Expansion Sphincter Pharyngoplasty

Video Type: CVideo
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Author: Tyler McElwee
Published:
Specialties: Otolaryngology, Pediatric Otolaryngology, Plastic Surgery
Schools: Emory School of Medicine
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Basic Info

Contributors: Raj Dedhia, M.D

Obstructive sleep apnea is a common disorder with many possible etiologies. Surgical therapy is aimed at reducing or eliminating an area of airway stenosis that predisposes patients to obstructive sleep apnea. Expansion sphincter pharyngoplasty consists of transecting the palatopharyngeus and reinserting it into the lateral soft palate and periosteum of the pterygoid hamulus to widen the pharyngeal airway.

DOI #: https://doi.org/10.17797/i9jgkva8m4

Advanced

Procedure

Expansion sphincter pharyngoplasty.

Clarification: Two suture methods are shown in a drawing in the video and either stitch can be used to secure the palatopharyngeal pedicle

Indications

o Symptomatic obstructive sleep apnea
o Obstruction located at the level of the velopharynx and accompanying lateral walls. This site determination is based on evaluations such as drug-induced sedated endoscopy and Friedman tongue position.
o Inability to tolerate or improve with positive airway pressure (PAP) therapy
o No improvement of symptoms with weight loss, oral appliance, or other non-surgical modalities

Contraindications

o No absolute contraindications
o Relative indications include high perioperative risk, anticoagulation and bleeding risk, poor nutritional status, pre-existing dysphagia or xerostomia, velopharyngeal insufficiency, or occupation dependent on pharyngeal function

Instrumentation

Setup

Tools necessary include tonsillectomy set, monopolar needle-tip cautery, toothed forceps, right angle clamp, kittners on tonsillectomy forceps, Metzenbaum scissors, Haney needle driver, 2-0 polysorb sutures for muscle suspension, and 4-0 chromic sutures for mucosal closure

Preoperative Workup

Workup begins with a detailed history of sleeping difficulties. Gold standard for diagnosis is polysomnography with AHI > 5 or RDI > 5 and the patient has documented symptoms of obstructive sleep apnea. Sleep endoscopy is then utilized to determine anatomic location of obstruction to guide which treatment modality would be best effective.

Anatomy and Landmarks

o Insertion of palatopharyngeus into the soft palate
o Superior constrictors in lateral tonsillar fossa
o Pterygoid hamulus and buccopharyngeal raphe as anchors for muscle pedicle

Advantages/Disadvantages

o Main advantage over non-surgical therapy is anatomic widening of airway to provide larger airway without the use of appliances or PAP therapy. Advantage over classic uvulopalatalpharyngoplasty is that expansion sphincter pharyngoplasty is more reconstructive rather than excisional that improves effectiveness and decreases potential morbidities.
o Disadvantages include all surgical risks

Complications/Risks

o Standard operative risks: bleeding, infection, possible need for further surgery
o Velopharyngeal insufficiency
o Dysphagia

Disclosure of Conflicts

o Standard operative risks: bleeding, infection, possible need for further surgery
o Velopharyngeal insufficiency
o Dysphagia

Acknowledgements

None

References

1. o Dedhia RC, Soose RJ. Advanced Palatal Surgery. Myers & Snyderman (Eds) Operative Otolaryngology, 3rd edition.
2. Pang KP, Pang EB, Win MT, Pang KA, Woodson BT. Expansion sphincter pharyngoplasty for the treatment of OSA: a systemic review and meta-analysis. Eur Arch Otorhinolaryngol. 2016;273(9):2329-2333.

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