Raol N, Hartnick CJ (eds): Surgery for Pediatric Velopharyngeal Insufficiency.

Adv Otorhinolaryngol. Basel, Karger, 2015, vol 76, pp 8688 (DOI: 10.1159/000368033)

Obstructive Sleep Apnea

J. Paul Willging a, b
a

Division of Pediatric Otolaryngology Head and Neck Surgery, Cincinnati Childrens Hospital Medical Center,
Cincinnati, Ohio, b Department of Otolaryngology Head and Neck Surgery, University of Cincinnati College of
Medicine, Cincinnati, Ohio, USA

Abstract
This chapter outlines the surgical management of children who experience symptoms of airway obstruction after undergoing pharyngeal flap surgery or sphincter pharyngoplasty for the correction
of velopharyngeal insufficiency. It also describes the management of children with hyponasality fol 2015 S. Karger AG, Basel
lowing these corrective surgical interventions.

Following the surgical correction of velopharyngeal insufficiency by pharyngeal flap

surgery or sphincter pharyngoplasty, the ports that were created may become stenotic. If this occurs, airway obstruction may ensue.
By 6 weeks postoperatively, postsurgical edema will have resolved, thereby allowing accurate assessment of the effect of the ports on breathing. If symptoms of airway obstruction are evident at this time, spontaneous improvement is unlikely to
occur.
Flexible endoscopy should be performed to assess the ports. Questions pertaining
to the significance of sleep-related airway symptoms should be addressed by having
the patient undergo overnight polysomnography. If obstructive sleep apnea (OSA)
is documented, continuous positive airway pressure may be used as a temporizing
measure. Although obstructive airway symptoms may gradually improve over time
as a child grows, it is the authors opinion that surgical intervention is preferable to
having the child remain technology dependent for a long and indefinite period of
time.

Downloaded by:
Siriraj Medical Library, Mahidol University
202.28.191.34 - 3/13/2015 2:32:16 PM

Background

Additionally, children with OSA generally have significant hyponasality. In this

setting, enlarging the velopharyngeal ports will not only correct the OSA but also normalize resonance.

Indications for Surgical Correction of Obstructive Sleep Apnea

Significant increase in the work of breathing while asleep

Documentation of OSA by polysomnography
Increasing the Size of the Ports
After flexible endoscopy documents the presence of stenotic port(s), surgical
enlargement of the port should be undertaken. The aim of surgical intervention
is to open the problematic port. Port Enlargement: Online supplementary
video (for online supplementary material, see http://www.karger.com/Article/
FullText/368033).
Procedure
A mouth gag is inserted, and the patient is placed in suspension.
A suction catheter is passed transnasally through the stenotic port. If the catheter
is difficult to pass, a dilator can be passed through the eye of the catheter and into
its lumen, and the dilator can be manipulated through the port. Traction on the
catheter(s) will tense the port, allowing better visualization.
With the port under tension, a beaver blade is used to make a V-shaped wedge in
the scar tissue that is obstructing the port.
If necessary, the revision is carried out bilaterally.
The resulting defect is left to granulate.

Procedure
A mouth gag is inserted, and the patient is placed in suspension.
The pharyngeal flap is visualized with a mirror.
A right-angle beaver blade is used to separate the pharyngeal flap from the posterior pharyngeal wall. Residual flap tissue is left attached to the free edge of the soft

Obstructive Sleep Apnea

Raol N, Hartnick CJ (eds): Surgery for Pediatric Velopharyngeal Insufficiency.

Adv Otorhinolaryngol. Basel, Karger, 2015, vol 76, pp 8688 (DOI: 10.1159/000368033)

87

Downloaded by:
Siriraj Medical Library, Mahidol University
202.28.191.34 - 3/13/2015 2:32:16 PM

Flap Takedown
If the pharyngeal flap is totally obstructing the nasopharyngeal inlet and the velopharyngeal ports cannot be opened satisfactorily by other methods, it may be necessary to
release the pharyngeal flap; this procedure restores the childs ability to breathe well at
night. It is prudent to obtain a sleep MRI (i.e. sagittal MRI of the head and neck performed under sedation) prior to undertaking this procedure to ensure that the flap is
the primary cause of the OSA, as tongue base obstruction may also present with similar symptoms.

palate; this retains bulk on the soft palate, which maximizes the ability to maintain
velopharyngeal closure while improving the airway.
The resulting defect on the posterior pharyngeal wall is left open to granulate.

Pearls and Pitfalls

Increasing the Size of the Ports

There is usually a specific site within the port that causes the obstruction. Attention
to that specific area will allow the port to spring open when it is divided.
Minimal modification to the flap itself is required to open the port.
Enlarging the velopharyngeal port(s) may cause abnormal resonance or the development of nasal air emission if the moving lateral wall cannot make contact with
the flap during connected speech.

J. Paul Willging, MD
Division of Pediatric Otolaryngology Head and Neck Surgery
Cincinnati Childrens Hospital Medical Center
3333 Burnet Avenue, MLC 2018, Cincinnati, OH 45229 (USA)

88

Willging

Raol N, Hartnick CJ (eds): Surgery for Pediatric Velopharyngeal Insufficiency.

Adv Otorhinolaryngol. Basel, Karger, 2015, vol 76, pp 8688 (DOI: 10.1159/000368033)

Downloaded by:
Siriraj Medical Library, Mahidol University
202.28.191.34 - 3/13/2015 2:32:16 PM

Flap Takedown
If a flap has been in position for a long period of time prior to takedown, resonance
often remains normal.
Flap takedown does not always normalize the airway, as tongue base obstruction
or hypopharyngeal collapse may also lead to OSA.