The efficacy of multilevel surgery of the upper airway in adults with obstructive sleep apnea/hypopnea syndrome

Classification of the Excitation Location of Snore Sounds in the Upper Airway by Acoustic Multifeature Analysis

OBJECTIVE

Obstructive sleep apnea (OSA) is a serious chronic disease and a risk factor for cardiovascular diseases. Snoring is a typical symptom of OSA patients. Knowledge of the origin of obstruction and vibration within the upper airways is essential for a targeted surgical approach. Aim of this paper is to systematically compare different acoustic features, and classifiers for their performance in the classification of the excitation location of snore sounds.

METHODS

Snore sounds from 40 male patients have been recorded during drug-induced sleep endoscopy, and categorized by Ear, Nose & Throat (ENT) experts. Crest Factor, fundamental frequency, spectral frequency features, subband energy ratio, mel-scale frequency cepstral coefficients, empirical mode decomposition-based features, and wavelet energy features have been extracted and fed into several classifiers. Using the ReliefF algorithm, features have been ranked and the selected feature subsets have been tested with the same classifiers.

RESULTS

A fusion of all features after a ReliefF feature selection step in combination with a random forests classifier showed the best classification results of 78% unweighted average recall by subject independent validation.

CONCLUSION

Multifeature analysis is a promising means to help identify the anatomical mechanisms of snore sound generation in individual subjects.

SIGNIFICANCE

This paper describes a novel approach for the machine-based multifeature classification of the excitation location of snore sounds in the upper airway.

Uvulopalatopharyngoplasty

Objectives

(1) Determine the rate of postoperative complications, reoperation, readmission, and death after uvulopalatopharyngoplasty (UPPP) for sleep apnea through multi-institutional clinical data. (2) Compare outcomes of UPPP between multilevel and single-level procedures for the treatment of sleep apnea.

Study Design

Retrospective database analysis.

Methods

The American College of Surgeons National Surgical Quality Improvement Program—a nationally validated, prospective, multi-institutional database from 2005 to 2013—was analyzed for patients who underwent UPPP, per corresponding Current Procedural Terminology codes. Patients were categorized into 3 groups: UPPP alone, UPPP + nasal cavity (NC), and UPPP + base of tongue (BOT). Perioperative outcome measures of interest include surgical/medical complications, reoperation, readmission, and death. Comparisons were made among surgical groups through univariate cross-sectional analysis.

Results

A total of 1079 patients underwent UPPP; 413 patients had UPPP + NC; and 200 patients had UPPP + BOT procedures. One death was reported for the entire cohort of patients. Among all 3 groups (UPPP, UPPP + NC, and UPPP + BOT), no differences were noted in the rates of medical complications ( P = .445), surgical complications ( P = .396), reoperation ( P = .332), and readmission ( P = .447). However, the length of hospital stay in days was greatest for the UPPP + BOT group (UPPP, 0.81 ± 0.69; UPPP + NC, 0.87 ± 0.90; UPPP + BOT, 1.50 ± 2.70; P < .001).

Conclusion

These national data demonstrate no significant increase in risk when UPPP is performed as a single- or multilevel procedure. When indicated, UPPP with multilevel procedures may be safely performed for treatment of sleep apnea. These data set a benchmark for perioperative risk in UPPP surgery and will prove useful for counseling patients.

Distraction osteogenesis as a treatment of obstructive sleep apnea syndrome: A systematic review

BACKGROUND

To conduct a systematic review to answer the clinical question "What are the effectiveness of mandibular distraction osteogenesis (MDO) and its complications to treat patients with obstructive sleep apnea syndrome (OSAS)?".

METHODS

A systematic search including a computer search with specific keywords, reference list search, and manual search were done. Relevant articles on MDO were assessed and selected in 3 rounds for final review based on 5 predefined inclusion criteria and followed by a round of critical appraisal. Different types of distraction and their treatment outcomes of OSAS were recorded with standardized form and analyzed.

RESULTS

Twelve articles were included in the final review. A total of 256 patients aged 7 days to 60 years were treated with either external or internal MDO, with a mean follow-up period of 6 to 37 months. The average distraction distance of 12 to 29 mm was achieved with various distraction protocols. The success rate for adult patients was 100%, and cure rates were ranged from 82% to 100%. The definition of success or cure for OSAS in children or infants was not defined. Therefore, there were no clearly reported success or cure rates for children/infants in the included studies. However, all studies reported that these patients showed significant improvement in OSAS, with many of them who avoided tracheostomy or had the tracheostomy decannulated. The complication rates were ranged from 0% to 21.4%, with most being from local wound infections or neurosensory disturbances.

CONCLUSION

This systematic review showed that MDO was effective in resolving OSAS in adults with retrognathic mandible. MDO also showed promising results in infants or children with OSAS. From the results of this systematic review, we recommend to define the criteria of success or cure for OSAS surgery in children and infants. We also recommend setting up randomized controlled trials to compare MDO with traditional maxillomandibular advancement surgery for OSAS patients and to provide a better evidence on the success and complication rates of the techniques.

Surgical Management of Obstructive Sleep Apnea

Surgical management of snoring and obstructive sleep apnea is indicated when a surgically correctable abnormality is believed to be the source of the problem. Many patients opt for surgical treatment after noninvasive forms of treatment have been proven ineffective or difficult to tolerate. With increasing frequency, functional rhinoplasty, septoplasty, turbinoplasty, palatal surgery, and orthognathic surgery are being used in the management of snoring and obstructive sleep apnea. Plastic surgeons' experience with aesthetic nasal surgery, nasal reconstruction, palatal surgery, and craniofacial surgery puts them at the forefront of performing surgery for snoring and sleep apnea. The role of functional septorhinoplasty, turbinoplasty, palatal surgery, genioglossal advancement, and orthognathic surgery is indispensable in the surgical management of obstructive sleep apnea. Multidisciplinary management of these patients is critical, and plastic surgeons are encouraged to work collaboratively with sleep medicine clinicians and centers.

Impact of Minimally Invasive Multilevel Surgery on Mild/Moderate OSA

Objective

To assess 10-year data on subjective and objective improvements in patients with mild to moderate obstructive sleep apnea (OSA) after single-stage multilevel minimally invasive surgery.

Study Design

Case series with chart review.

Setting

Tertiary academic center.

Subjects and Methods

A chart review was conducted of 601 patients diagnosed with mild to moderate OSA who were treated with single-stage multilevel minimally invasive surgery from January 2005 to January 2015. Patients were treated with a combination of procedures that included various nasal procedures, palatal stiffening, and radiofrequency tongue base reduction. Demographics and objective and subjective parameters were collected; all patients were included who had a mean of 6 months of follow-up data available. Pre- and postoperative values were compared.

Results

A total of 601 patients were included in this study (67.0% male; age, 38.2 ± 9.4 years; mean body mass index, 27.4 ± 4.1 kg/m2). Mean apnea-hypopnea index decreased significantly from 19.8 ± 5.9 events per hour preoperatively to 12.7 ± 7.6 events per hour postoperatively ( P < .0001), with a 45.9% rate of “surgical success.” Mean daytime sleepiness decreased significantly from 12.1 ± 4.8 to 6.8 ± 2.9 ( P < .001) per the Epworth Sleepiness Scale. Mean snoring intensity showed a significant decrease from 8.8 ± 0.8 to 4.0 ± 2.1 ( P < .001).

Conclusion

Ten-year experience shows that treatment with single-stage multilevel minimally invasive surgery decreases objective and subjective measures in selected patients with mild to moderate OSA. Although not curative, this technique helps to control symptoms in a population of patients who refused CPAP.

Investigation into the presence of human papillomavirus in patients with obstructive sleep apnea

OBJECTIVES/HYPOTHESIS

The human papillomavirus (HPV) is known to infect the tissues of the oropharynx as demonstrated in HPV-positive oropharyngeal squamous cell carcinoma (OPSCC). HPV has also been shown to induce benign lymphoid hypertrophy. We sought to investigate an association between obstructive sleep apnea (OSA) and the presence of HPV in palatine and lingual tonsillar oropharyngeal tissue.

STUDY DESIGN

Case series with chart review.

METHODS

This retrospective laboratory-based study of oropharyngeal tissue from patients with OSA included patients >18 years old who underwent surgical treatment for OSA at a single institution between January 2012 and May 2014. Surgical specimens of adequate size were analyzed for HPV6, 11, and 16 using real-time quantitative polymerase chain reaction from DNA extracted from formalin-fixed paraffin-embedded tissue blocks. Student t test, Pearson χ² test, and linear logistic regression were used to assess comparisons of body mass index (BMI), apnea-hypopnea index (AHI), age, and gender between HPV-positive and HPV-negative groups.

RESULTS

Of 99 cases included in the study, six were positive for HPV: two with HPV16 and four with HPV6. BMI, AHI, age, and gender showed no significant differences between the HPV-positive and HPV-negative groups. Logistic regression to predict HPV positivity accounting for each variable and multivariate analysis were not statistically significant.

CONCLUSIONS

Our study did not show HPV to have a statistically significant association with OSA. None of the covariates analyzed (BMI, AHI, gender, age) predicted HPV positivity in surgically resected oropharyngeal tissue from OSA patients.

LEVEL OF EVIDENCE

4 Laryngoscope, 127:1231-1234, 2017.

State of the art transoral robotic surgery for obstructive sleep apnea-hypopnea syndrome

Objective

To review the existing literature on the role of transoral robotic surgery (TORS) for tongue base reduction in the management of adult obstructive sleep apnea-hypopnea syndrome (OSAHS).

Methods

We searched PubMed, MEDLINE, and Scopus databases from the first literature report of this surgical technique to July 30, 2015 for studies investigating the use of TORS for tongue base reduction in treating adult OSAHS. Our primary outcome measures were Apnea– Hypopnea Index (AHI), lowest oxygen saturation (LSAT), Epworth Sleepiness Score (ESS), and the rates of surgical cure (AHI<5) and success (50% reduction in AHI accompanied by a postoperative AHI<20). Our secondary outcome measures were the volume of tissue resected and correlation to AHI, polysomnographic parameters, subjective outcomes, and body mass index. Complications of surgery were also analyzed.

Results

Thirteen articles were critically evaluated for this research. However, only four case series qualified for statistical analysis of postoperative polysomnographic outcomes and six case series for analysis of postoperative complications. They were case series with a total of 451 adult patients. Pooled analysis revealed statistically significant improvements in AHI, LSAT, and ESS after surgery by 26.83/hour, 5.28% and −8.03, respectively. The average rates of surgical cure and success were 23.8% and 66.7%, respectively. No study reported any deaths or complications related to the use of robotic equipment. The major complication rate was 6.9%, and the minor complication rate was 30.0%. Major complications included major bleeding (2.9%), severe odynophagia with dehydration (3.3%), and oropharyngeal stenosis (0.7%). Minor complications included transient bleeding (0.5%), transient dysphagia (3.8%), and dysgeusia (6.6%).

Conclusion

TORS for tongue base reduction, as a component of multilevel surgery, is an effective treatment option for OSAHS with an acceptable morbidity. This conclusion is based on the analysis of the results of multiple case series. Future studies should entail prospective randomized controlled trials with larger sample size for longer follow-up period.

Longitudinal brain structural alterations and systemic inflammation in obstructive sleep apnea before and after surgical treatment

Background

Systemic inflammation, neurocognitive impairments, and morphologic brain changes are associated with obstructive sleep apnea (OSA). Understanding their longitudinal evolution and interactions after surgical treatment provides clues to the pathogenesis of cognitive impairment and its reversibility. In the present study, we investigate clinical disease severity, systemic inflammation, cognitive deficits, and corresponding gray matter volume (GMV) changes in OSA, and the modifications following surgery.

Methods

Twenty-one patients with OSA (apnea-hypopnea index, AHI > 5) and 15 healthy volunteers (AHI < 5) underwent serial evaluation, including polysomnography, flow cytometry for leukocyte apoptosis categorization, cognitive function evaluation, and high-resolution brain scan. Disease severity, leukocyte apoptosis, cognitive function, and imaging data were collected to assess therapeutic efficacy 3 months after surgery.

Results

Pre-operatively, patients presented with worse cognitive function, worse polysomnography scores, and higher early leukocyte apoptosis associated with increased insular GMV. There was reduced GMV in the anterior cingulate gyrus before and after surgery in the cases compared to that in controls, suggesting an irreversible structural deficit. Post-operatively, there were significant improvements in different cognitive domains, including attention, executive and visuospatial function, and depression, and in early leukocyte apoptosis. There was also a significant decrease in GMVs after treatment, suggesting recovery from vasogenic edema in the precuneus, insula, and cerebellum. Improvement in early leukocyte apoptosis post-surgery predicted better recovery of precuneus GMV.

Conclusions

In OSA, increased disease severity and systemic inflammation can alter GMV in vulnerable regions. Surgical treatment may improve disease severity and systemic inflammation, with subsequent recovery in brain structures and functions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12967-016-0887-8) contains supplementary material, which is available to authorized users.

Heart failure and sleep disorders

Awareness of the importance of sleep-related disorders in patients with cardiovascular diseases is growing. In particular, sleep-disordered breathing, short sleep time, and low sleep quality are frequently reported by patients with heart failure (HF). Sleep-disordered breathing, which includes obstructive sleep apnoea (OSA) and central sleep apnoea (CSA), is common in patients with HF and has been suggested to increase the morbidity and mortality in these patients. Both OSA and CSA are associated with increased sympathetic activation, vagal withdrawal, altered haemodynamic loading conditions, and hypoxaemia. Moreover, OSA is strongly associated with arterial hypertension, the most common risk factor for cardiac hypertrophy and failure. Intrathoracic pressure changes are also associated with OSA, contributing to haemodynamic alterations and potentially affecting overexpression of genes involved in ventricular remodelling. HF treatment can decrease the severity of both OSA and CSA. Indeed, furosemide and spironolactone administration, exercise training, cardiac resynchronization therapy, and eventually heart transplantation have shown a positive effect on OSA and CSA in patients with HF. At present, whether CSA should be treated and, if so, which is the optimal therapy is still debated. By contrast, more evidence is available on the beneficial effects of OSA treatment in patients with HF.

Efficacy of Upper Airway Stimulation on Collapse Patterns Observed during Drug-Induced Sedation Endoscopy

OBJECTIVE

To describe upper airway collapse patterns observed on drug-induced sedation endoscopy (DISE) during screening for a clinical trial and to evaluate the impact of collapse patterns found on preoperative DISE on response rates to upper airway stimulation (UAS) therapy.

STUDY DESIGN

Retrospective review of an ongoing prospective multi-institutional cohort study.

SETTING

Twenty-two participating institutions of the STAR trial.

SUBJECTS AND METHOD

In total, 222 subjects were screened with DISE to determine eligibility for an implantable UAS device. Supine laryngoscopy was performed during moderate sedation (propofol and/or midazolam). Airway collapse pattern and severity were graded at 4 levels, including velum, oropharynx, tongue base, and epiglottis (VOTE classification). Patients with complete concentric collapse (CCC) at the velum were excluded from implantation.

RESULTS

The CCC at the velum was observed in 52 (23%) of screened subjects, and these subjects were subsequently excluded from implantation. Of the 170 subjects without CCC at the velum, 126 (77%) underwent implantation: 121 (96%) had multilevel collapse and 5 (4%) had single-level collapse. When comparing preimplantation DISE findings, UAS responders at 12 months had lower baseline VOTE scores compared with therapy nonresponders.

CONCLUSION

Drug-induced sedation endoscopy is an efficient and safe method for determining UAS eligibility and has the potential to identify UAS nonresponders. Most patients had multilevel airway collapse, illustrating the limitations of single-level upper airway surgery in treating obstructive sleep apnea. Upper airway stimulation is effective therapy for most patients with multilevel airway collapse; however, patients with complete anterior-posterior or lateral soft palate and/or epiglottic collapse may be at increased risk of therapy failure.

Transoral Robotic Surgery for Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis

OBJECTIVE

To perform a systematic review of the international biomedical literature evaluating the effectiveness, complications, and safety of transoral robotic surgery (TORS) for the treatment of obstructive sleep apnea (OSA).

DATA SOURCES

PubMed/MEDLINE, Embase, and EMB Reviews databases were searched up to November 27, 2015.

REVIEW METHODS

Two authors systematically and independently searched for articles on TORS for the treatment of OSA in adults that reported either outcomes for the apnea-hypopnea index (AHI), lowest oxygen saturation percentage (LSAT) or changes in the Epworth Sleepiness Scale (ESS), and/or rates and types of complications associated with the operation.

RESULTS

In total, 181 records were identified and 16 articles met inclusion criteria. Transoral robotic surgery was almost always combined with other sleep surgery procedures. The summary estimate of the decrease in AHI using TORS as part of a multilevel surgical approach was 24.0 (95% confidence interval [CI], 22.1-25.8; P < .001, I(2) = 99%). The summary estimate of a decrease in ESS score was 7.2 (95% CI, 6.6-7.7; P < .001, I(2) = 99%) and of the overall surgical "success" (defined as AHI <20 and 50% reduction) was 48.2% (95% CI, 38.8%-57.7%; P < .001, I(2) = 99%). Three large studies reported on their total complication rates with an average of 22.3% (range, 20.5%-24.7%).

CONCLUSIONS

The initial results for the use of TORS as part of a multilevel surgical approach for OSA are promising for select patients. However, the cost and morbidity may be greater than with other techniques offsetting its advantages in visualization and precision. More prospective studies are needed to determine the optimal role of this tool.

Otorhinolaryngological aspects of sleep-related breathing disorders

Snoring and obstructive sleep apnoea (OSA) are disorders within a wide spectrum of sleep-related breathing disorders (SRBD). Given the obesity epidemic, these conditions will become increasingly prevalent and continue to serve as a large economic burden. A thorough clinical evaluation and appropriate investigations will allow stratification of patients into appropriate treatment groups. A multidisciplinary team is required to manage these patients. Patient selection is critical in ensuring successful surgical and non-surgical outcomes. A wide range of options are available and further long term prospective studies, with standardised data capture and outcome goals, are required to evaluate the most appropriate techniques and long term success rates.

The influence of multilevel upper airway surgery on CPAP tolerance in non-responders to obstructive sleep apnea surgery

The aim of this study was to evaluate the influence of multilevel upper airway surgery on subsequent continuous positive airway pressure (CPAP) use and tolerance in patients with moderate to severe obstructive sleep apnea (OSA). The study cohort enrolled 67 consecutive patients, who underwent septoplasty plus modified uvulopharyngopalatoplasty (mUPPP) with or without modified tongue base suspension (mTBS) due to CPAP intolerance, and who had residual OSA requiring CPAP therapy [non-responders to surgery, apnea-hypopnea index (AHI) >15 events/h] that had been confirmed by control polysomnography at the sixth month postoperatively. A questionnaire including questions on postoperative CPAP use, problems faced during CPAP use after the surgery, change in OSA symptoms, and satisfaction with the surgery was designed, and filled through interviews. Seventeen (25.4 %) patients had septoplasty plus mUPPP and 50 (74.6 %) had septoplasty plus mUPPP combined with mTBS. Postoperatively, mean AHI (45.00 ± 19.76 vs. 36.60 ± 18.34), Epworth sleepiness scale (ESS) score (18.00 ± 4.45 vs. 13.00 ± 4.72), oxygen desaturation index (ODI) (48.98 ± 16.73 vs. 37.81 ± 17.03), and optimal CPAP level (11.80 ± 1.40 vs. 8.96 ± 1.20) were decreased (p < 0.001 for all parameters). Fifty-nine percent of patients reported that they fairly satisfied with the surgery and 49.2 % reported that their symptoms were completely resolved. While none of the cases could tolerate CPAP before surgery, almost half (47.8 %) of the cases used CPAP without problems postoperatively. Postoperative CPAP users had significantly higher postoperative AHI (p = 0.001), supine AHI (p = 0.009), ESS (p = 0.019), and ODI (p = 0.014), and significantly lower postoperative minimum O2 saturation (p = 0.001) compared with non-users. Multilevel upper airway surgery with less invasive techniques may improve CPAP tolerance in well-selected patients.

Effects of Oropharyngeal Exercises on Snoring: A Randomized Trial

BACKGROUND

Snoring is extremely common in the general population and may indicate OSA. However, snoring is not objectively measured during polysomnography, and no standard treatment is available for primary snoring or when snoring is associated with mild forms of OSA. This study determined the effects of oropharyngeal exercises on snoring in minimally symptomatic patients with a primary complaint of snoring and diagnosis of primary snoring or mild to moderate OSA.

METHODS

Patients were randomized for 3 months of treatment with nasal dilator strips plus respiratory exercises (control) or daily oropharyngeal exercises (therapy). Patients were evaluated at study entry and end by sleep questionnaires (Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index) and full polysomnography with objective measurements of snoring.

RESULTS

We studied 39 patients (age, 46 ± 13 years; BMI, 28.2 ± 3.1 kg/m2; apnea-hypopnea index (AHI), 15.3 ± 9.3 events/h; Epworth Sleepiness Scale, 9.2 ± 4.9; Pittsburgh Sleep Quality Index, 6.4 ± 3.3). Control (n = 20) and therapy (n = 19) groups were similar at study entry. One patient from each group dropped out. Intention-to-treat analysis was used. No significant changes occurred in the control group. In contrast, patients randomized to therapy experienced a significant decrease in the snore index (snores > 36 dB/h), 99.5 (49.6-221.3) vs 48.2 (25.5-219.2); P = .017 and total snore index (total power of snore/h), 60.4 (21.8-220.6) vs 31.0 (10.1-146.5); P = .033.

CONCLUSIONS

Oropharyngeal exercises are effective in reducing objectively measured snoring and are a possible treatment of a large population suffering from snoring.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT01636856; URL: www.clinicaltrials.gov.

Endoscope-guided coblator tongue base resection using an endoscope-holding system for obstructive sleep apnea

BACKGROUND

Multilevel obstruction in obstructive sleep apnea commonly includes retroglossal obstruction. To improve surgical success rates, tongue volume reduction with posterior midline glossectomy and/or lingual tonsillectomy is widely performed.

METHODS

Nasotracheal intubation was utilized, and the combined tongue procedure was performed as a final step after palatal surgery. The tongue was pulled maximally by a retraction suture and a McIVOR (Karl Storz, Tuttlingen, Germany) or Davis mouth gag (Karl Storz,Tuttlingen, Germany), and a medium-length tongue blade was applied to expose the tongue base. A 70-degree rigid endoscope was fixed by the holding system and introduced into the oral cavity. Endoscope-guided coblator tongue base resection was then performed.

RESULTS

The surgeon could use both hands for the surgery, enabling a more delicate resection of tongue base tissue.

CONCLUSION

This technique was acceptable and can be successfully used in patients with a large tongue, in whom exposing the tongue base for surgery is difficult.

Consensus and evidence-based Indian initiative on obstructive sleep apnea guidelines 2014 (first edition)

Obstructive sleep apnea (OSA) and obstructive sleep apnea syndrome (OSAS) are subsets of sleep-disordered breathing. Awareness about OSA and its consequences among the general public as well as the majority of primary care physicians across India is poor. This necessitated the development of the Indian initiative on obstructive sleep apnea (INOSA) guidelines under the auspices of Department of Health Research, Ministry of Health and Family Welfare, Government of India. OSA is the occurrence of an average five or more episodes of obstructive respiratory events per hour of sleep with either sleep-related symptoms or co-morbidities or ≥15 such episodes without any sleep-related symptoms or co-morbidities. OSAS is defined as OSA associated with daytime symptoms, most often excessive sleepiness. Patients undergoing routine health check-up with snoring, daytime sleepiness, obesity, hypertension, motor vehicular accidents, and high-risk cases should undergo a comprehensive sleep evaluation. Medical examiners evaluating drivers, air pilots, railway drivers, and heavy machinery workers should be educated about OSA and should comprehensively evaluate applicants for OSA. Those suspected to have OSA on comprehensive sleep evaluation should be referred for a sleep study. Supervised overnight polysomnography is the “gold standard” for evaluation of OSA. Positive airway pressure (PAP) therapy is the mainstay of treatment of OSA. Oral appliances (OA) are indicated for use in patients with mild to moderate OSA who prefer OA to PAP, or who do not respond to PAP or who fail treatment attempts with PAP or behavioral measures. Surgical treatment is recommended in patients who have failed or are intolerant to PAP therapy.

Increased circulating endothelial progenitor cells and anti-oxidant capacity in obstructive sleep apnea after surgical treatment

BACKGROUND

Obstructive sleep apnea (OSA) has increased risk of cardiovascular diseases. Profiles of endothelial progenitor cells (EPCs) reflect the degree of endothelial impairment. This study tested the hypothesis that surgical treatment not only improves clinical outcomes but also increases the number of circulating EPCs and antioxidant capacity.

METHODS

The number of circulating EPCs (CD133(+)/CD34(+) [%], KDR(+)/CD34(+) [%]), biomarkers for oxidative stress (thiols and TBARS), and polysomnography (PSG) study was prospectively evaluated in 62 OSA patients at two time points (pre-operative and at least 3-month post-operative). The biomarkers and PSG were compared with those of 31 age- and body mass index (BMI)-matched healthy controls.

RESULTS

Levels of HbA1c and LDL-C were significantly higher while CD133(+)/CD34(+) (%) and HDL were significantly lower in OSA patients than in healthy controls. The levels of CD133(+)/CD34(+) (%) and thiols significantly increased in both mild/moderate and severe OSA. The TBAR levels also significantly decreased in severe OSA patients after >3months of follow-up. The number of CD133(+)/CD34(+) (%) negatively correlated with both age and mO2 of <90% but positively correlated with thiols. Clinical efficiency after OSA surgery assessed by PSG showed improvement and mean systolic blood pressure (SBP) (night and morning) reduction and improved lipid profile in the severe OSA group while only the snoring index improved in the mild/moderate OSA group.

CONCLUSIONS

OSA surgery not only improves clinical outcomes, SBP reduction and improved lipid profile but also increases the number of circulating EPCs and antioxidant capacity, especially in patients with severe OSA.

National Institutes of Health Funding for Obstructive Sleep Apnea: An Opportunity for Otolaryngologists

OBJECTIVE

To describe current levels and trends of funding for the National Institutes of Health (NIH) in obstructive sleep apnea (OSA) and to recognize the current status of otolaryngologists in OSA research.

STUDY DESIGN

Scientometric analysis.

METHODS

The NIH RePORTER database was queried for the search term "obstructive sleep apnea" for all available years. Sex, degree, academic department, NIH funding source, geography, funding totals and years, and h-index of principal investigators (PIs) were collected and summarized.

RESULTS

A total of 397 projects spanning 1242 total funding years were funded. Of the 273 individual PIs, 33.3% (91/273) were female. Regarding credentials, 52.4% of PIs (143/273) were MD or MD/PhD, and 41.0% (112/273) were PhD alone. Academic departments of PIs were most often medicine (34.1%), pediatrics (12.1%), cell biology/physiology (10.6%), and psychiatry (7.7%). Seven otolaryngology faculty members had received NIH funding for OSA research (2.6% of total PIs) since 2000. They accounted for 8 grants (0.25% of total grants) and $7,235,729 (1.5% of total dollars) of research funding.

CONCLUSION

Despite studies showing increasing levels of OSA surgery being performed and major areas of research and clinical opportunity, otolaryngologists represent a small minority of OSA research funding. This information may help direct our specialty when setting priorities regarding research funding, as research into the basic science and clinical management of OSA represents a broad and interdisciplinary pursuit.

The status of cephalometry in the prediction of non-CPAP treatment outcome in obstructive sleep apnea patients

Obstructive sleep apnea syndrome (OSAS) is the most common sleep disordered breathing disorder (SDB) in adults and is characterized by a recurrent partial or complete collapse of the upper airway during sleep. This can be caused by many factors, sometimes interacting, such as skeletal malformations, soft tissue crowding, respiratory instability and the various effects of aging, obesity and gender that dictate craniofacial and upper airway anatomy. Research has demonstrated that the majority of patients exhibit at least one anatomical component such as retrognathia or a narrow posterior airway space that predisposes to the development of OSAS. Within the predisposing elements for OSAS many seem to point to anatomical characteristics. A standardized and relatively simple radiologic technique to evaluate anatomical craniofacial relationships is cephalometry. This has been used already for a long time in orthodontics, but is now gradually being introduced in OSAS treatment to envisage optimal treatment selection as well as to predict treatment outcomes. The purpose of the present review is to evaluate the contribution of cephalometry in the prediction of outcomes from OSAS treatments that depend on the upper airway morphology in their mechanisms of action such as oral appliances that advance the mandible as well as various surgical methods. In addition, an overview of imaging modalities and methods that currently are being used in cephalometric analysis in OSAS patients is provided. The findings indicate that isolated cephalometric parameters cannot be used to reliably predict treatment outcomes from mandibular advancement devices and surgical methods for OSAS. Extreme or outlying values of cephalometric parameters may rather be used as contra-indicators or 'red flags' instead of predictors.

Improvement of baroreflex sensitivity in patients with obstructive sleep apnea following surgical treatment

OBJECTIVE

Depressed baroreflex sensitivity (BRS) have been reported in patients with obstructive sleep apnea (OSA). This study aimed to determine if surgery can improve the clinical outcomes by investigating changes in BRS and in other cardiovascular autonomic parameters.

METHODS

Eighty-one OSA patients were enrolled. They were classified as mild OSA if their apnea-hypopnea index (AHI) was 5-15, moderate OSA if their AHI was 15-30, and sever OSA if their AHI was >30. Twenty-three subjects with AHI<5 were recruited as controls. For patients who received surgery, polysomnography (PSG) and autonomic tests were evaluated upon enrollment and six-months after surgery.

RESULTS

The patient number for mild, moderate, and severe OSA was 22, 22, and 37, respectively. BRS on enrollment showed significant difference among the four groups, with the highest BRS in the control group, follow by the mild, moderate, and severe OSA groups. There were significant correlations between BRS and all PSG parameters. The depressed BRS significantly improved after surgery.

CONCLUSIONS

Surgical modifications of the upper airways can improve the depressed BRS in OSA patients.

SIGNIFICANCE

The study offers the promise that surgical treatment for OSA not only improves the index of PSG, but also reduces the possibility of cardiovascular risk.

A Cost-Effectiveness Analysis of Surgery for Middle-Aged Men with Severe Obstructive Sleep Apnea Intolerant of CPAP

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is associated with increased cardiovascular morbidity and mortality. Conventional OSA therapy necessitates indefinite continuous positive airway pressure (CPAP). Although CPAP is an effective treatment modality, up to 50% of OSA patients are intolerant of CPAP. We explore whether surgical modalities developed for those intolerant of CPAP are cost-effective.

METHODS

We construct a lifetime semi-Markov model of OSA that accounts for observed increased risks of stroke, cardiovascular disease, and motor vehicle collisions for a 50-year-old male with untreated severe OSA. Using this model, we compare the cost-effectiveness of (1) no treatment, (2) CPAP only, and (3) CPAP followed by surgery (either palatopharyngeal reconstructive surgery [PPRS] or multilevel surgery [MLS]) for those intolerant to CPAP.

RESULTS

Compared with the CPAP only strategy, CPAP followed by PPRS (CPAP-PPRS) adds 0.265 quality adjusted life years (QALYs) for an increase of $2,767 (discounted 2010 dollars) and is highly cost effective with an incremental cost-effectiveness ratio (ICER) of $10,421/QALY for a 50-year-old male with severe OSA. Compared to a CPAP-PPRS strategy, the CPAP-MLS strategy adds 0.07 QALYs at an increase of $6,213 for an ICER of $84,199/QALY. The CPAP-PPRS strategy appears cost-effective over a wide range of parameter estimates.

CONCLUSIONS

Palatopharyngeal reconstructive surgery appears cost-effective in middle-aged men with severe OSA intolerant of CPAP. Further research is warranted to better define surgical candidacy as well as short-term and long-term surgical outcomes.

COMMENTARY

A commentary on this article appears in this issue on page 509.

Characterization of upper airway obstruction by fiber-optic nasolaryngoscopy and MRI in preoperative OSAHS patients

OBJECTIVE

To investigate changes in the upper airway and its surrounding soft tissue and to characterize the extent and severity of upper airway obstruction in 136 obstructive sleep apnea/hypopnea syndrome (OSAHS) patients who were awake.

METHODS

OSAHS patients and healthy controls were evaluated by fiber-optic nasolaryngoscopy and MRI. The cross-sectional area and pharyngeal wall thickness of the retropalatal, retroglossal and epiglottic region were determined.

RESULTS

Ninety-five percent of the mild OSAHS subjects had single-plane obstruction (vs. severe OSAHS, p < 0.05), 5.0% of the mild OSAHS subjects had two-plane obstruction (p < 0.05) and none of them had three-plane obstruction (p < 0.05). The cross-sectional area of the retropalatal, retroglossal and epiglottic region progressively declined as the severity of OSAHS increased (severe OSAHS vs. controls, p < 0.05). The lateral pharyngeal wall was significantly thicker in OSAHS subjects than in healthy controls (p < 0.05). The cross-sectional area of the soft palate in moderate and severe OSAHS subjects was markedly larger than that of the healthy controls (p < 0.05) and positively correlated with the apnea/hypopnea index (p < 0.05).

CONCLUSION

Moderate and severe OSAHS patients exhibit multi-plane obstruction of the upper airway, particularly in the retropalatal and retroglossal region. The severity of OSAHS negatively correlates with the thickness, length and cross-sectional area size of the soft palate.

Skeletal stability of patients undergoing maxillomandibular advancement for treatment of obstructive sleep apnea

PURPOSE

To determine the long-term stability of maxillomandibular advancement (MMA) in patients with obstructive sleep apnea (OSA).

MATERIALS AND METHODS

This was a retrospective cohort study of patients who underwent MMA and genial tubercle advancement (GTA) for treatment of OSA. Patients were included if they 1) were older than 19 years; 2) had a confirmatory polysomnogram; 3) underwent a Le Fort I osteotomy, bilateral sagittal split osteotomies, and GTA; 4) had adequate radiographic documentation; and 5) at least 11 months of follow-up. Exclusion criteria included previous orthognathic or other maxillofacial surgery. Predictor variables were the presence of OSA treated by MMA, pre- and postoperative orthodontia or no orthodontia, length of follow-up, and magnitude of advancement. The outcome variable was the stability of MMA judged by clinical examination and cephalometric measurements. Standardized lateral cephalometric measurements were performed preoperatively (T0), immediately postoperatively (T1), and at the latest follow-up beyond 11 months (T2). Differences in cephalometric measurements were calculated between time points (T0 to T1 and T1 to T2) for the overall group and for patients who had orthodontia (group 1) and those who did not (group 2). A correlation analysis using length of follow-up and magnitude of advancement as predictor variables of stability was completed. For all analyses, a P value less than .05 was considered statistically significant.

RESULTS

During the 9-year study period, 120 patients with OSA were evaluated and 112 had operative treatment; 25 patients specifically had MMA and GTA, met the inclusion criteria, and formed the study sample. The mean maxillary and mandibular advancements (T1 vs T0) were 9.48 mm (range, 1.6 to 15.2 mm) and 10.85 mm (range, 6.3 to 15.8 mm), respectively. From T1 to T2, no occlusal changes occurred. Changes in the subgroup analyses included a decrease in the angle formed by the sella, nasion, and A point (SNA) and the angle formed by the nasion and A and B points (ANB) and an increase in the angle formed by the mandibular plane (gnathion and gonion) to a line from the sella to the nasion in group 1 and a decrease in ANB in group 2. The only statistical mean difference in cephalometric measurements between groups was in the distance between the condylion and the gnathion. There was no correlation between length of follow-up (mean, 27.84 months) and changes in cephalometric measurements.

CONCLUSION

Results of this study indicate that although there were changes in the SNA and ANB from T1 to T2 suggesting maxillary relapse, the mean difference was no greater than 1° and no patients developed a malocclusion; therefore, the changes were considered clinically minor. Advancement of the maxillomandibular complex by 10 mm for treatment of OSA remains stable at a mean follow-up period longer than 2 years and preoperative orthodontic treatment does not appear to influence skeletal stability.

An evidence-based approach to the management of snoring in adults

BACKGROUND

Snoring is frequently encountered by the otolaryngologist. Given its significant impact on quality of life and that it is a symptom of sleep-related breathing disorders, diagnosis and treatment are of major importance. In particular, the diagnosis should aim to distinguish between simple snoring and obstructive sleep apnoea. This article aims to provide a systematic, concise and evidence-based method of managing the adult patient with snoring.

METHOD

This review was based on a literature search last undertaken on 30 June 2014. The MEDLINE, EMBASE and Cochrane databases were searched using the subject headings snoring and obstructive sleep apnoea in adults in combination with classification, diagnosis, investigations, management, treatment and surgery. Results were limited to English language articles including case series, clinical trials, randomised controlled trials, meta-analyses, systematic reviews and review articles. Relevant references from selected articles were also reviewed.

RESULTS

The majority of published literature for snoring is of level II/III evidence and that for obstructive sleep apnoea being of level I/II, with 36 relevant randomised controlled trials identified. The diagnosis of obstructive sleep apnoea involves thorough clinical assessment and typically a sleep study. Snoring may be managed with lifestyle modification, intra-oral devices or by surgical intervention, with continuous positive airway pressure being the treatment of choice for moderate-to-severe obstructive sleep apnoea.

CONCLUSIONS

A structured history of snoring and its associated symptoms, comprehensive examination including flexible laryngoscopy and sleep studies where relevant, in addition to targeted investigations, should lead to the correct diagnosis and appropriate management.

Evaluation of coblation lingual tonsil removal technique for obstructive sleep apnea in Asians: preliminary results of surgical morbidity and prognosticators

Retroglossal obstruction is one of the etiologies causing obstructive sleep apnea (OSA) and can be addressed by removing some tissues of the tongue base. However, because of its deep-seated location, its surgical removal is still challenging. Although coblation technique has been introduced, its efficacy and morbidity need further evaluation, particularly in Asians. This study aimed to assess its safety and effectiveness and to identify outcome prognosticators. Forty-seven OSA patients who underwent coblation lingual tonsil removal were included. Retroglossal obstruction was confirmed by drug-induced sleep videofluoroscopy. Attended full-night polysomnography was performed twice; before and 6 months after surgery in 27 patients. The tongue base was fully exposed with three deep-seated traction sutures, visualized with a 30° or 70° endoscope, and ablated using a coblator. Surgical success was defined with postoperative apnea hypopnea index (AHI) <20 and reduction >50 %. Postoperative morbidities were evaluated. Demographic and polysomnographic parameters between success and failure groups were compared. None of the patients had immediate postoperative hemorrhage. Postoperatively, one patient had delayed hemorrhage and one patient severe respiratory difficulty. Taste loss, tongue dysmotility, dental injury or severe oropharyngeal stricture were absent. A mean AHI decreased from 37.7 ± 18.6 to 18.7 ± 14.8/h (P < 0.001). The success rate was 55.6 %. Their mean minimal oxygen saturation was significantly lower (P = 0.004) in the failure group. Coblation lingual tonsil removal technique showed minimal morbidity and favorable outcome in Koreans. The surgical outcome might be associated with the severity of single respiratory events.

Effect of upper-airway stimulation for obstructive sleep apnoea on airway dimensions

Upper-airway stimulation (UAS) using a unilateral implantable neurostimulator for the hypoglossal nerve is an effective therapy for obstructive sleep apnoea patients with continuous positive airway pressure intolerance. This study evaluated stimulation effects on retropalatal and retrolingual dimensions during drug-induced sedation compared with wakefulness to assess mechanistic relationships in response to UAS. Patients with an implanted stimulator underwent nasal video endoscopy while awake and/or during drug-induced sedation in the supine position. The cross-sectional area, anterior-posterior and lateral dimensions of the retropalatal and retrolingual regions were measured during baseline and stimulation. 15 patients underwent endoscopy while awake and 12 underwent drug-induced sedation endoscopy. Increased levels of stimulation were associated with increased area of both the retropalatal and retrolingual regions. During wakefulness, a therapeutic level of stimulation increased the retropalatal area by 56.4% (p=0.002) and retrolingual area by 184.1% (p=0.006). During stimulation, the retropalatal area enlarged in the anterior-posterior dimension while retrolingual area enlarged in both anterior-posterior and lateral dimensions. During drug-induced sedation endoscopy, the same stimulation increased the retropalatal area by 180.0% (p=0.002) and retrolingual area by 130.1% (p=0.008). Therapy responders had larger retropalatal enlargement with stimulation than nonresponders. UAS increases both the retropalatal and retrolingual areas. This multilevel enlargement may explain reductions of the apnoea-hypopnoea index in selected patients receiving this therapy.

Volumetric three-dimensional computed tomographic evaluation of the upper airway in patients with obstructive sleep apnoea syndrome treated by maxillomandibular advancement

Obstructive sleep apnoea syndrome is the periodic reduction or cessation of airflow during sleep together with daytime sleepiness. Its diagnosis requires polysomnographic evidence of 5 or more episodes of apnoea or hypopnoea/hour of sleep (apnoea/hypopnoea index, AHI). Volumetric 3-dimensional computed tomographic (CT) reconstruction enables the accurate measurement of the volume of the airway. Nasal continuous positive airway pressure (CPAP) is the conventional non-surgical treatment for patients with severe disease. Operations on the soft tissues that are currently available give success rates of only 40%-60%. Maxillomandibular advancement is currently the most effective craniofacial surgical technique for the treatment of obstructive sleep apnoea in adults. However, the appropriate distance for advancement has not been established. Expansion of the air-flow column volume did not result in an additional reduction in AHI, which raises the important issue of how much the maxillomandibular complex should be advanced to obtain an adequate reduction in AHI while avoiding the risks of overexpansion or underexpansion. We have shown that there is a significant linear relation between increased absolute upper airway volume after advancement and improvement in the AHI (p=0.013). However, increases in upper airway volume of 70% or more achieved no further reduction in the AHI, which suggests that the clinical improvement in AHI reaches a plateau, and renders further expansion unnecessary. This gives a new perspective to treatment based on the prediction of changes in volume, so the amount of sagittal advancement can be tailored in each case, which replaces the current standard of 1cm.

The effect of uvulopalatopharyngoplasty with tonsillectomy in patients with obstructive sleep apnea

In the current study, we evaluated the effectiveness of uvulopalatopharyngoplasty (UPPP) in treatment of patients with obstructive sleep apnea (OSA) syndrome. All patients were previously received medical treatment but their symptoms did not resolve. A prospective study was conducted in Shahid Sadoughi Hospital in Yazd, Iran. Several sleep indices were evaluated using polysomnography (PSG) in all patients before performing UPPP and tonsillectomy. All patients were visited 6 months after surgery and PSG was repeated to assess the efficacy of surgical intervention. A total of 48 patients were enrolled and underwent UPPP and tonsillectomy. Six months after surgery, significant improvements were observed in all indices of sleep (apnea-hypopnea index, respiratory distress index, arterial oxygen saturation, and snoring index). The score of daytime sleepiness (assessed by Epworth score) was also improved. According to the result of this study, using UPPP surgery in patients with OSA can cause symptoms improvement in 64 % of cases. It seems that Muller's maneuver test has assisted in briefly increasing success rate after surgery, though to prove this claim; other studies should be designed and performed in a randomized clinical trial.

Multilevel treatment of moderate and severe obstructive sleep apnea with bone-anchored pharyngeal suspension sutures

Success rates for the surgical treatment of obstructive sleep apnea (OSA) vary, with phase I surgical success ranging from 40 to 75%. Pharyngeal suspension suture procedures are minimally invasive techniques with a reported efficacy of 20 to 78%. We conducted a study to evaluate the effectiveness of pharyngeal suspension suture procedures in conjunction with uvulopalatopharyngoplasty (UPPP) as a multilevel treatment for OSA. We retrospectively reviewed the charts of 30 adults-22 men and 8 women, with a mean age of 49 years and a mean BMI of 30.6-who were treated at a tertiary care academic medical center and a private otolaryngology practice. All patients had moderate or severe OSA, and all had failed continuous positive airway pressure therapy. Of this group, 20 patients underwent tongue base and hyoid suspension (TBHS) and 10 underwent tongue base suspension (TBS) alone; 23 patients had undergone concurrent or previous UPPP, 13 in the TBHS group and all 10 in the TBS group. Polysomnography was performed an average of 3.9 months postoperatively. Surgical success was defined as a reduction in respiratory distress index (RDI) of more than 50% and a postoperative RDI of 20 or less. The overall surgical success rate was 63% (19/30). In the surgical success group, the mean RDI fell from 44.6 to 9.4 (p < 0.0001); in the surgical failure group, the mean RDI rose from 41.3 to 48.9 (p = 0.58). There were 6 complications: 3 seromas, 2 suture breaks, and 1 dislodged screw. We conclude that pharyngeal suspension suture procedures as part of the multilevel treatment of moderate and severe OSA yields better outcomes than conventional surgical treatments with the added benefit of being minimally invasive.

Z-palatopharyngoplasty Combined with Endoscopic Coblator Open Tongue Base Resection for Severe Obstructive Sleep Apnea/Hypopnea Syndrome

OBJECTIVES

To investigate the safety and outcomes of Z-palatopharyngoplasty (ZPPP) combined with endoscopic Coblator open tongue base resection (Eco-TBR) for the treatment of severe obstructive sleep apnea/hypopnea syndrome (OSAHS).

STUDY DESIGN

Review of a prospective database.

SETTING

Academic tertiary medical center.

METHODS

Thirty-nine patients with severe OSAHS who had multilevel obstruction, failed continuous positive airway pressure therapy, and then underwent ZPPP plus Eco-TBR were enrolled in this study. The subjective symptoms and objective polysomnography parameters were collected preoperatively and at a minimum of 12 weeks postoperatively. Statistical analysis was determined by the Wilcoxon signed rank test.

RESULTS

Thirty-five patients, consisting of 3 female and 32 male patients (mean age, 42 years), had completed data for final analysis. None of the patients had perioperative or postoperative serious complications. The classical success rate was 62.9% (22/35). Three months postoperatively, the Epworth Sleepiness Scale decreased from 11.0 ± 4.2 to 8.7 ± 4.3 (P = .0006). The mean apnea/hypopnea index decreased from 50.6 ± 16.6 to 26.5 ± 23.5 events/h, the lowest oxygen saturation (%) improved from 70.4 ± 9.9 to 80.1 ± 11.3, and the snoring visual analog scale (0-10) as assessed by bed partner decreased from 9.86 ± 0.69 to 3.27 ± 1.96 (P < .0001 for all variables).

CONCLUSION

This study shows the significant benefits of ZPPP plus Eco-TBR in patients with severe OSAHS.

Temporal trends in sleep apnea surgery: 1993-2010

OBJECTIVES/HYPOTHESIS

Growing evidence supports the use of multilevel surgery to effectively address obstructive sleep apnea (OSA). We sought to characterize changes in the patterns of surgical sleep care over time.

STUDY DESIGN

Repeated cross-sectional study.

METHODS

Discharge data from the US Nationwide Inpatient Sample for 232,470 patients who underwent nasal, palatal, or hypopharyngeal procedures for sleep disordered breathing or OSA from 1993 to 2010 were analyzed using cross-tabulations and multivariate regression modeling.

RESULTS

Inpatient sleep surgical procedures increased from 97,363 performed in 1993-2000 to 135,107 in 2001-2010. Sleep surgery in 2001-2010 was associated with increased hypopharyngeal surgery (relative risk ratio [RRR] = 3.6, 95% confidence interval [CI] = 2.6-4.9, P < .001), tongue radiofrequency/midline glossectomy (RRR = 5.1, 95% CI = 3.4-7.5, P < .001), hyoid suspension (RRR = 6.8, 95% CI = 3.8-12.5, P < .001), nasal surgery (RRR = 1.3, 95% CI = 1.1-1.5, P = 0.002), and multilevel surgery (RRR = 5.6, 95% CI = 3.8-9.4, P < .001) and decreased tracheostomy (RRR = 0.58, 95% CI = 0.49-0.68, P < .001) compared to 1993-2000. Patients undergoing sleep surgery in 2001-2010 were more likely to have an OSA diagnosis (RRR = 1.9, 95% CI = 1.4-2.5, P < .001), obesity (RRR = 1.5, 95% CI = 1.4-1.7, P < .001), and advanced comorbidity (RRR = 2.4, 95% CI = 2.0-2.8, P < .001). In 2001-2010, surgeons (>23 cases/yr) in the top-volume quintile were more likely to perform hypopharyngeal procedures (RRR = 2.4, 95% CI = 1.7-3.4, P < .001,) and to be associated with teaching hospitals (RRR = 1.5, 95% CI = 1.0-2.2, P = 0.034) and less likely to perform tracheostomy (RRR = 0.27, 95% CI = 0.18-0.40, P < .001). However, they represented only 17% of surgeons performing sleep surgery in contrast to surgeons in the bottom-volume quintile, who performed 35% of cases.

CONCLUSIONS

These data reflect changing trends in the surgical management of OSA, with meaningful differences in the type of surgical care provided by high-volume surgeons and a significant increase in surgical sleep procedures, particularly nasal and hypopharyngeal surgery.

Innovative treatments for adults with obstructive sleep apnea

Obstructive sleep apnea (OSA) affects one in five adult males and is associated with significant comorbidity, cognitive impairment, excessive daytime sleepiness, and reduced quality of life. For over 25 years, the primary treatment has been continuous positive airway pressure, which introduces a column of air that serves as a pneumatic splint for the upper airway, preventing the airway collapse that is the physiologic definition of this syndrome. However, issues with patient tolerance and unacceptable levels of treatment adherence motivated the exploration of other potential treatments. With greater understanding of the physiologic mechanisms associated with OSA, novel interventions have emerged in the last 5 years. The purpose of this article is to describe new treatments for OSA and associated complex sleep apnea. New approaches to complex sleep apnea have included adaptive servoventilation. There is increased literature on the contribution of behavioral interventions to improve adherence with continuous positive airway pressure that have proven quite effective. New non-surgical treatments include oral pressure devices, improved mandibular advancement devices, nasal expiratory positive airway pressure, and newer approaches to positional therapy. Recent innovations in surgical interventions have included laser-assisted uvulopalatoplasty, radiofrequency ablation, palatal implants, and electrical stimulation of the upper airway muscles. No drugs have been approved to treat OSA, but potential drug therapies have centered on increasing ventilatory drive, altering the arousal threshold, modifying loop gain (a dimensionless value quantifying the stability of the ventilatory control system), or preventing airway collapse by affecting the surface tension. An emerging approach is the application of cannabinoids to increase upper airway tone.

Modified Hyoid Suspension Technique in the Treatment of Multilevel Related Obstructive Sleep Apnea

Objective

Using the Hörmann technique of hyoid suspension in sleep apnea surgery, a steel wire is placed through the thyroid cartilage and slung around the hyoid bone. However, we experienced thyroid cartilage fracture by steel wire traction. A modification is presented to avoid thyroid cartilage fracture.

Study Design

Case series with chart review.

Setting

University hospital.

Subjects and Methods

Twenty-seven patients affected by obstructive sleep apnea syndrome underwent Hörmann hyoid suspension. In 2 patients, the steel wire caused a fracture of the thyroid cartilage. The technique was therefore modified in 25 subsequent patients. The wire is threaded through an adaptation titanium miniplate placed on the surface of the thyroid cartilage.

Results

The apnea-hypopnea index decreased from 43.1 to 10.9/h. Nineteen patients (76%) met the criteria for a successful outcome. No complications related to this modification were noted.

Conclusions

The Hörmann hyoid suspension is a procedure that advances the hyoid bone to expand the airway, and its effectiveness has been proven previously. The modified hyoid suspension presented here promises similar results without the risk of serious complications such as thyroid cartilage fracture.

Comprehensive review of surgeries for obstructive sleep apnea syndrome

There are several surgical treatment modalities utilized for obstructive sleep apnea syndrome (OSAS). OSAS can cause excessive daytime sleepiness as well as cardiovascular morbidity and mortality. Patients who fail medical management often seek surgical treatment.

Objective

This paper reviews surgical treatment options for obstructive sleep apnea syndrome to include original descriptions as well as outcomes for snoring, apnea-hypopnea indices, and mortality benefits.

Method

A literature review was performed for OSAS surgical treatment options for soft tissue and skeletal surgeries. Articles with the original descriptions and surgical reviews are included for each procedure.

Results

A total of twenty-eight surgical treatment modalities for OSAS were identified. Original article authors and year of description were obtained and presented. Polysomnographic data for apnea indices, apnea-hypopnea indices and mortality are presented.

Conclusion

There is a large amount of variability in outcomes for sleep surgeries, however, in order to maximize success and cure rates, multiple procedures are most often necessary. Sleep surgeons must get familiar with modern surgical concepts and techniques, and participate in multi-disciplinary care in order to maximize treatment outcomes.