AAO-HNSF Primary Care Otolaryngology Handbook

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CHAPTER 1

while patients with small tonsils and a high modified Mallampati score (high-positioned tongue base) are unlikely to respond to a tonsillectomy alone. For patients with significant palate (velum)-level collapse or redundant palatal tissue, uvulopalatopharyngoplasty (UPPP) has traditionally been used to modify the upper airway in conjunction with tonsillectomy. The overall success of a traditional UPPP is estimated to be about 40–50 percent, which has prompted efforts to better predict which patients would benefit from this procedure. Similar to tonsillectomy, patients with large tonsils and a low tongue base have a much higher predicted rate of success with this surgery (80 percent) than those with small tonsils and a high tongue base (8 percent). More recent and effective modifications of the UPPP have evolved with a focus on tissue reposition. They include expansion sphincter pharyngo- plasty, transpalatal advancement pharyngoplasty, and lateral pharyngo- plasty. Complications of UPPP surgery can include bleeding, loss of taste, temporary or permanent velopharyngeal insufficiency, and a chronic globus sensation. Modifications to the base of tongue or oral tongue have been described for the treatment of OSA. These generally involve either a reduction in the volume of tongue tissue or repositioning of the tongue itself. A common method of tongue base reduction includes the technique of lingual tonsil- lectomy with other variations of tongue reduction described in the surgical literature. Tongue base suspension or repositioning of upper airway structures can be accomplished through such procedures as hyoid suspension, genioglossus advancement, and maxillomandibular advance- ment. These surgeries can have varying degrees of success and are many times performed in combination with other upper airway procedures to achieve enhanced results. Hypoglossal Nerve Stimulation A major paradigm shift in sleep surgery occurred in 2014, when the U.S. Food and Drug Administration approved the first upper airway stimula- tion system for widespread use in the United States (Inspire©). The concept of the therapy is that selective stimulation of the genioglossus muscle and other protrusor muscles of the tongue during sleep will prevent dynamic collapse of the upper airway in selected patients. The primary criteria for determining if patients are candidates for upper airway stimulation follow:

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Primary Care Otolaryngology