Associated Factors to Predict Outcomes of Uvulopharyngopalatoplasty Plus Genioglossal Advancement for Obstructive Sleep Apnea

Predictors of uvulopalatopharyngoplasty outcomes in patients with supine predominant positional obstructive sleep apnea: a prospective observational study

BACKGROUND

It is uncertain which factors substantially influence outcomes after uvulopalatopharyngoplasty (UPPP) in patients with supine predominant obstructive sleep apnea (POSA).

OBJECTIVE

To explore the predictors of UPPP outcomes in POSA patients.

METHODS

A total of 108 patient(52 positional patients (POSA) and 56 nonpositional patients(NPP)), who underwent the revised uvulopalatopharyngoplasty (H-UPPP), were retrospectively studied. The pre-operative information of these patients, including polysomnography (PSG), and upper airway CT, were collected for analysis.

RESULTS

No difference was found in surgical success rates between POSA and NPP undergoing H-UPPP. In POSA patients, there were statistically significant differences between responders and nonresponders in body mass index (BMI), preoperative supine AHI, time of SaO2 < 90% (TS90) (all p < .05), minimal anteroposterior airway (mAP) (p = .016), minimal lateral airway (mLAT) (p = .002), minimal cross-sectional airway area (mCSA) (p < .001) at the velopharynx. mLAT (p = .014) and mCSA (p = .002) at the glossopharynx. The independent associated factors for surgical success were lower BMI (p < .001), narrowerm LAT (p = .002) and mAP (p < .001) at velopharynx, and wider mCSA (p < .001) at glossopharynx in POSA.

CONCLUSION

POSA patients with lower BMI, narrower mLAT and mAP at velopharynx, wider mCSA at glossopharynx were more likely to achieve a positive outcome with H-UPPP.

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.

Systematic review and updated meta-analysis of multi-level surgery for patients with OSA

OBJECTIVES

To perform an updated systematic review for determining the surgical success rate of multilevel upper airway surgery for patients with obstructive sleep apnea/hypopnea syndrome (OSA).

METHODS

A systematic review was performed to identify English-language studies that evaluated the treatment of adult OSA patients with multilevel OSA surgery up to January, 2018. We used polysomnography as a metric of treatment success. Articles were only included if the surgery intervention involved at least two of the frequently involved anatomic sites: nose, oropharynx and hypopharynx. Eighty-seven studies fit the inclusion criteria and a meta-analysis was performed to determine the overall success.

RESULTS

The meta-analysis included 3931 subjects with a mean age of 46.1 years. The originally reported success rate in the included literature was 59.9%. A meta-analysis was performed to redefine the success rate to be consistent with the commonly agreed upon criteria - namely "a reduction in apnea/hypopnea index (AHI, /hr.) of 50% or more and an AHI of less than 20". The recalculated success rate was 60.2%. Standard meta-analytic techniques for combining p-values between studies after weighting for sample size found significant improvements in AHI, apnea index, % of rapid eye movement sleep, lowest saturation of oxygen (%), and Epworth Sleepiness Scale.

CONCLUSION

This study shows the significant improvement of treatment outcomes with multilevel surgery for OSA patients.

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), oxygen desaturation index (ODI), increase in lowest oxygen saturation (LSAT), sleep quality, and 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 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, ODI, and an increase in LSAT in adults with OSA and obesity. Analyses of very limited evidence suggest 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.

The influence of position dependency on surgical success in patients with obstructive sleep apnea undergoing maxillomandibular advancement

STUDY OBJECTIVES

(1) To evaluate surgical success in patients with obstructive sleep apnea undergoing maxillomandibular advancement (MMA) stratifying for the reduction of both the total apnea-hypopnea index (AHI) and the AHI in the supine and nonsupine position; (2) to evaluate the influence of position dependency on surgical outcome; and (3) to analyze the prevalence of residual position-dependent obstructive sleep apnea (OSA) in nonresponders after MMA.

METHODS

A single-center retrospective study including a consecutive series of patients with OSA undergoing MMA between August 2011 and February 2019.

RESULTS

In total, 57 patients were included. The overall surgical success was 52.6%. No significant difference in surgical success between nonpositional patients (NPP) and positional patients (PP) with OSA was found. Surgical success of the supine AHI was not significantly different between NPP and PP, but surgical success of the nonsupine AHI was significantly greater in NPP than in PP. Of the 17 preoperative NPP, 13 of them moved to being PP with less severe OSA postoperatively. In total, 21 out of 27 nonresponders (77.8%) were PP postoperatively.

CONCLUSIONS

No significant difference in surgical success between NPP and PP undergoing MMA was found. However, the improvement of total and nonsupine AHI in NPP was significantly greater compared to PP. In nonresponders, a postoperative shift from severe OSA in NPP to less severe OSA in PP was found, caused by a greater reduction of the nonsupine AHI than the supine AHI postoperatively. In patients with residual OSA in the supine position after MMA, additional treatment with positional therapy can be indicated.

The influence of position-dependency on surgical success in sleep apnea surgery - a systematic review

PURPOSE

To evaluate the influence of position-dependency on surgical success of upper airway (UA) surgery in obstructive sleep apnea (OSA) patients.

METHODS

Systematic review.

RESULTS

Two prospective cohort studies and seven retrospective cohort studies were included in this review. Despite the importance of the subject, it remains unclear whether position-dependency is a predictor for surgical success. No differences were found in surgical success rate between non-positional (NPP) and positional (PP) OSA patients undergoing uvulopalatopharyngoplasty/Z-palatoplasty with or without radiofrequent thermotherapy of the tongue, isolated tongue base or multilevel surgery and hypoglossal nerve stimulation. In one study PP undergoing relocation pharyngoplasty had a greater chance of surgical success. In the majority of the remaining studies, surgical success was in favor of NPP. Furthermore, in the vast part of included studies, the effect of UA surgery was suggested to be greater in the lateral position than supine position.

CONCLUSION

Although preoperative characteristics in PP (e.g., lower BMI and AHI) seem to be in favor for higher surgical success compared to NPP, it remains unclear whether position-dependency is a predictor for surgical outcome. It is suggested that the largest differences and expected preoperative and postoperative changes occur in non-supine AHI. In PP, the preoperative non-supine AHI is already lower compared to NPP suggesting a lower chance of surgical success in PP.

The status of cephalometry in the prediction of non-CPAP treatment outcome in obstructive sleep apnea patients

Obstructive sleep apnea syndrome (OSAS) is the most common sleep disordered breathing disorder (SDB) in adults and is characterized by a recurrent partial or complete collapse of the upper airway during sleep. This can be caused by many factors, sometimes interacting, such as skeletal malformations, soft tissue crowding, respiratory instability and the various effects of aging, obesity and gender that dictate craniofacial and upper airway anatomy. Research has demonstrated that the majority of patients exhibit at least one anatomical component such as retrognathia or a narrow posterior airway space that predisposes to the development of OSAS. Within the predisposing elements for OSAS many seem to point to anatomical characteristics. A standardized and relatively simple radiologic technique to evaluate anatomical craniofacial relationships is cephalometry. This has been used already for a long time in orthodontics, but is now gradually being introduced in OSAS treatment to envisage optimal treatment selection as well as to predict treatment outcomes. The purpose of the present review is to evaluate the contribution of cephalometry in the prediction of outcomes from OSAS treatments that depend on the upper airway morphology in their mechanisms of action such as oral appliances that advance the mandible as well as various surgical methods. In addition, an overview of imaging modalities and methods that currently are being used in cephalometric analysis in OSAS patients is provided. The findings indicate that isolated cephalometric parameters cannot be used to reliably predict treatment outcomes from mandibular advancement devices and surgical methods for OSAS. Extreme or outlying values of cephalometric parameters may rather be used as contra-indicators or 'red flags' instead of predictors.

Transoral robotic surgery for treatment of obstructive sleep apnea: factors predicting surgical response

OBJECTIVES/HYPOTHESIS

We reviewed our experience with the use of transoral robotic surgery (TORS) for base of tongue (BOT) reduction either alone or as part of multilevel strategy in the treatment of obstructive sleep apnea/hypopnea syndrome (OSAHS) in order to identify clinical characteristics that may be associated with surgical response.

STUDY DESIGN

Case series.

METHODS

Between June 2010 and May 2014, BOT reduction via TORS ± partial epiglottectomy ± uvulopalatopharyngoplasty were performed on 72 patients with OSAHS. Thirty-nine patients (15 females and 24 males) with complete preoperative and postoperative clinical information including polysomnograms were included in this study.

RESULTS

Mean apnea-hypopnea index (AHI) was 43.9 ± 32.3 preoperatively and 21.9 ± 23.5 postoperatively and reflected a statistically significant (P < 0.001) AHI reduction of 50.9% ± 38.1%. Statistical significant reduction in daytime somnolence, as measured by Epworth Sleepiness Scale (15.6 ± 5.4 preoperatively vs. 5.7 ± 4.3 postoperatively; P < 0.001), was also achieved. No statistical significant difference was found between preoperative and postoperative body mass index (BMI) (32.9 ± 7.0 vs. 32.4 ± 7.3; P = 0.270). Surgical response, as defined by > 50% reduction in AHI and final AHI < 15 with resolution of daytime somnolence, was achieved in 21 patients (53.8%). Clinical characteristics found to be significantly different between the responders and nonresponders were BMI, AHI, and lateral velopharyngeal collapse. Patients with BMI < 30, AHI < 60, or absence of lateral velopharyngeal collapse have excellent surgical response rate of 88.2%, 67.9%, or 66.7%, respectively.

CONCLUSIONS

We identified three clinical characteristics associated with increased surgical response rate. This finding may be useful for patient selection and counseling prior to surgery.

Sleep apnea increased incidence of primary central nervous system cancers: a nationwide cohort study

INTRODUCTION

Obstructive sleep apnea (OSA) was associated with increased incidence of all cancers. We aimed to determine the risk for primary central nervous system (CNS) cancers in patients with sleep apnea syndrome.

METHODS

A total of 23,055 incident cases of newly diagnosed sleep apnea syndrome (sleep apnea group) were identified between 2000 and 2003 in the medical claims database of Taiwan's National Health Institute (NHI) program and were matched by age and gender to patients without OSA (comparison group) in the same period. The occurrence of primary malignant CNS cancers was measured 2 years after the index date over a 10-year period.

RESULTS

The incidence density of primary CNS cancers (per 10,000 individual-years) was 2.14 and 1.28, respectively, for the OSA and comparison groups. The overall risk for developing primary CNS cancers was significantly higher in the OSA group (adjusted hazard ratio [HR], 1.54; P=0.046) after adjusting for age, gender, and obesity, among other variables. Subgroup analysis revealed a significantly higher risk for primary brain cancers but not primary spinal cord cancers in the OSA subgroup (adjusted HR, 1.71; P=0.027). The analysis also revealed a significantly higher risk for primary CNS cancers in the insomnia with OSA subgroup (adjusted HR, 2.20; P=0.001) and in the OSA without surgical treatment subgroup (adjusted HR, 1.831; P=0.003).

CONCLUSIONS

OSA, especially with insomnia, may increase the risk for primary CNS cancer development, though surgical treatment may reduce this risk in participants with OSA.

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

OBJECTIVES/HYPOTHESIS

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

STUDY DESIGN

Systematic review.

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of obesity on uvulopalatopharyngoplasty success in patients with severe obstructive sleep apnea: a retrospective single-center study in Taiwan

CONCLUSION

Our findings suggest that, in Asian patients with severe obstructive sleep apnea (OSA), obesity is a better predictor of uvulopalatopharyngoplasty (UPPP) failure than Friedman stage III.

OBJECTIVES

This study evaluated UPPP success rates in obese and non-obese Asian patients treated for severe OSA.

METHODS

Records of patients who underwent UPPP for treatment of OSA were retrospectively reviewed. Preoperative and postoperative apnea/hypopnea index (AHI) and Epworth Sleepiness Scale (ESS) score, and Friedman stage were compared in non-obese (body mass index (BMI) <27 kg/m(2)) and obese (BMI ≥27 kg/m(2)) patients. Treatment success was defined as >50% reduction in preoperative AHI or postoperative AHI of <20 events/h.

RESULTS

Treatment success was significantly lower (p < 0.0001) in the obese group (24.6%) compared with the non-obese group (62.5%). After adjusting for gender, age, BMI, Friedman stage, and preoperative AHI and ESS score, obesity was a significant independent negative predictor of treatment success (adjusted OR = 0.297, 95% CI = 0.114-0.773, p = 0.013).

[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.

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.

Diagnostic Studies in Obstructive Sleep Apnea

The standard for the diagnosis of obstructive sleep apnea (OSA) is polysomnography (PSG). Although PSG helps identify individuals who have OSA and guides medical management, it does not identify the obstruction site or predict surgical results. Radiologic and diagnostic studies have been used to direct surgical intervention and predict outcomes of sleep apnea surgery. These studies include lateral cephalometric radiographs, CT, MRI, asleep fluoroscopy, asleep and awake endoscopy, upper airway manometry, and acoustic reflection techniques. The ideal diagnostic study would identify individuals who have OSA, be cost-effective and readily accessible, and guide therapeutic, site-specific intervention with predictable results. In this article, the various modalities are reviewed in terms of their capability to effectively diagnose and guide treatment of OSA.

Down syndrome: Common otolaryngologic manifestations

Otolaryngologic or ear, nose, and throat (ENT) problems are common in children with Down Syndrome (DS). This includes problems with chronic ear infections and chronic middle ear effusions with associated hearing loss, airway obstruction, and sleep apnea, as well as problems with chronic rhinitis and sinusitis. In addition, many of these ENT problems require surgical interventions, and there are special anesthesia considerations that need to be addressed in children with DS. These include subglottic stenosis, post-operative airway obstruction, and cervical spine concerns. As the care of children with DS has become more consistent and proactive, outcomes from the treatment of these ENT manifestations have improved. Aggressive interventions, both medical and surgical, have led to a decreased incidence of hearing loss, good control of the chronic rhinitis, and a better awareness of the incidence of sleep apnea and sleep-disordered breathing in individuals with DS. These common otolaryngologic manifestations of DS are reviewed with recommendations for ongoing care and monitoring.