Complications Of Hypopharyngeal Surgery In The Treatment Of Obstructive Sleep Apnea Hyponea Syndrome

Obstructive sleep apnea hyponea syndrome(OSAHS) is characterized by recurent obstrctions of the upper airway during sleep. OSAHS is a serious disorder that significantly increases morbidity and mortality due to excessive daytime sleepiness or hypersomnolence. Continuous positive airway pressue(CPAP) is the standard treatment of obstructive sleep apnea hyponea syndrome.Surgery for OSAHS is a salvage procedure for those who faied CPAP and other conservative therapies and therefore have no other options.A meta-analysis by Sher et al showed that the overal response rate for OSA(defined as50%decrease in the respiratory disturbance index [RDI] and a postoperative RDI<20or a50%decrease in the apnea index and a postoperative apnea index<10) for all patients treated with suspected type1narrowing alone,the response rate increased to52.3%,but for those with type2and type3patterns,the response rate was only5.3%. OSAHS patients have multilevel disease in eluding retrolingual obstrutions,the appropriate surgical treatment should be multilevel.Barkdull et al suggested that the retrolingual airspace is the major site of obstruction in severe OSA and should be carefully evaluated before surgical treatment is considered.Attempts to treat patients with retrolingual obstrutions have led to the development of an array of procedures addressing the hypopharyngeal airway:genioglossus advancement,radiofrequency of the tongue,hyoid suspion,surgical reduction of the tongue base,tongue base stabilization,and maxillomandibular advancement.These procedures can be performed either alone or in combination.The most common procedures to manage the retrolingual obstrution have been hyoid suspion and radiofrequency of the tongue. The present study is composed of three parts.To investigate the complications of hyoid suspension with Repose System and tongue base reduction with radiofrequency tissue ablation on obstructive sleep apnea hypopnea syndrome and find out the effective prevention strategies,we respectively adopted retrospective study,prospective,observational study and the randomized, double-blinded, placebo controlled design. Part1Complications of hyoid suspension with Repose System on obstructive sleep apnea hypopnea syndromeTo investigate the complications of hyoid suspension with Repose System on obstructive sleep apnea hypopnea syndrome and find out the effective prevention strategies. Forty four OSAHS patients diagnosed by polysomnography were received hyoid suspension with Repose System from June2005to July2009. The intraoperative and postoperative complications were analyzed retrospectively. The patients who reported abnormal subjective swallowing were evaluated with water drinking test and video fluoragraphy swallow study to assess biomechanical changes in swallowing. Results showed that Incidence rate of perioperative titanium nial amotio was15.9%. It was avoided by implanting titanium nial again. No perioperative complications occurred such as injury of superior laryngeal nerve,blood vessel and thyrohyoid menbrane, foracture of hyoid bone, suture break. All the patients occurred dysfunctions of pronunciation and swallowing, edema of mouth floor, dysfunctions of movement of tongue that could relieved gradually after three days on most patients. No postoperative complications occurred such as titanium nial amotio, fat liquoring,edema of mouth floor, hematoma,infection,foreign body reaction, injury of root apex of anterior tooth, dysfunctions of movement and sensation of tongue, suture break, death. All the patients had over2year postoperative follow up. Incidence rate of dysfunctions of pronunciation and swallowing was4.5%and15.9%respectively. Main situation for dysfunctions of pronunciation was speaking ambiguity. Major manifestations of Swallowing abnormalities were occasional aspiration, food going down the wrong tube, food becoming stuck in the throat, deglutions with bowing head. Seven patients who had abnormal subjective swallowing possesed normal water drinking test and occurred asynersis of hyoid movement and laryngeal elevation,but aspiration were not observed. Three patients presenced obvious stagnation in epiglottic vallecula and sinus piriformis.It indicated that most complications of hyoid suspension with Repose System may be avoided or recover on short term.we should pay attention to postoperative dysfunctions of pronunciation and swallowing that exist on long term. Part2Complications of tongue base reduction with radiofrequency tissue ablation on obstructive sleep apnea hypopnea syndromeTo investigate the complications of tongue base reduction with radiofrequency tissue ablation on patients with obstructive sleep apnea hypopnea syndrome and find out the effective prevention strategies.One hundred ninety three OSAHS patients diagnosed by polysomnography were received tongue base reduction with radiofrequency tissue ablation from March2008to December2009. The intraoperative and postoperative complications including bleeding, hematoma of tongue base, abscess of tongue base, altered taste, tongue numbness, deviation of tongue extenison movement, dysfunctions of pronunciation and swallowing as well as the managements were analyzed Retrospectively. Results showed that no perioperative complications occurred. There were186cases of postioperative pain(96.4%),155cases of submandibular edema(80.3%). Nocturnal sudden cardiac death and secondary bleeding was encountered in only1case respectively. There was no case of ulceration of tongue base mucose, hematoma of tongue base, abscess of tongue base, altered taste, tongue numbness, tongue deviations, speech, swallowing,taste after the operation. The scale of postioperative pain claimed by patients was ranged between mild to moderate. Diclofenac suppository has analgesic effect for these patients. The bleeding quantity of the patient with secondary hemorrhage was so few that after proper treatment the bleeding was stopped and never happened again.Case with nocturnal sudden cardiac death occurred at thirty-seven hour after operation, beacouse swelling and pain of tongue base aggravated sleep apnea and night hypoxemia inducing fatal arrhythmia.In conclusion, this study shows that postioperative pain and Submandibular edema were2of the most common postoperative complications which can be easily controlled by antibiotics, Glucocorticoids and Diclofenac suppository. For those server OSAHS patients accompanied by cardiopulmonary diseases, the tongue base reduction with radiofrequency tissue ablation can induce nocturnal sudden cardiac death. It is important to pay more attention on arrhythmias at night and server OSAHS patients. Part3Efficacy and safety of diclofenac sodium suppositories in patients with obstructive sleep apnea hypopnea syndrome undergoing tongue base radiofrequency ablation:randomized double-blind placebo control trialTo evaluate the efficacy and safety of preemptive analgesia with inserting diclofenac sodium suppositories50mg into anus at30minutes before operation for patients with obstructive sleep apnea hypopnea syndrome undergoing tongue base radiofrequency ablation(TBRA).Adopting the randomized, double-blinded,placebo controlled design,38OSAHS patients undergoing TBRA were randomly divided into2groups with19patients in each group:test group received preemptive analgesia with inserting diclofenac sodium suppositories50mg into anus at30minutes before operation, control group received placebo. Postoperative pain was assessed using Visual Analogue Scale (VAS)(0=no pain10=worst pain). The pain was evaluated at0,1,2,4,6and8hours after operation. The adverse reaction of diclofenac sodium suppositories was also observed.VAS score was significantly lower in test group than in control group at1h (t=-2.639, p=0.012) and2h (t=-2.346, p=0.025) after operation, but there was no significantly difference between the two groups at0h,4h,6h and8h after operation. Adverse reaction was not observed in the research. No more diclofenac sodium suppositories were given to analgesia.This study suggested that the dosing regimen of diclofenac sodium suppositories50mg at30min before operation is effective and tolerable for the treatment of TBRA.