The epiglottis is a normal structure of the throat that serves an important role in swallowing. However, research from Dr. Kezirian and other leaders in the field has shown that the epiglottis can contribute to obstructive sleep apnea in about 5-10% of patients.  In these cases, an important option can be epiglottis surgery, such as moving the epiglottis forward (epiglottoplasty or epiglottopexy) or partial removal of the epiglottis (epiglottidectomy). Dr. Kezirian has written about the importance of the epiglottis in obstructive sleep apnea, his team’s research related to aging and epiglottis-related obstructive in sleep apnea, and techniques to identify the epiglottis as a cause of blockage in breathing.

How is epiglottis surgery for sleep apnea performed?

Epiglottis surgery is performed in the operating room under general anesthesia and is performed entirely by working through the open mouth, without any skin incisions. To move the epiglottis forward, the epiglottis stiffening operation technique involves cauterization of the side of the epiglottis facing the tongue. The body’s natural healing process then brings the epiglottis forward to open the space for breathing. In some cases, it can be helpful to place sutures to hold the epiglottis forward, making the procedure an epiglottopexy. Dr. Kezirian has written about the epiglottis stiffening operation in his blog.

Side view of the head and neck, showing the epiglottis displaced posteriorly towards the back of the throat

Side view of the head and neck after surgery to move the epiglottis forward and open the space for breathing

For partial removal of the epiglottis, a laser or other method of cutting is used to remove a portion of the epiglottis and control any bleeding.

Side view of the head and neck, before partial removal of the epiglottis

Side view of the head and neck, after partial removal of the epiglottis

 

RISKS

Bleeding

As with any procedure, there is a risk of bleeding. Bleeding in this area can be serious if it is substantial, as it would be close to the opening into the windpipe (trachea). Typically, however, there is only minor oozing from the cut edge of the epiglottis that resolves completely within the first 24 hours after surgery. A major factor in preventing serious bleeding is to avoid the use of aspirin, NSAIDs (such as ibuprofen, Advil®, Motrin®, naproxen, or Aleve®), vitamin supplements, or herbal medications for at least two weeks before and after surgery.

Infection

Infection is uncommon, but patients typically receive antibiotics at the time of surgery to reduce the chance of infection.

Tooth injury

Operating in the back of the throat is impossible unless an instrument is placed to keep the mouth open. This is the same instrument used when tonsillectomies are done. Rarely, a tooth may be injured by this instrument, and the risk is much higher if a tooth is loose or decayed prior to surgery.

Difficulty swallowing

The epiglottis is important in swallowing because it closes off the opening into the lungs through the trachea (windpipe). After epiglottis surgery, it is possible to have foods, especially liquids, entering the trachea, only to be cleared with a gentle cough. It is unusual for this complication to be permanent and significant.

Changes in speech

Any operation on the throat can cause changes in speech. The epiglottis is next to the larynx (voice box), but no surgery is performed on the larynx itself. Therefore, any changes in voice are usually temporary and are not noticeable.

Continued snoring

Many patients undergoing epiglottis surgery will also have loud snoring. The goal of epiglottis surgery is to eliminate obstructive sleep apnea. Usually snoring will improve dramatically if this goal is accomplished. However, many patients will continue to snore to some extent, even after surgery that resolves obstructive sleep apnea completely.

Need for additional procedures

Epiglottis surgery may not be effective in accomplishing the goals of surgery. Another procedure—either performed on the tongue region or on another area—may be necessary.

 

POSTOPERATIVE INSTRUCTIONS

NOTIFY DR. KEZIRIAN IMMEDIATELY IF YOU HAVE ANY TROUBLE BREATHING OR IF ANY BLEEDING DEVELOPS!

Hospital stay and discharge

Most patients stay in the hospital 1-2 days. The major concerns while you are in the hospital are making sure you are breathing freely, having no bleeding, controlling your pain with oral medications, and drinking enough fluids to have no risk of dehydration. Many people ask if they need someone to stay with them at home. You do need someone to stay with you the first night home after discharge, for safety. Beyond that, it is helpful to have someone available and checking on you to provide assistance when needed, although they do not have to stay with you 24 hours a day, every day. Planning before surgery (for example, buying milk or nutritional supplements) will decrease the amount of help you need at home after surgery.

Ice in the mouth

Holding ice in the mouth while they melt and cool the surgical area can help with pain control.  Doing this for the first 2-3 days after surgery is somewhat similar to applying ice to a sprained ankle.  It is one of the safest ways to reduce pain and can make the healing process easier.

Pain control

Like most surgeries, there is pain in the recovery period. However, we want to control your pain to make you comfortable during your recovery. Some people try to “hang in there” or suffer without taking pain medications. Controlling your pain is important for breathing, healing, and being able to swallow enough to maintain your nutrition.

While in the hospital, we will control your pain with oral medications, starting on the day of surgery. You can also hold ice chips inside your mouth to decrease swelling and reduce pain. Although we will use intravenous pain medications if necessary, the goal will be to use oral medications alone because this is what you will use when you go home after surgery. You will not receive a prescription for pain medications before surgery, as we will send you home with the type of medication and the amount that worked well for you in the hospital.

When you are at home, take your pain medication as you need it. You can also continue to hold ice chips inside your mouth to decrease pain and swelling. Try not to let the pain increase until it becomes intolerable before you take the medication. If you are running out of medication and need more, please call the office in advance to obtain another prescription. If you prefer to avoid narcotics, you should feel free to use acetaminophen (Tylenol®). Avoid aspirin, NSAIDs (such as ibuprofen, Advil®, Motrin®, naproxen, or Aleve®), vitamin supplements, or herbal medications for at least two weeks because they can increase your risk of bleeding after surgery. Your pain will be significant for at least the first 7-10 days following surgery, but it should improve markedly by 14 days following surgery.

Nutrition and fluids

It is very important to have good nutrition and avoid dehydration after surgery. Due to the pain and swelling that is expected after surgery, you will most likely only be able to tolerate a liquid diet for the first 4-5 days after surgery. Push yourself to drink fluids, even if it is painful. The first sign of dehydration is a decrease in urination, so keep track of this. In addition to water, it is It is helpful to drink other liquids, such as juices or Gatorade®. It is also essential that your body receive protein and fat in your diet to help with healing and maintaining your energy level. Every day, you should have 3 glasses of something with fat and protein like milk or chocolate milk, nutritional supplements like Muscle Milk® or Ensure®, or protein shakes. Dr. Kezirian may order a nutritional supplement like this while you are in the hospital. As your recovery continues, you will transition to soft solid foods such as eggs, yogurt, or mashed potatoes. You should be able to tolerate a fairly normal diet by 2 weeks after surgery. During the recovery period, you should avoid foods with sharp edges such as chips because these can cause bleeding. Otherwise, you can advance your diet according to your own schedule, being careful not to cause too much pain. Dr. Kezirian wants his patients to maintain their nutrition so that they do not lose weight in the few weeks right after surgery.

Antibiotics

Most patients receive an antibiotic while in the hospital. You may be prescribed an antibiotic to take when you go home. This can be useful for preventing infection and decreasing swelling. Take the antibiotics as directed. If you develop a rash or diarrhea (possible risks of antibiotics and other medications), stop the antibiotics and contact Dr. Kezirian immediately.

Activity

Walking after surgery is important. Patients should walk at least 3 times a day starting the day after surgery. Walking helps prevent blood clots from forming in your legs. Spending more time out of bed (walking or in a chair) than in bed is helpful because your lungs fill up with air, lowering the risk of fevers and pneumonia. Not walking enough is a major cause of fevers after surgery, so please do remember to walk at least 3 times every day. Patients should avoid strenuous activity for 4 weeks following surgery because that typically raises heart rate and blood pressure. For this reason, it can increase swelling or cause bleeding to start.

Do not use mouthwashes, lozenges, or throat sprays

Patients should not use mouthwashes, lozenges, or throat sprays following surgery because many of these contain alcohol or other chemicals that can irritate the lining of the mouth or numbing medication that can expose you to a serious complication when used for more than a couple of times.

Ear problems or jaw discomfort

The swelling in your throat that occurs after surgery can cause jaw pain or ear symptoms such as pain, pressure, or fullness. This is common and should improve within 1-2 weeks following surgery. It occurs because the soft palate and tonsils are next to the jaw and the small Eustachian tube that connects the space behind the eardrum to the top of the throat. Swelling in the throat can interfere with your ability to clear or pop your ears, and it can also be sensed by your body as pain coming from your ears even though the ears are not affected (a phenomenon called referred pain).

Sleep with head elevated (at 45 degrees) for at least three days

Elevating your head during sleep decreases blood flow to the head and neck regions. Therefore, it decreases swelling and the associated pain. Elevating the head during sleep may also improve breathing patterns in other ways. Therefore, we recommend elevating your head during sleep at 45 degrees for at least three days following the procedure.

Nausea and constipation

Nausea and constipation are very common after any surgery. The anesthetic medications that you receive during surgery and the narcotic pain medication you receive after surgery can cause these. You will receive medications after surgery to decrease nausea and constipation, but please notify Dr. Kezirian if you feel constipated or have not had a bowel movement in any 3 days after surgery.

Postoperative appointment

Dr. Kezirian likes to see his patients 1-2 weeks after surgery. If a postoperative appointment has not been scheduled, please contact the office to schedule this when you return home after your surgery.

Additional questions

For any emergencies, please call 911 or go to the nearest emergency room.  For other questions, please call the UCLA Health System page operator at (424) 259-6700 and ask for the Head and Neck Surgery resident on call.