gms | German Medical Science

Supraglottic obstruction in adults is a largely unknown and scarcely described airway disease. In our experience it plays a major role not only in dysphagia, globus sensation and intubation problems (Cormack/Lehane III/IV), but also in sleep related breathing disorders like OSA, especially in patients, suffering from supine position based apnea(asphyxia) (SPBA). SBPA can be present at 2 distinct anatomic levels: Level I – base of tongue, Level II – supraglottis. This anatomic variety is not rare and could be detected in almost 30% of our series of suspected apnea patients, receiving somnoscopic evaluation (2416 videodocumented cases, [1]). Still this condition is almost undetectable in medical literature. Even supraglottic obstruction is scarcely described and if, mostly in newborns.

We refer to SBPA level I as "hyoid based pharyngeal stenosis/obstruction" and level II as adult form of laryngomalacia, in typical case caused by overly large and/or "floppy epiglottis". In the ideal setting both conditions can be coped for by N-CPAP ventilation, while unfortunately level I and II obstructions are in our series a major cause for N-CPAP non-compliance or intolerance [1]. 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.

Since the year 2004, our primary indications for HPP like – Cormack/Lehane III/IV intubation problems, "retracted hyoid bone", inability of complete exposure of Larynx by straight endoscopy needed for oncologic reasons (e.g. microlaryngoscopic tumor resection), dysphagia caused by pharyngeal stenosis, SBPA, not always (or not yet?) correlated with OSA – have shifted towards surgical induction of N-CPAP tolerance.

This indication had been introduced at our hospital 04/2004: N=96 pat., m=72, f=24, range 24–73 years.

Indications: N-cPAP intolerance N=67, non-compliance (unclear reason) N=29, complications: N=13: persisting globus sensation>4 weeks N=7, dysphagia >4 weeks N=3, seroma N=2, wound infection N=1.

Results: average improvement of Cormack/Lehane index from 3,1 to 2,3 N=54 (n.s.), average improvement of AHI pre/post op: -11,6/h, range 3–42/h, N=88 pat., induction of N-CPAP tolerance N=37 (55%), induction of compliance N=12 (41%). Dysphagia improved N=34 pat., subjective improvement of airway and sleep quality N=76 (86%) of N=88 evaluable patients. Our data suggest an impact rate of procedure of approx. 50% in non tolerant/non compliant N-CPAP patients, but need to be verified in controlled, prospective trials. A subgroup of patients that discontinued N-CPAP for objective improvement of AHI and sleep quality is currently investigated.