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

Abstract

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.

Introduction

Obstructive sleep apnoe arepresents the most common and under-diagnosed sleep-disordered breathing (SDB) disease, with a prevalence in the Indian population as high as 32.5%. In the western world the incidence rate between 5 and 17% of the middle-aged population and 20 to 60% in people over 65 [1, 2] has been noted. Currently, the pathophysiology of OSA is related to four major endotypes related to specific pathophysiological traits: the upper airway size/pharyngeal collapsibility, the upper airway muscular responsiveness, the ventilatory control system or loop gain (LG), and the arousal threshold (AT) [6].

Differentiating OSA patients with predominant anatomical factors from OSA patients with a combination of anatomical and non-anatomical factors is of utmost importance to identify patients that can benefit from surgical vs non-surgical procedures.Continuous Positive Airway Pressure (CPAP) is recognized as the first-line standard treatment for OSA, but long-term acceptance or adherence to CPAP is reported by the literature to be from 50 to 70%. For this reason, multiple alternative treatment options are being advocated. Treatment options for OSA may include weight loss, mandibular advancement devices (MAD), positional therapy, and upper airways (UA) surgery, including hypoglossal nerve stimulation. Furthermore, orofacial myofunctional therapy and drug therapy represent an emerging treatment option for OSA.

However, with the plethora of treatment options available, the question arises of how to select the best treatment option, especially when considering UA surgery, knowing that the best outcomes are achievable with CPAP in OSA patients with the highest pharyngeal collapsibility (high P Crit >  + 2 cmH2O), whereas less pharyngeal collapsibility (low P Crit <  − 2 cmH2O) is related to more success with non-CPAP treatments. UA surgery is often recommended for treating OSA patients who have refused or cannot tolerate CPAP, and the main result achievable by the surgery is UA expansion, and/or stabilization, and/or tissue removal to different UA levels [3].

The decreased efficacy especially of the conventional/ endonasal surgery approach to treat nasal obstruction, PAP non-compliance and non-adherence, increased morbidity and increased economic burden on patientsand hence lowered compliance for the completion of treatment posed by multiple staged procedures were the concerns that haunted us. Our aim was to give our patients maximum benefit from multilevel single stage surgery to achieve a patent airway in patients with level 1(Nasal obstruction) and level 2 (retro palatal obstruction) obstructions in a single sitting as an alternative treatment option for PAP therapy in simple snorers, UARS, mild OSA and PAP non-compliant or PAP non-adherent patients. The study was carried out to analyse the efficacy and comfort of doing a multilevel single stage surgery in patients of mild OSA to achieve the reduction of morbidity of OSA and OSA surgeries, decreasing the economic burden on the patients and increase the compliance to our treatment. A single stage multilevel surgery avoids delay of time in the management of OSA and the need of repeated hospitalization for multiple procedures for OSA surgical management. The combination of the two surgeries is very effective and easily doable in cases of mild OSA with nasal and retro palatal obstructions.

Nasal surgeries for correction of nasal obstruction have been described and are being done for decades. Conventional septoplasty with various turbinate reduction procedures have been done by ENT surgeons routinely. Functional Rhinoplasty for reasons such as internal or external nasal valve obstructions, high anterior septal cartilaginous deviations, post traumatic lower and mid nasal vault collapse requiring extracorporeal septoplasties via the open rhinoplasty approach / extracorporeal septoplasty have been described in literature for over 2 decades now. Most ENT surgeons are aware and well versed with various nasal surgeries done for relieving nasal obstruction by means of conventional septoplasty. Although conventional endonasal septoplasties are adequate in most cases to correct mild deviated septum, these techniques remain largely incapable of reliably correcting severe nasal septal deformities, internal and external nasal valve deformities anterior nasal spine deviations. In such cases, open-approach septoplasty, which allows the entire nasal septum to be exposed using an open rhinoplasty technique, is usually needed. In the 1950s, King and Ashley and Perretsuggested extracorporeal septoplasty, in which the whole or part of the septal cartilage is removed, corrected, and reimplanted, to treat a markedly deviated nasal septum. This technique found followers starting only in the 1980s and 1990s. Reporting a large series of extracorporeal septoplasties, Prof Wolfgang Gubisch suggested this method for the reconstruction of the ‘‘difficult septum.’Gubisch suggested complete removal of the septum via a combination of hemi transfixion and intercartilaginous incisions. He would then reshape a straight septum from pieces of the deformed one using fine sutures or glue. The new septum is reinserted and fixed with two sutures to the anterior nasal spine and medial crura of the lower lateral cartilages. We at our centres have been doing open approach septoplasty andextracorporeal septoplasties for aesthetic and functional corrections of the nose since 2008 and hence the decided to extend this procedure for the benefit of the mild OSA and simple snoring patients with gross nasal deformities and obstructions.

OSA and its surgical management has been constantly evolving and vastly studied, especially for the retro palatal obstruction. The retro palatal region being so highly dynamic in nature, there have been multiple invasive procedures that have been described in the past. The main mechanism of the most classic palatal techniques for relieving snoring/obstructive sleep apnoea syndrome (OSAS) was basically the shortening of the soft palate by trimming the free edge (UPPP and LAUP) or pulling up the uvula and the soft palate. In the last years, many new palatal surgical techniques for snoring and OSAS were devised to address mainly the lateral pharyngeal wall and to enlarge the oropharyngeal inlet laterally (lateral pharyngoplasty [1], Z-palatoplasty [2], Uvulopalatoplasty (UP2) [3], Expansion sphincter pharyngoplasty (ESP) [4] and Relocation pharyngoplasty [5]).

The most recent and globally accepted palatal procedure being Barbed Relocation Palatoplasty or Barb suture Suspension palatoplasty.

In this study the multilevel single stage surgery described, includes various nasal surgeries via open approach for level 1 obstructions (open approach septoplasty, extracorporeal septoplasty, internal and external nasal valve reconstruction, turbinate reduction), and Barb relocation palatoplasty along with suspension for level 2 obstruction.

Material and Methods

Patients and Methods

This preliminary prospective observational multicentre study was conducted at Ghaisas ENT Hospital Pune and Prime ENT Centre Andheri West, Mumbai starting from since 2015 to 2023. Prior to conduction of the study, an informed detailed consent was taken from each patient. A group of 120 patients clinically diagnosed with OSA and obvious nasal septal deviations were selected. UARS patients were identified on the basis of flow limitation noted and correlation of RR- respiratory and pulse transition rate. Autonomic arousal detection on the plethysmogram enabled to score RERA ‘s and define sleep fragmentation in HST Level 3 lab—Sleep lab being used for the diagnoses was Somnomedics – SOMNOTouch Resp Eco having 11 channels. Patients underwent a PSG level 2 (Done for patients having co-morbidities like HNT or DM etc., as per AASM guidelines) or level 3 (depending on the probability of suspicion of OSA without co-morbidities) to assess the severity of the OSA, Drug induced sleep endoscopy, Rhinomanometry to ascertain the diagnosis. A 4 phase Rhinomanometry [7, 8] was done for objective evaluation of nasal obstruction in all 120 cases. CT PNS was on advised in selected cases suspected of having CRS and Allergic rhinitis patients with concomitant mild OSA and simple snoring. CT PNS findings of pan sinusitis or chronic rhino sinusitis were excluded from the study to avoid potential complications that could arise from concomitant infections to the skin envelope during open rhinoplasty approach. Patients with CT findings of gross septal deviations and inferior turbinate hypertrophy, concha bullosa and healthy sinuses and snoring were included.

Inclusion Criteria Included

• Age between 25–60 yrs.

• Mild OSA apnoea (AHI < 15, Hypopnea – 3% desaturation and 30% reduction in flow channel for more than 10 s)

• Patients not accepting or unwilling to use CPAP treatment after a 2 weeks of Auto PAP trial.

• On Auto PAP Trial – P Max 10 cmH2O- These patients underwent Rhinomanometry and DISE to evaluate the level of obstruction.

• Simple / Primary snorers (STOP BANG < 2) with internal or external nasal deformities with a history of loud snoring.

• Simple snores / Primary snorers (STOP BANG < 2) with only retro palatal collapse on DISE

• DISE indicating a purely nasal and retro palatal obstruction.

• BMI of no more than 30

Exclusion Criteria Included

• Patients with severe medical illness and co morbidities unfit for GA.

• PSG findings of AHI > 15 events per hour

• DISE indicating retro lingual or hypopharyngeal, primary epiglottis component of collapse.

• PAP non-adherent and non-compliant(< 4 h of use per night < 70% of nights – 2-week trial)

A careful general, ear nose and throat (ENT) history of each patient was taken with particular attention given to sleep history, preferably by the spouse or family member.

For all cases, the following data were recorded:

• Age

• Sex

• BMI

• ESS (Epworth Sleepiness Scale) Pre op and Post op after 1 year

• AHI – Pre and post op after 1 year

• Snore index pre and post 1 year.

• Arousal index pre and post 1 year

• Auto PAP P Max > 10 cmH2O

• Complications post-surgery – immediate and late

• 4 phase Rhinomanometry 1 pre- and post-operative

• DISE – drug induced sleep endoscopy.

• Awake Flexible Nasopharyngoscopy post-operative on post 1 year follow up.

DISE–Drug Induced Sleep Endoscopy

All patients underwent DISE to ascertain the level of collapse. Base line O2 saturation while awake was noted and Nose was anesthetized with topical 4% Lignocaine without decongestant on cotton patties. An awake rigid nasal endoscopy done to assess the nose, followed by an awake flexible nasopharyngoscopy and Muller’s manuver findings noted. Propofol infusion as per scheduled dose given by anaesthetist and pharyngeal collapsibility was noted according to VOTE classification. O2 Desaturation was noted during episodes of visual apnoeas during the procedure. Once the scope was pulled out, soft silicon nasopharyngeal airway was inserted into the nasal cavity to observe the abolishment of snoring and respiratory distress. All findings later being discussed with the patients and relatives, advise was rendered accordingly and surgical procedures planned as discussed with patients. Irrespective of pattern or severity of collapse at the level of the soft palate – all patients were counselled for barb relocation palatoplasty to resolve the retro palatal collapse.

Auto Pap Trial

All patients underwent an Auto PAP trial for a period of 2 weeks and AutoPMax / Auto PMin and Median pressures needed to overcome collapsibility of the upper airway was recorded. With reference to the extensive study done by Danny Eckert Et Al [9], some people with OSA have severe anatomical compromise (Pcrit >  + 2 cmH2O), others have intermediate or moderate anatomical impairment (Pcrit between -2 to + 2 cmH2O), while some have only minor anatomical impairment (Pcrit < -2cmH2O).Thus, the critical closing pressure of the pharynx or upper airway (which can be measured only in research labs) can be clinically corelated to the pressures needed on Auto PAP to open the collapsed airway. Hence a cut off of P Max no more than 10 cmH2O was considered, to accept patients for surgical procedures.

Surgical Technique

All cases were operated in a step wise manner, the first being nasal surgery in the form of functional rhinoplasty via open approach / ITH reduction with coblation channelling, internal nasal valve and external nasal valve collapse correction with spreader flaps or grafts/ batten grafts/ lateral crural turn over. The second step being tonsillectomy along BRP (Barb relocation Palatoplasty), operated under general anaesthesia, oral intubation with armoured South Pole tube.

Step 1

Nasal surgery was done in each patient as deemed necessary depending on the external and internal nasal examination along with DISE findings. An open approach rhinoplasty was done for all patients to treat the nasal component of obstruction. Total of 40 individuals had external nasal valve collapse, of which 23 were treated with LLC (lower lateral cartilage) batten grafts and 17 cases lateral crural turnover was done. Unilateral or Bilateral internal nasal valve collapse was noted in all 120 patients – in 62 patients spreader flaps were used while 58 were treated with spreader grafts harvested from the septal cartilage. 21 cases had mid nasal vault collapse due to weak ULC (Upper lateral cartilages) which was strengthened with the help of ULC batten. 63 patients had deviated anterior nasal spine, while 26 post traumatic cases had grossly deviate nasal septum which needed a complete structural reconstruction of the nasal septum. All 120 were treated for inferior turbinate hypertrophy with RF channelling and # lateralization (Tables 1, 2 and Figs. 1, 2).

Table 1.

Nasal surgeries done along with BRP (in all cases) in the multilevel single stage op

Site of nasal obstruction	Total No of patients	Grafts or techniques	Of 120 – Number that underwent said surgery/ procedure
External nasal valve collapse	40	LLC (Lower Lateral Cartilage) Batten grafts Lateral Crural Turnover	23 17
Internal nasal valve	83	Unilateral or bilateral Spreader flaps Unilateral or bilateral Spreader grafts	12 71
Mid vault collapse	21	ULC (Upper Lateral Cartilage) batten graft	21
Anterior nasal spine deviations causing caudal dislocation of septum	63	ANS # and medialization or drilling	63
Grossly deformed or collapsed mid and lower vault	26	Complete structural reconstruction with costal cartilage	26
Inferior turbinate hypertrophy	120	Unilateral or Bilateral Radiofrequency channelling along with inferior turbinate # lateralization	120

Table 2.

Pre-op and post op findings and Indices

Indices	Pre-Op (Mean)	Post-Op (Mean)
ESS – Epworth Sleepiness scale	13	04
Apnea-Hypoapnea index—AHI	12.3	8
Snore index	23.8%	8.2
LSat %	76%	87%
Arousal index	61	21

Fig. 1.

Rim Graft, LLC crural turn over, LLC Batten, ULC Batten, Spreader graft

Fig. 2.

Stratfix – Bidirectional BARB suture – 2–0 PDS

Step 2

All 120 patients underwent Barb Relocation Palatoplasty and combined surgical procedure. The oral cavity exposed by a slotted Boyle–Davis mouth gag with head extended in supine position. Extra capsular tonsillectomy done with coblation using EVAC 70 wand. Care was taken to preserve the mucosa over the palatoglossal and palatopharyngeal muscles. Marking for barb suturing was done (Fig. 3a). Oropharyngeal space was measure before barb suturing and relocation (Fig. 3c).The palatopharyngeal muscle bulk was split vertically along the length of the fibres to release it from its lower fibres and horizontally at lower 3rd of its length to ease the mobilization of the muscle bulk anterolaterally. The released posterior pillar bundled with encircled suture using Vicryl 3–0 – since during our earlier days of relocation palatoplasty we faced a few slippages and cut through the posterior pillar, we started to bundle up the posterior pillar with 3–0 Vicryl to aid a better grip on the posterior pillar once relocated. (Fig. 3b).A 2–0 round body, double needle bidirectional barb PDS suture (Fig. 2) was inserted up to the midpoint of the suture length (transition zone of the suture) at the PNS (Posterior Nasal Spine) submucosally. Each end running sub mucosal to the base of the uvula – reinserting submucosal to exit near the pterygoid Hamulus or superior end of the pterygomandibular raphe – there on to the tonsillar bed superior pole – inserting into the bulk of the released palatopharyngeal muscle and re inserting through the tonsillar bed to the pterygomandibular raphe on either side. Lastly creating the anterior suspension by bringing the same suture from one raphe to the opposite raphe at the level of the dimple of the soft palate. Thus, giving the soft palate an anterior and lateral pull and expanding the retropalatal space. (Fig. 3 d) The suture being knotless was pulled on either side to the required tension and the nipped off at the last point of exit. All 120 patients underwent BARB Relocation Palatoplasty irrespective of the severity and pattern of collapse noted on DISE.

Fig. 3.

a Marking suture follow through. b Measuring crowded posterior pharyngeal airway. c Bundling of the released palatopharyngeus muscle. d Anterior and lateral expansion of retropalatal area. e Post 1 yr. Palatal healing

Results

All patients underwent an awake flexible nasopharyngoscopy with mullers to visualize the patency and collapsibility of the velum and nose postoperatively along with a postoperative PSG level 3 (SOMNOMedic Touch Resp Eco – HST was used for post op sleep studies – arousal index and RERA are identified via Autonomic arousal detection on the plethysmogram enabled to score RERA ‘s and define sleep fragmentation) to compare the pre- and post-operative indices and findings.

• ESS (Epworth Sleepiness Scale)

• AHI – Pre and post op after 1 year.

• Snore index pre and post 1 year.

• LSat % pre and post op 1 year.

• Rhinomanometry Fig. 4a, b

• Arousal index

• Auto PAP P Max < 10 cmH2O

• Pre-op and post op ESS

• Pre-op and post op AHI

• Pre-op and post op Arousal Index

• Pre-op and post op Snore Index

• Pre-op and post op LSat %

• Pre-op and post op Rhinomanometry results–Table 3a, b

Fig. 4.

a Preoperative Velum patency. b Post-operative Velum Patency after 1 year

Table 3.

Pre-op and post op Rhinomanometry

Pre-op Mean Flow Ins/150 Pa	Post – Op Mean Flow Ins/150 Pa
60–180-Denotes high obstruction or resistance	> 500–denoting very low obstruction or resistance
a	b

Complications and Post op Observations

Since many patients underwent a functional rhinoplasty, the complications associated with an open rhinoplasty approach like nasal dorsal and tip swelling (usually subsides within 1–3-monthpost op), displacement of various grafts inserted, aesthetic disfigurement etc. were looked for in the complete post op period. There were no such complications noted in any of the patients during the post op period of one year. 26 patients out of the120, were operated aesthetic rhinoplasty along with BRP with informed consent, where in paramedian/ transverse and lateral nasal osteotomies were done of which 14 patients did have infra orbital hematoma and mild discoloration but this resolved within 3 weeks post op. No residual complications were noted. All nasal surgeries were uneventful and no post op bleed.

During palatal surgery the complications that can be expected are post tonsillectomy bleeding primary or secondary, we didn’t face any such uncontrollable intra or post-operative bleed. In 16 patients, partial slipping of the palatopharyngeal muscle due to tear through seen 2 weeks post op, leading to the barb suture loop showing within the tonsillar fossa and causing foreign body sensation, this was treated by diluted hydrogen peroxide gargles and anti-inflammatory drugs. Out of these 2 patients who had a complete slippage / tear through of the muscle, we had to cut out the loop, which was visible in the tonsillar fossa, since the patient didn’t tolerate it and persistently complained of pricking sensation due to the BARB’s. This eventually led to extrusion of the entire suture length approximately 4th week post op. This failure of the barb suture holding in place or the cut through of the palatopharyngeal muscle bulk was attributed to the inadequate inferior release / level of the transverse cut taken on the muscle, which was noted and corrected in the following cases by means of bundling of the palatopharyngeus to secure the released muscle bulk and avoid tear through or slipping due to BARB suture. Most patients complained of post op foreign body sensation in the soft palate which resolved about 1 month after the surgery. None of the patient complained of VPI (Velopalatal insufficiency) or any permanent change in voice quality.

Discussion

Open rhinoplasty or open approach rhinoplasty for functional nasal symptoms has been a well-known concept and has been practiced for over 4 decades now. Internal nasal valve collapse is treated with spreader grafts/ flaps that helps to increase the internal nasal valve dimensions to facilitate breathing through the nose, while external nasal valve collapse being corrected with lower alar batten grafts, rim grafts or onlay grafts. Mid vault nasal collapse due to ULC (upper lateral cartilage) can be reinforced with ULC batten grafts. Extracorporeal Rhinoplasty and structural reconstruction of the septum for anterior and high nasal septal deviations in grossly crooked noses with breathing difficulties have proved to be a treatment of choice instead of conventional septoplasties. We strongly propose that all ENT surgeons who intend to do effective septal and endonasal as well as external nasal framework corrections should be well versed with open approach and extracorporeal septoplasty to be able to deliver good post-operativeresults to patients.

Barbed reposition palatoplasty is deeply inspired by the relocation pharyngoplasty (RP) as devised and published by Li et al. The purpose is to use a series of sutures to widen the oropharyngeal isthmus laterally and to relocate anteriorly the lateral insertion of the soft palate to increase the retro palatal airway.

The anterior sustaining anatomical structure is the more stable fibrous pterygomandibular raphe instead of the weaker palatoglossal muscle; this solution is inspired to Mantovani technique (7) Pterygomandibular raphe is a fibrous band joining the pterygoid hamulus to the mandible relatively variable in the different subjects; it is always easy to locate during surgery by inspection or, may be better, by palpation. It lies anteriorly and laterally to the posterior pillar, in the best position for an effective pulling direction to increase the transversal oropharyngeal dimension and to widen the retro palatal anteroposterior distance. Its anatomical location is far from significant nerves and vessels preventing undesired complications during suturing.

The repositioned muscle is the palatopharyngeal muscle, after a preliminary inferior release; this solution is inspired to Cahali technique (1) The inferior muscle release is planned to allow an easier and more stable repositioning of the posterior pillar in a more lateral and anterior location without any significant tension.

The bidirectional barbed suture instead of a conventional series of single stitches; this solution is inspired to Mantovani technique (7). Barbed suture proved to be much faster and easier to handle, because it is a knotless technology (knotting inside the pharynx may be not easy for the less experienced surgeons, and even for the most experienced ones, it takes obviously more time). Also, barbed suture allows running more thread loops around the muscle, creating a sort of dense net, for a better distribution of the repositioning forces over the muscle flap. In comparison to Pang– Woodson technique [4], the pulling suture works with a 90 angle on the muscle fibres array, with a much less risk to tear the flap tip. 4.

Once the posterior pillar is released and freed for relocation, we noted that the chances of barb suture tearing or cutting through the muscle fibres after the relocation was high and hence, we have started to bundle up the posterior pillar with an encircling suture with Vicryl 3–0 (shown in Fig. 3c) to avoid the cut through post operatively. This was a minor modification made to the said procedure to avoid post-operative slipping or cutting through muscle fibres of the palatoglossus due to the strong barb suture.

An anterior pillar totally sparing approach for tonsillectomy proved to be very useful for the better tensionless reconstruction of the mucosal covering at the end of the procedure. Two more remarks about the posterior pillar repositioning are given. If properly located between the upper third and the inferior two-thirds of the posterior pillar, the first suture loop will produce a sort of ‘‘posterior pillar steal’’, inspired to the same concept of lateral crural steal technique in tip rhinoplasty. The meaning is that the upper part of the posterior pillar will be transposed into the soft palate free edge, which will be transversally enlarged in a very significant way. The posterior pillar mucosa is not dissected free from the flap but follows it in its repositioning. The meaning is less surgical time, no potential mucosal damage, immediate mucosal closure, probably faster recovery, and lesser pain.

Conclusion

Multilevel single stage surgery has been described in literature and is being carried out for OSA management. This not only helps to reduce the time consumption and economic burden on the patients by avoiding repeated hospitalization and need for anaesthesia, but also helps us as surgeons to give our patient safe and less invasive palatal procedure than ESP/ ZETA, yet very effective and an effective nasal patency by correcting all possible nasal deformities via open approach septoplasty / extracorporeal septoplasty or a functional rhinoplasty. In this prospective study we have specifically chosen only level 1- 2 obstructions for surgical management for simple snorers and mild obstructive sleep apnoea. We observed that open approach septoplasty / functional rhinoplasty along with BRP can provide as an effective and safe option with very promising results. Nasal surgeries being done routinely by ENT surgeons, adding BRP in the same stage has been proved to be a simple, easy to learn, safe procedure with promising results in the management of OSA. Key points to be, the level of obstruction noted on DISE, and proper patient selection can help us give the patients a good surgical result in a single stage procedure. Moreover, BRP is easy to learn even for the inexperienced surgeons and less time consuming and with no significant complications. The minimal muscle and mucosal resection and the absence of knots in the pharynx are well tolerated and accepted by the patient in terms of invasiveness. We strongly propose that all ENT surgeons who intend to do effective septal and endonasal as well as external nasal framework corrections should be well versed with open approach and extracorporeal septoplasty to be able to deliver good post operative results to patients.

Since all patients underwent BRP irrespective of the severity and pattern of collapse at the retro palatal level, we can safely conclude that BRP does stand as a promising and efficacious surgical method for anterior – posterior, lateral or concentric collapse of the soft palate.

As BRP is being presented as a step procedure in a multilevel single stage operation the individual role of BRP in these complex managements of OSA is yet to be studied. The number of patients being minimal for proving the long-term efficacy of BRP as a lone procedure, we are working on the topic and hopefully shall present more data with larger number of patients.

Declarations

Conflict of interest

We the author’s, N N Madkikar, Shailesh Pandey, Virendra Ghaisas here by declare that we do not have any conflict of interest.

Informed consent

An informed and written consent was obtained from all subjects included within the study.

Ethical approval

All procedures performed in the studies involving human participants were in accordance with the ethical standards.