The aim of this study was to analyze both short-term and long-term results of the expansion sphincter pharyngoplasty surgery, which is commonly used in obstructive sleep apnea syndrome (OSAS) and to compare it with objective and subjective methods.
Patients who underwent expansion sphincter pharyngoplasty were included in the study. Polysomnography at postoperative sixth-month, Epworth Sleepiness Scale, and visual analog score of snoring (VAS) were used to assess short-term results. Epworth Sleepiness Scale (ESS) and visual analog score of snoring (VAS) at postoperative third-year were used for long-term results. Sixth-month and third-year data before and after the surgery were compared. Possible complications and morbidity rates related to surgery were evaluated.
Of 39 patients, OSAS was assessed as mild in 16 (41%), moderate in 14 (36%), and severe in 9 (23%). Mean age of patients was 43.2 ± 7.5, and 21 were men (54%). According to postoperative six-month PSG data, the apnea hypopnea index (AHI) values decreased significantly from 25.2 ± 8.3 to 11.6 ± 6.9/h, p=0.012. There were decreases in ESS from baseline to 6-month and 3-years from 10.4, to 4.4, and 4.4, and VAS scores changed from 8.6 to 1.6 and 1.9, p<0.05. No serious complications were observed in patients in the early and late postoperative period.
The expansion sphincter pharyngoplasty procedure is an important option for OSAS surgery with long-term effective results and low morbidity and complication rates.
Snoring, which disrupts the quality of life and sleep of individuals, is considered a social problem that can can cause isolation between spouses and even between individuals and society. Because of the structural features of the soft palate, uvula, tongue root, epiglottis, and pharyngeal walls, which are structures in the mouth and oropharynx, their vibrations during sleep may cause snoring. Snoring is one of the most important indicators of obstructive sleep apnea syndrome (OSAS) . OSAS, one of the most common sleep disorders, manifests with recurrent hypopnea and apnea attacks, which lead to temporary oxygen desaturation. OSAS is a major health problem that affects 35–45% of obese people and ~4% of society . A study in which polysomnography (PSG) was performed for 602 subjects reported that the incidence of respiratory disorders in sleep was 9% in women and 24% in men. Moreover, 82% of men and 93% of women with OSAS in society continue their lives without being diagnosed . Furthermore, OSAS is an additional risk factor in diseases such as arterial hypertension, arrhythmia, stroke, and coronary heart disease.
PSG, the gold standard diagnostic test for diagnosing OSAS, is commonly used today, although it is a very expensive and tedious procedure that requires special equipment and trained personnel . Very different techniques have been described in surgical treatment of OSAS and are frequently applied today. The general purpose of these techniques is to increase the tension of tissues by creating scar tissue in areas that cause vibration during sleep and thereby reduce vibration. The first of these techniques was by Ellis in 1994 . Subsequently, many different techniques were developed, and quite satisfactory results were achieved especially with the expansion sphincter pharyngoplasty (ESP) surgery described by Pang and Woodson . This technique continues to be used quite often today. In this study, the purpose was to evaluate the effectiveness and long-term results of ESP in snoring, daytime drowsiness, and OSAS.
Patients and design
This study was conducted by retrospectively reviewing the files of patients who were diagnosed with OSAS and underwent ESP surgery in the otorhinolaryngology clinic of Aksaray University Research and Training Hospital between January 2012 and April 2020. Patients over the age of 18 who had stage 2 and stage 3 based on Friedman et al.  anatomical staging, as well as those who had a body mass index (BMI) below 35, who underwent ESP surgery, who had postsurgical control PSG (postop month 6) and who were followed at least three years were included in the study. Those who were over the age of 65, for whom other surgical methods were applied, who had collapse at the level of the tongue root, and who had postsurgical surgical follow-up for less than three years were excluded from the study. Physical examination was performed using a flexible endoscope (Olympus ENF, type GP, Hamburg, Germany) following transnasal local anesthesia (4% lidocaine and 0.5% ephedrine spray) to evaluate the upper airways and determine the collapse area before surgery.
PSG was made using the Alice 5 Model PSG device (Philips Respironics, Best, the Netherlands) during spontaneous sleep in our hospital sleep lab. Respiratory stop during sleep for at least 10 s was evaluated as apnea. A decrease of at least 3% in oxygen saturation along with a decrease in respiratory volume by at least 50% and a decrease in chest wall movements and/or arousal was evaluated as hypopnea. The apnea hypopnea index (AHI) was determined by dividing the total number of apnea and hypopnea by dormant time. According to PSG results, simple snoring was categorized as AHI <5/h, mild OSAS as 5/h ≤ AHI <15/h, medium OSAS as 15/h ≤ AHI <30/h, and severe OSAS as AHI ≥30/h.
Those patients who met the criteria (AHI > 20/h) were primarily encouraged to use CPAP. We defined CPAP compliance as using the therapy for an average of 4 hours a night for at least 70% of the nights . Collapse and vibration areas were evaluated to plan surgical treatment in the group of patients who did not tolerate CPAP. Because of this assessment, palatal surgery was performed in patients with retropalatal collapse and superior lateral pharyngeal collapse, and no apparent pathology at the level of the tongue root. Patients with multi-level collapse area and pathology that may require osteotomies and maxillomandibular advancement were not evaluated in this study.
In the surgical technique, the procedure was started by applying Boyle–Davis mouth gag while the patient was in a supine position and under general anesthesia. In patients with tonsils, bilateral tonsillectomy was performed at the initial stage using a unipolar or bipolar cautery. It was important to protect muscle fibers as much as possible at this stage. Subsequently, the palatopharyngeus muscle on both sides was dissected, and a horizontal incision was made from the inferior part. Then, a tunnel was created by blunt dissection to the hamulus pterygoideus from the tonsil upper pole line in the fossa tonsillaris. The palatopharyngeus muscle was passed through this tunnel, which was created by rotating and lifting the free lower end, and fixed to the hamulus using Vicryl 2-0. Consequently, a sufficient level of tension, a preliminary replacement of the soft palate, and a 3D expansion of the retropalatal lumen were achieved. At the last step, the anterior and posterior tonsils were sutured and closed with Vicryl 2-0. Moreover, no routine partial or full uvulectomy was performed; this procedure was performed only in cases with long uvula (>1.5 cm).
Most patients were hospitalized one night and discharged on postoperative day 1. Patients were treated with broad-spectrum antibiotics (amoxicillin–clavulanic acid), suitable analgesic (NSAID, paracetamol, and tramadol), antiseptic mouthwash, and methylprednisolone (32mg/5day, 16mg/5day, and 8 days mg/5 days; a total of 15 days) for 1 week after surgery. The short-term efficacy of ESP was evaluated with PSG, ESS, and VAS performed during the postop month 6. Note that 50% reduction in AHI or AHI<15/h was defined as surgical success . The long-term effects of ESP on quality of life were evaluated by comparing the results of the Epworth Sleepiness Scale (ESS) and visual analog score of snoring (VAS) prior to the surgery and at least three years after the surgery.
The data were analyzed using SPSS for Windows (SPSS Inc., Chicago, IL). The results were given as mean ± standard deviation, median (min–max), and percentage. Moreover, Kolmogorov–Smirnov normality test was used to confirm abnormal data distribution. The chi-square test was used to determine the relationship between groups and categorical variables, and Student’s t test was used to compare the group means of continuous variables. Statistical significance level was accepted as p< 0.05.
Of 51 patients who underwent ESP surgery for OSAS in our clinic, 39 patients who met the inclusion criteria were included in the study. With mean age 43.2±7.5 years, 21 men (54%). Before surgery, 16 patients had mild OSAS (41%), 14 patients had moderate OSAS (36%), and 9 patients had severe OSAS (23%). Preoperative BMI was 28.4 ± 4.5, and AHI was 25.2 ± 8.3/h. Table 1 lists the characteristics of the patients before surgery.
There was no significant difference in BMI values (28.3 ± 3.1) in postoperative controls during the sixth month compared to the preoperative values (p > 0.05). Based on PSG results, in the comparison of min O2 values, the preoperative value was 84.7 ± 4.1, and increasing to 91.5 ± 3.6 at the postoperative month 6, p = 0.021. AHI was 25.2 ± 8.3/h before surgery, and postoperative AHI was 11.6 ± 6.9/h, p = 0.012 (Table 2) (Fig. 1).
The total surgical success rate was 72% based on PSG control results at month 6. This rate was 79% in patients with mild OSAS, 72% in patients with moderate OSAS, and 67% in patients with severe OSAS; there was no statistical difference between the groups in terms of surgical success (p > 0.05).
The total score of >10 in ESS was defined as the presence of excessive daytime drowsiness . Preoperative mean ESS score, which was used to evaluate the long-term results of the ESP surgery, was 10.4, while in postoperative month 6 and year 3, this value decreased to 4.4 and 4.4, respectively. The differences between month 6 (p = 0.013) and year 3 (p = 0.014) scores were statistically significant (Fig. 2).
In terms of VAS of snoring, there was a statistically significant decrease of 81% in postoperative month 6 (p = 0.01) and 78% in year 3 (p = 0.01) compared to presurgical values (Fig. 3).
Based on discussions with the families, snoring completely disappeared in 8% of the spouses, and there was a significant decrease in its severity in 82% at the end of year 3. In 10% of the patients, patients did not benefit in the long term (3rd year) in terms of snoring (Table 3).
When postsurgical complications were examined, one patient had bleeding that did not require surgical intervention, and transient velopharyngeal insufficiency was detected in four patients. Although appropriate analgesic drug therapy was administered, 63% of patients complained of postoperative pain. In the long term, no patients had velopharyngeal insufficiency, three patients complained of taste changes, and two patients complained of excessive mucus production at the end of year 3.
The use of CPAP devices in OSAS is the gold standard treatment. The proper use of CPAP is known to have positive effects on this syndrome; however, studies report that CPAP devices are discontinued within an average of 1 year after prescription . These patients are unable to receive appropriate treatment, and the search for alternative treatment modalities proceeds.
In patients with OSAS, the lateral pharyngeal wall may be thicker and more prone to collapse compared to healthy individuals because of negative pressure in the upper airways . Furthermore, because of lateral pharyngeal collapse, partial or total obstruction in the upper airway occurs, airway resistance is increased, and this contributes to one of the most important anatomical disorders in OSAS . It is reported that this collapse is the most important factor in the mechanism of hypoxia and oxygen desaturation in patients with OSAS . Moreover, it was reported in a study that higher AHI values were reported in patients with lateral pharyngeal collapse compared to patients with anteroposterior upper airway stenosis . Among surgical treatment options for the oropharyngeal region, it is important to use the most effective, long-term treatment with minimal complications. Studies have reported that ESP surgery is significantly superior to uvulopalatoplasty (UPP) in terms of its results and reliability [14, 15].
In another study, Pang and Woodson  examined postoperative six-month PSG control results in the early results of ESP surgery and detected that mean AHI decreased from 44.2 to 12.0 and a decrease of 59% in total AHI. Moreover, they described the decrease in AHI values below 20% and 50% in total as a success criterion and reported a success rate of 82.6% in their studies. In their study in 2018, Karakoc et al. compared ESP, lateral pharyngoplasty, and anterior palatoplasty; moreover, they reported that all three techniques were effective, but they achieved better results with ESP . In another study, the short-term and long-term results of ESP surgery were analyzed. PSG was used in postoperative month 6 for short-term results, and VAS and ESS were used after 1 year for long-term results. In the short period, there was a decrease in AHI values from 44.3 to 17.4. In the long period, there was a 48% decrease in VAS and 86% decrease in snoring severity compared to ESS and a total recovery of snoring by 6% . In our study, short-term results of ESP surgery were evaluated with PSG, which was performed in the postoperative month 6. Unlike the previous study , long-term results were evaluated with ESS and VAS in the third year after surgery. Consistent with the information in the literature, there was a decrease in AHI values from 25.17 to 11.58/h in the short term. In the long term, there was a decrease in daytime drowsiness by 57.5% compared to ESS and a decrease in snoring by 78% according to VAS. Based on these results, it can be concluded that ESP surgery is effective and reliable in short and long terms.
Consistent with the information in the literature [15, 17], our patients had pain complaints similar to tonsillectomy in the early postoperative period despite appropriate analgesic treatment. After the fifth postoperative day, there was a decline in these complaints. Moreover, one patient had bleeding that did not require surgical intervention in the early period, and four patients had transient velopharyngeal insufficiency. ESP can be considered a reliable and well-tolerated technique with low morbidity and complication rates.
A possible limitation of our study is that the results of a single surgical procedure performed in OSAS were included, and there was no comparison with other procedures. Secondly, our high success rate (72%) may be related to a selection bias of this group of patients as most patients were in the mild to moderate OSAS group. Furthermore, performing PSG rather than ESS and VAS only in the evaluation of longer-term results would have provided more valuable information. The lack of drug-induced sleep endoscopy (DISE) information is another limitation of our study.
The findings suggest that ESP may be a reliable and effective therapy for patients with mild to severe OSAS. Because of low morbidity and long-term patient satisfaction, the procedure may be a treatment of choice in patients who cannot tolerate CPAP.
Sowho M, Sgambati F, Guzman M, Schneider H, Schwartz A (2020) Snoring: a source of noise pollution and sleep apnea predictor. Sleep 43(6):zsz305. https://doi.org/10.1093/sleep/zsz305
Tan S, Liu X, Xu Y, Luo L, Zhou S, Gao Y (2017) Serum high-density lipoprotein correlates with serum apolipoprotein M and A5 in obstructive sleep apnea hypopnea syndrome. Sleep Breath 21(1):37–44. https://doi.org/10.1007/s11325-016-1357-5
Young T, Evans L, Finn L, Palta M (1997) Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep 20(9):705–706. https://doi.org/10.1093/sleep/20.9.705
Hizli O, Cayir S, Coluk Y, Kayabasi S, Yildirim G (2020) The novel indicators of moderate to severe sleep apnea: fibrinogen to albumin ratio vs. CRP to albumin ratio. Eur Arch Otorhinolaryngol. https://doi.org/10.1007/s00405-019-05770-5
Ellis PD (1994) Laser palatoplasty for snoring due to palatal flutter: a further report. Clin Otolaryngol Allied Sci 19(4):350–351. https://doi.org/10.1111/j.1365-2273.1994.tb01245.x
Pang KP, Woodson BT (2007) Expansion sphincter pharyngoplasty: a new technique for the treatment of obstructive sleep apnea. Otolaryngol Head Neck Surg 137(1):110–114. https://doi.org/10.1016/j.otohns.2007.03.014
Friedman M, Ibrahim H, Joseph NJ (2004) Staging of obstructive sleep apnea/hypopnea syndrome: a guide to appropriate treatment. Laryngoscope 114(3):454–459. https://doi.org/10.1097/00005537-200403000-00013
Engleman HM, Martin SE, Douglas NJ (1994) Compliance with CPAP therapy in patients with the sleep apnoea/hypopnoea syndrome. Thorax 49(3):263–266
Izci B, Ardic S, Firat H, Sahin A, Altinors M, Karacan I (2008) Reliability and validity studies of the Turkish version of the Epworth Sleepiness Scale. Sleep Breath 12(2):161–168. https://doi.org/10.1007/s11325-007-0145-7
Cayir S, Hizli O, Kayabasi S, Yildirim G (2020) Eustachian tube dysfunction in sleep apnea patients and improvements afforded by continuous positive airway pressure therapy. Braz J Otorhinolaryngol S1808-8694(20):30028–30028. https://doi.org/10.1016/j.bjorl.2020.02.003
Soares D, Sinawe H, Folbe AJ, Yoo G, Badr S, Rowley JA, Lin HS (2012) Lateral oropharyngeal wall and supraglottic airway collapse associated with failure in sleep apnea surgery. Laryngoscope 122(2):473–479. https://doi.org/10.1002/lary.22474
Schellenberg JB, Maislin G, Schwab RJ (2000) Physical findings and the risk for obstructive sleep apnea. The importance of oropharyngeal structures. Am J Respir Crit Care Med 162(2 Pt 1):740–748. https://doi.org/10.1164/ajrccm.162.2.9908123
Genta PR, Sands SA, Butler JP, Loring SH, Katz ES, Demko BG, Kezirian EJ, White DP, Wellman A (2017) Airflow shape is associated with the pharyngeal structure causing OSA. Chest 152(3):537–546. https://doi.org/10.1016/j.chest.2017.06.017
Pang KP, Pang EB, Win MT, Pang KA, Woodson BT (2016) Expansion sphincter pharyngoplasty for the treatment of OSA: a systemic review and meta-analysis. Eur Arch Otorhinolaryngol 273(9):2329–2333. https://doi.org/10.1007/s00405-015-3831-2
Plaza G, Baptista P, O'Connor-Reina C, Bosco G, Pérez-Martín N, Pang KP (2019) Prospective multi-center study on expansion sphincter pharyngoplasty. Acta Otolaryngol 139(2):219–222. https://doi.org/10.1080/00016489.2018.1533992
Karakoc O, Binar M, Aydin U, Genc H, Akcam T, Gerek M (2018) A tertiary center experience with velopharyngeal surgical techniques for treatment of snoring and obstructive sleep apnea. Auris Nasus Larynx 45(3):492–498. https://doi.org/10.1016/j.anl.2017.06.005
Despeghel AS, Mus L, Dick C, Vlaminck S, Kuhweide R, Lerut B, Speleman K, Vinck AS, Vauterin T (2017) Long-term results of a modified expansion sphincter pharyngoplasty for sleep-disordered breathing. Eur Arch Otorhinolaryngol 274(3):1665–1670. https://doi.org/10.1007/s00405-016-4395-5
The Ethic Committee at Faculty of Medicine, Aksaray University approved the study protocol. The reference number of the study approval was REC 2020/06-72. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/ or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Written informed consent was obtained from all participants.
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Cayir, S., Yesildag, K. & Kayabasi, S. Long-term efficacy of expansion sphincter pharyngoplasty in obstructive sleep apnea syndrome. Sleep Breath (2021). https://doi.org/10.1007/s11325-021-02315-1
- Obstructive sleep apnea
- Expansion pharyngoplasty
- Continuous positive airway pressure