Swallowing evaluation after surgery for obstructive sleep apnea syndrome: uvulopalatopharyngoplasty vs. expansion pharyngoplasty

Functional Outcomes of Swallowing Following Surgery for Obstructive Sleep Apnea

OBJECTIVE

Identification and evaluation of swallowing dysfunction in patients undergoing upper airway surgery for obstructive sleep apnea (OSA) is limited. This study evaluated subjective swallowing function pre and postoperatively in patients undergoing multi-level reconstructive pharyngeal sleep surgery.

METHODS

A retrospective analysis of prospectively-administered Eating Assessment Tool (EAT-10) scores was conducted among adult patients undergoing surgery for OSA at a tertiary sleep surgery center. Preoperative and 1, 3, and 6-month postoperative time points were assessed. Patients were subdivided into two groups based on the degree of upper airway reconstruction performed. All patients underwent uvulopalatopharyngoplasty +/-tonsillectomy and tongue-base reduction. Patients undergoing Phase 1 reconstructive surgery additionally underwent tongue-base advancement procedures.

RESULTS

A total 100 patients underwent airway reconstructive surgery. Forty-one patients underwent Phase 1 surgery; 59 patients underwent Mini-Phase 1 surgery. Neither group demonstrated preoperative dysphagia. Both groups experienced significant subjective dysphagia at 1-month postoperatively, which was greater among Phase 1 patients (mean EAT-10 14.8; SD 10.4) versus Mini-Phase 1 patients (mean EAT-10 6.7; SD 7.5) (p < 0.001). Swallowing function among both groups normalized by 3 and 6 months postoperatively. Phase 1 patients with pre-operative dysphagia (mean EAT-10 9.6; SD 5) demonstrated initial worsening of their swallowing postoperatively; however, reported improved swallowing versus pre-operative levels by 6 months postoperatively (mean EAT-10 3.6; SD 4.3) (p = 0.03).

CONCLUSION

Pharyngeal surgery resulted in no significant, persistent adverse change in swallowing function. Among both groups, significant subjective dysphagia was reported at 1 month postoperatively, yet returned to preoperative levels by 6 months postoperatively. OSA patients with pre-existing dysphagia undergoing Phase 1 surgery trended towards improved swallowing function postoperatively.

LEVEL OF EVIDENCE

2 Laryngoscope, 133:199-204, 2023.

Fiberoptic endoscopic evaluation of swallowing and the Brazilian version of the Eating Assessment Tool-10 in resistant hypertensive patients with obstructive sleep apnea

OBJECTIVE

The aim of this study was to describe the prevalence and characteristics of OD through Fiberoptic Endoscopic Evaluation of Swallowing (FEES) and the Eating Assessment Tool-10 (EAT-10) in hypertensive patients with OSA, as well as to describe the sensitivity of EAT-10 for the detection of OD in this population.

METHODS

This study included a convenience sample in which 85 resistant hypertensive patients diagnosed with OSA in an university hospital participated. Participants were subjected to the EAT-10 (index test) and FEES (reference standard).

RESULTS

The median EAT-10 score was 2 (0-5.5). According to the FEES, 27 participants did not have dysphagia, 42 had mild dysphagia and 16 had mild to moderate dysphagia. The sensitivity of the EAT-10 was 70.7% (95% CI: 57.3-81.9) at a cutoff score ≥1, with a discriminatory power of 67.4% (p = 0.005). The most prevalent symptom in this population was "food stuck in the throat", while the most prevalent signs were delayed initiation of the pharyngeal phase of swallowing, premature bolus spillage and pharyngeal residue.

CONCLUSION

In our study, the cutoff score for the EAT-10 for screening for OD in this population was ≥ 1. In conclusion, this population presented a high prevalence of dysphagia detected in FEES and its severity is associated with higher EAT-10 scores.

Swallowing biomechanics pre-multi-level and post-multi-level upper airway surgery for obstructive sleep apnea

STUDY OBJECTIVES

The effect of contemporary multi-level upper airway surgery for obstructive sleep apnea (OSA) on swallowing is unclear. This study assessed the biomechanical swallowing function in participants with OSA pre- and post-modified uvulopalatopharyngoplasty and coblation channeling of the tongue (mUPPP+CCT).

METHODS

In this prospective, longitudinal study adults diagnosed with moderate-severe OSA who underwent mUPPP+CCT surgery had swallowing biomechanics assessed using high-resolution pharyngeal manometry (HRPM) and analyzed with swallowgateway.com. Symptomatic swallowing difficulty was evaluated using the Sydney Swallow Questionnaire (SSQ ≥234). General linear mixed model analysis was conducted to evaluate the difference pre- and post-mUPPP+CCT. Data presented as mean [95% confidence intervals].

RESULTS

HRPM assessments were conducted in 10 participants (7 male; median age 50 [IQR 36-65]) pre- and repeated post-operatively at 9 months [IQR 6-13]. Self-reported dysphagia was unchanged following surgery (SSQ 149 [53, 447] to 168 [54, 247]; P =0.093). HRPM outcomes indicated reduced mesopharyngeal pressures (148 [135, 161] to 124 [112, 137] mm Hg.s.cm; P =0.011), reduced hypopharyngeal pressures (113 [101, 125] to 93 [84, 102] mm Hg.s.cm; P =0.011) and reduced upper esophageal sphincter relaxation pressure (5 [4, 6] to 2 [1,3] mm Hg; P =0.001) but no change to velopharyngeal pressures (135 [123, 147] to 137 [117, 157] mm Hg.s.cm; P =0.850) post-surgery.

CONCLUSIONS

mUPPP may have less implications on the swallow mechanism than previously suspected. In contrast, the reduction in mesopharyngeal contractile pressures associated with CCT, although within normal limits, may effect bolus propulsion. Biomechanical alterations were insufficient to worsen self-reported swallowing function.

Palatopharyngoplasty and Palatal Anatomy and Phenotypes for Treatment of Sleep Apnea in the Twenty-first Century

Successful palatopharyngoplasty is critical for successful sleep apnea surgery. Traditional uvulopalatopharyngoplasty was primarily excisional, whereas newer techniques, such as expansion sphincterpharyngoplasty, are more reconstructive. Studies of flow dynamics even demonstrate that the effectiveness of maxillofacial surgery is significantly mediated through stiffening and enlargement of the lateral retropalatal and pharyngeal airway. The current modified technique of uvulopalatopharyngoplasty/expansion sphincteroplasty aims to maximize relocation and tension on the palatopharyngeus muscle, opening the retropalatal airway and the palatal genu, and minimizing tension on the final mucosal closure.

Long-Term Subjective Outcomes of Barbed Reposition Pharyngoplasty for Obstructive Sleep Apnea Syndrome Treatment

Background: The purpose of this study was to evaluate long-term subjective outcomes of barbed reposition pharyngoplasty for obstructive sleep apnea syndrome (OSAS) treatment using a specific questionnaire, the Palate Postoperative Problem Score (PPOPS). Methods: 140 patients who underwent barbed reposition pharyngoplasty (BRP) surgery in the Morgagni Pierantoni Hospital of Forlì, Italy were enrolled in the study. Postoperative outcomes were evaluated in a short- and long-term follow-up using the PPOPS questionnaire. The average period of follow-up was 26 months. All patients received the PPOPS questionnaire by telephone in a period between April and August 2019. Results: 51% of patients complained of swallowing problems after surgery. In 91% of cases, the problem cleared up spontaneously. At the time of the interview, only 9% of patients had a residual swallowing difficult. At the time of PPOPS evaluation, rhinolalia was observed in 8% of patients, whereas nose regurgitation was present in 2% of patients. In 20% of patients, the foreign body sensation was present during follow-up. The value of apnea–hypopnea index (AHI) reduced from the preoperative value of 31.5 to the postoperative value of 11.4. Conclusions: BRP surgery proved to be an effective technique, appreciated by the majority of patients. Use of the PPOPS questionnaire has demonstrated that the BRP technique seems to ensure efficacy and lower morbidity, with few complications after surgery.

Obstructive sleep apnea syndrome (OSAS) and swallowing function-a systematic review

OBJECTIVES

The purpose of this systematic review was to summarize and qualitatively analyze published evidence elucidating the prevalence of dysphagia and detail alterations in swallowing function in patients with OSAS.

METHODS

Computerized literature searches were performed from four search engines. The studies were selected based on the inclusion and exclusion criteria. The studies were screened using Covidence (Cochrane tool) and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards (PRISMA-2009). A total 2645 studies were initially retrieved, of which a total of 17 studies met inclusion criteria. Two reviewers, blinded to each other, evaluated level and strength of evidence using the Oxford Centre for Evidence-based Medicine Levels of Evidence and QualSyst, respectively.

RESULTS

Dysphagia prevalence ranged from 16 to 78% among the eligible studies. Studies varied in operational definitions defining swallowing dysfunction (dysphagia) and method used to assess swallowing function. Approximately 70% of eligible studies demonstrated strong methodological quality. The majority of studies (n = 11; 65%) reported pharyngeal swallowing impairments in patients with OSAS, including delayed initiation of pharyngeal swallow and penetration/aspiration.

CONCLUSION

This systematic review describes swallowing function in patients with OSAS. However, due to the variability in defining OSAS and dysphagia, in the assessment method used to determine dysphagia, and heterogeneity of study designs, true prevalence is difficult to determine. Clinicians involved in the management of OSAS patients should employ validated assessment measures to determine if swallow dysfunction is present.

The Impact of Upper Airway Stimulation on Swallowing Function

OBJECTIVE

To evaluate the impact of upper airway stimulation therapy (UAS) on swallowing function in patients with obstructive sleep apnea.

STUDY DESIGN

Prospective cohort study.

SETTING

Academic medical center.

PARTICIPANTS AND OUTCOME MEASURES

We recorded demographic, preoperative polysomnogram (PSG), operative, and postoperative PSG data. We assessed the patients swallowing function using the Eating Assessment Tool (EAT-10) dysphagia questionnaire. This was administered both pre- and postoperatively. The postoperative EAT-10 survey was administered at least 3 months after UAS implantation.

RESULTS

During the study period, 27 patients underwent UAS implantation, completed the pre- and postoperative EAT-10 questionnaire, met inclusion/exclusion criteria, and were included in the study. The cohort consisted of 16 men and 11 women with a mean age of 63.63 years. The mean preoperative BMI, Epworth Sleepiness Scale (ESS), and Apnea Hypopnea Index (AHI) were 29.37, 10.33, and 34.90, respectively. The mean postoperative ESS and AHI were 5.25 and 7.59, respectively. These were both significantly lower than the preoperative values (P = .026 and P < .001). The mean pre- and postoperative EAT-10 scores were 0.37 and 0.22, respectively (P = .461).

CONCLUSION

Our data suggest that UAS likely does not lead to postoperative dysphagia.