Lateral-Expansion Pharyngoplasty: Combined Technique for the Treatment of Obstructive Sleep Apnea Syndrome

Abstract Introduction Obstructive sleep apnea syndrome (OSAS) is a multifactorial disease characterized by episodes of partial or complete collapse during sleep of different regions of the upper airway. Surgery for OSAS evolved with the introduction of different techniques, considering new surgical concept of reconstruction of the upper airway. Objective To retrospectively evaluate the effectiveness of a new approach aimed at reducing pharyngeal collapse by combining two surgical techniques: lateral and expansion pharyngoplasty. Methods We reviewed the medical records of 38 patients with OSAS undergoing lateral/expansion pharyngoplasty from January 2012 to December 2016. The following data were collected: patient age, gender, and pre- and postoperative body mass index (BMI), Epworth sleepiness scale (ESS) scores, snoring visual analogue scale (VAS) scores, and polysomnography (PSG) results. Results The PSG results showed a significant reduction in the apnea/hypopnea index (AHI) from 22.4 ± 27.3 events/h preoperatively to 13.6 ± 17.9 events/h postoperatively (p = 0.009), with postoperative AHI reduction greater than 50% in 63.2% of the patients. There was also a significant reduction in the microarousal index (19.5 ± 22.6 vs 11.0 ± 13.4 events/h; p = 0.001) and in the minimum oxygen saturation (82.6 ± 10.3 vs 86.9 ± 11.1; p = 0.007). Conclusions Lateral-expansion pharyngoplasty represents a new surgical strategy for the treatment of OSAS in patients with palatal collapse by combining two different techniques: lateral and expansion pharyngoplasty. The two techniques, performed as a one-stage procedure, led to improvements in excessive daytime sleepiness, snoring, and PSG respiratory parameters by acting on lateral and retropalatal collapse, produc- ing favorable results with good applicability in otolaryngology clinical practice.

The Role of Modified Expansion Sphincter Pharyngoplasty in Multilevel Obstructive Sleep Apnea Syndrome Surgery

Abstract Introduction Obstructive sleep apnea syndrome (OSAS) is a sleep disorder caused by an excessive narrowing of the pharyngeal airway that also collapses during inspiration, with an important role played by the lateral pharyngeal wall in the development of the obstruction. Objective To describe our surgical experience with modified expansion sphincter pharyngoplasty (MESP) in the management of lateral collapse in upper airway multilevel surgery. Methods A total of 20 patients with moderate to severe OSAS were recruited in the Ear, Nose and Throat (ENT) Department of the University of Palermo, Italy. All of the enrolled patients refused the ventilatory therapy. The subjects were evaluated for snoring, and daytime sleepiness had a clinical evaluation including collection of anthropometric data and ENT examination and rhinofibroscopy with Müller maneuver. The patients undergoing upper airway multilevel surgery and we selected for MESP the patients with an oropharyngeal transverse pattern of collapse at Müller maneuver. Results In the postoperative assessment, all of the patients reported a reduction in snoring scores and daytime sleepiness. We observed a reduction in the mean apnea-hypopnea index (AHI) of 57.5% of the sample, which decreased from a mean value of 41.7 ( ± 21.5) to 17.4 ( ± 8.9) (p< 0.05), with a success rate, according to the Sher criteria, of 65%. We observed very few postoperative complications. Conclusion Modified expansion sphincter pharyngoplasty in multilevel surgical therapy preceded by a careful selection of patients has proven to be effective in treating patients with moderate to severe syndromes.

Uso del láser CO2 en la cirugía de la disfagia cricofaríngea: caso clínico / CO2 Laser use in the surgery of the cricopharyngeal muscle dysfunction: case report

La miotomía cricofaríngea es una técnica quirúrgica introducida hace años para el tratamiento de la disfagia asociada a disfunción del músculo cricofaríngeo con o sin divertículo de Zenker, mostrando resultados exitosos que revierten la sintomatologta y mejoran la calidad de vida del paciente. Con los avances científicos surge la cirugía láser endoscópica que permite ser una alternativa quirúrgica segura, viable y efectiva respecto a la miotomía clásica abierta, según diferentes series publicadas, mostrando disminuir los tiempos de anestesia, quirúrgico y de recuperación. En este artículo describimos un caso clínico, la técnica quirúrgica utilizada y los resultados en un paciente con disfagia por disfunción cricofaríngea con buen resultado posoperatorio.

Cricopharyngeal myotomy is a surgical technique introduced years ago for the treatment of dysphagia associated with cricopharyngeal muscle dysfunction with or without Zenker’s diverticulum, showing successful results that reverse the symptoms and improve the quality of life of patients. With scientific advances endoscopic laser surgery allows to be an open safe, feasible and effective for classical surgical myotomy alternative, according to various published series showing decreasing times anesthesia, surgical and recovery emerges. In this article we describe a case, the surgical technique used and results in a patient with dysphagia by cricopharyngeal dysfunction with good postoperative outcome.

ASSESSMENT OF MECHANICAL AND MANUAL SUTURE IN THE SURGICAL TREATMENT OF THE PHARYNGOESOPHAGEAL DIVERTICULUM / AVALIAÇÃO DA SUTURA MECÂNICA E MANUAL NO TRATAMENTO CIRÚRGICO DO DIVERTÍCULO FARINGOESOFÁGICO

Background: The occurrence of the pharyngoesophageal, or Zenker diverticulum is not frequent in the national scenario, and the technique of the diverticulectomy with cricomyotomy in medium and great dimension diverticula is still the most indicated. Because the resection of the diverticulum requires the suture of the pharynx, dehiscence can occur, thereafter delaying swallowing. Hence, the idea is to accomplish this surgical procedure, comparing the manual and mechanical suture, in order to evaluate the real benefit of the mechanical technique. Aim: To evaluate the results of the pharyngoesophageal diverticulectomy with cricomyotomy using manual and mechanical suture with regard to local and systemic complications. Method: Fifty-seven patients with pharyngoesophageal diverticula diagnosed through high digestive endoscopy and pharyngeal esophagogram were studied. The applied surgical technique was diverticulectomy with myotomy of the cricopharyngeal muscle, done in 24 patients (42.2%) the mechanical suture (group A) with the mechanical linear suture device and in 33 (57.8%) a manual closure of the pharynx (group B). Results: In the postoperative period, one patient of group A (4.1%) presented fistula caused by dehiscence of the pharyngeal suture, and three of group B (15.1%) presented the same complication, with a good outcome using a conservative treatment. In the same group, three patients (9.0%) presented stenosis of the suture of the pharynx, with good outcome and with endoscopic dilatations, and no patient from group A presented such complication. Lung infection was present in five patients, being two (8.3%) of group A and three (9.0%) on B, having good outcomes after specific treatment. In the late review, done with 43 patients (94.4%) of group A and 22 (88.0%) on B, the patients declared to be pleased with the surgical procedure, because they were able to regain normal swallowing. Conclusion: The diverticulectomy with myotomy and pharyngeal closure using mechanical suture was proven appropriate, for having restored regular swallowing in most of the patients, and the mechanical closure of the pharynx proved to be more effective in comparison to the manual one, because it provided a lower index of local post-surgical complications.

Racional: A ocorrência do divertículo faringoesofágico, ou de Zenker, é pouco frequente no cenário nacional, sendo que a técnica da diverticulectomia com cricomiotomia em divertículos de média e grandes dimensões ainda é a mais indicada. Devido à ressecção do divertículo necessitar de sutura da faringe ocorre possibilidade de deiscência, o que retarda o retorno da deglutição. Daí a ideia de realizar este procedimento cirúrgico, comparando a sutura manual com a mecânica, para avaliar o real benefício da técnica mecânica. Objetivo: Avaliar os resultados da diverticulectomia faringoesofágica com cricomiotomia utilizando à sutura manual e mecânica em relação às complicações locais e sistêmicas. Métodos: Foram estudados 57 pacientes com divertículos faringoesofágicos diagnosticados através da endoscopia digestiva alta e faringoesofagograma. A técnica cirúrgica empreendida foi a diverticulectomia com miotomia do músculo cricofaríngeo, sendo a sutura mecânica realizada em 24 pacientes (42,2%, grupo A) com o aparelho linear e em 33 (57,8%, grupo B) a manual para o fechamento da faringe. Resultados: Na avaliação do pós-operatório precoce, um paciente do grupo A (4,1%) apresentou fístula consequente à deiscência da sutura da faringe e três do grupo B (15,1%) ambos com boa evolução com tratamento conservador. Neste mesmo grupo, três pacientes (9,0%) apresentaram estenose da sutura da faringe, com boa evolução com dilatações endoscópicas sendo que nenhum do grupo A apresentou esta complicação. A infecção pulmonar esteve presente em cinco pacientes, dois (8,3%) do grupo A e três (9,0%) do grupo B, com boa evolução com tratamento específico. Na avaliação tardia, realizada em 43 pacientes, 17(94,4%) do grupo A e 22 (88,0%) do grupo B, os pacientes referiram estarem satisfeitos com o procedimento cirúrgico, pois conseguiram resgatar a deglutição normal. Conclusões: A diverticulectomia com a miotomia do cricofaríngeo demonstrou ser procedimento cirúrgico ...

A miotomia do cricofaríngeo: artigo de revisão / Cricopharyngeal myotomy: review article

A miotomia do cricofaríngeo é um procedimento cirúrgico que pode ser indicado para pacientes com disfagia orofaríngea que, em geral, caracterize-se por distúrbio motor limitado à fase faríngea da deglutição, incoordenação cricofaríngea ou relaxamento incompleto do Esfíncter Esofágico Superior (EES). A indicação da miotomia, porém, tem sido discutida e aplicada em muitos casos, sem efeito na melhora da dinâmica da deglutição. O objetivo deste estudo foi verificar os critérios de indicação e eficácia da miotomia do cricofaríngeo, com base nos estudos da fisiologia da deglutição em pacientes com disfagia orofaríngea. Realizou-se, então, uma revisão da literatura sobre este procedimento e a descrição de seus resultados na dinâmica da deglutição. Os resultados demonstraram que os melhores indicadores para uma miotomia bem sucedida são: fase oral eficiente e boa elevação laríngea durante a deglutição. Assim, para uma adequada indicação da miotomia do cricofaríngeo, não se deve avaliar apenas a fase faríngea e o funcionamento isolado do EES, mas a coordenação e relação entre as fases oral e faríngea da deglutição.

Cricopharyngeal myotomy is a surgical procedure that might be indicated to patients with oropharyngeal dysphagia that, in general, are characterized by a motor impairment limited to the pharyngeal phase of swallowing, cricopharyngeal incoordination or incomplete relaxation of the Upper Esophageal Sphincter (UES). Indication of the myotomy, however, have been discussed and applied in many cases, with no effect on the improvement of deglutition dynamics. The aim of this study was to verify the criteria of indication and efficacy of cricopharingeal myotomy, based on studies of deglutition physiology in patients with oropharyngeal dysphagia. A literature review about this procedure and the description of its results on deglutition dynamics was carried out. Results showed that the best indicators of a well-succeeded myotomy are: efficient oral phase and good laryngeal elevation during deglutition. Therefore, an adequate indication of cricopharyngeal myotomy must consider not only the pharyngeal phase and the isolated functioning of the UES, but also the coordination and the relationship between the oral and the pharyngeal phases of deglutition.

Voice Restoration with Low Pressure Blom Singer Voice Prosthesis after Total Laryngectomy

The main problem after total laryngectomy is permanent loss of voice. Current methods of vocal rehabilitation after total laryngectomy include development of esophageal speech, use of artificial larynx, tracheoesophageal shunt operations and more recently surgical restoration of the voice with prosthesis. Primary voice restoration using Blom- Singer voice prosthesis after total laryngectomy and pharyngeal myotomy was performed in 187 patients between October 1992 and July 2000. There were 184 male and 3 female patients of average age 63.7 years (range 42-76). Mean follow up period was 62 months. Satisfactory speech was achieved in 156 patients (83.5%). During the follow-up period, we experienced complaints of insufficient voice in 31 (16.5%) patients, due to partial spasm in 17 and total spasm in the pharyngoesophageal segment in 14. Furthermore, 24 (12.8%) patients preferred esophageal speech or electro larynx because of low socioeconomic level. The overall success rate was 70.7%. In this study the results of the surgical technique and prosthesis insertion, as well as the associated complications and socioeconomic levels of the patients, are discussed.

Disfunçäo cricofaríngea / Cricopharyngeal dysfunction

A disfunçäo idiopática do músculo cricofaringeo é uma afecçäo rara, que representa um problema complexo devido a limitada compreensäo da fisiologia faringoesofágica e sua fisiopatologia. O presente trabalho analisa três pacientes portadores de disfunçäo cricofaringea idiopática submetidos a cricomiotomia. Uma doente näo obteve melhora com a cirurgia. Discutem-se as dificuldades no diagnóstico, tratamento e na seleçäo dos pacientes que seräo beneficiados com o tratamento cirúrgico.

Electromanometric study of the esophageal sphincters and their correlation

Clinical and experimental studies on esophageal sphincters are easily found in the literature. However, the correlation between sphincters is seldom focused. The purpose of this work is to verify whether changes in the upper esophageal sphincter (UES) affects the resting pressure of the lower esophageal sphincters (LES). Electromanometric measurements of the esophageal esphincters of 8 mongrel dogs were taken by using the technique of station pull-through and continous infusion of catheters. Then, the animals were submitted to miotomy of the cricopharyngeus muscle. Sphincteric pressure was measured before and after surgery. Results revealed the following pressure values for UES: 27 + 12 mmHg (prior to surgery) and 12 + 5 mmHg (after surgery); (p<0.01). Nonetheless, LES resting pressure did not change (22 + 11 mmHg prior to and after surgery; p>0.80).

Is diverticulopexy better than diverticulectomy in the treatment of Zenker's diverticulum?

Dez pacientes portadores de diverticulo de Zenker foram submetidos a diverticulopexia associada a miotomia do musculo cricofaringeo para tratamento dessa afeccao, entre o periodo de 1983 a 1992. A tecnica consiste na disseccao do diverticulo e ancoramento do mesmo a fascia pre-vertebral de modo a ficar invertido, o que impede o seu enchimento com a degluticao. A media de idade dos pacientes era de 78,8 anos e todos tinham o diagnostico de diverticulo confirmado pela historia clinica e pela radiografia contrastada do esofago. Os sintomas mais comuns eram disfagia e regurgitacao, que foram avaliados no pos-operatorio em todos os pacientes...

Eletromanometria do esfíncter superior do esôfago e suas relaçöes com o esfíncter inferior / Electromanometry of the upper esophageal sphyncter and their correlations with the lower esophageal sphyncter

Foram utilizados 25 cäes adultos, realizando-se exames eletromanométricos do esfíncter inferior e superior do esôfago, medindo-se pressäo de repouso e comprimento destas estruturas, através de três técnicas de puxada: uma técnica intermitente e duas técnicas contínuas, uma delas lenta e outra rápida. Cada animal sofreu três introduçöes de sonda para cada técnica em uma fase inicial e em seguida, foi submetido a um dos três procedimentos cirúrgicos seguintes: 1. Miotomia do músculo cricofaríngeo; 2. Miotomia dos músculos supra e infra-hióideos e do músculo cricofaríngeo; 3. Miotomia dos músculos eupra e infra-hióideos. No pós operatório imediato as medidas de pressäo e comprimento dos esfíncteres esofágicos foram repetidas. A pesquisa objetivou: 1. Estudar as técnicas de puxada nos esfíncteres inferior e superior do esôfago, investigar o efeito de seqüência de uma medida sobre as subsequentes e analisar a variabilidade dos valores colhidos pelas diversas técnicas; 2. Comparar as técnicas de puxada nas duas etapas da pesquisa e as repercussöes sobre a pressäo e o comprimento; 3. Comparar o comportamento de ambos os esfíncteres frente às técnicas de puxada; 4. Avaliar o efeito das manipulaçöes cirúrgicas do ESE sobre o EIE; 5. Avaliar o papel dos músculos supra e infra-hióideos na pressäo de repouso do ESE. Os resultados obtidos permitiram concluir que: - As técnicas de puxada aplicada aos esfíncteres superior e inferior do esôfago, revelam, indistintamente, grande variabilidade dos valores de pressäo e comprimento. - Para grupos de indivíduos, em um dado momento, podem-se obter valores confiáveis através de uma única introduçäo para coletas de dados, pois näo existe efeito de sequência entre puxadas. - O comportamento do ESE é semelhante ao do EIE, frente às técnicas de puxada, nas possíveis variaçöes ocorridas na pressäo de repouso, produzidas pela presença da sona na luz esofágica. - Para pressöes de repouso, näo existe efeito de técnica e as puxadas podem ser usadas indiferentemente, em ambos os esfíncteres, para grupos de indivíduos. - Os comprimentos diferem significativamente quando obtidos pels técnica contínua rápida säo sempre maiores que aqueles fornecidos pela técnica intermitente. - Alteraçäo da pressäo de repouso do ESE devido a manipulaçöes cirúrgicas näo interfere na pressäo de repouso do EIE. - Após cirurgias realizadas sobre o ESE, a relaçäo entre as técnicas de puxada utilizadas permanece, em geral, inalterada...