Tongue base reduction with temperature-controlled radiofrequency volumetric tissue reduction for treatment of obstructive sleep apnea syndrome

Tissue properties and respiratory kinematics of the tongue base and soft palate in the obese OSA minipig

Obesity is a common finding and a major pathogenetic factor in obstructive sleep apnea (OSA) in adults. To understand the mechanisms behind this, the present study investigated the tissue properties and respiratory kinematics of the tongue base and soft palate in the obese OSA minipig model. In 4 verified obese/OSA and 3 non-obese/non-OSA control minipigs, MRI fat-weighted images, ultrasound elastography (USE), and sleep video-fluoroscopy (SVF) were performed to quantify the fat composition, tissue stiffness, and respiratory kinematics of the tongue base and soft palate during sedated sleep. The results indicated that the fat composition gradually increased from the rostral to caudal tongue base, particularly in the posterior 1/3 of the tongue base, regardless of the presence of obesity and OSA. However, this trend was not seen in the soft palate and pharyngeal wall. The pharyngeal wall presented the highest fat composition as compared with the tongue base and soft palate. Overall, obese OSA minipigs showed stiffer tongue tissue than the controls, particularly in the rostral region of the tongue in obese Yucatan minipigs. The respiratory moving ranges of the soft palate were greater in both dorsal-ventral and rostral-caudal directions and during both respiratory and expiratory phases in OSA obese than control minipigs, and the largest moving ranges were seen in OSA obese Panepinto minipigs. The moving range of the tongue base was significantly smaller. These results suggest more fat infiltration in the caudal region of the tongue base regardless of the presence of obesity and/or OSA. The greater tissue stiffness of the tongue in obese OSA minipigs may result from altered neuromuscular drive.

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.

Safety of tongue base procedures for sleep apnoea in adults: A systematic review and metanalysis from the YO-IFOS study group

OBJECTIVE

Tongue base and hypopharynx are the major sites of obstruction in OSA patients with failed palatal surgery. In recent years, several minimally invasive procedures have been developed to address tongue base obstruction. However, the research focus has consistently been on the effectiveness of surgery in reducing obstructive sleep apnoea rather than on postoperative complications. In this systematic review and metanalysis we aim to review the complication rate of minimally invasive base of tongue procedures for OSAS in adults.

DATA SOURCES

PubMed (Medline), the Cochrane Library, EMBASE, Scopus, SciELO and Trip Database.

REVIEW METHODS

Data sources were checked by three authors of the YO-IFOS sleep apnoea study group. Three authors extracted the data. Main outcome was expressed as the complication rate and 95% confidence interval for each surgical technique.

RESULTS

20 studies (542 patients) met the inclusion criteria. The mean complication rate is 12.79%; 4.65% for minor complications, 6.42% if they are moderate, and 1.77% if severe. The most reported complication overall is infection, in 1.95% of cases, followed by transient swallowing disorder, occurring in 1.30% of the total sample.

CONCLUSION

The heterogeneity amongst the included studies prevents us from obtaining solid conclusions. The available evidence suggests that minimally invasive base of tongue procedures may present a wide spectrum of complication rates, ranging from 4.4% in tongue base radiofrequency to up to 42.42% in tongue base ablation.

Assessment and Management of Postoperative Pain Associated with Sleep Apnea Surgery

A literature review was conducted regarding the assessment and treatment of postoperative pain following surgery for obstructive sleep apnea (OSA). Given the risks of opioid use by patients with OSA, special attention to opioid risk reduction and avoidance is warranted in this population. The results of this review demonstrate the existence of a body of evidence that supports the use of nonopioid analgesics and nonpharmacologic approaches pain management. Strategies for managing postoperative pain should emphasize the use of local anesthetic infiltration, nonsteroidal antiinflammatory drugs, acetaminophen, topical analgesics, surgical wound cooling, and when necessary, safer opioid medications, such as tramadol and intranasal butorphanol.

Robo-Cob technique; transoral endoscopic coblation tongue base resection in obstructive sleep apnea patients

BACKGROUND

Another transoral tongue base surgical procedure for obstructive sleep apnea (OSA) is described. The procedure was named as the "Robo-Cob" technique because it is similar to transoral robotic surgery (TORS) but using a coblation technology to manage tongue base hypertrophy in patients with OSA especially in countries where TORS is not an available option for such benign conditions.

METHODS

The technique is described step by step. The new surgical technique was carried out in 25 adult OSA patients with mean age of 41.36 ± 8.72 years (average 23-56) with confirmed tongue base hypertrophy by preoperative drug-induced sleep endoscopy (DISE). Coblation was used to resect, not ablate, the tongue base with similar technique as described in TORS.

RESULTS

The Robo-Cob technique is proved to be feasible and effective in all cases either alone or when combined with other procedures in multilevel surgery settings. There were no significant intraoperative or postoperative complications. No tracheostomy was done in any patient. Objective clinical improvement was confirmed by polysomnography 3 months postoperatively with significant decrease in mean AHI from 33.84 ± 10.54 to 11.52 ± 5.42 (P < 0.005). Moreover, this technique provided tongue base tissue specimen that allowed measurement of its volume that ranged from 10 to 22 cc (mean 14.96 ± 3.62 cc) to monitor extent of tissue resection.

CONCLUSION

The added value of using coblation in resection, not ablation, is being quicker, and being able to provide tissue specimen to measure its volume to judge resection limits.

Transoral Endoscopic Coblation Tongue Base Surgery in Obstructive Sleep Apnea: Resection versus Ablation

BACKGROUND

A new transoral tongue base surgical procedure for the treatment of snoring and obstructive sleep apnea (OSA) is described. It is named "Robo-Cob" technique because it is similar to transoral robotic surgery (TORS) but it is performed by means of coblation technology in order to resect the tongue base in countries where TORS is not an available option for such benign conditions.

METHODS

In this prospective, randomized, controlled trial, the new Robo-Cob technique was carried out in 25 adult OSA patients with confirmed tongue base hypertrophy at preoperative drug-induced sedation endoscopy. The results of this procedure were compared with the coblation endoscopic lingual lightening (CELL) technique used to ablate (or minimally resect) the central part of the tongue base, in another 25 adult OSA patients with similar characteristics (age, sex, preoperative body mass index and Apnea-Hypopnea Index, AHI). The base of tongue surgery was part of multilevel surgery including also septoturbinoplasty and barbed reposition pharyngoplasty (with/without tonsillectomy).

RESULTS

In this study, the Robo-Cob technique is proved to be feasible and effective in all cases either alone or when combined with other procedures in multilevel surgical settings. No/minimal intraoperative or postoperative complications were observed. Postoperative pain as measured by visual analog scale ranged from 3 to 7. No tracheostomy was done in any patient. Objective clinical improvement was confirmed by a level 3 polygraphy performed 6 months after surgery. There was significant difference in operative time at the level of the tongue base between Robo-Cob and CELL techniques, with shorter times observed within the Robo-Cob group. Moreover, the Robo-Cob technique provided tongue base tissue specimens that allowed measurement of the volume that ranged from 5 to 17 cm3 (mean 11.64 ± 3.49 cm3). It was found that resection of at least 10 cm3 of tongue base tissue was associated with better outcomes in terms of postoperative AHI reduction.

CONCLUSION

In this study, the added values of using coblation for resection and not ablation appear to be the short surgical time, the low postoperative tissue edema, and the possibility of providing tissue specimens to measure resected volumes.

Complications associated with surgical treatment of sleep-disordered breathing among hospitalized U.S. adults

The purpose of this cross-sectional study is to examine the relationship between surgical treatments for sleep-disordered breathing (SDB) and composite measure of surgical complications in a nationally representative sample of hospital discharges among U.S. adults. We performed secondary analyses of 33,679 hospital discharges from the 2002-2012 Nationwide Inpatient Sample that corresponded to U.S. adults (≥18 years) who were free of head-and-neck neoplasms, were diagnosed with SDB and had undergone at least one of seven procedures. Multivariate logistic regression models were constructed to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI), controlling for age, sex, race/ethnicity, obstructive sleep apnea (OSA) and obesity diagnoses. Positive associations were found between composite measure of surgical complications and specific procedures: palatal procedure (aOR = 12.69, 95% CI: 11.91,13.53), nasal surgery (aOR = 6.47, 95% CI: 5.99,6.99), transoral robotic assist (aOR = 5.06, 95% CI: 4.34-5.88), tongue base/hypopharynx (aOR = 4.24, 95% CI: 3.88,4.62), maxillomandibular advancement (MMA) (aOR = 3.24, 95% CI: 2.74,3.84), supraglottoplasty (aOR = 2.75, 95% CI: 1.81,4.19). By contrast, a negative association was found between composite measures of surgical complications and tracheostomy (aOR = 0.033, 95% CI: 0.031,0.035). In conclusion, most procedures for SDB, except tracheostomy, were positively associated with complications, whereby palatal procedures exhibited the strongest and supraglottoplasty exhibited the weakest association.

The First Patient Report of Tongue Abscess Among Iraqi Population

Tongue abscess is a serious clinical entity which scarcely affects the tongue. It should be treated urgently to prevent airway obstruction or dissemination of infection to a more deep or distant area of the body. This article presented the first clinical report of tongue abscess in Iraq which discussed its clinical presentation, diagnosis, and treatment with a review of literature.

Intermittent hypoxia causes mandibular growth retardation and macroglossia in growing rats

INTRODUCTION

In this study, we aimed to examine the role of intermittent hypoxia (IH) in dentofacial morphologic changes in growing rats.

METHODS

Seven-week-old male rats were exposed to IH at 20 cycles per hour (nadir of 4% oxygen to peak of 21% oxygen) for 8 hours per day for 6 weeks. Control rats were exposed to normoxia (N). Maxillofacial growth was compared between the 2 groups by linear measurements on cephalometric radiographs. To examine the dental arch morphology, study models and microcomputed tomography images of the jaws were taken. Additionally, tongue size was measured.

RESULTS

The gonial angle and the ramus of the mandible were smaller in the IH group than in the N group, whereas the body weights were not different between the 2 groups. Morphometric analysis of the dentition showed a significantly wider mandibular dentition and narrower maxillary dentition in the IH than in the N group. The relative width (+4.2 %) and length (tongue apex to vallate papillae, +3.5 %) of the tongue to the mandible were significantly greater in the IH group than in the N group.

CONCLUSIONS

IH induced dentofacial morphologic discrepancies in growing rats.

Multilevel Temperature-Controlled Radiofrequency for Obstructive Sleep Apnea: Extended Follow-Up

OBJECTIVE: To determine long-term effectiveness of multilevel (tongue and palate) temperature-controlled radiofrequency tissue ablation (TCRFTA) for patients with obstructive sleep apnea syndrome (OSAS).

STUDY DESIGN AND SETTING: Prospective, 2-institution case series. Twenty-nine subjects with mild to moderate OSAS and who were at least 1 year from completion of multilevel TCRFTA were included, representing a subset of subjects who were enrolled in a previously published controlled trial. Exclusion criteria for this extended follow-up study included any additional treatment for OSAS after completion of TCRFTA.

RESULTS: Median follow-up was 23 months. Daytime sleepiness and OSAS-related quality of life were significantly improved at extended follow-up (both P 0.001). Median reaction time testing and apnea-hypopnea index (AHI) were also significantly improved at long-term follow-up ( P = 0.03 and 0.01). Body mass index was unchanged ( P = 0.94).

CONCLUSIONS: Multilevel TCRFTA treatment of mild to moderate OSAS resulted in prolonged improvement in daytime somnolence, OSAS-related quality of life, psychomotor vigilance, and AHI in this group of subjects at extended follow-up.

Volumetric tissue reduction in radiofrequency surgery of the tongue base

OBJECTIVES:

Radiofrequency surgery is a minimally invasive technique for the treatment of the tongue base in sleep-disordered breathing. The aim of this study was to evaluate the changes in upper airway anatomy induced by radiofrequency surgery with MRI.

STUDY DESIGN AND SETTING:

10 patients with sleep-disordered breathing were treated with radiofrequency surgery at tongue base. MRI measurements were performed before and after surgery with the help of a recently published protocol.

RESULTS:

The mean total number of energy delivered per patient was 4750 ± 1641 Joule. Relevant changes could be observed neither for tongue volume or dimension nor for retrolingual space.

CONCLUSIONS:

Changes in upper airway anatomy could not be demonstrated. The effects of radiofrequency surgery of the tongue base may more likely be a result of changes in upper airway collapsibility.

SIGNIFICANCE:

Functional effects of surgical interventions in sleep-disordered breathing should be considered in addition to mechanistic concepts alone.

Tongue Base Suspension Combined with UPPP in Severe OSA Patients

Objective:

Tongue base surgery in the severe OSA patients may improve the success of uvulopalatopharyngoplasty (UPPP) as the collapse is multilevel. The aim of this study was to evaluate the long-term objective and subjective effectiveness of the minimally invasive tongue base suspension combined with UPPP in severe OSA patients.

Study Design and Setting:

We conducted a retrospective analysis of 22 OSA patients undergoing UPPP and the tongue base suspension for the treatment of severe OSA.

Results:

Twenty-two men who had their preoperative and postoperative polysomnography had a 54% reduction in the preoperative Respiratory Disturbance Index (RDI), from 47.50 ± 15.74 to a level of 17.31 ± 14.17. The standard surgical cure rate which is a >50% reduction in the RDI and a postoperative RDI of <20 events/hour was 81.81%. All patients had some degree of subjective improvement in their snoring, daytime sleepiness, and the Epworth sleepiness scale.

Conclusions:

The tongue base suspension combined with UPPP has been shown to reduce RDI better than UPPP alone. This minimally invasive technique is highly successful at 81.81% when combined with UPPP in the severe OSA patients with multilevel airway collapse.

Significance:

This study shows the benefits of minimally invasive tongue base suspension combined with UPPP in severe obstructive sleep apnea syndrome.

Multilevel Surgery for Obstructive Sleep Apnea: Short-Term Results

OBJECTIVE: To determine the efficacy of a new multilevel surgical protocol for obstructive sleep apnea (OSA).

STUDY DESIGN AND SETTING: Sixty patients with moderate to severe OSA because of multilevel pharyngeal obstruction were enrolled into this prospective, controlled clinical trial after clinical examination, endoscopy, and polysomnography. Surgery included uvulaflap, tonsillectomy, hyoid suspension, and radiofrequency treatment of the tongue base (group A). A second group did not receive hyoid suspension (group B). In both groups, nasal surgery was performed if necessary. Polysomnography and Epworth Sleepines Scale (ESS) were recorded at baseline and 2 to 15 months after surgery.

RESULTS: In group A, the mean apnea-hypopnea index (AHI) decreased significantly after surgery (38.9 ± 20.0 vs 20.7 ± 20.6, P < 0.0001), whereas in group B the AHI did not. All secondary variables (minimal oxygen saturation, mean oxygen saturation, arousal index), and the ESS significantly improved in group A with only changes in arousal index and ESS reaching levels of significance in group B.

CONCLUSION: The presented protocol including the hyoid suspension proved to be effective in the treatment of OSA, whereas surgery without hyoid suspension was less successful.

Combined Uvulopalatopharyngoplasty and Radiofrequency Tongue Base Reduction for Treatment of Obstructive Sleep Apnea/Hypopnea Syndrome

OBJECTIVE

In this study, we compare the objective results of uvulopalatopharyngoplasty (UPPP) combined with tongue base radiofrequency reduction (TBRF) with standard UPPP treatment of obstructive sleep apnea/hypopnea syndrome (OSAHS).

STUDY DESIGN

We conducted a retrospective study of 277 patients who had stage I, II, or III OSAHS based on the Friedman staging system previously presented.

METHODS

One hundred thirty-four patients who had treatment with UPPP only were used as a control group. This included 31 patients with stage I, 29 patients with stage II, and 74 patients with stage III OSAHS. An additional 143 patients with Stage II (n = 52) and III (n = 91) OSAHS were treated with combined UPPP and TBRF, initially and followed by additional TBRF treatments (up to 9000 J) as necessary. Subjective results were collected based on questionnaires and the Epworth Sleepiness Scale score for the experimental group, but these subjective measures were not available for the control group. Objective results were compared based on the polysomnographic findings before and after surgery.

RESULTS

Subjectively, the study group did extremely well. Based on objective measures of successful treatment, UPPP plus TBRF resulted in a significantly higher percentage of patients who were "cured" of OSAHS compared with the control group.

CONCLUSIONS

Stage I patients were usually successfully treated with UPPP only. However, patients allocated to stage II or III will benefit from the addition of TBRF to standard UPPP. Many UPPP-plus-TBRF patients in this study aborted further recommended TBRF treatments after subjective improvement and therefore objective results for this group, although improved in comparison to stage II and III patients treated with UPPP only, may not represent maximal potential improvement.

The Effect of Hyoid Suspension in a Multilevel Surgery Concept for Obstructive Sleep Apnea

OBJECTIVE: This study investigated the outcome of the hyoid suspension as a part of a multilevel surgery protocol.

STUDY DESIGN AND SETTING: Eighty-three patients with obstructive sleep apnea (OSA) underwent a multilevel surgical treatment because of continuous positive-airway pressure intolerance, 67 with the hyoid suspension and 16 without the hyoid suspension. All patients underwent a pre- and postoperative polysomnography in the sleep laboratory.

RESULTS: The mean preoperative apnea hypopnea index (AHI) was 36.4 ± 21.2 and 19.4 ± 19.7 postoperatively for all patients ( P < 0.0001). Further statistically significant changes were found for the arousal index, the oxygen saturation, and the daytime sleepiness. No statistically significant change was found for body mass index. In the group of patients treated without the hyoid suspension, the AHI did not decrease statistically significant. After surgery, 59.7% of the subjects with the hyoid suspension were regarded as cured.

CONCLUSION: Multilevel surgery including the hyoid suspension is an effective treatment in subgroup of OSA patients.

EBM rating: C-4

Factors Associated with Successful Treatment by Radiofrequency Treatment of the Soft Palate in Obstructive Sleep Apnea as the First-Line Treatment

Background. Radiofrequency ablation (RFA) is recommended as the second-line treatment for obstructive sleep apnea (OSA). This study aims to study the factors associated with successful treatment by RFA in OSA patients as the first-line treatment. Methods. All patients diagnosed as mild to moderate OSA were enrolled prospectively and treated with RFA. Three points of soft palate were ablated: midline, left, and right paramedian sites. Baseline characteristics and clinical factors including snoring score (SS), Epworth Sleepiness Scale (ESS), and apnea-hypopnea index (AHI), with minimal oxygen saturation, were recorded at baseline and three months after treatment. Results. During the study period, there were 51 patients who met the study criteria and received RFA treatment. At three months, the SS, ESS, and AHI were significantly lower than baseline values, while the minimal oxygenation was significantly increased from the baseline values. There were 16 patients (31.37%) who had an AHI of < 5 times/h. Only baseline AHI was significantly associated with an AHI of < 5 times/h at three months after RFA treatment. The adjusted odds ratio was 0.804 (95% CI: 0.699, 0.924). Conclusion. Transoral RFA treatment may be effective in mild to moderate OSA as the first-line treatment. Baseline AHI is associated with preferable outcome by RFA treatment.

Temperature controlled radiofrequency ablation at different sites for treatment of obstructive sleep apnea syndrome: a systematic review and meta-analysis

BACKGROUND

This study seeks to determine the efficacy of temperature controlled radiofrequency tissue ablation (TCRFTA) to alleviate symptoms of obstructive sleep apnea (OSA) and reduce polysomnographic measures of OSA in the first year post-treatment.

METHODS

Systematic review and meta-analysis. Two independent searches of MEDLINE, EMBASE bibliographic databases, and Evidence Based Medicine Reviews to identify publications relevant to OSA and TCRFTA. Effectiveness of TCRFTA was measured separately for application of TCRFTA at the base of tongue and soft palate, and for multilevel intervention using the respiratory disturbance index (RDI), lowest oxygen saturation (LSAT), Epworth sleepiness scale (ESS), and bed partner's rating of snoring using a visual analogue scale (VAS snoring). The most recent search was conducted in April 2013. Statistical analysis was performed using Review Manager Version 5.2 using a relative measure of effect, i.e., ratio of means (RoM).

RESULTS

Our initial search resulted in 29 eligible studies, and subsequently, 20 studies were included in the meta-analysis. Substantial and consistent improvement in PSG and subjective outcomes were observed post-TCRFTA in the base of tongue (BOT) and multilevel surgery groups only. Application of TCRFTA at the BOT was associated with a significant reduction in RDI (RoM 0.60, CI 0.47-0.76), ESS (RoM 0.59, CI 0.51-0.67), and VAS snoring (RoM 0.48, CI 0.37-0.62) and increase in lowest oxygen saturation (RoM 1.05, CI 1.01-1.10). Similarly, a significant reduction in RDI (RoM 0.61, CI 0.47-0.80) and ESS (RoM 0.79, CI -0.71 to 0.88) was observed after multilevel TCRFTA, but substantial heterogeneity between these studies was observed.

CONCLUSION

TCRFTA is clinically effective in reducing RDI levels and symptoms of sleepiness in patients with OSA syndrome when directed at the base of tongue or as a multilevel procedure.

Inferior turbinoplasty during cosmetic rhinoplasty: techniques and trends

BACKGROUND

The sheer number of accepted inferior turbinoplasty techniques emphasizes the fact that there is no general agreement on which approach yields optimal results, nor are there data available that describes prevalent techniques in turbinate surgery among plastic surgeons.

OBJECTIVE

The aim of this study was to identify practice patterns among plastic surgeons who perform inferior turbinoplasty during rhinoplasty.

METHODS

Members of the American Society of Plastic Surgeons were invited to participate in an anonymous, Internet-based survey containing questions related to personal preferences and outcomes in inferior turbinate surgery.

RESULTS

A total of 534 members of the American Society of Plastic Surgeons participated in the survey. Most (71.7%) trained in an independent plastic surgery program with prerequisite training in general surgery. More than half (50.6%) had more than 20 years of operative experience; only 15.2% reported performing greater than 40 rhinoplasties per year. The 5 most preferred inferior turbinate reduction techniques were outfracture of the turbinates (49.1%), partial turbinectomy (33.3%), submucous reduction via electrocautery (25.3%), submucous resection (23.6%), and electrocautery (22.5%). Fewer than 10% of the respondents reported the use of newer techniques such as radiofrequency thermal ablation (5.6%), use of the microdebrider (2.2%), laser cautery (1.1%), or cryosurgery (0.6%). Mucosal crusting and desiccation were the most frequently reported complications.

CONCLUSIONS

The results of this survey provide insights into the current preferences in inferior turbinate reduction surgery. Plastic surgeons are performing more conventional methods of turbinate reduction rather than taking advantage of the many of the more novel technology-driven methods.

Identification of craniofacial risk factors for obstructive sleep apnoea using three-dimensional MRI

The alteration of craniofacial structures has been associated with obstructive sleep apnoea (OSA). We hypothesised that: 1) a smaller mandible is a risk factor for OSA; and 2) the previously observed inferiorly positioned hyoid bone in apnoeics is associated with enlarged tongue volume. This is a case-control study using three-dimensional magnetic resonance imaging cephalometry. 55 apneics and 55 controls were matched for age, sex and race. The analysis was stratified by sex and controlled for age, race, height, neck visceral fat, skeletal type and tongue volume. We found that a 1-sd increase in mandibular length and depth were associated with decreased risk of sleep apnoea (OR 0.52, 95% CI 0.28-0.99 and OR 0.46, 95% CI 0.23-0.91, respectively) in males but not in females. Greater hyoid-to-nasion (OR 2.64, 95% CI 1.19-5.89 in males and OR 5.01, 95% CI 2.00-12.52 in females) and supramentale-to-hyoid (OR 2.39, 95% CI 1.12-5.14) in males and OR 3.38, 95% CI 1.49-7.68 in females) distances were associated with increased risk of OSA. The difference for hyoid position between apnoeics and controls was lost after controlling for tongue volume. Enlargement of tongue is likely to be the pathogenic factor for inferior-posterior positioning of hyoid. A small and shallow mandible is an independent risk factor for OSA in males but not in females.

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.

Reoperative treatment of obstructive sleep apnea

Over the last several decades, various surgical treatments have been advocated and used to treat obstructive sleep apnea. Treatments ranging from aggressive procedures, such as tracheostomy, to the least-invasive procedures, such as radioablation, have not yielded satisfactory results. One of the major causes for surgical failures and lower success rates lies in the inadequate understanding and appreciation of the anatomic and pathophysiologic factors that contribute to upper airway obstruction. In some cases, combinations of various surgical techniques may help improve the conditions. This article reviews several major types of surgical procedures, their complications, and the recommended approaches for retreatments.

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.

Radiological airway changes following bipolar radiofrequency volumetric tissue reduction

Objective:

To characterise the appearance of lesions of the tongue base and soft palate induced by bipolar radiofrequency volumetric tissue reduction, using magnetic resonance imaging up to six weeks post-procedure.

Methods:

Five men with sleep-disordered breathing were treated with one session of bipolar radiofrequency volumetric tissue reduction to a number of sites, including the tongue base and soft palate. Magnetic resonance imaging was performed pre-operatively and one week and six weeks after surgery.

Results:

Lesions were visible from day one. T1 (spine lattice relaxation Time)-weighted images demonstrated areas of central hyperintensity, reflecting haemorrhagic, coagulative necrosis, surrounded by hypointensity, representing oedema; corresponding short tau inversion recovery (STIR) sequences showed central hypointensity with surrounding high signal. The lesions expanded up to day three and then gradually diminished, but were still evident at week six on short tau inversion recovery images.

Conclusion:

The characterisation of lesions induced by bipolar radiofrequency volumetric tissue reduction enables us to elucidate the pathophysiology of this procedure, to optimise treatment benefits and clinical outcomes, and to explain patient symptoms.

[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.

Radiofrequency Surgery for the Treatment of Obstructive Sleep Apnea: Short-Term and Long-Term Results

OBJECTIVE: To compare the short-term and long-term results in patients undergoing radiofrequency (RF) for obstructive sleep apnea (OSA).

STUDY DESIGN: Case series and planned data collection.

SETTING: Tertiary referral center.

SUBJECTS AND METHODS: A study was undertaken on 72 OSA patients with palatal and tongue base obstruction based on radiography and physical findings. Multilevel RF was conducted to reduce the tissue.

RESULTS: Patients had a mean age of 35.8 ± 10.9 years and a mean body mass index (BMI) of 28.8 ± 2.4 kg/m 2 . The mean follow-up was 14.2 ± 1.8 months, with arange of 12 to 16 months. Mean baseline apnea-hypopnea index (AHI), short-term AHI, and long-term AHI were 35.6 ± 9.2, 12.5 ± 4.8, and 16.8 ± 3.2, respectively. Mean baseline lowest oxygen saturation (LSAT), short-term LSAT, and long-term LSAT were 85.6 ±3.4 percent, 88.7 ± 2.9 percent, and 88.2 ±1.7 percent, respectively. The change in BMI was significantly different in the patients with and without recurrence (2.8 ± 1.8 vs 0.3 ± 0.2 kg/m 2 , P < 0.01). Forty (55.6%) patients had long-term success, and eight (16.7%) patients with short-term success failed in the long term. Serious complications were not encountered.

CONCLUSION: RF is a minimally invasive and effective procedure that results in long-term success for patients with a relatively low BMI and mild to moderate OSA without nasal obstruction. However, a recommendation concerning weight control and a regular follow-up are important because some patients will relapse in the long term.

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.

Soft palate implants as a minimally invasive treatment for mild to moderate obstructive sleep apnea

CONCLUSION

The palatal implant method originally designed to reduce snoring can significantly reduce the apnea-hypopnea index (AHI) in some patients with mild to moderate obstructive sleep apnea (OSA) in a single office-based procedure.

OBJECTIVE

An initial study designed to evaluate the short-term efficacy and safety of palatal implants as primary treatment for patients with mild to moderate OSA.

MATERIALS AND METHODS

This was a prospective, non-randomized study of 16 previously untreated and undiagnosed patients with sleep apnea. The inclusion criteria were an AHI of 10-30/h and a body mass index (BMI) < or = 30.

RESULTS

The mean AHI was reduced following implantation, from 16.1 to 11.8 (p<0.01). A reduction in AHI was achieved in 13 patients (81%). Ten of 16 patients had their AHI reduced to <10.0. Snoring intensity decreased from 8.3+/-1.8 to 4.7+/-2.5 on a visual analog scale (p<0.001) and daytime sleepiness dropped from 7.2+/-2.5 to 4.6+/-3.2 on the Epworth Sleepiness Scale (p<0.05). No significant adverse events were reported.

Radiofrequency surgery of the tongue base in the treatment of snoring—a pilot study

In a previously published study, a significant reduction of snoring was reported after treatment with radiofrequency surgery of the tongue base in patients suffering from obstructive sleep apnea syndrome. The aim of this study was to investigate the efficacy of radiofrequency surgery of the tongue base in the treatment of primary snoring. Twenty patients suffering from primary snoring (AHI < 10/h, body mass index < 32 kg/m(2)) and an isolated hypertrophic tongue base at clinical examination were enrolled in this clinical trial. The patients underwent bipolar radiofrequency surgery of the tongue base under local anaesthesia. Pre- and post-operative body weight, daytime sleepiness (Epworth sleepiness scale) and snoring scores (visual analogue scales) were evaluated by the patients and their bed partners, respectively. Postoperative follow-up data was collected 6-8 weeks after treatment. A statistically significant reduction of the preoperative snoring levels from 7.5 +/- 2.4 to 6.1 +/- 2.8 was seen after treatment (p < 0.001). Body weight and daytime sleepiness remained unaffected. Only 3 out of 20 patients were satisfied with the result as defined by VAS < 3. Despite statistically significant reduction of the subjective snoring scores after radiofrequency of the tongue base, only minimal clinical improvement was achieved. Only 3 out of 20 patients were satisfied with the results. With regard to the clearly beneficial effect seen in patients with obstructive sleep apnea, this result indicates different pathophysiological principles in the generation of snoring.

Obstructive sleep apnea - management update

Obstructive sleep apnea (OSA) is a highly significant condition based both on the high prevalence in community and significant consequences. Obstructive sleep apnea syndrome (OSAS), OSA together with hypersomnolence, is seen in 4% of middle-aged men and 2% of middle-aged women. OSA is associated with impaired quality of life and increased risks of motor vehicle accidents, cardiovascular disease (including hypertension and coronary artery disease), and metabolic syndrome. There is some evidence for the use of conservative interventions such as weight loss and position modification. CPAP remains the mainstay of treatment in this condition with high-level evidence supporting its efficacy. Continuous positive airway pressure (CPAP) is an intrusive therapy, with long-term adherence rates of less than 70%. Dental appliances have been shown to be effective therapy in some subjects but are limited by the inability to predict treatment responders. Alternative treatments are discussed but there is little role for upper airway surgery (except in a select few experienced institutions) or pharmacological treatment. The current levels of evidence for the different treatment regimens are reviewed.

Bipolar radiofrequency induced thermotherapy of the tongue base: Its complications, acceptance and effectiveness under local anesthesia

We assessed adverse events and complications of bipolar radiofrequency induced thermotherapy of the tongue base (RFTB) in patients with socially unacceptable snoring (SUS) or obstructive sleep apnea syndrome (OSAS) and determine its acceptance and effectiveness when conducted under local anesthesia. This investigation consisted of (1) a prospective, open-enrollment study of 24 consecutive patients with snoring and OSAS at the tongue base level only (Fujita III), assessed by sleep endoscopy. Polysomnography, questionnaires, and visual analog scales (VAS) were used to assess outcome. (2) In addition, a retrospective review of 83 patients, who underwent RFTB (in 59 cases as part of a multilevel treatment), was performed to evaluate adverse events and complications. Twenty-two of the 24 patients completed postoperative questionnaires and VAS, and ten patients had postoperative polysomnography. Reduction in snoring (P = 0.0003), hypersomnolence (P = 0.002), and globus (P = 0.031) was significant. A positive trend in AHI (P = 0.001, n = 3) is shown in patients with moderate to severe OSAS. Concerning postoperative adverse events and complications, only two patients had a mild and transient tongue deviation directly after the procedure, which resolved within an hour postoperatively (adverse event rate 1.8%). No postoperative complications such as infections, abscesses, hematomas, or ulcerations of the tongue base occurred. This study demonstrates that bipolar RFTB in patients with obstruction at the tongue base only (Fujita type III) as visualized by sleep endoscopy is a safe and simple procedure under local anesthesia and can be effective in patients with SUS. No complications during this study were observed. Its effect on OSAS has been shown by other authors, although long-term effects are not stable. The RFTB can be considered as first choice treatment in case of snoring and mild OSAS in Fujita type III obstruction. In the case of moderate to severe sleep apnea, RFTB can be considered as an additional treatment.

[Subjective outcome after multi-level surgery in sleep-disordered breathing]

INTRODUCTION

Previous results showed the high effectiveness of our multi-level surgery concept based on the modified hyoid suspension for obstructive sleep apnea (OSA). This study was aimed at evaluating the discomforts and side-effects of this surgical concept.

METHODS

Between November 2001 and June 2004, 102 patients with OSA and/or with laryngeal stenosis, who were all treated with a hyoid suspension in combination with surgery at the base of tongue, the soft palate or the nose, were included in the study. A questionnaire on discomfort and snoring was given to the patients. They were asked to answer the questions at the earliest 1 month after surgery. A reduction in snoring to a level which was tolerated by the bed-partner was regarded as success.

RESULTS

Half of the patients needed analgesics until the 14th day after surgery, complained dysphagia until day 20 and had problems with their speech until day 30. However, 84% indicated that they would undergo surgery again; 94% reported a successful reduction in their snoring.

CONCLUSION

Nearly all of the patients tolerated the discomforts and side-effects of our multi-level surgical concept. In combination with a reduction in snoring in 94% of all cases, this surgical concept was considered favorably by the patients.

Incidence of complications in radiofrequency treatment of the upper airway

OBJECTIVES

To investigate the incidence of complications after temperature-controlled radiofrequency (TCRF) treatment of the inferior turbinates, palate, and tongue. To compare these complication rates with those reported in the literature.

STUDY DESIGN

Prospective, observational study.

METHODS

All patients treated with TCRF to the inferior turbinates, palate, and tongues during a 12-month period were included. Data were collected for parameters of energy delivery and the development of complications.

RESULTS

One hundred thirty-six patients were treated with a total of 470 TCRF lesions. The overall incidence of minor complications was 1.2% (6/470 lesions); there were no complications of moderate or major severity.

CONCLUSION

The incidence of minor complications after TCRF in this series was low, and there were no complications of greater severity. These findings are in stark contrast with some previously published papers with higher complication rates. These significantly higher rates may be caused by a marked learning curve, problems in patient selection and the technique of application, excessive energy delivery, and perioperative management.

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.

Effectiveness of multilevel (tongue and palate) radiofrequency tissue ablation for patients with obstructive sleep apnea syndrome

OBJECTIVES

The primary objective is to determine the effectiveness of multilevel (tongue base and palate) temperature controlled radiofrequency tissue ablation (TCRFTA) for patients with obstructive sleep apnea syndrome (OSAS). The secondary objective is to compare multilevel TCRFTA to nasal continuous positive airway pressure (CPAP).

STUDY DESIGN AND METHODS

The study is a controlled case series of one investigator's experience with multilevel TCRFTA for patients with OSAS. Twenty-two subjects with mild to severe OSAS, without tonsil hypertrophy, completed multilevel TCRFTA (mean 4.8 tongue base and 1.8 palate treatment sessions) and had both pre- and posttreatment polysomnography. Primary outcomes included change from baseline in apnea/hypopnea index (AHI), daytime somnolence, and reaction time testing measured 2 to 3 months after TCRFTA. Secondary outcomes included change in other respiratory parameters, OSAS related quality of life, and upper airway size. Comparison of 18 patients treated with TCRFTA for mild to moderate OSAS (AHI > 5 and < or = 40) is made with 11 matched patients treated with nasal CPAP for mild to moderate OSAS.

RESULTS

Multilevel TCRFTA significantly improved AHI (P = .001), apnea index (P = .02), as well as respiratory and total arousal indices (P = .0002 and P = .01). Significant improvement with moderate or large treatment effect sizes were noted for OSAS related quality of life (P = .01) and daytime somnolence (P = .0001), with a trend toward significant improvement in reaction time testing (P = .06), with mean posttreatment normalization of all three outcome measures. Fifty-nine percent of subjects demonstrated at least a 50% reduction in AHI to less than 20. The targeted upper airway, measured in the supine position, demonstrated a trend toward significant improvement in mean cross sectional area (P = .05) and volume (P = .10). Side effects of TCRFTA were infrequent, mild, and self-limited. No significant correlation between pretreatment parameters and outcome improvement was noted. Nasal CPAP resulted in significant improvement in AHI (P = .0004) to near normal levels, with an associated improvement in OSAS related quality of life (P = .02) and a trend toward significant improvement in daytime somnolence (P = .06). Reaction time testing demonstrated no significant improvement (P = .75). No significant differences were seen for change in AHI, OSAS related quality of life, daytime somnolence, or reaction time testing between multilevel TCRFTA and CPAP.

CONCLUSION

Multilevel (tongue base and palate) TCRFTA is a low-morbidity, office-based procedure performed with local anesthesia and is an effective treatment option for patients with OSAS. On average, abnormalities in daytime somnolence, quality of life, and reaction time testing demonstrated improvement from baseline and were normalized after treatment. Polysomnographic respiratory parameters also demonstrated significant improvement with multilevel TCRFTA.

[Snoring/sleep apnea--surgically curable]

INTRODUCTION

Obstructive sleep apnea (OSA) is characterized by nocturnal collapsing of the upper airways. Nasal continuous positive airway pressure (nCPAP) ventilation is the gold standard in the treatment of obstructive sleep apnea syndrome (OSAS). Long-term compliance rates do not exceed more than 60 to 70%. Alternative multi-level surgeries are of interest, combining procedures at the level of the base of tongue and the soft palate in order to stabilize the airway. Preliminary results suggested the hyoid suspension as one part of the multi-level surgery concept to be of high effectiveness. Therefore this study investigated the outcome of the hyoid suspension and compared it with the CPAP therapy.

METHODS

Between March 2001 and February 2003, 66 patients with OSA were treated with a hyoid suspension in combination with surgeries at the base of tongue, the soft palate or the nose (always performed by the same surgeon). All patients underwent a pre- and postoperative polysomnography in the sleep lab. Daytime sleepiness was assessed using the Epworth Sleepiness Scale (ESS). Mean age was 52,1 years, the mean body mass index (BMI) was 28,04 kg/m(2).

RESULTS

The mean apnea-hypopnea-index (AHI) was 38,9121,10/h before operation and 19,25+/-19,64/h after operation (p<0,0001). More statistically significant changes were found for the arousal index, the oxygen saturation and the ESS (p<0,05). After surgery 57,6% of the subjects (38/66) were regarded as cured (reduction of AHI > or =50% and below 15/h). Another 21,2% (14/66) improved (reduction of AHI >20%). Altogether 78,8% of the patients were counted as responders.

CONCLUSION

Multi-level surgeries based on the hyoid suspension show the effectiveness of this concept. This surgical strategy could be equal to the CPAP mask, especially in cases of CPAP intolerance.

Surgical treatment of the inferior turbinate: new techniques

PURPOSE OF REVIEW

Nasal obstruction causing airway resistance is often a result of structural abnormalities. Frequently, turbinate reduction procedures have been used after failure of medical management to address enlarged inferior turbinates, which potentially cause functional narrowing at the nasal valve. Controversy still exists as to the best or most appropriate method for surgical reduction of the inferior turbinate. The multitude of approaches available to the rhinologist is a testament to the lack of a single established method.

RECENT FINDINGS

This paper highlights recently published literature regarding current popular and cutting-edge techniques. There is a trend toward less invasive techniques that can potentially be performed in the clinic setting, rather than in the operating room. In addition, surgical turbinate intervention demonstrates benefit in controlling symptoms of allergic rhinitis other than nasal obstruction.

SUMMARY

Surgical reduction of the inferior turbinate can be performed using a variety of techniques. When analyzing different methods, emphasis on efficacy, function preservation, and avoidance of complications is paramount.

[Magnetic resonance imaging in the evaluation of temperature-controlled radiofrequency volumetric tissue reduction]

BACKGROUND

Due to its minimally invasive character, radiofrequency surgery has become a topic of increasing attention, especially with respect to the surgical treatment of sleep-related breathing disorders. Temperature-controlled radiofrequency volumetric tissue reduction is the most common technique employed in these cases. However, despite the increasingly widespread use of this technique, there is little data available on the induced effects in vivo. The aim of the present study was to investigate whether magnetic resonance imaging could be used in the evaluation of the in vivo effects of radiofrequency surgery at the base of the tongue.

PATIENTS AND METHODS

Six patients were treated at the base of tongue with radiofrequency surgery. At 4-6, 8-10 and 24 h after surgery, magnetic resonance imaging was performed using an inversion recovery technique (TIRM) and the lesions created were evaluated.

RESULTS

The lesions could be visualised at all postoperative measurement times. They appeared as oval hypointense structures encircled by a hyperintense area. Lesion size diminished slightly over time.

DISCUSSION

Lesions induced by radiofrequency surgery can be clearly visualised with magnetic resonance imaging. Lesion size may be assessed in relation to energy application. In the future, the treatment of sleep-related breathing disorders may be further optimised with the help of this technique.

Lesion formation in radiofrequency surgery of the tongue base

OBJECTIVES

Temperature controlled radiofrequency volumetric tissue reduction (RFVTR) of the tongue base is a minimally invasive technique for the treatment of obstructive sleep apnea. But despite its widespread use, little is yet known about in vivo effects in humans. Such knowledge would be essential for evidence-based criteria in the selection of energy application.

METHODS

In a preparatory in vitro study, porcine tongues were preserved in growing medium. Lesions with different amounts of energy were applied, and maximum diameters were assessed. In the in vivo study, 11 patients were treated with RFVTR at the tongue base by employing different energy levels (800, 600, 400, or 200 J) on two application sites. Magnetic resonance imagery scans were performed 4 to 6, 8 to 10, and 24 hours after surgery. An inversion recovery technique was used to visualize the lesions.

RESULTS

RFVTR created lesions at the porcine tongue from 50 J and higher. Maximum lesion sizes were achieved with 400 J. In vivo, all the lesions were clearly visible in the postoperative scans. Lesion size increased with the amount of energy applied. Maximum diameters were created from 600 J and higher. Higher amounts of energy only resulted in a slight increase in lesion length.

CONCLUSIONS

The application of 600 J at 85 degrees C leads to optimal lesion sizes. Higher amounts of energy will not lead to a relevant increase in tissue necrosis. With regard to the time needed for application, 600 J appears to be the ideal adjustment for energy delivery in the treatment of the human tongue.