Complications and side effects after barbed pharyngoplasty: a systematic review

Barbed tonsillectomy

PURPOSE

Although tonsillectomy is a common otolaryngological procedure renowned for its ease and safety, it is associated with various complications such as hemorrhage, dysphagia, pain, and infection. Post-tonsillectomy bleeding, especially secondary bleeding, poses a significant risk, with mortality rates reported as 5% of cases. Various techniques have been proposed to mitigate these risks, including the closure of the tonsillar fossa to prevent hemorrhage. Suturing of tonsil pillars has been suggested to enhance healing by reducing exposed surfaces. However, complications such as arterial injury and infection have been reported. This study aimed to investigate the efficacy of barbed sutures for reducing post-tonsillectomy complications compared to standard techniques.

METHODS

This prospective case-control study included 25 patients to receive a tonsillectomy with silk sutures (n = 11) or a tonsillectomy with barbed sutures (n = 14). Patients underwent either Barbed Tonsillectomy (BT) or standard tonsillectomy with external silk sutures. Pain scores were assessed using a visual analogue scale (VAS), while oropharyngeal dysphagia was evaluated using the Eating Assessment Tool (EAT-10) at two weeks and one month post-operation.

RESULTS

BT showed significantly lower postoperative pain scores than standard tonsillectomy at 24 hours (VAS: 2.9 vs. 7.0) and after two weeks (VAS: 0.1 vs. 3.4). Similarly, BT demonstrated lower EAT-10 scores at two weeks (0.6 vs. 8.2) and one month (0.9 vs. 5.3), thus indicating reduced dysphagia. Only one patient in the control group required surgical revision due to bleeding, and none in the BT group. Comparison of all variables showed always a statistically significant (p<0.05).

CONCLUSIONS

This study showed that barbed sutures in tonsillectomy may be a safe technique with reduced complications and a faster recovery. Initial findings regarding hemorrhage, pain management, and recovery outcomes are highly promising, warranting further investigation with larger sample sizes to endorse these results.

International expert consensus statement: surgical failure in obstructive sleep apnea

PURPOSE

Upper airway (UA) surgery is commonly employed in the treatment of patients with obstructive sleep apnea (OSA). The intricate pathophysiology of OSA, variability in sites and patterns of UA collapse, and the interaction between anatomical and non-anatomical factors in individual patients may contribute to possible surgical failures. This clinical consensus statement aims to identify areas of agreement among a development group comprising international experts in OSA surgery, regarding the appropriate definition, predictive factors in patients, and management of surgical failure in OSA treatment.

METHODS

A clinical consensus statement (CCS) was developed using the Delphi method by a panel of 35 contributors from various countries. A systematic literature review adhering to PRISMA guidelines was conducted. A survey consisting of 60 statements was then formulated and presented to the experts.

RESULTS

Following two rounds of the Delphi process, consensus or strong consensus was achieved on 36 items, while 24 items remained without consensus. Specifically, 5 out of 10 statements reached consensus regarding on the 'Definition of Surgical Success/Failure after OSA Surgery'. Regarding the 'Predictive Factors of Surgical Failure in OSA Surgery', consensus was reached on 10 out of 13 statements. In the context of the 'Diagnostic Workup in OSA Surgery', consensus was achieved on 9 out of 13 statements. Lastly, in 'Treatment in Surgical Failure Cases', consensus was reached on 12 out of 24 statements.

CONCLUSION

The management of OSA after surgical failure presents a significant clinical challenge for sleep specialists. This CCS provides valuable guidance for defining, preventing, and addressing surgical failures in the treatment of OSA syndrome.

Consensus Statements among European Sleep Surgery Experts on Snoring and Obstructive Sleep Apnea: Part 3 Palatal Surgery, Outcomes and Follow-Up, Complications, and Post-Operative Management

Background/Objectives: Exploring and establishing a consensus on palatal surgery, the outcomes and follow-up after the palatal surgery, the complications of palatal surgery, and the post-operative management after palatal surgery for snoring and obstructive sleep apnea (OSA) among sleep surgeons is critical in the surgical management of patients with such conditions. Methods: Using the Delphi method, a set of statements was developed based on the literature and circulated among a panel of eight European experts. Responses included agreeing and disagreeing with each statement, and the comments were used to assess the level of consensus and to develop a revised version. The new version with the level of consensus and anonymized comments was sent to each panel member as the second round. This was repeated over a total of five rounds. Results: The final set included a total of 111 statements, 27 of which were stand-alone questions and 21 of which contained 84 sub-statements. Of the 34 statements regarding palatal surgery, consensus was achieved among all eight, seven, and six panelists for 50%, 35.3%, and 5.9% of the questions, respectively. Of the 43 statements regarding the outcomes and follow-up after the palatal surgery, consensus was achieved among all eight, seven, and six panelists for 53.5%, 23.3%, and 4.7% of the questions, respectively. Of the 24 statements regarding complications after the palatal surgery, consensus was achieved among all eight, seven, and six panelists for 91.7%, 0%, and 4.2% of the questions, respectively. Of the 10 statements regarding post-operative management after palatal surgery, consensus was achieved among all eight, seven, and six panelists for 10%, 30%, and 30% of the papers, respectively. Conclusions: This consensus provides an overview of the work of European sleep surgeons to develop a set of statements on palatal surgery for the treatment of snoring and OSA, the outcomes and follow-up, the complications, and the post-operative management of palatal surgery. We believe that this will be helpful in everyday practice. It also indicates key areas for further studies in sleep surgery.

Barbed Repositioning Pharyngoplasty: Tips and Tricks

The barbed repositioning pharyngoplasty surgical technique is becoming more widely used for patients with obstructive sleep apnea due to its safety, effectiveness, and rapidity, as evidenced by multicenter studies and Meta-analyses. In order to achieve uniform surgical outcomes, avoid errors that could worsen outcomes, and enable adequate data comparison, a standardized procedure is required to overcome surgeon-related variability. The aim of this paper is to provide practical tips and tricks based on our surgical practice that can make the surgeon's work easier and aid in achieving desired outcomes.

Reasonable Risk Ratio of Palate Surgery: A New Critical Analysis

OBJECTIVE.

A new critical complication risk analysis, the reasonable risk ratio (RRR or R3) for palate surgeries in obstructive sleep apnea patients.

METHODS.

Analysis from published meta-analyses, systematic reviews on success rates, and complications encountered for 3 palate surgeries, expansion sphincter pharyngoplasty (ESP), barbed repositioning pharyngoplasty (BRP) and modified uvulopalatopharyngoplasty (mUPPP), over 20 years. The RRR is derived from a ratio of the percentage of each respective complication over the success rate of that particular surgical procedure. The benchmark RRR of tonsillectomy is set at 0.035 to 0.078. An RRR below this benchmark value is more favorable as tonsillectomy is a widely accepted ENT procedure with risks to benefit well accepted.

RESULTS.

The RRR for foreign body (FB) sensation (BRP) ranged from 0.03 to 0.23 (mean RRR of 0.14), FB sensation (ESP) 0.01, FB sensation (mUPPP) ranged from 0.33 to 0.55 (mean RRR of 0.44). The RRR for swallowing difficulties (BRP) ranged from 0.04 to 0.23 (mean RRR of 0.11), mUPPP, was 0.37; no reported swallowing difficulties with the ESP. The RRR for velopharyngeal insufficiency (VPI) (BRP) ranged from 0.009 to 0.18 (mean RRR of 0.07), and RRR VPI (mUPPP) was 0.14. The RRR (BRP) for dry throat was 0.06 and the mUPPP was 0.35, with no reported VPI or dry throat for ESP. The overall RRR for the BRP was 0.09, ESP was 0.01 and mUPPP was 0.29.

CONCLUSION.

RRR provides a summarized data-driven, statistical guide to aid decision-making, and helps in patient counseling. BRP and ESP have been shown to have less complications compared to mUPPP.Level of evidence: IV.

Barbed palatal surgery: single stage or multilevel setting-a systematic review by the Young Otolaryngologists of the Italian Society of Otolaryngology

PURPOSE

This systematic review aims to compare the efficacy and safety of multilevel and single level surgery, including barbed pharyngoplasties, in the treatment of obstructive sleep apnea (OSA).

METHODS

The study followed PRISMA guidelines and searched PubMed/MEDLINE, Google Scholar, and Ovid databases for studies evaluating the effect of barbed pharyngoplasties on adults with OSA. Prospective and retrospective cohort studies were included with pre- and post-treatment comparisons of sleep tests and self-reported clinical outcomes. Exclusion criteria were non-English studies, case reports, reviews, conference abstracts, letters, and pediatric studies. Successful surgery was classified using Sher's criteria.

RESULTS

The study selected a total of 1014 patients from 26 studies, 24 of which were longitudinal studies with 10 retrospective trials and 14 prospective studies. The average age of the patients was 46.9 years, with an average Body Mass Index (BMI) of 25.6 kg/m2. Most of the patients were male (84.6%). The study included only palatal surgical techniques with barbed sutures, and patients who underwent cardio-respiratory monitoring and Drug Induced Sleep Endoscopy (DISE) before surgery. Mean Apnea Hypopnea Index (AHI) preoperative was 32.9/h, AHI postoperative was 11.9/h, and mean reduction of AHI was 62.3%. The most commonly adopted palatoplasty was Barbed Repositioning Pharyngoplasty (BRP) in 16 out of 26 studies, followed by its subsequent modifications in 3 studies.

CONCLUSIONS

Barbed pharyngoplasties appear to be effective both on objective measurement and subjective scores. DISE represents a fundamental tool to assess uni-level or multilevel obstruction. When retro-palatal collapse is present, barbed pharyngoplasty appears to be effective. Barbed pharyngoplasties maintain their good results both in single level or multilevel surgery. Randomized clinical controlled trials with multi-center cooperation and long-term study are necessary.