Multilevel Surgery for Obstructive Sleep Apnea: Short-Term Results

Intubation of underestimated airway in a patient with epiglottis adhesion to the posterior wall of the laryngeal cavity -A case report

BACKGROUND

Epiglottis abnormality is rare condition and can lead embarrassing intubation to anesthesiologists. Here, we reported a case of successful management in a patient with unexpected hidden vocal cords due to epiglottis adhesion to the posterior wall of the laryngeal cavity.

CASE

A 60-year-old female with no underlying disease was scheduled for general anesthesia to undergo a left-cochlear implant operation. After the induction procedure (including intravenous injection of rocuronium), an epiglottic adhesion to the posterior wall of the laryngeal cavity and invisible vocal cords were confirmed. Although the first trial of intubation failed, the patient's airway was successfully managed using a technique that combined a video-styletscope (Markstein Sichtec Medical Co., 5.0 mm ID) with a video-laryngoscope (Insighters ®, Cedrus Medical).

CONCLUSIONS

Anesthesiologists may unexpectedly encounter asymptomatic abnormal airways with unknown causes. In such a situation, it is essential to establish a strategy and to select appropriate device according to patient circumstances.

Characteristics and Mechanism of Upper Airway Collapse Revealed by Dynamic MRI During Natural Sleep in Patients with Severe Obstructive Sleep Apnea

Purpose

Upper airway collapse during sleep in patients with obstructive sleep apnea (OSA) is a complex and dynamic phenomenon. By observing and analyzing the dynamic changes in the upper airway and its surrounding tissues during airway obstruction, we aim to reveal dynamic characteristics in different obstruction patterns, and the relationship between anatomical features during normal breathing and dynamic characteristics of airway obstruction.

Patients and Methods

Dynamic MRI was performed in 23 male patients (age range 26-63) with severe OSA diagnosed by overnight polysomnography, and obstruction events were identified from their images. Dynamic changes in parameters of the upper airway and surrounding tissues were measured to assess the key characteristics in different obstruction patterns.

Results

We categorized airway obstruction into four types based on the obstruction location and motion characteristics of tissues during collapse, and detailed the alterations in the airway and surrounding tissues under each obstruction pattern. In all 112 obstruction events extracted from the dynamic images of 23 patients, type A (retropalatal obstruction caused by the soft palate separated from the tongue), BI, BII (both retropalatal obstructions caused by the soft palate attached to the tongue, and C (retropalatal and retroglossal obstruction caused by the soft palate and the tongue), accounted for 28.6%, 44.6%, 12.5%, and 14.3% respectively. In severe OSA patients with tongue and palatal obstruction related to type B or C, the more posterior hyoid position, shorter distance between tongue and uvula, and wider retropalatal space, the larger the tongue displacement and deformation during collapse, and the greater the reduction in airway space.

Conclusion

There are multiple airway obstruction patterns, each with its own anatomical characteristics and behaviors during collapse. Hyoid position, tongue and uvula distance, and retropalatal space play an important role in airway collapse and should be paid more attention in the treatment of OSA.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Effects of Soft Tissue Sleep Surgery on Morbidly Obese Patients

INTRODUCTION

Morbidly obese patients with obstructive sleep apnea (OSA) are often intolerant of continuous positive airway pressure (CPAP). The effects of sleep surgery in this population is not well documented, and sleep surgery is generally avoided due to the expectation of poor outcomes, leaving these patients untreated.

METHODS

This retrospective study included 42 patients with a body mass index (BMI) ≥40.0 and OSA with a preoperative apnea hypopnea index (AHI) ≥5. Preoperative BMI ranged from 40.0 to 69.0 kg/m². Preoperative AHI ranged from 7.2 to 130.0. Of 42 patients, 12 (28.6%) underwent concurrent pharyngeal and retrolingual surgery. Subgroup analysis of change in AHI was measured with respect to preoperative OSA severity, change in preoperative BMI, and BMI severity. Univariate linear and logistic regression was performed assessing change in AHI and surgical success with respect to age, sex, preoperative AHI, preoperative BMI, change in BMI, total procedures, palatal procedure, retrolingual procedure, nasal procedure, and multilevel procedures.

RESULTS

The mean AHI improved from 45.9 ± 31.8 to 31.9 ± 31.6 (P = .007). Epworth sleepiness score (ESS) improved from 13.2 ± 5.5 to 9.6 ± 5.4 (P = .00006). Lowest oxygen saturation (LSAT) improved from 74.4 ± 10.7 to 79.9 ± 10.4 (P = .002). About 33.3% of patients had surgical success (AHI < 20 with at least 50% reduction in AHI). Preoperative AHI was the most significant factor for change in AHI in univariate and multivariate models (P = .015).

CONCLUSION

Sleep surgery is effective in reducing OSA burden in most morbidly obese patients and can result in surgical cure for a third of patients.

Respiratory Arousals in Patients with Very Severe Obstructive Sleep Apnea and How They Change after a Non-Framework Surgery

Respiratory arousal is the change from a state of sleep to a state of wakefulness following an apnea or hypopnea. In patients with obstructive sleep apnea (OSA), it could have a helpful role to activate upper airway muscles and the resumption of airflow and an opposing role to contribute to greater ventilatory instability, continue cycling, and likely exacerbate OSA. Patients with very severe OSA (apnea-hypopnea index (AHI) ≥ 60 events/h) may have specific chemical (e.g., possible awake hypercapnic hypoxemia) and mechanical (e.g., restricted dilator muscles) stimuli to initiate a respiratory arousal. Little was reported about how respiratory arousal presents in this distinct subgroup, how it relates to AHI, Epworth Sleepiness Scale (ESS), body mass index (BMI), and oxygen saturation, and how a non-framework surgery may change it. Here, in 27 patients with very severe OSA, we show respiratory arousal index was correlated with each of AHI, mean oxyhemoglobin saturation of pulse oximetry (SpO2), mean desaturation, and desaturation index, but not in BMI or ESS. The mean (53.5 events/h) was higher than other reports with less severe OSAs in the literature. The respiratory arousal index can be reduced by about half (45.3%) after a non-framework multilevel surgery in these patients.

Variables predictive of surgical outcomes after hyoid myotomy with suspension to thyroid cartilage

OBJECTIVES

To evaluate variables predicting improvement in obstructive sleep apnea (OSA) with hyoid suspension to thyroid cartilage 4-suture technique.

METHODS

Sixty adult patients (age range 23-78 years) with OSA underwent hyoid suspension to thyroid cartilage with or without concurrent multi-level surgery over an eight-year period from 2011 to 2019 at a tertiary academic center. All patients had a preoperative apnea hypopnea index (AHI) ≥ 5. Changes in mean AHI, Epworth Sleepiness Scale (ESS), and lowest oxygen saturation (LSAT) were measured with paired Student t-test. Linear and logistic regression models were used to predict change in AHI and surgical success respectively with respect to body mass index (BMI), age, sex, previous sleep surgery, concurrent retrolingual surgery, concurrent palatopharyngoplasty, and preoperative AHI.

RESULTS

The mean AHI demonstrated a significant improvement from a preoperative AHI of 39.0 ± 25.5 to a postoperative AHI of 31.2 ± 23.4 (p = 0.005). The mean Epworth Sleepiness Score (ESS) significantly improved from 13.1 ± 6.0 to 9.2 ± 5.7 (p = 0.000012). Surgical success, defined as a 50% reduction in preoperative AHI to a postoperative AHI ≤ 20, was obtained in 18/60 (30.0%) patients. Preoperative BMI significantly correlates with variation of change in AHI in multivariable linear regression model (p = 0.003). Preoperative AHI was significant predictor of surgical success in multivariable logistic regression model.

CONCLUSION

The magnitude of improvement in polysomnographic parameters after hyoid suspension to thyroid appears to be more significant in patients with lower BMI. Even patients with an obese BMI and severe OSA achieve significant improvement from this procedure.

The comparison of multilevel surgery (hyoid myotomy and suspension with uvulopalatopharyngoplasty) with CPAP in moderate to severe OSAS patients

PURPOSE

The study aimed to determine the efficacy of multilevel surgery (hyoid myotomy and suspension with uvulopalatopharyngoplasty) and continuous positive airway pressure (CPAP) for the treatment of moderate to severe obstructive sleep apnea syndrome (OSAS) and to clarify whether our surgical protocol could be as effective as CPAP.

METHODS

We conducted a case series study comparing the effects of multilevel surgery and CPAP in the same subjects to minimize the influence of confounding factors. Fifteen subjects were enrolled with a pretreatment apnea-hypopnea index (AHI) ≥ 15.

RESULTS

Both CPAP and multilevel surgery could improve the AHI and oxygen desaturation index (ODI). The median AHI for baseline, CPAP and surgery were 38.9, 1.2 and 12.6, respectively (p < 0.001). The medina ODI for baseline, CPAP and surgery were 34.8, 0.9 and 7.2, respectively (p < 0.001). However, the results indicated CPAP as the more efficacious treatment modality compared with multilevel surgery. Moreover, CPAP not only decreased N1 sleep but also had beneficial effects on blood pressure control, whereas multilevel surgery did not have any significant difference.

CONCLUSION

CPAP is efficacious in improving OSAS severity, oxygen desaturation, sleep stage, and blood pressure control; while hyoid myotomy and suspension with uvulopalatopharyngoplasty are only efficacious in improving OSAS severity and oxygen desaturation. This study suggested that CPAP is the first choice when considering treatment of OSAS, especially in patients with hypertension or other cardiovascular diseases.

Multi-level obstruction in obstructive sleep apnoea: prevalence, severity and predictive factors

OBJECTIVES

To characterise multi-level obstruction in terms of prevalence, obstructive sleep apnoea severity and predictive factors, and to collect epidemiological data on upper airway morphology in obstructive sleep apnoea patients.

METHODS

Retrospective review of 250 obstructive sleep apnoea patients.

RESULTS

On clinical examination, 171 patients (68.4 per cent) had multi-level obstruction, 49 (19.6 per cent) had single-level obstruction and 30 (12 per cent) showed no obstruction. Within each category of obstructive sleep apnoea severity, multi-level obstruction was more prevalent. Multi-level obstruction was associated with severe obstructive sleep apnoea (more than 30 events per hour) (p = 0.001). Obstructive sleep apnoea severity increased with the number of obstruction sites (correlation coefficient = 0.303, p < 0.001). Multi-level obstruction was more likely in younger (p = 0.042), male (p = 0.045) patients, with high body mass index (more than 30 kg/m2) (p < 0.001). Palatal (p = 0.004), tongue (p = 0.026) and lateral pharyngeal wall obstructions (p = 0.006) were associated with severe obstructive sleep apnoea.

CONCLUSION

Multi-level obstruction is more prevalent in obstructive sleep apnoea and is associated with increased severity. Obstruction at certain anatomical levels contributes more towards obstructive sleep apnoea severity.

Various combinations of velopharyngeal and hypopharyngeal surgical procedures for treatment of obstructive sleep apnea: Single-stage, multilevel surgery

OBJECTIVE

The aim of this study was to investigate the safety and outcomes of velopharyngeal surgeries combined with hypopharyngeal surgeries as single-stage interventions for treatment of obstructive sleep apnea (OSA).

METHODS

Retrospective analysis of operated patients. The velopharyngeal surgical interventions were uvulopalatal flap, anterior palatoplasty, expansion sphincter pharyngoplasty, transpalatal advancement pharyngoplasty, Cahali lateral pharyngoplasty, Z-palatoplasty, and modified uvulopalatopharyngoplasty. The hypopharyngeal surgical interventions were tongue base suspension, mucosal sparing partial glossectomy, genioglossus advancement, mandibulohyoid suspension, thyrohyoid suspension, and epiglottoplasty.

RESULTS

Forty-one patients were enrolled after inclusion and exclusion criteria. The evaluation of symptoms and polysomnographic findings were performed preoperatively and at a minimum of 3months postoperatively. The mean age was 42.17±9.50years and the mean follow-up time was 6.8±6.0months. After single-stage multilevel surgery, the mean apnea hypopnea index (AHI) improved from 29.13±15.87events/h to 14.28±16.14events/h (p<0.001). According to the classical definition of success criteria (>50% reduction in AHI and postoperative AHI<20events/h), the surgical success rate was 56%, with cure of OSA (AHI<5events/h) in 41% of study population. The combined surgeries also improved Epworth scores, snoring scores, and respiratory parameters significantly (in all p<0.05). The major complications were bleeding requiring re-admission in surgery room and severe tongue base edema which regressed by steroid administration. The minor complications were pain, difficulty in swallowing, velopharyngeal insufficiency, regurgitation, minor bleeding, and occlusion disorder. The mean postoperative period to beginning of normal feeding was 1.81±1.01days. The percentage of pain, the number of patients with major bleeding, and the need for patient-controlled analgesia were higher in patients undergoing tissue resection/ablative hypopharyngeal procedures. The mean postoperative period to beginning of normal feeding was shorter in patients undergoing suture/repositioning hypopharyngeal procedures.

CONCLUSION

According to outcomes of this study, OSA patients with multilevel obstructions can benefit from combined surgeries for velopharyngeal and hypopharyngeal regions at the same operation stage, without experiencing persistent complaints. It is promising that, despite multiple levels of obstruction was operated at single-stage, airway safety was preserved in all patients.

[Treating nasal obstruction in obstructive sleep apnea patients]

The impact of treating nasal obstruction in obstructive sleep apnea (OSA) patients is still intensively discussed at congresses. This is likely due to the highly conflicting results of nasal treatments in regard to restorative sleep on the one hand, and their influence on the severity of OSA on the other. Both conservative and surgical nasal treatments result in a highly significant improvement of sleep quality. Patients' sleep is more restorative, which has a huge impact on several quality of life parameters. In contrast, the impact of conservative and surgical nasal treatments on the severity of OSA measured using the apnea-hypopnea index is very limited, apart from rare exceptions. However, there are preliminary data indicating that successful nasal surgery may facilitate or enable nasal ventilation therapy by lowering the effective pressure.

Reconsidering first-line treatment for obstructive sleep apnea: a systematic review of the literature

BACKGROUND

Continuous positive airway pressure (CPAP) is typically recommended as first line therapy for obstructive sleep apnea, but the adherence rate of CPAP is problematic. This study's objective was to systematically review the literature relating to CPAP as first line therapy for OSA and compare it to surgical literature on the same topic.

METHODS

A systematic review was conducted according to PRISMA guidelines, examining Medline-Ovid, Embase, and Pubmed databases. The primary search objective was to identify all papers reporting the results of (1) randomized clinical trials (RCT) of CPAP for the treatment of adults with OSA; and (2) both randomized and non-randomized clinical trials and case series on the surgical treatment of OSA in adults. A PhD-level biostatistician first screened papers, and then those that met study criteria were retrieved and analyzed using standardized forms for each author. The primary outcomes were adherence rates of CPAP.

RESULTS

A total of 82 controlled clinical trials for CPAP and 69 controlled and non-controlled surgery trials were identified for analysis. Variation in CPAP use within reported RCT trials were identified, and the majority of patients in the studies would eventually be considered non-adherent to CPAP.

CONCLUSIONS

When considering the numerous patient-related factors that come into play when CPAP is prescribed, the concept of CPAP as gold-standard therapy for OSA should be reconsidered. In many cases surgery can provide a better overall outcome. This study's results suggest that certain patients with OSA may be managed more effectively with surgery than CPAP, without confounding issues of treatment adherence.

Unanticipated difficult airway due to undiagnosed oropharyngeal stenosis: a case report

Unanticipated difficult airway is a challenging problem for anesthesiologists. Oropharyngeal stenosis (OPS) is a rare complication of upper airway surgery which may cause difficult airway. We present a patient whose postsurgical OPS was revealed during the induction of general anesthesia, and necessitated reschedule of surgery and tracheotomy. We also discuss the etiology and risk factors of postsurgical OPS.

Thirteen Years of Hyoid Suspension Experience in Multilevel OSAHS Surgery: The Short-Term Results of a Bicentric Study

Aims. To evaluate thirteen years of hyoid suspension experience in multilevel OSAHS surgery, for which hyoidthyroidpexia represented the exclusive hypopharyngeal approach applied. Materials and Methods. From 1998 to 2011, a bicentric retrospective study was conducted: all adult patients with a diagnosis of OSAHS were enrolled. Specific eligible criteria were established. Pre-/postoperative data concerning ENT and sleep findings were recorded. Recruited subjects were surveilled for a follow-up range from 6 to 18 months. Results. A total of 590 hyoid suspensions were evaluated, but only 140 patients met the specific inclusion criteria. A success rate of 67% was obtained. No intraoperative adverse events or major complications occurred. Excessive daytime sleepiness was observed in 28% of nonresponders. Despite the homogeneous candidate anatomy, ENT awake findings changed differently after surgery. Statistical analysis revealed multilevel surgery to be more effective when AHI < 30. Postoperative AHI was statistically not influenced by preoperative BMI. Conclusions. Hyoid suspension in multilevel treatment is effective when short-term results are considered. The necessity of a more valuable anatomic-based diagnostic approach is crucial to guide the patient selection. Long-term followups and randomized prospective trials with case-control series are needed to increase the level of evidence of this surgery.

Primary and secondary telegnathic maxillomandibular advancement, with or without adjunctive procedures, for obstructive sleep apnea in adults: a literature review and treatment recommendations

PURPOSE

To further define the role, surgical principles, and therapeutic efficacy of primary and secondary maxillomandibular advancement (MMA), with and without intrapharyngeal or extrapharyngeal adjunctive procedures, for obstructive sleep apnea in adults.

MATERIALS AND METHODS

A review of the literature, using mean percent reduction in apnea hypopnea index as the primary outcome measure of therapeutic efficacy for standardized comparison. Other occasionally reported MMA outcome parameters were sleep staging variables, lowest oxyhemoglobin saturation levels, Epworth scores, blood pressure changes, lateral cephalometric data, and complications.

RESULTS

Mean percent reduction in apnea hypopnea index was 92.1% for primary MMA with extrapharyngeal procedures, 88.4% for primary MMA, 86.6% for secondary MMA, 79.4% for primary MMA with intrapharyngeal procedures, 53.0% for non-MMA multilevel surgery, 31.3% for uvulopalatopharyngoplasty, and 89.8% for nasal continuous positive airway pressure. Treatment recommendations for telegnathic MMA included surgical goals and guidelines, indications and staging protocols, surgical principles and techniques, and postoperative airway management.

CONCLUSIONS

Primary and secondary MMA are highly therapeutic, and extrapharyngeal are more therapeutic than intrapharyngeal procedures when performed concomitantly with primary MMA. However, long-term success of obstructive sleep apnea treatment should be measured by a yet undefined comprehensive algorithm of standardized multiple weighted outcome parameters.

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.

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.

[Guideline: Treatment of obstructive sleep apnea in adults]

The current guideline discusses conservative and surgical therapy of obstructive sleep apnea (OSA) in adults from the perspective of the ear, nose and throat specialist. The revised guideline was commissioned by the German Society of Ear-Nose-Throat, Head-Neck Surgery (DG HNO KHC) and compiled by the DG HNO KHC's Working Group on Sleep Medicine. The guideline was based on a formal consensus procedure according to the guidelines set out by the German Association of Scientific Medical Societies (AWMF) in the form of a"S2e guideline". Research of the literature available on the subject up to and including December 2008 forms the basis for the recommendations. Evaluation of the publications found was made according to the recommendations of the Oxford Centre for Evidence-Based Medicine (OCEBM). This yielded a recommendation grade, whereby grade A represents highly evidence-based studies and grade D those with a low evidence base.

Hypertonic saline injections to enhance the radiofrequency thermal ablation effect in the treatment of base of tongue in obstructive sleep apnoea patients: a pilot study

CONCLUSION

Hypertonic saline (HS) infiltration in the base of the tongue (BOT) in multilevel radiofrequency ablation (RFA) treatment was followed by significant acute complications in terms of soft tissue swelling. Three patients were defined as cured. No significant changes in the measured parameters were encountered, although, several of them showed a clear trend. New treatment modalities are needed to keep multilevel RFA treatment as a minimally invasive procedure.

OBJECTIVES

To assess the efficacy and morbidity of RFA of the soft palate (SP) and BOT infiltrated with HS in obstructive sleep apnoea in a prospective, non-randomized clinical study.

PATIENTS AND METHODS

The inclusion criteria were age between 30 and 65 years, habitual snoring and excessive daytime sleepiness, a body mass index < or =33, and an apnoea-hypopnoea index > or =20. RFA of the SP and the BOT was delivered under local anaesthesia. HS solution was injected before the treatment into the BOT. The morbidity of the procedure was assessed with a visual analogue scale, and efficacy by separate questionnaires and sleep registration. The volume changes induced by the procedure were evaluated with cephalometric radiographs (CRs).

RESULTS

Twelve males and one female with a median age of 50 years (range 41-62) entered the study. Six patients (46%) had more postoperative swelling in the upper airway than expected. Three patients were defined as cured. The trend in the questionnaires was clear, but not significant. In the soft tissue airway CR measurements no significant changes were encountered, although a trend towards volume reduction was seen in the posterior airway space measure.

Effect of Orthognathic Surgery on the Posterior Airway Space (PAS)

Orthognathic surgery has been used regularly to treat dentofacial deformities. The surgical procedures affect both the facial appearance as well as the posterior airway space (PAS). Our current literature indicates that setback procedures produce an inferior repositioning of the hyoid bone and posterior displacement of the tongue and the soft palate. These movements cause anteroposterior and lateral narrowing of the PAS. Most authors agree that these effects are permanent. The PAS changes in turn produce an adaptive posturing, with an increased craniocervical angle to open up the PAS. Even though most patients do not display snoring and obstructive sleep apnoea (OSA) post-surgery, there is certainly an increased possibility in patients with already compromised airways. Therefore, patients who are undergoing orthognathic surgery should be screened for excessive daytime somnolence, snoring, increased body mass index (BMI) and medical conditions related to OSA and sent for an overnight polysomnography (PSG) if OSA is suspected. Then the proposed treatment plan may be modified according to the risk of potential airway compromise or even to improve it. Conversely, advancement of the maxilla and mandible causes widening of the airway in both the anteroposterior and lateral dimensions. This effect would translate to better airflow and decreased airway resistance. This is supported by the evidence showing high success rates when orthognathic surgery, especially maxillomandibular advancement (MMA), is utilised to treat OSA. Key words: Airway changes, Cephalometrics, Maxillomandibular advancement, Obstructive sleep apnoea, Orthognathic surgery

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

OBJECTIVE

Many patients with obstructive sleep apnea/hypopnea syndrome (OSAHS) are incapable of using continuous positive airway pressure. These patients therefore turn to surgical options as a salvage treatment. Early studies and reviews focused on the efficacy of uvulopalatopharyngoplasty, a single-level procedure for the treatment of OSAHS. Since OSAHS is usually caused by multilevel obstructions, the true focus on efficacy should be on multilevel surgical intervention. The purpose of this paper is to provide an overview of the literature on multilevel surgery for OSAHS patients.

STUDY DESIGN

Systematic review of the literature and meta-analysis focusing on subjective and objective outcomes of patients with OSAHS treated with multilevel surgery of the upper airway.

METHODS

We searched PubMed, the Cochrane database, and MEDLINE bibliographic databases up to March 31, 2007, for studies dealing with multilevel surgical modification of the upper airway for the treatment of OSAHS. Additional studies were identified from their reference lists. Articles were included only if the surgical intervention involved at least two of the frequently involved anatomic sites: nose, oropharynx, and hypopharynx.

RESULTS

After applying specific inclusion criteria, 49 multilevel surgery articles (58 groups) were identified. There were 1,978 patients included in the study. The mean minimal follow-up time was 7.3 months (range, 1 to 100 months). A meta-analysis was performed to redefine the success rate to be consistent with the commonly agreed upon criteria, namely "a reduction in the apnea/ hypopnea index (AHI) of 50% or more and an AHI of less than 20." "Success" implies an improved condition and is not meant to imply cure. The recalculated success rate was 66.4%. The overall complication rate was 14.6%. The evidence-base medicine (EBM) level of these 49 studies revealed that only one study was EBM level 1, two papers were EBM level 3, and the other 46 papers were ranked as level 4 evidence.

CONCLUSIONS

Multilevel surgery for OSAHS is obviously associated with improved outcomes, although this benefit is supported largely by level 4 evidence. Future research should focus on prospective and controlled studies.

Hyoidthyroidpexia as a treatment in multilevel surgery for obstructive sleep apnea

CONCLUSION

This type of surgery is effective in patients with obstructive sleep apnea syndrome (OSAS), but may not be effective in obese patients or those with a preoperative apnea hypopnea index (AHI)>35. For these reasons, the careful study and selection of patients is fundamental in the surgical treatment of OSAS.

OBJECTIVES

Evaluation of the efficacy of hyoid surgery combined with oropharynx and nose surgery in the treatment of OSAS.

SUBJECTS AND METHODS

A total of 109 OSAS patients underwent hyoidthyroidpexia as a treatment in multilevel surgery. Before surgery all patients were treated with continuous positive airway pressure (CPAP) therapy for at least 6 months and underwent preoperative and postoperative polysomnography. The preoperative examination was composed of upper airways endoscopy, lateral cephalometric radiograph, calculation of body mass index (BMI), and subjective analysis of daytime sleepiness.

RESULTS

In all, 67/109 patients (61.5%) with postoperative AHI<20 were defined as 'responders', while the other 42 patients (38.5%) were defined as 'non-responders'. The correlation between preoperative BMI and postoperative AHI revealed that non-responders had a much higher average BMI compared with responders. Moreover, when analyzing median preoperative and postoperative AHI, it emerged that non-responders had a much higher preoperative AHI compared with responders.

Minimally invasive single-stage multilevel treatment for obstructive sleep apnea/hypopnea syndrome

OBJECTIVES

To assess subjective and objective improvement after single-stage multilevel minimally invasive treatment for obstructive sleep apnea/hypopnea syndrome (OSAHS).

STUDY DESIGN

A retrospective review of a prospective dataset of patients treated in a tertiary care referral center.

METHODS

Charts of 145 patients with mild/moderate OSAHS treated with a single-stage multilevel minimally invasive technique were reviewed to abstract pre- and posttreatment symptoms and polysomnographic data. One hundred twenty-two patients had minimum follow-up of 6 (range, 6-23) months and complete data available for analysis. All patients studied had three-level treatment that included nasal surgery, palatal stiffening by Pillar implant technique, and radiofrequency volume reduction of the tongue base. Primary outcomes included change from baseline in apnea/hypopnea index (AHI). Secondary outcomes included change in Epworth Sleepiness Scale (ESS) and bed-partner assessed snoring visual analogue scale (VAS, 0-10), pain levels, narcotic use, and complications.

RESULTS

Mean AHI decreased from 23.2 +/- 7.6 preoperatively to 14.5 +/- 10.2 postoperatively (P < .0001). Classical "cure" was achieved in 54 (47.5%) patients. Mean ESS decreased from 9.7 +/- 3.9 preoperatively to 6.9 +/- 3.3 postoperatively (P < .0001). Mean snoring VAS decreased from 9.4 +/- 0.9 preoperatively to 3.2 +/- 2.4 postoperatively (P <. 0001).

CONCLUSION

Polysomnographic respiratory parameters, ESS, and snoring VAS significantly improved in patients with mild/moderate OSAHS treated with single-stage multilevel minimally invasive surgery. Multilevel minimally invasive single-stage surgery is a valid option for selected patients with mild/moderate OSAHS with the understanding that they may require secondary treatment.

[Surgical management of obstructive sleep apnea]

INTRODUCTION

Obstructive sleep apnea (OSA) is a common disorder in adults, however it also occurs in neonates with severe mandibular hypoplasia. The clinical significance of OSA results from hypoxemia and sleep fragmentation due to a collapse of the upper airway. Recently OSA has received much attention due to its potentially serious consequences on cardiac function. Besides daytime sleepiness and fatigue life expectancy is significantly shortened by a higher risk for apoplectic insults and heart failures. This paper reviews common surgical procedures with an emphasis on jaw advancement procedures.

MATERIAL AND METHODS

In six adults (mean age 46,9 ys; 2 female, 4 male; BMI averaged 28kg/m(2)) suffering from OSA with a history of a long-lasting unsuccessful continuous positive airway pressure (CPAP) therapy a bimaxillary advancement was performed. The respiratory disturbance was preoperatively evaluated by polysomnography; daytime sleepiness was recorded according to the 'Epworth Sleepiness Scale'. Controls were performed six months after therapy. All patients had a regular intermaxillary relation. Bimaxillary advancement was planned and performed according to the principles of cranio-maxillofacial corrective surgery. To widen the posterior airway space much attention was focused on the advancement of the mandible by 10mm.

RESULTS

The apnea/hypopnea index decreased from preoperatively 37/h to 4/h after treatment. The minimal peripheral oxygen saturation increased from 78% to 89%, whereas the average oxygen saturation raised from 92 to 95%. The arousal index decreased from 24/h to 9/h. Periods of snoring were reduced from 29,5% to 6,9%. According to the 'Epworth Sleepiness Scale' the patients' estimation improved from a level of 11 to 4. Sleep had a recuperating effect. All surgical procedures were uneventful.

CONCLUSION

Standard treatment of OSA is the CPAP-therapy. In some patients, however, CPAP-therapy cannot be applied, fails or is not well accepted. A great variety of surgical procedures for the treatment of OSA have been described. Bimaxillary advancement in adults and osteodistraction in neonates are safe and successful surgical techniques for an immediate improvement in OSA. Osteodistraction treatment can help to avoid tracheotomy in neonates.

Acceptance and long-term compliance of nCPAP in obstructive sleep apnea

In a retrospective cohort study, we evaluated whether improvements in nasal continuous positive airway pressure (nCPAP) technology, particularly the introduction of automatic adjustment of the nCPAP pressure (auto-CPAP), have led to better acceptance and (long-term) compliance in patients with obstructive sleep apnea syndrome (OSAS) as compared to earlier reported data. Questionnaires were sent to 256 patients, who were referred to our clinic for an overnight polysomnography from January 1997 to July 2005 and received nCPAP therapy for OSAS. Of the 256 patients, 24 patients were unavailable for follow-up. Of the remaining 232 patients, 58 patients (25%) had discontinued therapy, while 174 patients (75%) were still using nCPAP after 2 months to 8 years of follow-up. One Hundred and thirty eight (79%) of these 174 patients used nCPAP for at least 4 h/night during >or= 5 nights/week, 82,1% of the conventional nCPAP (fixed pressure CPAP) group (n = 78) and 77,1% of the auto-CPAP group (n = 96). Therefore, including the 58 failures, only 59.5% of patients can be seen as compliant. There were no statistical differences between the fixed pressure CPAP and auto-CPAP users, and between the compliant and non-compliant users according to age, BMI, AHI and Epworth sleepiness scale (ESS). Auto-CPAP patients used significantly more cm H2O. The long-term compliance of nCPAP therapy has have increased only slightly since the introduction of the fixed pressure CPAP 25 years ago, in spite of many efforts to improve it. It seems that a plateau has been reached and that it is unrealistic to aim at a substantially higher compliance rate.