[Sleep-related breathing disorders. Sleep anamnesis questionnaire and determination of clinical results within the framework of staged diagnostics]

The surgical treatment of sleep-related upper airway obstruction

BACKGROUND

Obstructive sleep apnea (OSA) is a very common disorder among adults: the prevalence of mild OSA is 20%, and that of moderate or severe OSA is 6% to 7%. Simple snoring is even more common. Conservative treatments such as nocturnal ventilation therapy and oral appliances are successful as long as the patient actually uses them, but they do not eliminate the underlying obstruction of the upper airway.

METHOD

The relevant literature up to 2008 on the surgical treatment of OSA was selectively reviewed.

RESULTS

Five types of surgical treatment for OSA are available, each for its own indications: optimization of the nasal airway to support nasal ventilation therapy, (adeno-)tonsillectomy as first-line treatment for OSA in children, minimally invasive surgery for simple snoring and mild OSA, invasive surgery as first- and second-line treatment for mild OSA, and invasive multilevel surgery as second-line treatment of moderate to severe OSA that remains refractory to ventilation therapy.

CONCLUSION

Surgical treatment for OSA is appropriate for specific indications as a complement to the established conservative treatment methods.

[Endoscopy in sleep medicine]

Endoscopic evaluation of the upper airway in patients with sleep disordered breathing (SDB) using rigid and flexible endoscopes is a typical investigation in otorhinolaryngology. Visualizing the anatomic structure as well as the dynamic mechanism of snoring and pharyngeal obstruction during wakefulness, natural sleep, and under sedation are of special interest. The results obtained have increased our understanding of SDB with obstruction of the upper airway. Videoendoscopy under sedation (ViSe) has become increasingly established as a tool to identify the therapeutic concept in cases of CPAP failure, leading to changes compared to the concept derived from basic awake endoscopy. The success of mandibular advancement devices can be adequately predicted. However, it remains unclear to what extent the success rate of surgery can be improved by ViSe. Further research into these approaches is needed in order to become valuable tools in the diagnostic work-up of patients with sleep apnea.

[Update on upper airway evaluation in obstructive sleep apnea]

During the past two decades, different methods of upper airway evaluation for patients with obstructive sleep apnea (OSA) have been investigated. Although clinical assessment is the basis of any diagnostic workflow in OSA, the Mueller maneuver is apparently of no importance. Imaging techniques have increased our knowledge of the pathophysiology of OSA. Cephalometry is done only if maxillomandibular advancement is planned; dynamic investigations such as computed tomography and magnetic resonance imaging are able to picture the pharyngeal collapse and have the capacity to simulate the effect of interventions on OSA severity. So far, video endoscopy under sedation can only predict the success of oral appliances. Multichannel pressure recordings depict the distribution of obstructive events in the upper or lower pharyngeal segment during the entire night. The impact of sophisticated upper airway evaluation remains limited compared with standard clinical assessment. Further research is needed to develop valuable tools for the diagnostic workup of patients with OSA.

[Anterior spondylosis of the cervical spine causing dyspnea and sleep disturbance]

BACKGROUND

Cervical osteochondrosis is a rare differential diagnosis leading to dysphagia, inspiratory stridor and obstructive sleep apnea syndrome (OSAS).

PATIENTS AND METHODS

We report six cases of patients with episodes of neck pain (n=6), pain reflected to the arm (n=1), sleep apnea (n=5), inspiratory stridor (n=3) and/or unclear dysphagia (n=6), who presented between 2000 and 2003 at the Römerwallklinik Mainz and the university hospitals of Mainz and Cologne. None of these patients had symptoms of spinal or radicular compression. All underwent otorhinolaryngological and radiological examination followed by excision of anterior spondylophytes and intervertebral fusion. One patient required immediate tracheotomy due to perforation of the pharyngeal wall associated with severe supraglottic swelling.

RESULTS

All patients were free of inspiratory stridor postoperatively. Symptoms of dysphagia disappeared in four patients and were reduced in two. Three of five patients were free of apnea. OSAS had improved in two. Neck pain was eliminated in four cases and markedly improved in two cases.

CONCLUSIONS

In case of symptoms of pharyngeal compression and OSAS, a vertebragenic cause should be considered.