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Original Investigation |

Modified Expansion Sphincter Pharyngoplasty for Treatment of Children With Obstructive Sleep Apnea

Seckin O. Ulualp, MD1,2
[+] Author Affiliations
1Department of Otolaryngology–Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas
2Division of Pediatric Otolaryngology, Children’s Medical Center, Dallas, Texas
JAMA Otolaryngol Head Neck Surg. 2014;140(9):817-822. doi:10.1001/jamaoto.2014.1329.
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Importance  Lateral pharyngeal wall collapse has been implicated in the pathogenesis of obstructive sleep apnea (OSA). Modified expansion sphincter pharyngoplasty (ESP) is a simple procedure and can be considered in the surgical management of children with severe OSA.

Objective  To describe a modified ESP addressing lateral pharyngeal muscle wall collapse in the treatment of children with OSA.

Design, Setting, and Participants  Retrospective review of the medical records of children with OSA and lateral pharyngeal muscle wall collapse who underwent modified ESP and children who had tonsillectomy and adenoidectomy (TA) for OSA between 2008 and 2013 at a tertiary care children’s hospital.

Interventions  Modified ESP.

Main Outcomes and Measures  The primary outcome measure was the rate of cure, which was defined as an apnea-hypopnea index (AHI) lower than 1. Other outcomes were differences in preoperative and postoperative AHI, minimum saturation of peripheral oxygen, and percentage of total sleep study time with oxygen saturation less than 90%.

Results  Twenty-five children who had modified ESP and 25 AHI-matched children who had TA for severe OSA were identified. The postoperative AHI was lower than the preoperative AHI in both groups. Preoperative AHI was similar between modified ESP and TA groups. The mean (SD) postoperative AHI of the modified ESP group (2.4 [3.9]) was lower than that of the TA group (6.2 [6.0]) (P < .001). Cure rates for the modified ESP group (AHI <1, 64%; AHI <2, 72%; and AHI <5, 80%) were greater than those for the TA group (AHI <1, 8%; AHI <2, 44%; and AHI <5, 60%).

Conclusions and Relevance  Modified ESP provided objective clinical improvement of OSA in children with severe OSA and lateral pharyngeal wall collapse and might serve as an effective alternative to TA for treatment of OSA.

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Figure 1.
The Main Steps of the Modified Expansion Sphincter Pharyngoplasty (ESP)

After completion of a tonsillectomy (A), a horizontal incision is made to divide the anterior fascicules of the palatopharyngeus muscle (B), and the superficial fibers of the palatopharyngeus muscle are isolated. C, A blunt palate tunneling extending superolaterally from the arching fibers of the palatoglossus muscle into soft palate is created. D, Then the isolated portion of palatopharyngeus muscle is attached to the arching fibers of the soft palate. Comparative views before modified ESP (A) and after modified ESP (E) show the created tension in lateral pharyngeal walls and the increased distance between the lateral pharyngeal walls.

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Figure 2.
Comparison of the Cure Rates of Modified Expansion Sphincter Pharyngoplasty (ESP) and Tonsillectomy and Adenoidectomy (TA) Groups

The cure rates, as defined by 4 of the 5 illustrated apnea-hypopnea index (AHI) criteria, were significantly greater in the modified ESP group than in the TA group. The cure rates as defined by 50% reduction in AHI and AHI lower than 20 were similar between the modified ESP and TA groups.

aP < .05 for comparison.

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