TORS as Part of Multilevel Surgery in OSA: The Importance of Careful Patient Selection and Outcomes

The Repeatability of Pharyngeal Opening Pressure Under Drug-Induced Sleep Endoscopy

OBJECTIVE

Pharyngeal opening pressure (PhOP) is a measure of upper airway collapsibility that can be obtained during drug-induced sleep endoscopy (DISE) using a continuous positive airway pressure (CPAP) titration. However, the stability of PhOP over the course of sedation during DISE remains unclear. This study aims to compare repeat measures of PhOP over the course of DISE.

STUDY DESIGN

Single arm prospective study.

SETTING

Single tertiary care institution.

METHODS

Patients had 2 CPAP titrations while undergoing DISE. Collected data included patient demographics, PhOP, patient sedation index (PSI), and duration of and between CPAP titrations. t Tests, test-retest coefficient analysis, and repeated measures correlation were performed.

RESULTS

Twenty-five patients completed the study between 2022 and 2023 with 22 patients having sedation depth (PSI) recording. Most were male (76%), obese (average body mass index: 30.24 kg/m2), with severe obstructive sleep apnea (average apnea-hypopnea index: 39.8 events/hr). Test-retest analysis showed good-excellent correlation between PhOP values (intraclass correlation coefficient = 0.892, P < .0001, n = 25). Average time between CPAP titrations was 15 minutes to 6 seconds. Over that time, PhOP increased by an average of 0.72 cmH2O (P = .06, n = 25) and PSI decreased by 9.5 units (P = .01, n = 22). Repeated measures correlation showed a weak negative correlation between PhOP and PSI (r = -.45, P = .03, n = 22).

CONCLUSION

The results showed repeatability of PhOP values over the course of DISE. When adjusted for sedation depth (PSI), deeper sedation was weakly associated with greater PHOP. However, the magnitude of this change was small and we conclude that PhOP remains relatively stable over the course of DISE (Effects of Lung Volume on Upper Airway Patency During DISE [DISE-Pulm], NCT05350332, clinicaltrials.gov).

Are new and young generations of surgeons more aware of transoral robotic surgery than older ones? An international survey

The objective of this study is to investigate adoption, perception, and awareness of otolaryngologist-head neck surgeons (OTO-HNS) toward transoral robotic surgery (TORS) according to the surgeon experience. A total of 1,383 OTO-HNS of YO-IFOS and IFOS received an online survey dedicated to the adoption, perception, and awareness toward TORS. The following outcomes were compared between residents and fellows, young/middle-aged and older OTO-HNS: awareness/perception; indications; advantages; barriers and expected improvements of TORS practice. From the 357 responders (26%), 147 participants were residents and fellows; while 105 and 105 OTO-HNS reported 10 to 19, and more than 20 years of practice. The main barriers of using TORS included the cost and the availability of robot, and the lack of training opportunity. The better view of the operative field and the shorter patient hospital stay were considered as the main advantages. Older surgeons trust more likely in TORS benefits (p = 0.001) and surgical field view advantages (p = 0.037) compared to younger participants. TORS is an important surgical minimal invasive approach for the future for 46% of residents and fellows versus 61% of older OTO-HNS (p = 0.001). Compared to older OTO-HNS, residents and fellows reported more frequently that the lack of training opportunity is the main barrier of TORS (52% versus 12%; p = 0.001). Residents and fellows did not share the same expectations of robot improvement for the future than older OTO-HNS. Experienced OTO-HNS had better perception and trust toward TORS than residents and fellows. Residents and fellows identified the lack of training opportunity as the main barrier to the use of TORS. TORS access and training programs need to be improved in academic hospitals for residents and fellows.

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.