Muscular Assessment in Patients With Severe Obstructive Sleep Apnea Syndrome: Protocol for a Case-Control Study

Use of Ultrasound to Verify the Impact of Telemedicine Myofunctional Therapy on Sleep Apnea Syndrome: Study Protocol Proposal

The anatomy of the upper airways influences the risk of obstructive sleep apnea (OSA). The size of soft tissue structures, such as the tongue, soft palate, and lateral walls of the pharynx, contributes to the pathogenesis of OSA. New lines of treatment for sleep apnea, such as myofunctional therapy (MT), aim to strengthen the oropharyngeal musculature to improve the defining parameters of apnea. The present protocol uses ultrasound imaging to measure the size of the lingual musculature non-invasively and cost-effectively and evaluates the changes in its morphology. Eligible patients include those with OSA who have undergone submental cervical ultrasound and drug-induced sleep endoscopy before starting MT with the AirwayGym app. Follow-up evaluations are conducted at 3 months after beginning treatment. Patients diagnosed with OSA via questionnaires and polysomnography or respiratory polygraphy are evaluated anatomically and functionally using the Iowa Oral Performance Instrument, a tongue digital spoon, somnoscopy, and submental cervical ultrasound to assess their responses to the AirwayGym app. The lingual thickness (mm) and volume (cm3) and the distance between both lingual arteries (mm) are measured. The AirwayGym app helps users and therapists monitor the patient performance of MT. Incorporating submental ultrasound can be a useful non-invasive tool to evaluate OSA and MT.

Assessment of Muscular Weakness in Severe Sleep Apnea Patients: A Prospective Study

OBJECTIVE

There are no official diagnostic tools to evaluate the weakness of the genioglossus muscle. We have developed a protocol for muscular assessment in patients with severe obstructive sleep apnea-hypopnea syndrome (OSAHS) and evaluated its effectiveness.

STUDY DESIGN

Case and controls prospective study.

SETTING

Sleep Unit Hospital Quironsalud Marbella (Spain).

METHODS

Twenty-nine cases and 20 controls were recruited. Patients were examined by a phonoaudiologist that performed biometric measurements and the Orofacial Myofunctional Evaluation With Scores (OMES), Friedman, and Epworth Sleepiness Scale (ESS). In addition, upper airway muscle strength measures were performed using the Iowa Oral Performance Instrument (IOPI) and Tongue Digital Spoon (TDS).

RESULTS

The final cohort consisted of 49 subjects, including 29 cases and 20 controls. According to the univariate and multivariate logistic regression analyses, ESS, OMES protocol, IOPI score, and TDS were associated with severe OSAHS. Multivariate regression revealed an IOPI score below 48 kps with an adjusted odds ratio (OR) of 9.96 (95% confidence interval [CI] 2.5-39.1, p = .001), and a 0.72 specificity (Spe), a 0.79 sensitivity (Sens), and a 0.82 area under the curve (AUC). Similarly, an OMES score lower than 200 had an adjusted risk ratio of 4.02 (95% CI 2-7, p < .001), 1 Spe, 0.79 Sens, and 0.98 AUC; and finally, TDS scores lower than 201 g/cm2 showed an adjusted OR of 27 (95% CI 4.74-153.6, p = .0001), 0.66 Spe, a 0.93 Sens, and a 0.86 AUC.

CONCLUSION

Our findings suggest that severe OSAHS patients present different muscle patterns than controls.

The Effects of Orofacial Myofunctional Therapy on Children with OSAHS’s Craniomaxillofacial Growth: A Systematic Review

Orofacial myofunctional therapy (OMT) is one of the therapeutic methods for neuromuscular re-education and has been considered as one of the auxiliary methods for obstructive sleep apnea hypopnea syndrome (OSAHS) and orthodontic treatment. There is a dearth of comprehensive analysis of OMT’s effects on muscle morphology and function. This systematic review examines the literature on the craniomaxillofacial effects of OMT in children with OSAHS. This systematic analysis was carried out using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) standards, and the research was scanned using PICO principles. A total of 1776 articles were retrieved within a limited time, with 146 papers accepted for full-text perusing following preliminary inspection and 9 of those ultimately included in the qualitative analysis. Three studies were rated as having a severe bias risk, and five studies were rated as having a moderate bias risk. Improvement in craniofacial function or morphology was observed in most of the 693 children. OMT can improve the function or morphology of the craniofacial surface of children with OSAHS, and its effect becomes more significant as the duration of the intervention increases and compliance improves. In the majority of the 693 infants, improvements in craniofacial function or morphology were seen. The function or morphology of a kid’s craniofacial surface can be improved with OMT, and as the duration of the intervention lengthens and compliance rises, the impact becomes more pronounced.

Does Frenotomy Modify Upper Airway Collapse in OSA Adult Patients? Case Report and Systematic Review

Ankyloglossia (tongue-tie) is a condition of the oral cavity in which an abnormally short lingual frenulum affects the tongue's mobility. Literature on the correlation between ankyloglossia and obstructive sleep apnea (OSA) is scarce. The main objective of this study was to report our preliminary experience in adult OSA patients before and after ankyloglossia treatment, using drug-induced sleep endoscopy (DISE) to evaluate the upper airway modifications resulting after treatment, and to present a systematic review of the impact of ankyloglossia and its treatment on OSA adults. We found that, after frenotomy, regarding the DISE findings, and according to the VOTE classification, two of the three patients showed an improvement in tongue level, from 2A-P (complete anteroposterior collapse) to 1ap (partial anteroposterior collapse). The third patient showed no changes in his UA after frenotomy, neither worsening nor showing improvement. Thus, the results of this study suggest that frenotomy in OSA patients with ankyloglossia could reduce tongue collapse, probably by allowing the tongue to take into the physiological position in the oral cavity. These patients should undergo speech therapy and oropharyngeal exercises prior to any surgical procedure, in order to avoid glossoptosis and to improve the quality of life and sleep apnea results.

Evaluation of the Muscle Strength of the Tongue with the Tongue Digital Spoon (TDS) in Patients with Obstructive Sleep Apnea

Myofunctional therapy (MT) is a recent treatment option for obstructive sleep apnea (OSA). The Iowa Oral Performance Instrument (IOPI) is a useful but expensive tool for measuring tongue strength in patients with OSA. We validated the Tongue Digital Spoon (TDS) to monitor tongue hypotonia in patients with OSA. Measurements with the IOPI and TDS were compared in patients with OSA before and after MT for tongue hypotonia. Baseline mean tongue strength measured with the IOPI in patients with moderate and severe OSA were 35.36 ± 9.05 and 33.83 ± 12.05, respectively, and that with the TDS were 168.55 ± 42.8 and 129.61 ± 53.7, respectively. After MT, mean tongue strength significantly improved: measured with the IOPI in patients with moderate and severe OSA were 53.85 ± 10.09 and 55.50 ± 9.64 (p = 0.8), and that with the TDS were 402.36 ± 52.92 and 380.28 ± 100.75 (p = 0.01), respectively. The correlation between the IOPI and TDS was high (r = 0.74; p = 0.01 pre-treatment, and r = 0.25; p = 0.05 post-treatment). The TDS is a useful tool for monitoring the efficacy of MT in patients with short-term OSA. Future randomized studies will determine the effectiveness of MT for the treatment of OSA.

The effect of tongue elevation muscle training in patients with obstructive sleep apnea: A randomised controlled trial

BACKGROUND

Oropharyngeal myofunctional therapy is a multi-component therapy effective to reduce the severity of obstructive sleep apnoea (OSA). However, existing protocols are difficult to replicate in the clinical setting. There is a need to isolate the specific effectiveness of each component of the therapy.

OBJECTIVE

To assess the effects of a 6 weeks tongue elevation training programme in patients with OSA.

METHODS

We conducted a multicentre randomised controlled trial. Eligible participants were adults diagnosed with moderate OSA who presented low adherence to continuous positive airway pressure therapy (mean use <4 h per night). The intervention group completed a 6 weeks tongue elevation training protocol that consisted in anterior tongue elevation strength and endurance tasks with the Iowa Oral Performance Instrument. The control group completed a 6 weeks sham training protocol that involved expiratory muscle training at very low intensity. Polygraphy data, tongue force and endurance, and OSA symptoms were evaluated pre- and post-intervention. The primary outcome was apneoa-hypopnea index (AHI).

RESULTS

Twenty-seven patients (55 ± 11 years) were recruited. According to modified intention-to-treat analysis (n = 25), changes in AHI and c did not significantly differ between groups. Daytime sleepiness (Epworth Sleepiness Scale) and tongue endurance significantly improved in the intervention group compared to the control group (p = .015 and .022, respectively). In the intervention group, 75% of participants had a decrease in daytime sleepiness that exceeded the minimal clinically important difference.

CONCLUSION

Six weeks of tongue elevation muscle training had no effect on OSA severity.

Quantitative Measurement of Swallowing Performance Using Iowa Oral Performance Instrument: A Systematic Review and Meta-Analysis

Swallowing is a complex but stereotyped motor activity aimed at serving two vital purposes: alimentary function and the protection of upper airways. Therefore, any impairment of the swallowing act can represent a significant clinical and personal problem that needs an accurate diagnosis by means of reliable and non-invasive techniques. Thus, a systematic review and meta-analysis was performed to investigate the reliability of the Iowa Oral Pressure Instrument (IOPI) in distinguishing healthy controls (HC) from patients affected by swallowing disorders or pathologies and conditions that imply dysphagia. A comprehensive search was conducted following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and using PubMed, Scopus, Web of Science, Cochrane, and Lilacs databases. Overall, 271 articles were identified and, after a three-step screening, 33 case-control and interventional studies reporting IOPI measurements were included. The methodological quality of the retrieved studies resulted in being at a low risk of bias. The meta-analysis on case-control studies showed that maximum tongue pressure (MIP) values were always higher in HC than in patients, with an overall effect of the MIP difference of 18.2 KPa (17.7–18.7 KPa CI). This result was also confirmed when the sample was split into adults and children, although the MIP difference between HC and patients was greater in children than in adults (21.0 vs. 15.4 KPa in the MIP mean difference overall effect, respectively). Tongue endurance (TE) showed conflicting results among studies, with an overall effect among studies near zero (0.7 s, 0.2–1.1 s CI) and a slight tendency toward higher TE values in HC than in patients. Among the intervention studies, MIP values were higher after treatment than before, with a better outcome after the experimental tongue training exercise than traditional treatments (the MIP mean difference overall effect was 10.8 and 2.3 KPa, respectively). In conclusion, MIP values can be considered as a reliable measure of swallowing function in adults and in children, with a more marked MIP difference between HC and patients for the children population. MIP measures in patients are also able to detect the best outcome on the tongue function after the training exercise compared to traditional training.

Improving Adherence to Myofunctional Therapy in the Treatment of Sleep-Disordered Breathing

Myofunctional therapy (MT) is used to treat sleep-disordered breathing. However, MT has low adherence-only ~10% in most studies. We describe our experiences with MT delivered through a mobile health app named Airway Gym®, which is used by patients who have rejected continuous positive airway pressure and other therapies. We compared ear, nose, and throat examination findings, Friedman stage, tongue-tie presence, tongue strength measured using the Iowa oral performance instrument (IOPI), and full polysomnography before and after the 3 months of therapy. Participants were taught how to perform the exercises using the app at the start. Telemedicine allowed physicians to record adherence to and accuracy of the exercise performance. Fifty-four patients were enrolled; 35 (64.8%) were adherent and performed exercises for 15 min/day on five days/week. We found significant changes (p < 0.05) in the apnoea-hypopnoea index (AHI; 32.97 ± 1.8 to 21.9 ± 14.5 events/h); IOPI score (44.4 ± 11.08 to 49.66 ± 10.2); and minimum O2 saturation (80.91% ± 6.1% to 85.09% ± 5.3%). IOPI scores correlated significantly with AHI after the therapy (Pearson r = 0.4; p = 0.01). The 19 patients who did not adhere to the protocol showed no changes. MT based on telemedicine had good adherence, and its effect on AHI correlated with IOPI and improvement in tongue-tie.