Upper Airway Surgery in the Adult
INTRODUCTION Sleep-disordered breathing (SDB) is a collective term, which encompasses snoring, upper airway resistance syndrome (UARS), obstructive sleep apnea-hypopnea syndrome, and obstructive sleep apnea (OSA). These terms describe a partial or complete obstruction of the upper airway during sleep. Patency of the pharyngeal airway is maintained by two opposing forces: negative intraluminal pressure and the activity of the upper airway musculature. Anatomical or central neural abnor malities can disrupt this delicate balance with resultant compromise of the upper airway. This reduction of airway caliber may cause sleep fragmentation and subsequent behavioral derangements, such as excessive daytime sleepiness (EDS) (1-3). Thus, medical and surgical therapy attempt to alleviate this obstruction and increase airway patency
Surgical management was the first therapeutic modality employed to treat SDB. Kuhlo (4) described placement of a tracheotomy tube in an attempt to bypass upper airway obstruction in Pickwickian patients. Although effective, tracheotomy is not readily accepted by most patients and does not address the specific sites of pharyngeal collapse. These regions include the nasal cavity/nasopharynx, oropharynx, and hypopharynx. Often, multilevel obstruction is present. Consequently, the surgical armamentarium has evolved to create techniques, which correct the specific anatom ical sites of obstruction. The objective of surgical intervention is to eliminate SDB. To achieve this goal, it is necessary to alleviate all levels of obstruction in an organized and safe protocol. Ultimately, it is the obligation of the surgeon to counsel the patient regarding all surgical techniques, risks, complications, and alternative medical therapies.