Obstructive sleep apnea surgery: patient perspective and polysomnographic results

Patient Referral and Acceptance of Maxillomandibular Advancement for Obstructive Sleep Apnea

OBJECTIVE

Maxillomandibular advancement (MMA) is an effective surgical treatment for obstructive sleep apnea (OSA); however, it is unclear how many patients who are referred for MMA actually undergo surgery. This study aims to determine follow-up rates for patients referred for MMA and the reasons behind their choices.

METHODS

Via retrospective review, we assessed consecutive patients with OSA intolerant to continuous positive airway pressure (CPAP) who underwent drug induced sleep endoscopy (DISE) between 2018 and 2020 at our institution. Patients recommended for MMA based on DISE and other findings were included. Patients were then contacted and administered an IRB-approved survey in present time.

RESULTS

One hundred and fifty nine patients were referred to oral maxillofacial surgery (OMFS) for MMA consult. Seventy seven patients (48%) followed up with OMFS and 29 (18%) underwent MMA. Sixty two (40%) patients resumed CPAP. Fifty eight patients (36.5%) were lost to follow up. Seventy three patients (46%) completed our survey. Of those patients, 37 (51%) followed up with OMFS and 17 (23%) underwent MMA. Patients who did not follow up with OMFS cited the invasiveness of the surgery (39%), recovery time (17%), or both (31%) as reasons. Those who pursued consultation cited inability to tolerate CPAP (73%), not being a candidate for inspire (14%), and desire to learn about alternative treatments (14%) as reasons. Of those who did not undergo MMA, 28.6% are not using OSA treatment.

CONCLUSION

Less than half of patients referred for MMA followed up, and less than half of those patients underwent MMA. Most patients cited concerns about the invasiveness of the surgery and recovery process.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:2964-2969, 2024.

Maxillomandibular Advancement and Upper Airway Stimulation for Treatment of Obstructive Sleep Apnea: A Systematic Review

This systematic review aimed to comparatively evaluate the efficacy and safety of maxillomandibular advancement (MMA) and upper airway stimulation (UAS) in obstructive sleep apnea (OSA) treatment. A MEDLINE and Embase database search of articles on MMA and/or UAS for OSA was conducted. Twenty-one MMA studies and nine UAS studies were included. All the MMA studies demonstrated a reduction in apnea hypopnea index (AHI) postoperatively, and success rates ranged from 41.1% to 100%. Ten MMA studies reported pre- and postoperative Epworth sleepiness scale (ESS), and all but one study demonstrated a reduction in ESS. In the UAS studies, all but one demonstrated a reduction in AHI, and success rates ranged from 26.7% to 77.8%. In the eight UAS studies reporting pre- and postoperative ESS, an ESS reduction was demonstrated. No studies reported any deaths related to MMA or UAS. The most common postoperative complications after MMA and UAS were facial paresthesia in the mandibular area and discomfort due to electrical stimulation, respectively. This systematic review suggests that both MMA and UAS are effective and generally safe therapies for OSA. However, due to the limitations of the included studies, there is no evidence yet to directly compare these two procedures in OSA treatment.

Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment

INTRODUCTION

This systematic review provides supporting evidence for the accompanying clinical practice guideline on the referral of adults with obstructive sleep apnea (OSA) for surgical consultation.

METHODS

The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies that compared the use of upper airway sleep apnea surgery or bariatric surgery to no treatment as well as studies that reported on patient-important and physiologic outcomes pre- and postoperatively. Statistical analyses were performed to determine the clinical significance of using surgery to treat obstructive sleep apnea in adults. Finally, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process was used to assess the evidence for making recommendations.

RESULTS

The literature search resulted in 274 studies that provided data suitable for statistical analyses. The analyses demonstrated that surgery as a rescue therapy results in a clinically significant reduction in excessive sleepiness, snoring, blood pressure (BP), apnea-hypopnea index (AHI), respiratory disturbance index (RDI), and oxygen desaturation index (ODI); an increase in lowest oxygen saturation (LSAT) and sleep quality; and an improvement in quality of life in adults with OSA who are intolerant or unaccepting of positive airway pressure (PAP) therapy. The analyses demonstrated that surgery as an adjunctive therapy results in a clinically significant reduction in optimal PAP pressure and improvement in PAP adherence in adults with OSA who are intolerant or unaccepting of PAP due to side effects associated with high pressure requirements. The analyses also demonstrated that surgery as an initial treatment results in a clinically significant reduction in AHI/RDI, sleepiness, snoring, BP, and ODI and an increase in LSAT in adults with OSA and major anatomical obstruction. Analysis of bariatric surgery data showed a clinically significant reduction in BP, AHI/RDI, sleepiness, snoring, optimal PAP level, BMI, and ODI and an increase in LSAT in adults with OSA and obesity. Analyses of very limited evidence suggested that upper airway surgery does not result in a clinically significant increase in risk of serious persistent adverse events and suggested that bariatric surgery may result in a clinically significant risk of iron malabsorption that may be managed with iron supplements. The task force provided a detailed summary of the evidence along with the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations.

CITATION

Kent D, Stanley J, Aurora RN, et al. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med. 2021;17(12):2507-2531.

Long-term Results for Maxillomandibular Advancement to Treat Obstructive Sleep Apnea: A Meta-analysis

Objective

To examine outcomes in the intermediate term (1 to <4 years), long term (4 to <8 years), and very long term (≥8 years) for maxillomandibular advancement (MMA) as treatment for obstructive sleep apnea (OSA).

Data Sources

The Cochrane Library, Google Scholar, Embase, Cumulative Index to Nursing and Allied Health, and PubMed/MEDLINE.

Review Methods

Three authors systematically reviewed the international literature through July 26, 2018.

Results

A total of 445 studies were screened, and 6 met criteria (120 patients). Thirty-one patients showed a reduction in apnea-hypopnea index (AHI) from a mean 48.3 events/h (95% CI, 42.1-54.5) pre-MMA to 8.4 (95% CI 5.6, 11.2) in the intermediate term. Fifty-four patients showed a reduction in AHI from a mean 65.8 events/h (95% CI, 58.8-72.8) pre-MMA to 7.7 (95% CI 5.9, 9.5) in the long term. Thirty-five showed a reduction in AHI from a mean 53.2 events/h (95% CI 45, 61.4) pre-MMA to 23.1 (95% CI 16.3, 29.9) in the very long term. Improvement in sleepiness was maintained at all follow-up periods. Lowest oxygen saturation improvement was maintained in the long term.

Conclusion

The current international literature shows that patients with OSA who were treated with MMA maintained improvements in AHI, sleepiness, and lowest oxygen saturation in the long term; however, the mean AHI increased to moderate OSA in the very long term. Definitive generalizations cannot be made, and additional research providing individual patient data for the intermediate term, long term, and very long term is needed.

A novel implantable device for the treatment of obstructive sleep apnea: clinical safety and feasibility

OBJECTIVE

Many cases of obstructive sleep apnea (OSA) involve collapse of the tongue base and soft palate during sleep, causing occlusion of the upper airway and leading to oxygen desaturation. Existing therapies can be effective, but they are plagued by patient adherence issues and the invasiveness of surgical approaches. A new, minimally invasive implant for OSA has been developed, which is elastic and contracts a few weeks after deployment, stabilizing the surrounding soft tissue. The device has had good outcomes in preclinical testing; this report describes the preliminary feasibility and safety of its implementation in humans.

PATIENTS AND METHODS

A prospective, multicenter, single-arm feasibility study was conducted. Subjects were adults with moderate-to-severe OSA who had previously failed or refused conventional continuous positive airway pressure treatment. Intraoperative feasibility data, postoperative pain, and safety information were collected for a 30-day postoperative period.

RESULTS

Forty subjects participated (37 men, three women; average age of 46.1 years); each received two tongue-base implants and two soft-palate implants. Surgical procedure time averaged 43 minutes. Postsurgical pain resolved readily in most cases; at 30 days post implantation, <20% of subjects reported pain, which averaged less than two out of ten. Adverse events were generally the mild and expected sequelae of a surgical procedure with general anesthesia and intraoral manipulation. The device was well tolerated. Implant extrusions were reported with soft-palate implants (n=12), while tongue-base implants required few revisions (n=2). Quantitative and qualitative sleep effectiveness outcomes (including full-night polysomnographic and quality-of-life measures) will be presented in a subsequent report.

CONCLUSION

Implantation of the device was feasible. Although a relatively high rate of extrusions occurred in the now-discontinued palate implants, tongue-base implants were largely stable and well tolerated. The minimally invasive and maintenance-free implant may provide a new alternative to higher morbidity surgical procedures.

Quality of Life Assessment After Maxillomandibular Advancement Surgery for Obstructive Sleep Apnea

PURPOSE

Although maxillomandibular advancement (MMA) surgery is highly efficacious for the management of obstructive sleep apnea (OSA), little information exists regarding the subjective effect of this treatment modality. The present study was undertaken to investigate the effect of MMA on patient-perceived quality of life (QOL) in OSA.

PATIENTS AND METHODS

A retrospective cohort study of patients treated with MMA for OSA from May 2010 to April 2015 was performed. The primary outcome measure was a change in the QOL detected using the Ottawa Sleep Apnea Questionnaire (OSA-Q), which assesses the MMA-related changes in QOL with a 5-point Likert scale. The secondary outcome measure was a change in the apnea hypopnea index (AHI).

RESULTS

Twenty-two patients participated in the present study. The mean maxillary and mandibular advancement were 8.36 and 11.08 mm, respectively. The AHI decreased from 42.4 to 6.9 events per hour postoperatively (P < .001). The QOL improved significantly after MMA (OSA-Q score 3.98 ± 0.35; P < 001). The sleep quality (4.35 ± 0.63), daytime function (4.13 ± 0.46), physical health (4.19 ± 0.45), mental and emotional health (4.02 ± 0.55), and sexual health (3.78 ± 0.62) categories all improved postoperatively (P < .001). The MMA-related side effects did not adversely affect the QOL.

CONCLUSIONS

MMA for OSA significantly improves patient's subjective overall QOL, with few MMA-related side effects.

Maxillomandibular Advancement and Tracheostomy for Morbidly Obese Obstructive Sleep Apnea

Objective

The objective of this study is to systematically review polysomnography data and sleepiness in morbidly obese (body mass index [BMI] ≥40 kg/m2) patients with obstructive sleep apnea (OSA) treated with either a maxillomandibular advancement (MMA) or a tracheostomy and to evaluate the outcomes.

Data Sources

MEDLINE, Scopus, Web of Science, and the Cochrane Library.

Review Methods

A search was performed from inception through April 8, 2014, in each database.

Results

Six maxillomandibular advancement studies (34 patients, age 42.42 ± 9.13 years, mean BMI 44.88 ± 4.28 kg/m2) and 6 tracheostomy studies (14 patients, age 52.21 ± 10.40 years, mean BMI 47.93 ± 7.55 kg/m2) reported individual patient data. The pre- and post-MMA means ± SDs for apnea-hypopnea indices were 86.18 ± 33.25/h and 9.16 ± 7.89/h ( P < .00001), and lowest oxygen saturations were 66.58% ± 16.41% and 87.03% ± 5.90% ( P < .00001), respectively. Sleepiness following MMA decreased in all 5 patients for whom it was reported. The pre- and posttracheostomy mean ± SD values for apnea indices were 64.43 ± 41.35/h and 1.73 ± 2.68/h ( P = .0086), oxygen desaturation indices were 69.20 ± 26.10/h and 41.38 ± 36.28/h ( P = .22), and lowest oxygen saturations were 55.17% ± 16.46% and 79.83% ± 4.36% ( P = .011), respectively. Two studies reported outcomes for Epworth Sleepiness Scale for 5 patients, with mean ± SD values of 18.80 ± 4.02 before tracheostomy and 2.80 ± 2.77 after tracheostomy ( P = .0034).

Conclusion

Data for MMA and tracheostomy as treatment for morbidly obese, adult OSA patients are significantly limited. We caution surgeons about drawing definitive conclusions from these limited studies; higher level studies are needed.

Impact of Perioperative Fluid Administration on Postoperative Morbidity and Length of Hospital Stay Following Maxillomandibular Advancement for Obstructive Sleep Apnea

PURPOSE

The purpose of this study was to evaluate whether the volume of perioperative fluids administered to patients undergoing maxillomandibular advancement (MMA) for treatment of obstructive sleep apnea (OSA) is associated with an increased incidence of postoperative complications and prolonged length of hospital stay.

MATERIALS AND METHODS

A retrospective cohort study design was implemented and patients undergoing MMA for OSA at the Mayo Clinic were identified from 2001 through 2014. The primary predictor variable was the total volume of intravenous fluids administered during MMA. The primary outcome variable was length of hospital stay in hours. Secondary outcome variables included the presence of complications incurred during postoperative hospitalization. Additional covariates abstracted included basic demographic data, preoperative body mass index, preoperative apnea-hypopnea index, preoperative Charlson comorbidity index, preoperative American Society of Anesthesiologists score, type of intravenous fluid administered, surgical complexity score, duration of anesthesia, duration of surgery, and the use of planned intensive care unit admission. Univariate and multivariable models were developed to assess associations between the primary predictor variable and covariates relative to the primary and secondary outcome variables.

RESULTS

Eighty-eight patients undergoing MMA for OSA were identified. Total fluid volume was significantly associated with increased length of stay (odds ratio [OR] = 1.34, 95% confidence interval [CI], 1.05-1.71; P = .020) in univariate analysis. Total fluid volume did not remain significantly associated with increased length of hospital stay in stepwise multivariable modeling. Total fluid volume was significantly associated with the presence of postoperative complications (OR = 1.69; 95% CI, 1.08-2.63; P = .021) in univariate logistic regression.

CONCLUSION

Fluid administration was not found to be significantly associated with increased length of hospital stay after MMA for OSA. Increased fluid administration might be associated with the presence of postoperative complications after MMA; however, future large multicenter studies will be required to more comprehensively assess this association.

Maxillomandibular advancement in obstructive sleep apnea syndrome patients: a restrospective study on the sagittal cephalometric variables

OBJECTIVES

The present retrospective study analyzes sagittal cephalometric changes in patients affected by obstructive sleep apnea syndrome submitted to maxillomandubular advancement.

MATERIAL AND METHODS

15 adult sleep apnea syndrome (OSAS) patients diagnosed by polysomnography (PSG) and treated with maxillomandubular advancement (MMA) were included in this study. Pre- (T1) and postsurgical (T2) PSG studies assessing the apnea/hypopnea index (AHI) and the lowest oxygen saturation (LSAT) level were compared. Lateral cephalometric radiographs at T1 and T2 measuring sagittal cephalometric variables (SNA, SNB, and ANB) were analyzed, as were the amount of maxillary and mandibular advancement (Co-A and Co-Pog), the distance from the mandibular plane to the most anterior point of the hyoid bone (Mp-H), and the posterior airway space (PAS).

RESULTS

Postoperatively, the overall mean AHI dropped from 58.7 ± 16 to 8.1 ± 7.8 events per hour (P < 0.001). The mean preoperative LSAT increased from 71% preoperatively to 90% after surgery (P < 0.001). All the patients in our study were successfully treated (AHI < 20 or reduced by 50%). Cephalometric analysis performed after surgery showed a statistically significant correlation between the mean SNA variation and the decrease in the AHI (P = 0.01). The overall mean SNA increase was 6°.

CONCLUSIONS

Our findings suggest that the improvement observed in the respiratory symptoms, namely the apnea/hypopnea episodes, is correlated with the SNA increase after surgery. This finding may help maxillofacial surgeons to establish selective criteria for the surgical approach to sleep apnea syndrome patients.

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 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.

Same question, different answers: a comparison of global health assessments using visual analogue scales

PURPOSE

To compare responses to two global health VAS of patients with rheumatoid arthritis at the same assessment within the same questionnaire.

METHODS

Secondary analysis of randomised controlled trial data. Patients completed the patient global assessment VAS (PG-VAS) (horizontal 10 cm scale, left (0), right (100), no incremental markers) and EQ-5D-VAS (EQ-VAS) (vertical 20 cm scale, 100 at the top, markers at each increment of 10). Both asked "how good or bad is your health today, in your opinion, from 100 'Best imaginable health state' to 0 'Worst imaginable health state'." Agreement was assessed using intra-class correlation co-efficients (ICC) and Bland-Altman plots.

RESULTS

Four hundred and forty-eight patients reported median PG-VAS 66 (IQR 51, 77) and EQ-VAS 65 (IQR 50, 80) scores. Correlation of the VAS scales was moderate at baseline (ICC 0.564) and longitudinally (ICC 0.503). Bland-Altman plots suggested poor concordance of the PG-VAS and EQ-VAS; the limits of agreement were +/-32.3 on a 0-100 scale. PG-VAS scores were evenly distributed; EQ-VAS scores clustered at increments of 10; rounding did not improve agreement.

CONCLUSIONS

The EQ-VAS and PG-VAS scores are not interchangeable at the individual level. The EQ-VAS correlated more strongly with disease-specific and health-related quality of life measures, therefore, appears preferable.

Current trends in the treatment of obstructive sleep apnea

Obstructive sleep apnea (OSA) is a condition of partial or complete upper airway obstruction leading to increased resistance to airflow and potential cessation of breathing during sleep. Effective treatment of OSA is challenging and there has been greater recognition by the medical and dental disciplines. By understanding the rationale, indications, benefits, risks and success of the various treatment options available, clinicians will be able to make more informed treatment recommendations in patient management.

Hypopharyngeal airway surgery

Obstructive sleep apnea (OSA) is the result of upper airway obstruction during sleep. Hypopharyngeal airway obstruction can be caused by the prominence or relaxation of the base of the tongue, lateral pharyngeal wall, and occasionally, the aryepiglottic folds or epiglottis. Although nasal continuous positive airway pressure (CPAP) is considered as the first treatment for obstructive sleep apnea, surgery has been shown to be a viable option for patients who are intolerant of positive pressure therapy. This article presents the current state of hypopharyngeal surgery for sleep apnea. Preoperative airway evaluation with fiberoptic nasopharyngoscopy, the use of lateral cephalometric radiograph, and the formulation of a surgical plan with selection of procedures to address hypopharyngeal obstruction are discussed.

Surgical therapy for adult obstructive sleep apnea

Despite advances in positive pressure therapy for obstructive sleep apnea, compliance continues to be a problem for many patients. Sleep apnea surgery is a viable option for patients who are intolerant of positive pressure therapy. This review will present the current state of art in sleep apnea surgery, including airway evaluation with fiberoptic nasopharyngoscopy and lateral cephalometric radiograph, formulation of a surgical plan through a selection of procedures to address specific sites of obstruction, as well as discussion of published surgical outcomes.

Gender differences in sleep and sleep-disordered breathing

Sleep and sleep disorders are different in several important ways between men and women. Because of pregnancy and menopause, women experience changes in sleep that may present as clinical problems. In clinical populations, women are more likely to present with insomnia than are men, although their sleep may be better preserved. The presentation of sleep apnea in women is distinct from that of men and is less likely to include a "classic" history of witnessed ap-nea or heavy snoring. More likely it presents with nonspecific symptoms, such as fatigue or mood disturbance. There are little data on the effects of different treatments for OSA between men and women. OHS is a syndrome that may be as common in women as in men. The role of hormones in its pathophysiology is not well-defined.

Maxillomandibular Expansion for the Treatment of Sleep-Disordered Breathing: Preliminary Result

OBJECTIVE

To assess the outcomes of maxillomandibular expansion (MME) by distraction osteogenesis (DO) for the treatment of sleep-disordered breathing (SDB).

METHODS

This was a prospective study of six consecutive patients with SDB. All of the patients have maxillary and mandibular constriction and were treated with MME. Variables examined include age, sex, body mass index (BMI), polysomnographic results (PSG), Epworth Sleepiness Scale (ESS), and the extent of the widening of the maxilla and mandible.

RESULTS

All six patients (4 males) completed MME for the treatment of SDB. The mean age was 22.2 +/- 11.4 years. The mean maxillary expansion was 10.3 +/- 3.0 mm, and the mean mandibular expansion was 9.5 +/- 2.9 mm. ESS improved from 10.2 +/- 1.9 to 5 +/- 2.9. The mean apnea/ hypopnea index (AHI) improved from 13.2 +/- 15.6 to 4.5 +/- 5.8 events per hour, and the mean lowest oxygen saturation (LSAT) improved from 88.2 +/- 2.9% to 91.3 +/- 3.3%. The mean esophageal pressure improved from -20 +/- 11.3 cm H2O to -8 +/- 3.6 cm H2O. No complications were encountered, and the follow-up period was 18.1 +/- 9.8 months.

CONCLUSION

: The result suggests that MME improves SDB in patients with maxillary and mandibular constriction and can be a valid treatment.

Surgical management of obstructive sleep apnea

Nasal CPAP is and should be the first-line treatment for OSA. Any physician who uses nasal CPAP undoubtedly recognizes that this treatment modality has limitations, however. The authors believe that surgery offers a viable alternative to nasal CPAP in patients who are intolerant of nasal CPAP. Potential risks and complications must be explained fully to any potential surgical candidate. The selection of surgical procedure(s) should be determined based on a patient's airway anatomy, medical status, severity of sleep apnea, and his or her desire and preference.

The limitations of isolated palatal surgery for patients with obstructive sleep apnea

Obstructive sleep apnea is a condition for which palatal surgery in isolation has been shown to have limited success. In comparison, palatal procedures combined with other surgical approaches that address the multiple sites of obstruction in the upper aerodigestive tract seem to have improved success in the carefully selected patient.

Evidence-based medicine in sleep apnea surgery

Since the first description of sleep apnea as a clinical entity, the understanding of it within the medical community has increased significantly. Much research has explored the causes, assessment, and treatment of this disease. This research has resulted in a variety of tools for assessment and approaches to treatment. As research progresses, new data have shed light on the strengths of traditional approaches and their limitations. This article gives background for current approaches and charts a potential future course for sleep apnea assessment and treatment.

The role of oral appliances in treating obstructive sleep apnea

BACKGROUND

Sleep-related breathing disorders are common and often are associated with vascular complications such as arterial hypertension, coronary heart disease and stroke. The most widely studied form of these disorders is obstructive sleep apnea. Patients usually are diagnosed with obstructive sleep apnea years after the onset of symptoms, which generally are nonspecific and include excessive daytime sleepiness, chronic fatigue and habitual snoring. The risk factors for sleep apnea are obesity, advancing age, male sex and maxillofacial abnormalities. This review focuses on the diagnosis and treatment of obstructive sleep apnea and, specifically, on the utility of oral appliances in the management of this disorder.

METHODS

The review is based on a MEDLINE search for articles in English on this topic. The article discusses results of randomized studies and prospective case series.

CLINICAL IMPLICATIONS

Several treatment options are quite effective. Nasal continuous positive airway pressure, with an overall acceptance rate of 70 percent, is the most widely used treatment modality. Maxillofacial surgery, although effective, is reserved for patients who have not responded to the more conventional therapies. Newer methods include application of oral appliances. Oral appliances have been shown to alleviate the severity of respiratory disturbances during sleep by about 60 percent, with an overall acceptance rate of 75 percent. The long-term complications generally are minor and are related to occlusal changes and temporomandibular joint discomfort.

CONCLUSIONS

With the advent of oral appliances, dentists are increasingly involved in managing the care of patients with sleep-related breathing disorders. Further studies are needed to determine the long-term complications of this type of intervention for the treatment of sleep-related breathing disorders.

Validation of a Chinese version of the Epworth sleepiness scale

Epworth sleepiness scale (ESS) is widely used to evaluate degree of somnolence among Chinese patients with sleep-disordered breathing. Yet no Mandarin-Chinese translation has ever reported its validation data. In this study we translated and validated the ESS into Mandarin Chinese (CESS). We found, in 31 bilingual patients' responses to the CESS and the English ESS obtained 1-2 weeks apart did not differ significantly (10.5 +/- 3.7 vs. 9.6 +/- 3.9, p = 0.32, Wilcoxon's signed rank test) and were significantly correlated (Spearman's p = 0.67, p = 0.0004). A total of 359 sleep-disordered breathing subjects were enrolled into the validation study in a prospective manner. The CESS showed acceptable internal consistency (Cronbach's alpha = 0.81). Thirty out of these patients answered CESS twice at an interval of 2-4 weeks, to yield an acceptable level of test-retest reliability (p = 0.74, p = 0.001). The respiratory disturbance indices obtained from 251 out of 359 subjects were significantly correlated with their CESS scores (p = 0.22, p < 0.001). The standard response mean of CESS was 0.86 as obtained from 94 out of 359 subjects who had initial control of their symptoms at 3 months after radio-frequency palate surgery. We conclude that the CESS is reliable in both a linguistic and a test-retest sense, and appears to be valid and sensitive to clinical change. The CESS could be used to advantage among other Mandarin-speaking subjects as a standardised screening test of sleepiness in daily life.

Validation assessment of the Chinese version of the Snore Outcomes Survey

The aim of this study was to use a parallel model to translate the Snore Outcomes Survey (SOS) into Mandarin Chinese language by comparing performing characteristics and statistical properties of the original and Chinese versions SOS. The Chinese version SOS (CSOS) was validated in a prospective, non-randomized manner. A total of 359 patients with sleep-disordered breathing (SDB) aged 18 years and older diagnosed as having SDB participated in the study at entry. Reliability, validity, and longitudinal sensitivity data for CSOS were obtained. CSOS demonstrated good test-retest reliability (Intra-class correlation coefficient = 0.751). The Cronbach's alpha coefficient was 0.86. The item-total correlation coefficients varied from 0.30 to 0.99. The CSOS correlated well with polysomnogram (PSG) parameters including respiratory distress index (RDI), lowest arterial O2 saturation (LAST). CSOS also yielded significant correlations with vitality subscale of Chinese Taiwan version SF-36 (r = 0.4, p = 0.0011). The standard response mean (SRM) for CSOS was 1.33. The validation demonstrated only minor effects of language; the statistical properties of the CSOS were equivalent to the English version. The CSOS is a valid tool to evaluate adults with SDB among Chinese-speaking population.

Obstructive sleep apnea and maxillomandibular advancement: an assessment of airway changes using radiographic and nasopharyngoscopic examinations

PURPOSE

The study aim was to evaluate the resultant changes in the upper airway after maxillomandibular advancement (MMA) for obstructive sleep apnea.

METHODS

Twelve patients were evaluated before and after MMA using fiberoptic nasopharyngoscopy (NPG) with Müller maneuver. An inspiratory force meter was used to ensure the consistency of the inspiratory efforts between the 2 examinations. Preoperative and postoperative lateral cephalometric radiographs were also compared.

RESULTS

Decrease in the airway obstruction was shown by the lateral cephalometric radiograph as well as by fiberoptic NPG during passive respiration. Fiberoptic NPG with Müller maneuver also revealed a decrease in airway collapsibility. Although the retrodisplacement of the tongue base was improved, the improvement in lateral pharyngeal wall stability was the most striking.

CONCLUSIONS

MMA achieved expansion of the upper airway. In addition, MMA decreased the collapsibility of the airway, especially the lateral pharyngeal walls. These findings may explain the highly successful outcomes of MMA for the treatment of obstructive sleep apnea.