Surgery and Site of Upper Airway Collapse

Different methods have been described to determine the site of collapse in the upper airway. These methods can be divided in those attempting to define the site of obstruction during wakefulness, normal sleep, and anesthesia-invoked sleep. Some of the techniques used include cephalometry, fluoroscopy, computed tomo-graphic (CT)- and magnetic resonance (MR)-imaging, acoustic reflection, and nasopharyngoscopy.

Surgical success for uvulopalatopharyngoplasty (UPPP) in OSA is only 5% in patients with an obstruction at the base of the tongue (76). Since most patients present with multiple sites of upper airway obstruction during sleep (77), diagnostic techniques must be developed which can improve surgical outcome. However, this quest is hindered by the fact that upper airway obstruction during sleep is a dynamic process. Varying sites of obstruction have been documented within one individual (78,79).

As mentioned before, no systematic studies of surgical intervention for UARS have been conducted. UARS and upper airway obstruction in general share patho-physiologic mechanisms. Thus, it seems appropriate to hypothesize that similar surgical procedures used in the treatment of PS and OSA may have a positive effect on UARS. Among those specifically, the less intrusive surgical methods seem appropriate candidates, such as turbinectomy, septoplasty, UPPP, laser-assisted uvuloplasty, uvulopalatal-flap (80), radiofrequency-assisted uvulopalatoplasty, radiofrequency ablation of the palate and tongue, and more recently, distraction osteogenesis (81). As in surgical treatment for OSA these procedures may be combined in a stepwise approach, which has been referred to as multilevel surgery to improve surgical outcome (82).

Any surgical procedure should include follow-up polysomnographic investigations as it is required for surgical treatment of OSA (83). If multilevel surgery is performed, polysomnographic investigation should be conducted between each surgical intervention (83).

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