Background: Many patients with obstructive sleep apnea syndrome (OSAS) have multiple obstructive sites simultaneously such as the oropharynx, hypopharynx, and larynx. Multilevel surgery is starting to be widely performed by ENT surgeons and accepted by patients.Methods: Twenty consecutive patients with moderate or severe OSAS were treated with single-stage multilevel surgery. They underwent transoral robotic surgery for tongue base reduction or epiglottoplasty, expansion sphincter pharyngoplasty, and septoplasty. Results:The average length of hospitalization was 5.2 ± 0.9 days. No serious complications were observed. At the postoperative control with polysomnography, the apnea-hypopnea index (AHI) had decreased by at least 50% in 90% of patients;improvements were observed in all sleep parameters. Conclusion:Single-stage multilevel surgery has proven to be effective in treating patients with moderate to severe OSAS, without experiencing persistent complaints.Despite multiple levels of obstruction being operated in a single stage, airway safety was maintained in all patients. K E Y W O R D S expansion sphincter pharyngoplasty, multilevel surgery, OSAS, TORS 1 | INTRODUCTION Obstructive sleep apnea syndrome (OSAS) is characterized by recurring events of partial or complete upper airway collapse during sleep.It is related to increased risk of cardiovascular diseases and causes daytime sleepiness altering the quality of life. To eliminate the collapsing points in the airway, continuous positive airway pressure (CPAP) is the first-choice treatment and the first option that is recommended to the patient. Nevertheless, a significant number of patients refuse CPAP treatment, and in this case, surgical treatment becomes an alternative along with weight loss, orthodontic, and positional therapy.Most OSAS patients have multilevel obstructions at sites including the oropharynx, hypopharynx, and larynx, so the best surgical management must be multilevel. 1
The authors studied the overall microscopical anatomy of the middle ear and of the eustachian tube in 20 tympanic bullae of 10 Wistar rats. Large hexagonal epithelial flat cells covered the roof of the bulla, the two upper thirds of both lateral walls, the upper half of the eustachian tube, and the upper third of the tympanic orifice; ciliated and secretory cells lined the inferior thirds of both walls of the bulla while a ciliated epithelium with strong cilia, all directed towards the tubal orifice, located on the floor of the tympanic cavity together with groups of non-ciliated cells was detectable near the tubal and antral areas and on the floor of the eustachian tube. Non-ciliated cells covered by microvilli were found near the pharyngeal orifice. These observations seem to demonstrate the following: (1) the ciliated elements present a well-defined topographic distribution; (2) a preferential pathway for mucociliary clearance made up of strong ciliated cells located on the floor of the bulla is clearly detectable, and (3) the roof of the bulla seems to be mainly involved in the ventilatory function.
Morphological changes of the middle ear were investigated by means of microotoscopy and scanning electron microscopy in 40 developing Albino rats. In 20 one nostril (group B) and in 20 both nostrils (group C) had been experimentally obstructed. 20 rats were used as controls (group A). Microotoscopy and scanning electron microscopy on the middle ear mucosa were performed when the animals were 2 months old, i.e. at 90% of their development. At microotoscopy the tympanic membranes, homolateral to the obstructed nostril, proved to be abnormal in 81% of group B rats and in almost all rats belonging to group C. Scanning electron microscopy, performed after the bullae had been removed, showed the following epithelial surface changes of the middle ear homolaterally to the obstructed nostril: (a) a significant increase of nonciliated elements with a secretory behavior as compared to controls, even of the floor where normally a large number of ciliated cells is present; (b) several ciliated cells were destroyed and their cilia were irregular and untidy; (c) thick mucous secretions covered the floor of the tympanic bulla; and (d) squamous metaplasia of the hypotympanic epithelium. Extrarotation of the eustachian tubes and developmental abnormalities of the skull base in growing rats, caused by nasal obstruction, seem to be able to induce pathological events of the middle ear.
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