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

Reviewing the Systematic Reviews in OSA Surgery

Objective

There is an extensive amount of literature on surgeries as treatment for obstructive sleep apnea syndrome on adults. Previous systematic reviews have been performed to summarize the outcomes for sleep surgeries, with conflicting results. The objective of this study was to critically evaluate these systematic reviews to provide an overview of their quality, strengths, and conclusions.

Data Sources

MEDLINE, Scopus, and the Cochrane Collaboration databases were searched from inception to April 2013.

Review Methods

An overview of systematic reviews was undertaken. Studies included in this review are the systematic reviews whose primary objective was to evaluate the outcomes of sleep apnea surgery on adults. The methodological quality of the studies was analyzed with AMSTAR checklist, and the quality of evidence was evaluated using the GRADE assessment tool. Primary outcome measures assessed the effect of surgery on snoring, sleepiness, and the apnea-hypopnea index.

Results

A total of 11 studies were included in this study, and the pooled overview includes 378 studies. The systematic reviews were mostly graded as low quality using the GRADE tool and low to moderate according to the AMSTAR checklist. Outcome for apnea-hypopnea index demonstrated substantial variation leading to conflicting results. Despite a high amount of heterogeneity, outcomes for sleepiness and snoring demonstrated significant improvement across included reviews.

Conclusions

Although obstructive sleep apnea surgery is associated with improved outcomes in most studies, the level and quality of evidence reviews requires improvement.

Tongue suspension: an evidence-based review and comparison to hypopharyngeal surgery for OSA

OBJECTIVES/HYPOTHESIS

Our first objective was to perform a systematic review of suture-based tongue suspension procedures as a stand-alone therapy for hypopharyngeal obstruction in obstructive sleep apnea (OSA). A second objective compared outcomes of tongue suspension as part of a multilevel approach to OSA surgery to genioglossus advancement (GA) with uvulopalatopharyngoplasty (UPPP), and to genioglossus advancement with hyoid suspension (GAHM) with UPPP.

STUDY DESIGN

Systematic review.

METHODS

The PubMed database was queried for English-language studies published after 1997 to create four cohorts: tongue suspension alone, tongue suspension with UPPP, GA + UPPP, and GAHM with UPPP. Chi-squared test was used to compare outcomes between cohorts.

RESULTS

Twenty-seven studies were included, broken down into cohorts based on our selection criteria. Six studies qualified for the tongue suspension-alone group with a surgical success rate of 36.6%. Eight studies qualified for our cohort of tongue suspension with UPPP with a surgical success rate of 62.3%. Eighteen studies qualified for our remaining two cohorts: GA + UPPP, and GAHM + UPPP. Their surgical success rates were both 61.1%. A chi-squared test to compare surgical outcomes showed that there was no difference between tongue suspension with UPPP, GA + UPPP, and GAHM + UPPP.

CONCLUSION

Tongue suspension is effective and safe as part of a multilevel surgical approach for patients with OSA. As a stand-alone procedure, its success rate is 36.6%, comparable to UPPP procedures for OSA success rates across the board. Tongue suspension should be considered in patients with OSA who demonstrate tongue base obstruction.

Evaluation of open midline glossectomy in the multilevel surgical management of obstructive sleep apnea syndrome

OBJECTIVE

To analyze the overall success rate of open midline glossectomy with lingual tonsillectomy in the surgical management of obstructive sleep apnea syndrome (OSAS) as well as a subset analysis to determine whether certain patient factors influence clinical outcome.

STUDY DESIGN

Case series with retrospective data collection.

SETTING

Private practice with surgeries performed at a single community hospital (St Johns-Riverside Hospital).

SUBJECTS AND METHODS

Fifty consecutive patients who had moderate to severe OSAS with Friedman tongue position III or IV and underwent midline glossectomy with lingual tonsillectomy as part of multilevel sleep apnea surgery and had pre- and postsurgery in-laboratory sleep studies performed.

RESULTS

The overall success rate was 56.0% using success defined as a postoperative apnea-hypopnea index (AHI) less than 20 and a decrease of greater than 50%. Median AHI decreased from 52.0 to 18.3 with a median change of -26.1 (interquartile range, -41.6 and -17.1). Of significance on subset analysis, patients with a preoperative AHI <60 had a 68.8% success rate (P = .02), and patients with Friedman tongue position III had a 75.9% success rate (P = .0009).

CONCLUSION

The findings of this case series would suggest that multilevel sleep apnea surgery, incorporating midline glossectomy with lingual tonsillectomy, is a valid alternative for managing moderate to severe OSAS in patients who do not respond or are resistant to continuous positive airway pressure therapy. In patients with a preoperative AHI <60 or Friedman tongue position III, surgical success rate is significantly improved.

Surgical therapy of obstructive sleep apnea: a review

Obstructive sleep apnea (OSA) is a disease characterized by intermittent and repetitive narrowing of the airway during sleep. Surgical therapies for the treatment of OSA aim to improve airway patency by addressing selected site(s) of obstruction. Because several areas may each be responsible for the narrowing, different surgical modalities have also been developed. In this review, we give an overview of surgery for each of potential obstruction site(s). As a consequence of the multi-factorial and heterogeneous etiology of OSA, surgical therapies need to be selected and performed specifically for each patient, as there is no perfect surgery that will fit all patients. As with any other treatment modalities for OSA, surgical therapies have variable efficacy, but are a very important tool on OSA management in selected patients and have been shown effectiveness in decreasing the morbidity and mortality associated with the disease.

Surgical reconstruction of the upper airway for obstructive sleep apnea

Positive airway pressure can be effective for OSA treatment but is not effectively used by many patients. Surgical reconstruction of the airway is appropriate for patients who are not otherwise effectively treated or as first-line treatment for patients with focal airway lesions. For surgical planning, examination schemes of the awake patient, as well as sleep endoscopy may be used. Nasal surgery may facilitate treatment using positive airway pressure or oral appliances or to improve quality of life. Pharyngoplasty and tongue base techniques for therapeutic upper airway reconstruction may be performed staged or simultaneously. Current and future approaches are described.

Drug-induced sleep endoscopy vs awake Müller's maneuver in the diagnosis of severe upper airway obstruction

OBJECTIVE

To compare fiber-optic nasal endoscopy with Müller's maneuver (FNMM) against drug-induced sleep endoscopy (DISE) in diagnosing the presence of severe level-specific upper airway collapse in patients with obstructive sleep apnea/hypopnea syndrome (OSAHS).

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary care academic center.

SUBJECTS AND METHODS

Medical records of all adult patients undergoing diagnostic DISE as part of their surgical evaluation were reviewed. Patients were included if they had undergone FNMM and had documented Friedman tongue position and tonsillar grade prior to DISE. Airway obstruction on both endoscopic procedures was described according to airway level and severity. Severe airway obstruction was defined as >75% collapse on endoscopy.

RESULTS

Fifty-three patients were included in this study. Fiber-optic nasal endoscopy with Müller's maneuver and DISE did not differ significantly regarding the presence of severe retropalatal airway collapse. There was a statistically significant difference in the incidence of severe retrolingual collapse identified via DISE (84.9% [45/53]) compared with FNMM (35.8% [19/53]; P < .0001). This discrepancy between FNMM and DISE findings was statistically significant in individuals with Friedman I and II tongue positions (FNMM = 16.7%, DISE = 88.9%, P < .0001) and individuals with Friedman III tongue position (FNMM = 31.8%, DISE = 81.8%, P = .002). Patients with Friedman IV showed no significant difference (P = .65) between FNMM (69.2%) and DISE (84.6%).

CONCLUSION

This study shows a significant difference between FNMM and DISE in the identification of severe retrolingual collapse. Since the effectiveness of surgical interventions depends largely on the accurate preoperative identification of the site of obstruction, further scrutiny of each diagnostic endoscopic technique is warranted.

Implanted upper airway stimulation device for obstructive sleep apnea

OBJECTIVES/HYPOTHESIS

Previous feasibility studies have shown that electrical stimulation of the hypoglossal nerve can improve obstructive sleep apnea (OSA). The current study examined the safety and preliminary effectiveness of a second generation device, the Upper Airway Stimulation (UAS) system, and identified baseline predictors for therapy success.

STUDY DESIGN

Two consecutive open prospective studies.

METHODS

UAS systems were implanted in patients with moderate to severe OSA who failed or were intolerant of continuous positive airway pressure (CPAP). The study was conducted in 2 parts. In part 1, patients were enrolled with broad selection criteria. Apnea hypopnea index (AHI) was collected using laboratory-based polysomnography at preimplant and postimplant visits. Epworth Sleepiness Scale (ESS) and Functional Outcomes of Sleep Questionnaire (FOSQ) were also collected. In part 2, patients were enrolled using selection criteria derived from the experience in part 1.

RESULTS

In part 1, 20 of 22 enrolled patients (two exited the study) were examined for factors predictive of therapy response. Responders had both a body mass index ≤32 and AHI ≤50 (P < .05) and did not have complete concentric palatal collapse. Part 2 patients (n = 8) were selected using responder criteria and showed an improvement on AHI from baseline, from 38.9 ± 9.8 to 10.0 ± 11.0 (P < .01) at 6 months postimplant. Both ESS and FOSQ improved significantly in part 1 and 2 subjects.

CONCLUSIONS

The current study has demonstrated that therapy with upper airway stimulation is safe and efficacious in a select group of patients with moderate to severe OSA who cannot or will not use CPAP as primary treatment.

Changes in facial appearance after maxillomandibular advancement for severe obstructive sleep apnoea hypopnoea syndrome in Chinese patients: a subjective and objective evaluation

This study evaluates the outcome and change in facial appearance after maxillomandibular advancement (MMA) in Chinese adults with severe obstructive sleep apnoea hypopnoea syndrome (OSAHS). Twelve patients underwent MMA with adjunctive procedures for severe OSAHS. All underwent physical examination, Epworth Sleepiness Scale evaluation, cephalometry, polysomnography, and facial photographic assessment before and 6 months after MMA. The aesthetic plane (relationship of nose, lips, and chin) was used to judge soft tissue facial profile change after MMA. Postoperative cephalometric data were compared with normal occlusive standards and aesthetic norms. Pre- and postoperative aesthetic appearance was evaluated by 100 lay people using a 10-point visual analogue scale. The maxillomandibular complex (MMC) was advanced 5-10 mm (mean 7.4 mm). The success rate was 83%. All patients were satisfied with the functional and aesthetic results. Postoperative SNA, SNB, and posterior airway space increased and mandibular plane-to-hyoid distance decreased significantly in all patients. The lower lip was closer to EP than the preoperative and normal occlusive standard. In 11 of 12 patients, the lay aesthetic scores were significantly higher postoperatively. MMA is effective for Chinese adults with severe OSAHS. In most patients, facial appearance was more attractive after MMC advancement of 5-10 mm.

Does drug-induced sleep endoscopy change the treatment concept of patients with snoring and obstructive sleep apnea?

PURPOSE

Success rates of non-ventilation therapies for sleep disordered breathing (SDB) remain hardly acceptable. Drug-induced sleep endoscopy (DISE) tends to show the level and mechanism of obstruction and helps to specify therapy individually. Therefore, increasing success rates are expected. The objective of this study is to detect whether locations of treatment recommendations given after DISE are different to those made after clinical basic ENT (ear, nose, throat) examination (CBE).

METHODS

This study included patients with obstructive sleep apnea (OSA) and primary snoring who wish or require an alternative therapy to the gold standard, continuous positive airway pressure (CPAP). After CBE, a theoretical treatment recommendation was given comprising surgery (possible surgical target: soft palate, tonsils, tongue base, epiglottis) and mandibular advancement splints (MAS) or both. A second ENT specialist conducted a DISE and independently recommended a second therapy concept without knowing the first one. A third person compared both theoretical locations of treatment recommendations (CBE vs. DISE).

RESULTS

A total of 97 patients (eight female and 89 male, age 30-85 years, AHI 1.9-88.6/h, body mass index [BMI] 20.3-36.3 kg/m²) received two therapy recommendations. Regarding surgical options only, 63.9% of the examined patients got a different recommendation in at least one of four levels. If MAS was included, a change was found in 78.4% of the patients. Subdivided into each type of intervention, the following changes were found in the therapy concept: 24.7% (n = 24/97) soft palate, 12.4% (n = 12/97) tonsils, 33.0% (n = 32/97) tongue base, 27.8% (n = 27/97) epiglottis, 38.1% (n = 37/97) MAS.

CONCLUSIONS

DISE shows a relevant influence on the location of treatment recommendation. Thus, a change in success rates of non-CPAP therapy in OSA and snoring appears possible.

Lateral oropharyngeal wall and supraglottic airway collapse associated with failure in sleep apnea surgery

OBJECTIVES/HYPOTHESIS

To identify patterns of airway collapse during preoperative drug-induced sleep endoscopy (DISE) as predictors of surgical failure following multilevel airway surgery for patients with obstructive sleep apnea-hypopnea syndrome (OSAHS).

STUDY DESIGN

Retrospective clinical chart review.

METHODS

Medical records of patients who underwent site-specific surgical modification of the upper airway for treatment of OSHAS were reviewed. Patients were included in this study if they had a preoperative airway evaluation with DISE as well as preoperative and postoperative polysomnography. Airway obstruction on DISE was described according to airway level, severity, and axis of collapse. Severe airway obstruction was defined as >75% collapse on endoscopy. Surgical success was described as a postoperative apnea-hypopnea index (AHI) of <20 and a >50% decrease in preoperative AHI.

RESULTS

A total of 34 patients were included in this study. The overall surgical success rate was 56%. Surgical success (n = 19) and surgical failure (n = 15) patients were similar with regard to age, gender, body mass index, preoperative AHI, Friedman stage, adenotonsillar grades, and surgical management. DISE findings in the surgical failure group demonstrated greater incidence of severe lateral oropharyngeal wall collapse (73.3% vs. 36.8%, P = .037) and severe supraglottic collapse (93.3% vs. 63.2%, P = .046) as compared to the surgical success group.

CONCLUSIONS

The presence of severe lateral pharyngeal wall and/or supraglottic collapse on preoperative DISE is associated with OSAHS surgical failure. The identification of this failure-prone collapse pattern may be useful in preoperative patient counseling as well as in directing an individualized and customized approach to the treatment of OSHAS.

Medical Therapy for Obstructive Sleep Apnoea

Obstructive Sleep Apnoea (OSA) is increasingly recognised as a condition that not only causes excessive daytime sleepiness, but is also an important cardiovascular risk factor. Treatment of OSA should include conservative measures such as weight loss and positional therapy, the nuances of which are discussed in this article. However this in itself is not sufficient treatment for most patients. The first line of treatment for OSA that is recommended across the entire spectrum of disease is continuous positive airway pressure (CPAP) therapy. Indications for initiating CPAP are discussed, as well as possible alternatives to CPAP such as surgery or dental devices. In initiating CPAP treatment, machine-patient interface needs to be carefully considered, as there is a wide range of masks available. Factors to be considered in the choice of CPAP machine and mode are discussed. Finally, patient-specific factors such as patient acceptance of treatment, common problems encountered in CPAP follow-up and the importance of patient education are addressed.

Treatment options for obstructive sleep apnea

Sleep apnea is a major public health problem that afflicts 9% of women and 24% of men 30 to 60 years of age. It is highly treatable, but when untreated, it has been associated with (but not necessarily linked to) increased probability of cerebral and coronary vascular disease, congestive heart failure, metabolic dysfunction, cognitive dysfunction, excessive daytime sleepiness, motor vehicle accidents, reduced productivity, and decreased quality of life. The gold standard for treatment in adults is positive airway pressure (PAP) therapy: continuous PAP (CPAP), bilevel PAP, autotitrating CPAP, or autotitrating bilevel PAP. Measures to increase compliance with PAP therapy include medical or surgical treatment of any underlying nasal obstruction, setting appropriate pressure level and airflow, mask selection and fitting, heated humidification, desensitization for claustrophobia, patient and partner education, regular follow-up with monitoring of compliance software, and attendance of support groups (eg, AWAKE). Adjunctive treatment modalities include lifestyle or behavioral measures and pharmacologic therapy. Patients with significant upper airway obstruction who are unwilling or unable to tolerate PAP therapy may benefit from surgery. Multilevel surgery of the upper airway addresses obstruction of the nose, oropharynx, and hypopharynx. A systematic approach may combine surgery of the nose, pharynx, and hypopharynx in phase 1, whereas skeletal midface advancement or tracheotomy constitutes phase 2. Clinical outcomes are reassessed through attended diagnostic polysomnogram performed 3 to 6 months after surgery. Oral appliances can be used for patients with symptomatic mild or moderate sleep apnea who prefer them to PAP therapy or for whom PAP therapy has failed or cannot be tolerated. Oral appliances also may be used for patients with severe obstructive sleep apnea who are unable or unwilling to undertake PAP therapy or surgery. For children, the main treatment modality is tonsillectomy and adenoidectomy, with or without turbinate surgery. Children with craniofacial abnormalities resulting in maxillary or mandibular insufficiency may benefit from palatal expansion or maxillary/mandibular surgery. PAP therapy may be used for children who are not surgical candidates or if surgery fails.

Obstructive sleep apnea syndrome: from phenotype to genetic basis

Obstructive sleep apnea syndrome (OSAS) is a complex chronic clinical syndrome, characterized by snoring, periodic apnea, hypoxemia during sleep, and daytime hypersomnolence. It affects 4-5% of the general population. Racial studies and chromosomal mapping, familial studies and twin studies have provided evidence for the possible link between the OSAS and genetic factors and also most of the risk factors involved in the pathogenesis of OSAS are largely genetically determined. A percentage of 35-40% of its variance can be attributed to genetic factors. It is likely that genetic factors associated with craniofacial structure, body fat distribution and neural control of the upper airway muscles interact to produce the OSAS phenotype. Although the role of specific genes that influence the development of OSAS has not yet been identified, current researches, especially in animal model, suggest that several genetic systems may be important. In this chapter, we will first define the OSAS phenotype, the pathogenesis and the risk factors involved in the OSAS that may be inherited, then, we will review the current progress in the genetics of OSAS and suggest a few future perspectives in the development of therapeutic agents for this complex disease entity.

What is the efficacy of nasal surgery in patients with obstructive sleep apnea syndrome?

PURPOSE

Obstructive sleep apnea syndrome (OSAS) is characterized by repetitive episodes of partial or complete obstruction of the upper airway during sleep and is associated with increasing respiratory efforts, with a consequent oxyhemoglobin desaturation, sleep fragmentation, and daytime symptoms, most commonly excessive sleepiness. The effectiveness of continuous positive airway pressure (CPAP) is undoubtedly high in treating those patients who use it regularly, but for those who refuse it, the success rate is 0. It is for this subset of patients that surgical therapy can be useful. The purpose of this study was to evaluate the effects of nasal surgery on nasal resistance, sleep apnea, sleep quality, and nasal volumetric measurement in adult male patients with OSAS.

METHODS

Twenty male patients with complaints of hypersomnia and snoring were included in the study. Polysomnography of patients with the prediagnosis of OSAS was planned. All patients underwent CPAP treatment before and after surgery. Patients, who had anatomic structural defects causing nasal valve shrinkage, were operated on at the Plastic Reconstructive and Aesthetic Department. Volumetric measurements of the nose were obtained before and after the operation.

RESULTS

In our study, it was observed that respiratory tract space of patients increased subsequent to the surgery, and thereby OSAS level decreased, and tolerating CPAP device was easier. Measurements of internal nasal valve vertex and fields and external nasal valve fields before and after operation were significant.

CONCLUSIONS

Surgical relief of this nasal obstruction may improve quality of life in patients with OSAS.

Reporting results of obstructive sleep apnea syndrome surgery trials

Obstructive sleep apnea syndrome surgery studies largely evaluate single procedures or procedure combinations in case series designs, but it can be difficult to compare results across studies. The authors present a standardized format for presentation of surgical study results to facilitate pooled analyses and subgroup analyses. The format includes thorough characterization of baseline subject characteristics and the use of outcome measures that reflect the spectrum of obstructive sleep apnea and its consequences. As the apnea-hypopnea index is the most common, albeit controversial, primary outcome measure in obstructive sleep apnea syndrome surgery studies, the authors propose analysis and reporting standards to facilitate understanding its role as an outcome measure. Because surgical outcomes vary according to subject characteristics, investigators should also evaluate the potential association between baseline subject characteristics and outcomes.

Reliable calculation of the efficacy of non-surgical and surgical treatment of obstructive sleep apnea revisited

BACKGROUND

Various treatment methods exist to treat obstructive sleep apnea (OSA); continuous positive airway pressure (CPAP) is considered the gold standard. It is however a clinical reality that the use of CPAP is often cumbersome. CPAP treatment is considered compliant when used ≥ 4 h per night as an average over all nights observed. Surgery, on the other hand, is regarded as successful when the apnea hypopnea index (AHI) drops at least 50% and is reduced below 20/h postoperatively in patients whose preoperative AHI was > 20/h. The effectiveness of CPAP compliance criteria can be questioned, just as the effectiveness of surgical success criteria has often been questioned.

STUDY OBJECTIVES

The aim of the study was to compare non optimal use of optimal therapy (CPAP) with the continuous effect (100%) of often non optimal therapy (surgery).

DESIGN

Using mathematical function formulas, the effect on the AHI of various treatment modalities and their respective compliance and success criteria were calculated.

RESULTS

The more severe the AHI, the more percentage of total sleep time (TST) CPAP must be used to significantly reduce the AHI. Patients with moderate OSA reduce the AHI by 33.3% to 48.3% when using CPAP 4 h/ night (AHI 0-5, respectively). The required nightly percentage use rises as one reduces the AHI target to < 5. CPAP must be used 66.67% to 83.33% per night to reduce the AHI below 5 (AHI of 0 while using CPAP).

CONCLUSION

Using a mean AHI in CPAP therapy is more realistic than using arbitrary compliance rates, which, in fact, hide insufficient reductions in AHI.

Correlation between severity of sleep apnea and upper airway morphology: Cephalometry and MD-CT study during awake and sleep states

CONCLUSION

The data show that the evaluation of obstruction site in patients with obstructive sleep apnea (OSA) should be performed in the sleep state rather than in wakefulness.

OBJECTIVE

The aim of this study was to identify correlation between severity of OSA as measured by the apnea-hypopnea index (AHI) and upper airway morphology examined by cephalometry and dynamic multidetector computed tomography (MD-CT) in awake and sleep states.

METHODS

Polysomnography and cephalometry were performed in 94 patients with snoring or OSA. Among them, 64 patients underwent MD-CT study. Thirteen cephalometric variables were measured. We analyzed the correlations between AHI and MD-CT measurements - minimal cross-sectional area (mCSA) and collapsibility index (CI) in high retropalate (HRP), low retropalate (LRP), high retroglossal (HRG), and low retroglossal (LRG) areas.

RESULTS

Statistically significant correlations between the AHI and inferior displacement of the hyoid bone and pharyngeal length were identified in the cephalometric study. In wakefulness, AHI had a negative correlation with mCSA in the LRP area and a significant correlation with CI in LRP and HRG in MD-CT measurements. However, in the sleep state, the AHI had a negative correlation with mCSA in LRP, HRG, and LRG areas and a meaningful correlation with CI for the whole upper airway (HRP, LRP, HRG, and LRG).

Surgical modifications of the upper airway for obstructive sleep apnea in adults: a systematic review and meta-analysis

A substantial portion of patients with obstructive sleep apnea (OSA) seek alternatives to positive airway pressure (PAP), the usual first-line treatment for the disorder. One option is upper airway surgery. As an adjunct to the American Academy of Sleep Medicine (AASM) Standards of Practice paper, we conducted a systematic review and meta-analysis of literature reporting outcomes following various upper airway surgeries for the treatment of OSA in adults, including maxillomandibular advancement (MMA), pharyngeal surgeries such as uvulopharyngopalatoplasty (UPPP), laser assisted uvulopalatoplasty (LAUP), and radiofrequency ablation (RFA), as well as multi-level and multi-phased procedures. We found that the published literature is comprised primarily of case series, with few controlled trials and varying approaches to pre-operative evaluation and post-operative follow-up. We include surgical morbidity and adverse events where reported but these were not systematically analyzed. Utilizing the ratio of means method, we used the change in the apnea-hypopnea index (AHI) as the primary measure of efficacy. Substantial and consistent reductions in the AHI were observed following MMA; adverse events were uncommonly reported. Outcomes following pharyngeal surgeries were less consistent; adverse events were reported more commonly. Papers describing positive outcomes associated with newer pharyngeal techniques and multi-level procedures performed in small samples of patients appear promising. Further research is needed to better clarify patient selection, as well as efficacy and safety of upper airway surgery in those with OSA.

Z-palatopharyngoplasty plus radiofrequency tongue base reduction for moderate/severe obstructive sleep apnea/hypopnea syndrome

CONCLUSION

Z-palatopharyngoplasty (ZPPP) combined with radiofrequency to the base of tongue (RFBOT) resulted in short-term morbidity only. This study shows the clinical benefits of ZPPP plus RFBOT in patients with moderate/severe obstructive sleep apnea/hypopnea syndrome (OSAHS).

OBJECTIVE

To study the safety and efficacy of ZPPP combined with RFBOT for the treatment of moderate/severe OSAHS.

METHODS

Charts of all patients with moderate/severe OSAHS who failed or refused CPAP therapy and underwent surgical treatment of ZPPP plus RFBOT were reviewed. The subjective symptoms and objective polysomnographic parameters were collected preoperatively and postoperatively. Postoperative morbidity was recorded.

RESULTS

Forty-three OSAHS patients (2 females, 41 males, mean age 39 years) had full data and a minimum 6 month follow-up to assess efficacy. Intraoperative, short-term, and long-term morbidities are reported. No long-term velopharyngeal insufficiency was encountered. The classical success rate was 60.5% (26/43). Six months after the treatment, the mean Epworth sleepiness scale changed from 12.8 +/- 5.1 to 10.0 +/- 4.3 (p = 0.002). The apnea/hypopnea index (/h), lowest oxygen saturation (%), and bed partner assessed snoring visual analog scale (0-10) changed from 51.5 +/- 25.4 to 23.4 +/- 24.7, 75.5 +/- 10.4 to 82.1 +/- 10.9, and 8.4 +/- 1.6 to 2.9 +/- 1.6, respectively (all p < 0.0001, paired t test).

Surgical options for the treatment of obstructive sleep apnea

Obstructive sleep apnea (OSA) is a prevalent condition characterized by repetitive airway obstruction during sleep with associated increased morbidity and mortality. Although CPAP is the preferred treatment, poor compliance is common. Patients intolerant of conventional OSA medical treatment may benefit from surgical therapy to alleviate pharyngeal obstruction. Case series suggest that maxillomandibular advancement has the highest surgical efficacy (86%) and cure rate (43%). Soft palate surgical techniques are less successful, with uvulopalatopharyngoplasty having an OSA surgical success rate of 50% and cure rate of 16%. Further research is needed to more thoroughly assess clinical outcomes (eg, quality of life, morbidity), better identify key preoperative patient and clinical characteristics that predict success, and confirm long-term effectiveness of surgical modalities to treat OSA.

Uvulopalatopharyngoplasty funded by the Australian government's Medicare scheme (1995-2007)

Objective: To describe the provision, through the Australian state-funded Medicare system, of uvulopalatopharyngoplasty (UPPP) and its laser-assisted variation (LAUP) to the population of Australia between 1995 and 2007.

Study Design: Case series using a comprehensive national administrative database.

Setting: The Commonwealth of Australia.

Subjects and Methods: Subjects comprised the population of Australia. The raw numbers of procedures, reimbursement amounts in Australian dollars, and per capita adjustment nationwide and in each state/territory for UPPP and LAUP for each calendar year from 1995 to 2007 were downloaded from a publicly accessible database run by Medicare.

Results: The Australian federal government paid AUD 8.2 million for 19,534 UPPP procedures and AUD 1.1 million for 3270 LAUP procedures in the calendar years 1995 to 2007, inclusive. There is substantive variability between states in provision. Over time, provision of UPPP has declined slightly compared with population growth and overall Medicare provision. LAUP provision has declined markedly.

Conclusion: Provision of UPPP under Medicare in Australia has declined slowly relative to population growth and overall growth in Medicare per capita provision. Laser-assisted UPPP (LAUP) has steadily declined and is now rarely used compared with the peak in its provision in the mid 1990s.

Surgical intervention represents a feasible option for patients with mild obstructive sleep apnoea

CONCLUSIONS

Patients with mild obstructive sleep apnoea (OSA) depict the disease as being detrimental to their health, causing significant symptoms. These patients were found to achieve significant improvements in OSA-related symptoms after surgical intervention.

OBJECTIVES

Although the effects of surgical treatment on OSA have been encouraging in many previous studies, little is known about its effects in patients with mild OSA. The aim of our study was to assess the evolution of symptoms experienced by mild OSA patients after surgical intervention.

SUBJECTS AND METHODS

This was an observational follow-up study in a university hospital in Finland. The change in daytime and night-time symptoms was assessed by a standardized questionnaire before treatment and after a mean follow-up time of 3 years in both operative and control groups in 81 adult patients with mild OSA.

RESULTS

At the follow-up, the control group experienced significantly more daytime sleepiness (p<0.001) compared with the operative group. Adjusted odds ratio (OR) for daytime sleepiness was 0.05 (95% CI 0.01-0.25, p<0.001) in operatively treated patients as compared with control patients, with improvement of witnessed apnoeas (p<0.001) and sleep quality (p=0.033). The OR for intensive snoring was 0.06 (95% CI 0.02-0.22) in the operative group as compared with the control group.

Upper airway function in the pathogenesis of obstructive sleep apnea: a review of the current literature

PURPOSE OF REVIEW

Obstructive sleep apnea is an increasingly prevalent disease, with a considerable societal burden. The disease is defined by recurrent intermittent collapse of the upper airway. Understanding of and treatment for the disease is largely confined to relief of the mechanical obstruction of the upper airway by application of continuous positive airway pressure, and less commonly weight loss or surgery. However, recent work has focused on the function, rather than structure alone, of the upper airway.

RECENT FINDINGS

The following contributors to upper airway structure and function have been studied: traditional fixed anatomical abnormalities, dynamic anatomical changes, upper airway dilator muscle dysfunction, lung volumes, and instability in control of breathing. In each patient with obstructive sleep apnea, the relative contribution of each of these components may be quite variable. The studies reviewed here describe methods to evaluate these factors, and some attempts at treatment.

SUMMARY

Ongoing studies are attempting to classify patients on the basis of the underlying pathophysiology. This work suggests that obstructive sleep apnea is a heterogeneous disease with multiple root causes. Ultimately, such a classification may allow more individualized treatment, not only relying on mechanical relief of the upper airway obstruction.