Acute Obstructive Sleep Apnea as a Complication of Sphincter Pharyngoplasty

Abstract

This report describes postoperative airway compromise following sphincter pharyngoplasty (SP) for treatment of post-palatoplasty velopharyngeal dysfunction. A retrospective review of 58 SPs performed for post-palatoplasty velopharyngeal dysfunction, on 30 male, and 28 female patients, over a 5-year study period was undertaken at a tertiary referral academic institution (Washington University School of Medicine), at the St. Louis Children's Hospital, Cleft Palate and Craniofacial Deformities Institute. Eight patients were identified who had the following inclusion criteria: overt perioperative and/or postoperative airway dysfunction, identifiable syndromes, or microretrognathia. Items reviewed were patient demographic factors, associated medical problems, genetics evaluations, nasendoscopic characteristics of velopharyngeal closure, anesthetic evaluation of the patients, and the incidence and severity of perioperative complications. Particular attention was paid to factors contributing to the airway obstruction. Of the eight subjects with perioperative and/or postoperative upper airway dysfunction following SP, five patients had Pierre Robin sequence/micrognathia, while three patients had a history of perinatal respiratory and/or feeding difficulties without micrognathia or an identified genetic disorder. All but two episodes of airway dysfunction resolved within 3 days postoperatively. These patients were discharged home with apnea monitors; both were readmitted with recurrent airway dysfunction. Continuous positive airway pressure (CPAP) was utilized successfully in all instances, and no patients required take-down of the SP to relieve airway dysfunction. CPAP is an effective, noninvasive treatment strategy for management of iatrogenically induced apnea following SP, without sacrificing the surgical benefit of improved speech intelligibility.

72 Velopharyngeal Dysfunction

“…Early reports of acute respiratory compromise and even death following pharyngeal flap surgery have sensitized health care personnel to this complication, but it should be noted that the risk is also present for patients undergoing sphincter pharyngoplasty. 62,63 The etiology for early postoperative obstructive sleep apnea is thought to be a combination of inflammation, edema, reduced airway dimension, and decreased pharyngeal muscle tone. 64 While initial case series reported high rates of postoperative obstructive sleep apnea, recent large series suggest the percentage of patients with obstructive sleep apnea following pharyngeal flap surgery is from 0 to 3%, although the prevalence of respiratory symptoms may be higher.…”

Posterior Pharyngeal Wall Augmentation With Muscular Flap Versus Musculomucosal Flap for Correction of Velopharyngeal Incompetence

“…Of greatest clinical consequence is the potential for the iatrogenic induction of obstructive sleep apnea (OSA) in high-risk patients. 17 This adverse consequence is even more germane to cases requiring velopharyngoplasty revision: when VPI persists despite secondary speech surgery, the standard approach has been to repeat the operation in a more aggressive fashion (i.e., create a larger posterior pharyngeal flap or a tighter sphincter pharyngoplasty. 18 Posterior pharyngeal augmentation could represent an alternative and/or adjunct to traditional speech surgery.…”

Commentary on “Obstructive Sleep Apnea After Dynamic Sphincter Pharyngoplasty”

“…2,5,6 Although frank OSA has also been reported, 2,5 it has not generally been felt to be a common complication of this operation, particularly in comparison with its frequency after pharyngeal flaps. 1Y4 Postoperative airway obstruction of variable severity has been reported after sphincter pharyngoplasty, in some instances requiring CPAP.…”