gms | German Medical Science

Adult form of supraglottic obstruction (SGO) is a largely unknown and scarcely described airway disease [1]. Still it seems to be not quite uncommon in apnea patients. In our series of 2416 consecutive, videodocumented somnoscopies, we found about 35% incidence of SGO [2]. What is SGO? We see 3 different obstruction types. Our classification of obstruction level comprises Level I: Base of tongue (hyoid based pharyngeal obstruction or "retracted hyoid"), Level II: Epiglottis (e.g. large, flat,omega shaped,"floppy") and Level III: Arytenoid region (hyperplasia of arytenoid mucosa, arymucosal aspiration phenomenon) [1], [2]. Level I and II are anterior, and Level III posterior supraglottic obstructions. In our experience Level I plays a major role not only in OSA, but also in dysphagia, globus sensation, intubation problems (Cormack/Lehane III/IV) and unability to expose larynx via straight endoscopy (Microlaryngoscopy). Level I and II SGO may predispose for a condition, we named "supine position based apnea (asphyxia)" (SPBA), meaning unability to ly in supine position and breath normally, especially in deep sleep. SBPA can be present at 2 distinct anatomic levels: Level I – base of tongue, Level II – epiglottis and in severe cases even be combined. Obstructions at Levels II and III may be regarded as "adult acquired Laryngomalacia" (AAL)[1]. These anatomic varieties are not rare and could be detected in about one third of our series of suspected apnea patients. In our recent evaluation of 2416 videodocumented somnoscopies in suspected apnea patients we counted 30% incidence of Level I and II , and 4–5% of Level III SGO [1], [2]. Still these conditions are almost undetectable in medical literature, and if, mostly in newborns [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22].

We refer to SBPA level I as "hyoid based pharyngeal stenosis/obstruction" (HBPS) and level II as adult form of laryngomalacia, in typical case caused by overly large, overhanging and/or "floppy epiglottis". In the ideal setting both conditions can be treated by N-CPAP ventilation, while unfortunately Level I and especially Level II obstructions with deflected epiglottis are in our series a major cause for N-CPAP non-compliance or intolerance [1], [2]. Regarding this group of non compliant patients, a differential indication, regarding obstruction level and morbidity, had to be implemented. We found, a resection of hyoid corpus and pre-epiglottic adipose tissue, followed by a "dead space suture" (Hyoidpharyngoplasty-HPP) to be very help-full in Level I obstructions, i.e. resolving compliance problems and enabling tolerance to N-CPAP ventilation [1], [2]. In Level II obstruction a Laser partial resection of epiglottis (LEPR) proved to be effective. In patients having both conditions, as well HPP as laser assisted epiglottis partial resection , had to be performed. We named this 2 stage procedure, with a time interval of at least 6–8 weeks, supraglottoplasty (SGP). Usually LEPR was performed first and HPP was second stage. In cases, where not even the epiglottis could be exposed by straight microlaryngoscopy ,resection of hyoid corpus (HPP) had to be performed first. In some of these cases the narrowness of pharyngeal lumen would actually mask the "floppy" condition of epiglottis, since it would somehow "lean" against the posterior pharyngeal wall and thus not show the full amount of laxity it indeed already had. In this case a one stage supraglottoplasty, HPP and LEPR in one session, had to be carried out. By Oct 2011 we had performed LEPR N=149, HPP N=117 and SGP N=12, 1 of which as one stage procedure, presented here. 2 other one stage SGP had been performed after deadline of this publication and will be reported later.

A 23 years old male with a BMI of 28,6 and midgrade adenotonsillar hyperplasia suffering from OSA with AHI 35/h and average SA-O2 of 94%, minimal SA-O2 72%, was operated for SGO Level I, base of tongue. We performed HPP since epiglottis appeared to be stabile. During routinely performed post op somnoscopy at end of surgical procedure, a floppy epiglottis, with severe deflection and aspiration phenomenon of epiglottis was noted. We decided to perform additional LEPR, for supraglottoplasty in one stage procedure. Extubation and post op course was uneventful and without major problems. Mild dysphagia was the only post op complication and major improvement of airway patency noted already in recovery room immediately after surgical procedure. Further post op course was smooth without major complaints and patient could be released from inpatient treatment after 3 days. 8 weeks post op, persisting adenotonsilar hyperplasia, but otherwise normally configured airway could be documented in somnoscopic evaluation. Sleep study showed improvement of AHI from 35/h to 7/h, average SA-O2 94% to 97% and minimal SA-O2 of 72% versus 80% post op. Patient experienced normalisation of sleep quality and QOL parameters.

As well HPP, as SGP proved to be safe procedures. In 110 out of 117 cases of HPP and all SGP cases we noted an instant improvement of airway patency, accompanied by only mild to moderate dysphagia from 5 days to 4 weeks post op, except N=3 up to 6 weeks [2]. Tube feeding wasn't needed at any time of post op course. In 3 out of 117 HPP cases, we had to perform SGP (additional LEPR) in a time interval of less than one week, because of developping airway problems on Level II. In presented case epiglottal collapse was so massive, that LEPR had to carried out in same surgical session (1 stage SGP). In 2 other cases instability of epiglottis had not been evident in routinely – immediately post op (during extubation) – executed somnoscopy. These cases of delayed second procedure (executed on day 3 and 5 post op) proved to be difficult to handle. Especially inserting and positioning straight endoscope (Weerda's spreading laryngoscope) was impaired. Both cases could be resolved successfully without tracheostomy and tube feeding, showing good airway patency after completion SGP. Both individuals had extremely narrow, retracted mandible, hindering exposition of larynx. We recommend to try to perform LEPR first, if ever possible. Patients with small chin and prognathia should be considered risk cases for HPP and straight endoscopic exposition of larynx be verified before attempting surgery. If epiglottis could not be exposed and therefore HPP needed to be carried out first, a critical reevaluation of surgical indication should be considered. If still indicated, one stage SGP seems to be the better choice.