EXPANSION SPHINCTER PHARYNGOPLASTY (ESP) PLUS ANTERIOR PHARYNGOPLASTY (AP) IN THE TREATMENT OF OSAHS

Retropalatal airway segment is the main contributor to airway obstruction in sleep apnea. Direct visualization of the pharynx during drug-induced sleep and pathophysiological studies emphasized the role of the lateral pharyngeal wall collapse in the origin of obstructive events. Based on these findings, new surgical techniques which create adequate lateral pharyngeal wall tension to prevent its collapse have been proposed. The expansion sphincter pharyngoplasty (ESP), consists in creating a palatopharyngeus muscular flap and its superolaterally rotation, aimed to stenting lateral pharyngeal wall and increasing retropalatal airway space; the procedure allows to achieve better functional outcome than UPPP on pharyngeal collapsibility without pharyngeal discomfort and swallowing disturbance. The reported success rate in appropriately (video sleep endoscopy) selected patients is 80%. Many patients selected for ESP who present a remarkable redundancy of the soft palate or a narrowing in the upper retropalatal segment, require an additional surgical procedure in order to remove the bulky palatal tissue and stiffen the proximal soft palate. The Anterior Pharyngoplasty, a modified CAPSO (Cautery Assisted Palatal Stiffening Operation)technique used for snoring and mild OSAS treatment and based on removal of a mucosal rectangle of the anterior surface of the soft palate and subsequent suture of the margins with sparing of the underlying muscular plain, allows to obtain this aim avoiding retracting scars with abnormal persistent narrowing at the level of the palate arch as observed in many patient treated with a classic or modified UPPP. Moreover this technique is able to amplify the functional effect of the ESP without additional morbidity. The authors propose a surgical technique that combines the ESP plus AP in patients with OSAHS due to lateral pharyngeal wall collapse and proximal retropalatal narrowing. The video shows the surgical steps and the functional and anatomical outcome of the ESP plus AP in a patient with severe OSAHS caused by retropalatal obstruction.