx, or hypopharynx. 3) Subjects ≥ 18 y/o 4) Sufficient pre- and postoperative data

Systematic Review of Multilevel Surgery 73 multilevel OSA surgery articles (84 groups, 3, 147 patients ) were identified.

Forest Plot in AHI Change -18. 49 /hr.

Sleep Surgery 1970’s – Tracheotomy (Kuhlo, 1969) 1980’s – UPPP (1979, Fujita) CPAP (1979, Sullivan) 1990’s – LAUP (1990, Kamami) 2000’s – Modified oropharyngeal techniques, RF, Pillar implant, Coblator, Repose system … etc. 2010’s – TORS, HGN …etc. Post-op. Morbidity and Complications!

Classifications of Multilevel Surgery UPPP + invasive hypopharyngeal procedure (Success 44% - 100%). - more invasive and more radical hypopharyngeal surgery UPPP + second hypopharyngeal procedure (Success 20% - 100%). Bimaxillary advancement Multilevel minimally invasive techniques - 2003 Fischer Y. (n=16, M & Se. , RF palate + BOT): 33% - 2004 Weaver E. (n=22, m & M, RF palate + BOT): 59% - 2007 Friedman M, Lin H-C. (n=122, m & M, Nose + Pillar +RFBOT): 47. 5% - 2009 Ceylan K. (n=26, m & M, RF palate + BOT): 53. 8% - 2009 Neruntarat C. (n = 72, M & Se. , RF palate + BOT): 55. 6%

Multi-level Minimally Invasive OSA Surgery l l l Subjective improvement: 77. 9% (95 /122 pt’s) Classical success rate: 47. 5% (54 /122 pt’s) No major complications occurred. Patients that failed MISS MLS were still candidates for “classical” treatment with traditional palatal and hypopharyngeal surgery.

~ H-C Lin, et al. JAMA Otolaryngology - Head & Neck Surgery 2017; 143: 1 -8.

MISS MLS * Response rate: 46. 8% (22/47) * 41/47 (87. 2%): They would like to have the same surgery again if necessary.

~ H-C Lin, et al. Ann Oto Rhin Laryn 2018; 127: 118 -123. N = 37, 30 M/ 7 F, 46. 8 Y/O, BMI 23. 9 p Epworth Sleepiness Scale changed from 12 ± 4. 3 to 10. 6 ± 4. 3 (P =. 004, Wilcoxon signed-rank test). p Snoring Visual Analog Scale reduced from 9. 5 ± 1. 3 to 4. 0 ± 2. 0 (P <. 0001).

MISS MLS in QOL ü Mean score of SF-36: 65. 5 ± 19. 6 to 75. 2 ± 16. 7 (P =. 001).

Soft Palate & Eustachian Tube TVP LVP E-tube Salpingo pharyngeus Hamulus Palatal musculature is responsible for the active opening of the Eustachian tube and plays a role in the middle ear function.

Results N = 30, 5 F/25 M, 44. 3 Y/O Pre-Op. POD 1 POD 7 POM 1 POM 3 P* value Rp 0 -0. 75 0 0 5 0. 0006 Rv 0. 35 0. 30 0. 40 0. 180 Lp 0 0 2. 5 0 0. 304 Lv 0. 35 0. 30 0. 35 0. 40 0. 007 Data were expressed as median *: by Friedman’s test. - Rp and Lp: right and left middle ear pressure in decipascals - Rv and Lv: right and left middle ear volumen in milliliters Paired comparisons (by Wilcoxon signed rank test for paired data) Lv Rp: P P POD 1 vs. POM 3 0. 015 Pre-Op. vs. POD 1 0. 013 POD 7 vs. POM 3 0. 007 Pre-Op. vs. POD 7 0. 024 POM 1 vs. POM 3 0. 026

Middle Ear Pressure (da. Pa)/Mean Pre-Op. POD 1 POD 7 POM 1 POM 3 Rp -13. 8 -36. 3 -3. 5 -9. 3 -7. 5 Lp -7 -13. 3 -3. 3 -2 　

Middle Ear Volume (ml)/Mean Pre-Op. POD 1 POD 7 POM 1 POM 3 Rv 0. 5 0. 4 0. 5 Lv 0. 4 0. 5 　

~ Hsin-Ching Lin, et al. Eur Arch Oto. Rhino. Laryn Head Neck 2013; 270: 2339 -43. The minimally invasive surgery with pillar implants for OSA induces changes in middle ear function. However, the changes were temporary and not significant 1 week after surgery.

Value of OSA Surgery Success Rate Complications

Conclusion Success rate vs. Complications MISS MLS is a safe and feasible method for OSA treatment. MISSMLS offers reasonable outcomes without major complications. MISS MLS could be one of the treatments for the selected patients with OSA.

10 th INTERNATIONAL SURGICAL SLEEP SOCIETY Congress May 10 -11, 2019 Marriott Marquis 1535 Broadway, New York, NY, USA Program Chairs: Maria Suurna, MD Ofer Jacobowitz, MD, Ph. D surgicalsleep. org

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