Down under BRP: Friedman 3 no longer a barrier for surgical success

 

Dr Mylestone Monna, Dr Michael Nasserallah, Dr Juan Mulder, Mr Nalaka De Silva, 

 

Peninsula Health, Victoria, Australia

 

Aim: Obstructive sleep apnoea (OSA) is a significant health issue with considerable public and personal costs. This study evaluated the efficacy of modified barbed reposition pharyngoplasty (BRP) and coblation tongue channelling (CCT) in adult OSA patients. Additionally, we assessed airway obstruction sites using the Velum, Oropharynx, Tongue base, and Epiglottis (VOTE) classification during awake nasoendoscopy to identify the most correctable types of airway collapse. We propose that Friedman staging is not a reliable predictor of surgical success, suggesting the need for a new prognostic index. 

 

Methodology: A prospective, 2-centre cohort trial was conducted to evaluate outcomes of combined modified BRP and CCT in 116 adult OSA patients. Polysomnography, Epworth Sleepiness Scale (ESS), and VOTE anatomy assessment were performed preoperatively and 3 months post-surgery by a single investigator. The results showed significant improvements in sleep quality, daytime alertness, and upper airway anatomy. 

 

Results: The study enrolled 116 participants, 92 had complete data set. (74% male; mean age 40.6±12.7 years). Statistically significant improvements were observed in AHI and ESS. Median AHI improved from 27.4±33 to 7.1±11.6 (p = 0.000), a 65% reduction. Median ESS improved from 12.5±8 to 4±4 (p = 0.000). Surgical success was achieved in 75% of patients, with 87.6% symptomatically better.  43% were cured (AHI < 5 and AHI reduction > 50% from baseline). Oxygen Desaturation Index (ODI) reduce from a median of 27.7 +/- 33 to post op median of  4.6 +/- 8.4 (p =0.007)

 

Friedman III patients (traditionally difficult anatomy)  had 76% success rate and 45% cure rate. Using the VOTE classification, the most correctable site of collapse was the oropharynx (100 % reduction of complete collapse), followed by velopharynx (85%) , with improvements also noted at the base of tongue (65%). 

 

Conclusion: Modified BRP with CCT is a safe and effective surgical option for OSA patients. Friedman stage III anatomy is not a barrier to success. Future studies should investigate new staging systems to better predict postoperative outcomes of modern sleep surgery techniques.