Multilevel-Single Stage-Functional Rhinoplasty & BRP (Barb Reposition Palatoplasty) in Surgical Management of Primary Snorers, UARS and Mild OSA.

Obstructive sleep apnoea syndrome (OSA) is a multi-factorial disorder, with quite complex endotypes, consisting of anatomical and non-anatomical pathophysiological factors. Continuous positive airway pressure (CPAP) is recognized as the first-line standard treatment for OSA, whereas upper airway (UA) surgery is often recommended for treating mild OSA patients who have refused or cannot tolerate CPAP, mild and primary snorers. The main results achievable by the surgery are UA expansion, and/or stabilization, and/or removal of the obstructive tissue to different UA levels. The site and pattern of UA collapse identification is of upmost importance in selecting the customized surgical procedure to perform, as well as the identification of the relation between anatomical and non-anatomical factors in each patient. It has become increasingly clear in the past decade that surgical management of OSA is most successfully managed with multilevel surgery (Cahali in Laryngoscope, 113(11):1961-1968, 2003; Friedman et al. in Otolaryngol Head Neck Surg 131(1):89-100, 2004; Laryngoscope 114(3):441-449, 2004; Pang Woodson in Otolaryngol Head Neck Surg 137(1):110-114, 2007; Li Lee in Laryngoscope 119(12):2472-2477, 2009; Vicini et al. in Head Neck 36(1):77-78, 2014; Mantovani et al. in Acta Otorhinolaryngol Ital 32:48-53, 2012; Morgenthaler in Sleep 30(4):519-529, 2007). Drug-induced sleep endoscopy (DISE) has shown that the nose amounting more than 50% of flow limitation and soft palatal collapse are important anatomic components of obstruction in OSAHS and therefore should be treated as far as possible as a single stage procedure. The nasal patency being pivotal in the outcome of the sleep apnoea surgery. Choosing the right patient and the right surgical approach for such patients is extremely important to decrease the overall burden of the disease. We have chosen functional rhinoplasty or an open approach septoplasty for management of various nasal deformities that lead to significant obstruction in patients suffering from snoring and mild OSA. While the palatal component of obstruction being treated with BRP (BARB Relocation Palatoplasty) for anterior- posterior, lateral and concentric collapses at retro palatal level. (1) To be able to offer an effective and reliable surgical management to simple snorers, Mild OSA, upper airway resistance patients, PAP non-compliant or non-adherent patients. (2) To ascertain the effectiveness and ease of carrying out multilevel single stage procedure in above mentioned patients of snorers to mild obstructive sleep apnoea, and to use Functional Rhinoplasty & BARB sutures for relocation and suspension Palatoplasty to address retro palatal collapse without excising soft palatal tissue. (3) To make minor modification in the surgical steps namely - bundling of the posterior pillar after release to avoid cut through or spillage of the barb suture from point of relocation. (4) Identifying surgical candidacy for better outcomes in terms of reduction of disease burden and better quality of life. We have carried out a prospective observational multicentre study of 120 OSA (mild) patients over a period of 8 years who underwent open approach septoplasty / functional rhinoplasty along with Barb relocation and suspension Palatoplasty for mild obstructive sleep apnoea with a mean follow up of 3 years. Patients with nasal and retro palatal collapse diagnosed on 4-phase rhinomanometry and DISE respectively having mild sleep apnoea (AASM Definition-AHI < 15, Hypopnea - 3% desaturation and 30% reduction in flow for more than 10 s). Patients having retroglossal or hypo pharyngeal collapse or primary epiglottis collapse were excluded from the study. Patients having moderate to severe OSA and severe OSA (AHI > 15) on HST were also excluded from the study. Simple snorers and patients complaining of daytime sleepiness or cognitive impairment, with no comorbidities and ones refusing to use or non-adherent to PAP therapy were chosen. All patients underwent a level 2 sleep study, rhinomanometry and a DISE with consent. The nasal obstructive component of obstruction was treated via a functional rhinoplasty/ extracorporeal septoplasty approach. Retro palatal component addressed by barbed relocation Palatoplasty (BRP). All 120 patients underwent an open approach septoplasty with Barb Relocation Palatoplasty under GA. We observed that open approach septoplasty can help us address the nasal obstructive component in a much more efficient way to correct not only internal but also external nasal valve deformities along with gross septal deformities to relieve obstructions adequately and efficiently. An adequately done nasal surgery along with BRP can provide as an effective and safe option with very promising results in this era of multi-level single stage procedures. Adding BRP in the same stage with nasal surgery has been proved to be a simplebut effective procedure for simple snorers and patients with mild obstructive sleep apnoea. Key factors being that the right anatomical correction in the carefully selected patients who are falling within the spectrum of simple primary snorers without obstructive sleep apnoea to UARS to mild OSA (not moderate or severe OSA) can be efficiently and effectively treated with this surgical approach. Patients who having a low P Crit / Auto PAP trial P 90/95 < 10 cmH2O respond well to surgical management. Hence giving such candidates an Auto PAP trial not only helps to identify the level of compliance and adherence to PAP therapy but also helps to identify surgical candidates that can benefit after surgery.