From the Education Committees: What Is the Effect of Obstructive Sleep Apnea and Its Surgical Management on Voice and Swallowing?
There is an increasing prevalence of obstructive sleep apnea (OSA) in the United States, affecting an estimated 25 million Americans. (1)
Mark Weidenbecher, MD, AAO-HNSF Laryngology and Bronchoesophagology Education Committee member
There is an increasing prevalence of obstructive sleep apnea (OSA) in the United States, affecting an estimated 25 million Americans.1 Positive airway pressure (PAP) therapy is considered standard therapy for OSA; however, there is oftentimes poor compliance with up to 50% of OSA patients not tolerating therapy.2 Untreated OSA carries significant comorbidities, including cardiac arrhythmias, diabetes, high blood pressure, and stroke. Other treatment options, in particular sleep surgical options, must therefore be considered in this patient population. A common concern is that physical examination on an awake patient with static observation of the patient’s upper airway anatomy cannot reliably identify the dynamic upper airway collapse responsible for the patient’s OSA. Drug-induced sleep endoscopy (DISE) has emerged as a valuable tool to identify specific structures and anatomic subsites responsible for the dynamic pharyngeal airway collapse, which allows for a patient-specific and individualized treatment approach.3 Many sleep surgery approaches aim to statically alter the upper airway anatomy to prevent nocturnal pharyngeal airway collapse. Sleep surgeries routinely performed by otolaryngologists include uvulopalatpharyngoplasty (UPPP) or modifications thereof, hyoid suspension, or base of tongue resection. Hypoglossal nerve stimulation therapy (HGNS), in contrast, is a non-static and rather dynamic sleep procedure. HGNS is an implantable medical device that treats OSA by electrically stimulating the hypoglossal nerve to cause tongue protrusion during inspiration to mitigate upper airway collapse.4 In general, indication for each sleep procedure depends on the upper airway anatomy and the collapse pattern.
Patients with moderate-to-severe OSA have been found to suffer from baseline altered biomechanical swallowing biomechanics, including upper esophageal dysfunction, increased hypopharyngeal distension, and velopharyngeal contractility.5 The incidence of dysphagia in the OSA patient population is estimated to be almost twice as high compared to the average patient population (14% versus 8%).6,7 There is also evidence that irritable larynx symptoms such as chronic cough, dyspnea sensation, and dysphonia are more commonly seen in OSA patients.8
The larynx can be viewed as the sound source while the pharynx not only serves as a resonator but also assists with swallowing. Since sleep surgery for OSA addresses the pharyngeal airway, the question must be raised whether it affects swallow and voice function. While sleep surgery can certainly lead to temporary laryngopharyngeal complaints, such as odynophagia, globus, and dysphagia, in terms of long-term effects, the literature is somewhat conflicting. Franklin et al. examined the side effects of OSA surgery and found that UPPP, a commonly performed sleep surgery to enlarge the retropalatal airway, resulted in permanent swallowing difficulties in 31% of the patients while other authors found no evidence for UPPP to cause any long-term effects on swallowing or voice.9-11 Hyoid suspension is another example of a static sleep surgery that is used in OSA patients for base of tongue obstruction by moving the hyoid and base of tongue complex anteriorly and superiorly. This can be accomplished by performing a hyothyroidpexy (HTP) or by suspending the hyoid to the mandibular symphysis via suturing or via genioglossus advancement. Several studies have shown that HTP does not affect swallowing or voice function after 12 months, as noted on postoperative swallow testing and voice analysis.12,13 In a large metanalysis examining voice outcome following various types of palate procedures or hyoid suspension, it was found that surgical management of OSA, regardless of the type of procedure, did not impair voice or swallowing function permanently.14 Similarly, HGNS, a non-static and rather dynamic sleep procedure, has also demonstrated not to cause any swallowing or voice problems at one week, three months, and six months postoperatively. This was studied on 14 patients via validated VHI-10 and EAT-10 questionnaires.15 In other studies, several authors have reported on persistent neck and tongue pain in patients using HGNS, which in some patients could be resolved by changing the intensity of the stimulation.16 In some cases, manual neck therapy can also help with this muscle tension, like neck pain.
In summary, OSA patients have a slightly higher incidence of laryngopharyngeal symptoms compared to the average population. With the exception of HGNS, all other sleep surgeries alter the upper airway permanently. Depending on the type of sleep surgery, conflicting information in the medical literature exists as to whether it can result in long-term voice and swallowing problems.
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