Pang ExpansionSphincter PDF

Expansion Sphincter
Pharyngoplasty
&
Functional Expansion
Pharyngoplasty
Kenny P. Pang
ENT Consultant
FRCS(Edinburgh) FRCS(Ireland)(OTO)
Singapore Sleep Surgery Course
Expansion Sphincter
Pharyngoplasty
Pang, Woodson
Expansion Sphincter Pharyngoplasty
Pang, Woodson
Background:
 Orticochea. Construction of a dynamic muscle sphincter
in cleft palates. 1959 (treatment of VPI)
Transposition of the palatopharyngeus on the midline
 Christel et al. Sphincter pharyngoplasty. 2003
(Modified Orticochea procedure)
Transposition of palatopharyngeus higher up, midline.
Closure of lateral defects (Z-plasty suture)
 Effective in VPI treatment, more effective than posterior
pharyngeal wall augmentation, posterior pharyngeal
flaps
Sphincter Pharyngoplasty for VPI
Orticochea 1959
*
Pang, Woodson
 Many OSA patients have thick bulky lateral pharyngeal
walls
 These lateral pharyngeal walls collapse on Mueller’s
maneuver
Objective:
 Stiffen lateral pharyngeal walls
 Prevent lateral pharyngeal wall collapse
 Debulk the lateral pharyngeal wall mass
 Anatomically sound
 Low morbidity
 Minimal complications
Pang, Woodson
Inclusion criteria:
 Obstructive sleep apnea (AHI > 15)
 Fujita I (retropalatal collapse)
 BMI<30, age > 18
 Tonsil size 1 & 2
 Friedman clinical stage II and III
 Friedman Tongue Position 1 to 4
 Muller’s maneuver showing minimal BOT

collapse, mainly retropalatal collapse
Pang, Woodson
Methodology:
 Prospective randomized clinical trial
 45 consecutive patients
 Fulfill inclusion criteria
 Recruited from June 2005 to Jan 2006
 Mean follow up 6.7 months (post-op PSG)
 Using the Wilcox Signs Rank Test for statistical

analysis
 Approved by the Institution Review Board
(Ethics Committee)
Pang, Woodson
Procedure:
 Tonsillectomy
 Dissection of the palatopharyngeus muscle
 Rotation of the palatopharyngeus muscle
 Partial uvulectomy
 Closure of the anterior and posterior tonsillar

pillars
Pang, Woodson
Pang, Woodson
Pang, Woodson
Post-procedure:
 Post-op monitoring according to severity of OSA and
anesthesia protocols
 Liberal analgesics including Cox-2 Inhibitors, NSAIDS,
PPIs, analgesic gargles, lozenges
 Liberal medical leave
Success criteria:
 Snoring – improvement VAS
 Tiredness – improvement Epworth sleepiness scale
 AHI – reduction by 50% of pre-op value and AHI<15

(post-op PSG)
Pang, Woodson
Pang, Woodson
Pang, Woodson
Pang, Woodson
Pang, Woodson
Pang, Woodson
Pang, Woodson
Pang, Woodson
Pang, Woodson
Pang, Woodson
Results:
 45 patients (23 ESP, 22 UPPP)
 41 males, 4 females
 Mean age 42.1 (24 to 47)
 Mean BMI 28.7 (21.7 to 29.8)
 Mean pre-op AHI 42.3 (23.5 to 64.8) (45 pts)
 Mean post-op AHI 19.2 (10.2 to 56.3) (45 pts)
 Mean – 6.7 month f/u

Pang, Woodson
ESP UPPP
Pre-op AHI 44.2 ± 10.2 38.1 ± 6.6
Post-op AHI 12.0 ± 6.6 19.6 ± 7.9
p value <0.005 <0.05
Success rate 82.6% 68.1%

AHI<20,50%reduction
Pang, Woodson
ESP UPPP
Pre-op AHI 44.2 ± 10.2 38.1 ± 6.6
Post-op AHI 12.0 ± 6.6 19.6 ± 7.9
p value <0.005 <0.05
Success rate 78.2% 45.5%

AHI<15,50%reduction
Pang, Woodson
UPPP pre post AHI AHI pre post Ex SP
60 80
70
50
60
40
50
AHI
AHI
30 40
30
20
20
10
10
0 0
Pre Post Pre Post
Pang, Woodson
Results:
 Snoring improvement (any improvement) – 100%
 Tiredness improvement (ESS) – 91.1% (45 pts)
4 patients felt no change in tiredness
Complications:
 No VPI
 No fistula rate
 4.4% secondary hemorrhage rate (2 pts)
 No dysphagia
 No swallowing problems
 Soft diet on 1st POD
Expansion Sphincter
Pharyngoplasty –
Modifications
&
in Multilevel OSA Surgery
TORS & Palate Surgery: ESP vs UP3
Claudio Vicini, Filippo, Pang KP et al. Head & Neck .May 2013
Claudio Vicini, Filippo, Pang KP et al. Head & Neck .May 2013
Claudio Vicini, Filippo, Pang KP et al. Head & Neck May 2013
 24 patients, matched 2 groups

(age, BMI, AHI, gender, co-morbidity)
 TORS/ESP and TORS/UPPP
 Moderate/Severe OSA
 Palate, Lateral Wall & BOT collapse
Functional Expansion Pharyngoplasty
Sorrenti G, Ottavio P. Laryngoscope. 2012
Functional Expansion Pharyngoplasty
Sorrenti G, Ottavio P. Laryngoscope. 2012
 85 patients underwent FEP – 3 yr period

 Mean age 42 yrs old
 Pre-op AHI 33.3 to 11.7
 Success 50% reduction, AHI<20
 89.2% success rate
 No major complications
Mod ESP in Children with OSA
Ulualp SO. JAMA OHNS. July 2014
Modified ESP in Children with OSA
Ulualp SO. JAMA OHNS. July 2014
“Hey Doc, I’m Still Snoring”
“Hey Doc, I’m Still Snoring”
Pang Rotenberg Sign:

Prognosticator of
Snoring/OSA Surgery – 137 patients
Pang KP, Rotenberg B, Srivinas K, Chung J, Siow JK et al.
Prognosticator of
Snoring/OSA Surgery – 137 patients
Pang KP, Rotenberg B, Srivinas K, Chung J, Siow JK et al.
Pang Rotenberg Sign (PR sign)

Hypothesis:
PR + better post-surgery snoring reduction
PR – less satisfactory post-surgery reduction
Prognosticator of Snoring/OSA Surgery
Pang KP, Rotenberg B, Srivinas K, Chung J et al.
Pang Rotenberg Sign (PR sign)
 Hypothesis:
PR + better post-surgery snoring reduction

PR – less satisfactory post-surgery reduction
Multi-center Trial
(Singapore, Canada, Hong Kong, India)
 137 patients
 Age >18, BMI<33, Friedman I,II,III, ESS,
Snoring VAS, Mean f/u 7.4 months
 Intervention: Nose and Palate surgery
Pang KP, Rotenberg B, Srivinas Kishore, Chung J et al.
Intervention: Nose and Palate surgery
 Nose: Septoplasty, SMR, FESS, RF InfTurb
 Palate: UPF, FB’s UPPP, ESP, AntPalato, Tonsil
Results:
 122 males, 15 females, mean 44.6yo
 99PR+, 38PR-, mean BMI 26.1
Snoring Reduction:
 PR+ VAS 9.04 to 1.02
 PR- VAS 8.91 to 4.44 (p<0.001)
Pang KP, Rotenberg B, Srivinas Kishore, Chung J et al.
Control Group (unintentional)
 Refused Palate Surgery
 16 patients
 Nose: Septoplasty, SMR, FESS, RF InfTurb
 Inconsistent Snoring Reduction (mouth open)
 Regardless of PR status +/-
 VAS 9.21 to 6.72 (poor results)
Anterior Palatoplasty
for the Treatment of OSA
– 3 year results
Kenny P. Pang FRCSEd
Chief, Asia Sleep Centre, SINGAPORE
Raymond Tan FRCS(Glas)

P. Puraviappan MS(ORL)
Pantai Hospital, MALAYSIA
David J. Terris M.D. F.A.C.S.

Chief, Medical College Georgia, AUGUSTA, USA
Modified CAPSO
Pang, Terris OHNS, May 2007
Objective:
 Avoid the stellate scar
 Increase lateral distance
 Superior scarring
Modified CAPSO
 Modified from CAPSO, LAUP

 Anatomically more sound
 Low cost
 Prospective study
Modified CAPSO
Modified CAPSO
Modified CAPSO
Modified CAPSO
Modified CAPSO
Modified CAPSO
Pang, Terris
Modified CAPSO
Pang, Terris
Modified CAPSO
Pang, Terris
Modified CAPSO
Pang, Terris
Modified CAPSO
Anterior Palatoplasty – 3 yr results
Pang KP, Tan R, Puraviappan P, Terris DJ
Results:
 77 patients, 69 males, 8 females
 Mean age 39.3 years old (range of 21 to 51 years)
 Mean BMI was 24.9 (range of 20.7 to 26.8)
 Mean AHI 25.3 ± 12.6 to 11.0 ± 9.9 (p<0.05)
 Success rate for OSA group was 71.8%
 Snore scores (VAS) improved and maintained

from 8.4 to 2.5 (33 months)
Singapore 5th Sleep Surgery Course
November 2015, drkpang@gmail.com

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Expansion Sphincter

 Prevent lateral pharyngeal wall collapse

 Debulk the lateral pharyngeal wall mass

 Fujita I (retropalatal collapse)

 BMI<30, age > 18

 Tonsil size 1 & 2

 Friedman clinical stage II and III

 Friedman Tongue Position 1 to 4

 Muller’s maneuver showing minimal BOT

 Fulfill inclusion criteria

 Recruited from June 2005 to Jan 2006

 Mean follow up 6.7 months (post-op PSG)

 Using the Wilcox Signs Rank Test for statistical

 Dissection of the palatopharyngeus muscle

 Rotation of the palatopharyngeus muscle

 Closure of the anterior and posterior tonsillar

 Tiredness – improvement Epworth sleepiness scale

 AHI – reduction by 50% of pre-op value and AHI<15

 Mean age 42.1 (24 to 47)

 Mean BMI 28.7 (21.7 to 29.8)

 Mean pre-op AHI 42.3 (23.5 to 64.8) (45 pts)

 Mean post-op AHI 19.2 (10.2 to 56.3) (45 pts)

 Mean – 6.7 month f/u

Pre-op AHI 44.2 ± 10.2 38.1 ± 6.6

Post-op AHI 12.0 ± 6.6 19.6 ± 7.9

p value <0.005 <0.05

Success rate 82.6% 68.1%

Pre-op AHI 44.2 ± 10.2 38.1 ± 6.6

Post-op AHI 12.0 ± 6.6 19.6 ± 7.9

p value <0.005 <0.05

Success rate 78.2% 45.5%

UPPP pre post AHI AHI pre post Ex SP

 24 patients, matched 2 groups

 85 patients underwent FEP – 3 yr period

Pang Rotenberg Sign:

Pang Rotenberg Sign (PR sign)

PR + better post-surgery snoring reduction

Raymond Tan FRCS(Glas)

David J. Terris M.D. F.A.C.S.

 Increase lateral distance

 Modified from CAPSO, LAUP

 Mean age 39.3 years old (range of 21 to 51 years)

 Mean BMI was 24.9 (range of 20.7 to 26.8)

 Mean AHI 25.3 ± 12.6 to 11.0 ± 9.9 (p<0.05)

 Success rate for OSA group was 71.8%

 Snore scores (VAS) improved and maintained

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