Long-Term Subjective Outcomes of Barbed Reposition Pharyngoplasty for Obstructive Sleep Apnea Syndrome Treatment

Consensus Statements among European Sleep Surgery Experts on Snoring and Obstructive Sleep Apnea: Part 3 Palatal Surgery, Outcomes and Follow-Up, Complications, and Post-Operative Management

Background/Objectives: Exploring and establishing a consensus on palatal surgery, the outcomes and follow-up after the palatal surgery, the complications of palatal surgery, and the post-operative management after palatal surgery for snoring and obstructive sleep apnea (OSA) among sleep surgeons is critical in the surgical management of patients with such conditions. Methods: Using the Delphi method, a set of statements was developed based on the literature and circulated among a panel of eight European experts. Responses included agreeing and disagreeing with each statement, and the comments were used to assess the level of consensus and to develop a revised version. The new version with the level of consensus and anonymized comments was sent to each panel member as the second round. This was repeated over a total of five rounds. Results: The final set included a total of 111 statements, 27 of which were stand-alone questions and 21 of which contained 84 sub-statements. Of the 34 statements regarding palatal surgery, consensus was achieved among all eight, seven, and six panelists for 50%, 35.3%, and 5.9% of the questions, respectively. Of the 43 statements regarding the outcomes and follow-up after the palatal surgery, consensus was achieved among all eight, seven, and six panelists for 53.5%, 23.3%, and 4.7% of the questions, respectively. Of the 24 statements regarding complications after the palatal surgery, consensus was achieved among all eight, seven, and six panelists for 91.7%, 0%, and 4.2% of the questions, respectively. Of the 10 statements regarding post-operative management after palatal surgery, consensus was achieved among all eight, seven, and six panelists for 10%, 30%, and 30% of the papers, respectively. Conclusions: This consensus provides an overview of the work of European sleep surgeons to develop a set of statements on palatal surgery for the treatment of snoring and OSA, the outcomes and follow-up, the complications, and the post-operative management of palatal surgery. We believe that this will be helpful in everyday practice. It also indicates key areas for further studies in sleep surgery.

Unraveling the Complexities of Oxidative Stress and Inflammation Biomarkers in Obstructive Sleep Apnea Syndrome: A Comprehensive Review

BACKGROUND

Obstructive sleep apnea syndrome (OSAS), affecting approximately 1 billion adults globally, is characterized by recurrent airway obstruction during sleep, leading to oxygen desaturation, elevated carbon dioxide levels, and disrupted sleep architecture. OSAS significantly impacts quality of life and is associated with increased morbidity and mortality, particularly in the cardiovascular and cognitive domains. The cyclic pattern of intermittent hypoxia in OSAS triggers oxidative stress, contributing to cellular damage. This review explores the intricate relationship between OSAS and oxidative stress, shedding light on molecular mechanisms and potential therapeutic interventions.

METHODS

A comprehensive review spanning from 2000 to 2023 was conducted using the PubMed, Cochrane, and EMBASE databases. Inclusion criteria encompassed English articles focusing on adults or animals and reporting values for oxidative stress and inflammation biomarkers.

RESULTS

The review delineates the imbalance between pro-inflammatory and anti-inflammatory factors in OSAS, leading to heightened oxidative stress. Reactive oxygen species biomarkers, nitric oxide, inflammatory cytokines, endothelial dysfunction, and antioxidant defense mechanisms are explored in the context of OSAS. OSAS-related complications include cardiovascular disorders, neurological impairments, metabolic dysfunction, and a potential link to cancer. This review emphasizes the potential of antioxidant therapy as a complementary treatment strategy.

CONCLUSIONS

Understanding the molecular intricacies of oxidative stress in OSAS is crucial for developing targeted therapeutic interventions. The comprehensive analysis of biomarkers provides insights into the complex interplay between OSAS and systemic complications, offering avenues for future research and therapeutic advancements in this multifaceted sleep disorder.

Reasonable Risk Ratio of Palate Surgery: A New Critical Analysis

OBJECTIVE.

A new critical complication risk analysis, the reasonable risk ratio (RRR or R3) for palate surgeries in obstructive sleep apnea patients.

METHODS.

Analysis from published meta-analyses, systematic reviews on success rates, and complications encountered for 3 palate surgeries, expansion sphincter pharyngoplasty (ESP), barbed repositioning pharyngoplasty (BRP) and modified uvulopalatopharyngoplasty (mUPPP), over 20 years. The RRR is derived from a ratio of the percentage of each respective complication over the success rate of that particular surgical procedure. The benchmark RRR of tonsillectomy is set at 0.035 to 0.078. An RRR below this benchmark value is more favorable as tonsillectomy is a widely accepted ENT procedure with risks to benefit well accepted.

RESULTS.

The RRR for foreign body (FB) sensation (BRP) ranged from 0.03 to 0.23 (mean RRR of 0.14), FB sensation (ESP) 0.01, FB sensation (mUPPP) ranged from 0.33 to 0.55 (mean RRR of 0.44). The RRR for swallowing difficulties (BRP) ranged from 0.04 to 0.23 (mean RRR of 0.11), mUPPP, was 0.37; no reported swallowing difficulties with the ESP. The RRR for velopharyngeal insufficiency (VPI) (BRP) ranged from 0.009 to 0.18 (mean RRR of 0.07), and RRR VPI (mUPPP) was 0.14. The RRR (BRP) for dry throat was 0.06 and the mUPPP was 0.35, with no reported VPI or dry throat for ESP. The overall RRR for the BRP was 0.09, ESP was 0.01 and mUPPP was 0.29.

CONCLUSION.

RRR provides a summarized data-driven, statistical guide to aid decision-making, and helps in patient counseling. BRP and ESP have been shown to have less complications compared to mUPPP.Level of evidence: IV.

Association Between Severity of COVID-19 Respiratory Disease and Risk of Obstructive Sleep Apnea

OBJECTIVES

The purpose of this observational retrospective study was to evaluate, in patients with a severe acute respiratory syndrome coronavirus 2 infection, the association between the severity of coronavirus disease 2019 (COVID-19) respiratory illness and the risk of infected patients to develop obstructive sleep apnea (OSA).

METHODS

Ninety-six patients with confirmed COVID-19 infection were enrolled in the study. The STOP-BANG questionnaire to investigate the risk of the OSA syndrome was filled in by the patients at admission. The enrolled patients were divided into 2 groups according to the respiratory disease: group 1 (72 patients), hospitalized patients undergoing conventional oxygen therapy; group 2 (24 patients), patients requiring enhanced respiratory support. STOP-BANG results of these 2 groups were compared to observe whether patients with high OSA risk more frequently presented a severe form of COVID-19.

RESULTS

41.6% of the patients in group 2 had a STOP-BANG score between 5 and 8 (high risk of having apnea); in contrast, 20.8% of the patients in group 1 had a STOP-BANG score between 5 and 8, with a statistically significant difference between the 2 groups (P = .05). A complementary trend was observed regarding the proportion of patients in the range 0 to 2, which classifies patients at a low risk of OSA (48.6% vs 20.8% for groups 1 and 2, P = .01).

CONCLUSIONS

According to our data, the chances of having a severe case of COVID-19 should be considered in patients at high risk of OSA.

CURRENT KNOWLEDGE/STUDY RATIONALE

Emerging research suggests that OSA could represent a potentially important risk factor for the severe forms of COVID-19. The purpose of this observational retrospective study was to evaluate the potential association between OSA and the severity of COVID-19 disease.

STUDY IMPACT

According to our data, the likelihood of contracting a severe form of COVID-19 disease should be considered in patients at high risk of OSA.

Barbed palatal surgery: single stage or multilevel setting-a systematic review by the Young Otolaryngologists of the Italian Society of Otolaryngology

PURPOSE

This systematic review aims to compare the efficacy and safety of multilevel and single level surgery, including barbed pharyngoplasties, in the treatment of obstructive sleep apnea (OSA).

METHODS

The study followed PRISMA guidelines and searched PubMed/MEDLINE, Google Scholar, and Ovid databases for studies evaluating the effect of barbed pharyngoplasties on adults with OSA. Prospective and retrospective cohort studies were included with pre- and post-treatment comparisons of sleep tests and self-reported clinical outcomes. Exclusion criteria were non-English studies, case reports, reviews, conference abstracts, letters, and pediatric studies. Successful surgery was classified using Sher's criteria.

RESULTS

The study selected a total of 1014 patients from 26 studies, 24 of which were longitudinal studies with 10 retrospective trials and 14 prospective studies. The average age of the patients was 46.9 years, with an average Body Mass Index (BMI) of 25.6 kg/m2. Most of the patients were male (84.6%). The study included only palatal surgical techniques with barbed sutures, and patients who underwent cardio-respiratory monitoring and Drug Induced Sleep Endoscopy (DISE) before surgery. Mean Apnea Hypopnea Index (AHI) preoperative was 32.9/h, AHI postoperative was 11.9/h, and mean reduction of AHI was 62.3%. The most commonly adopted palatoplasty was Barbed Repositioning Pharyngoplasty (BRP) in 16 out of 26 studies, followed by its subsequent modifications in 3 studies.

CONCLUSIONS

Barbed pharyngoplasties appear to be effective both on objective measurement and subjective scores. DISE represents a fundamental tool to assess uni-level or multilevel obstruction. When retro-palatal collapse is present, barbed pharyngoplasty appears to be effective. Barbed pharyngoplasties maintain their good results both in single level or multilevel surgery. Randomized clinical controlled trials with multi-center cooperation and long-term study are necessary.

Complications and side effects after barbed pharyngoplasty: a systematic review

BACKGROUND

Recently, the use of barbed pharyngoplasty (BP) has become widespread in snoring and obstructive sleep apnoea (OSA) palatal surgery, but there are no studies regarding the short- and long-term complications resulting from these different techniques. This systematic review aimed to report the complications and side effects of different BP techniques.

METHODS

An electronic search was performed on PubMed/MEDLINE, Google Scholar, and Ovid databases. The PRISMA statement was followed. Databases were searched from inception through September 2, 2021.

RESULTS

We included 14 prospective clinical studies consisting of 769 patients aged 23 to 81 years. The associated intra-operative complications of BP were as follows: partial thread extrusion (2.9%), self-limited bleeding (2.9%), broken needle (1.0%), and suture rupture (1.0%). Short-term complications were as follows: thread/knot extrusion (12.4%), dysphagia (5.6%), bleeding (1.5%), velopharyngeal insufficiency (1.5%), anterior pharyngoplasty dehiscence (1.2%), tonsillar haemorrhage (1.0%), excessive postnasal discharge (1.0%), barbed suture failure (0.5%), acute infection (0.2%), mucosal granulomas (0.2%), chipped tooth caused by mouth gag displacement (0.2%), and fibrous scar (0.2%). Long-term complications were as follows: foreign body sensation (7.8%), sticky mucus in throat (5.9%), dysphagia (3.6%), rhinolalia (3.1%), throat phlegm (1.1%), nose regurgitation (0.8%), dry throat (0.6%), and throat lump (0.3%).

CONCLUSION

BP is a safe technique free of significant side effects and major complications. However, in this review, patients undergoing BP were very heterogeneous in terms of characteristics of patients chosen and severity of diseases, surgical technique used (myoresective vs non-myoresective), time of follow-up, and mono level vs multilevel surgery. More studies on a larger scale with long-term follow-up are needed to confirm these promising results.

The Effects of Barbed Repositioning Pharyngoplasty in Positional and Non-Positional OSA Patients: A Retrospective Analysis

PURPOSE

The aim of our retrospective study is evaluating the effectiveness of barbed repositioning pharyngoplasty (BRP) in a consecutive cohort of patients and assessing its impact on positional indexes in order to potentially identify specific obstructive sleep apnea (OSA) phenotypes for patients who might benefit more significantly from this intervention.

METHODS

A single-center retrospective study with baseline and follow-up type III sleep tests evaluating the Apnea Hypopnea Index (AHI), supine AHI, non-supine AHI, oxygen desaturation index (ODI), mean SaO2, percentage of time spent at SaO2 below 90% (CT90), and lowest oxygen saturation (LOS) were performed. The patients were then divided into groups according to Sher's criteria and Amsterdam Positional OSA Classification (APOC). Parametric and non-parametric tests and univariate and multivariate analyses were conducted.

RESULTS

The study finally included 47 patients. The statistical analysis showed significant improvement in AHI, supine AHI, non-supine AHI, and ODI after surgery. The linear regression showed that high values of baseline AHI, AHI supine, and AHI non supine predict more significant postoperative reductions in AHI, AHI supine, and AHI non supine, respectively. Therapeutic success was achieved in 22 patients out of 47. The logistic regression did not find any independent risk factors for success. The most significant reduction in AHI, supine AHI, and non-supine AHI was observed in the APOC 3 group while the APOC 1 patients experience a substantially lower improvement.

CONCLUSIONS

BRP appears to be an effective surgical procedure for the treatment of OSA. The non-positional patients might benefit more from BRP in comparison with positional patients. Moreover, OSA severity should not be considered an absolute contra-indication for this surgical procedure.

Head rotation improves airway obstruction, especially in patients with less severe obstructive sleep apnea without oropharyngeal collapse

Purpose

Head rotation is thought to have an effect on obstructive sleep apnea (OSA) severity. However, keeping the head rotated fully during sleep is difficult to maintain, and the effect of head rotation is not the same in all OSA patients. Thus, this study aimed to identify whether less head rotation has an effect on airway patency and determine the responder characteristics to the head rotation maneuver (HRM).

Methods

We recruited 221 patients who underwent overnight polysomnography and drug-induced sleep endoscopy (DISE) in a tertiary hospital from June 2019 to July 2020. Airway patency and the site of airway collapse were determined in the supine position with the head at 0, 30, and 60 degrees of rotation (HRM0°, HRM30°, and HRM60°, respectively) during DISE. The site of collapse was determined using the VOTE classification system: the velum (palate), oropharyngeal lateral walls, tongue base, and epiglottis. Each structure was labeled as 0, 1, or 2 (patent, partially obstructed, and completely obstructed, respectively). Airway response to the HRM30° and 60° and the clinical characteristics associated with airway opening were analyzed.

Results

The study population had a median age of 52 (25–61) years, a body mass index of 26.7(24.6–29.4) kg/m², and the apnea-hypopnea index (AHI) of 28.2(13.7–71.9) events/h. HRM influenced airway patency positively not only with HRM60° (p<0.001) but also following limited rotation (HRM30°, p<0.001). Patients with tongue base (40.0% with HRM 60°) and epiglottic (52.6% with HRM 60°) collapse responded particularly well to HRM. Multivariate analysis revealed that lower AHI (p<0.001) and an absence of oropharyngeal lateral walls collapse (p = 0.011) were significant predictors of responders to HRM.

Conclusion

Head rotation improved airway obstruction in OSA patients, even with a small degree of rotation, and should be further explored as a potential form of therapy in appropriately selected patients.

Quality of Life and Excessive Daytime Sleepiness in Adults with Obstructive Sleep Apnea Who Are Treated with Multilevel Surgery or Adherent to Continuous Positive Airway Pressure

Obstructive Sleep Apnea (OSA) syndrome is a respiratory sleep disorder characterized by a reduction (hypopnea) in or a complete cessation (apnea) of airflow in the upper airways at night, in the presence of breathing effort. The gold standard treatment for OSA is ventilation through continuous positive airway pressure (CPAP), although this often shows poor patient compliance. In recent years, transoral robotic surgery (TORS) has been proposed as a valid surgical treatment for patients suffering from OSA in a multilevel surgical setting. The aim of this study is to analyze the effects on QoL and daytime sleepiness of multilevel surgery for OSA (barbed pharyngoplasty + transoral robotic surgery). Furthermore, we compared the impact on QoL and daytime sleepiness of two different treatments for patients with moderate to severe OSA, such as CPAP and TORS. Sixty-seven OSA patients who underwent multilevel robotic surgery and sixty-seven OSA patients treated with CPAP were enrolled, defined as Group 1 and Group 2, respectively. The Glasgow Benefit Inventory (GBI) questionnaire was administrated to evaluate the changes in the QoL. Respiratory outcomes were evaluated and compared. Group 1 showed a GBI total average value of +30.4, whereas Group 2, a value of +33.2 (p = 0.4). General benefit score showed no difference between groups (p = 0.1). Better values of social status benefit (p = 0.0006) emerged in the CPAP Group, whereas greater physical status benefit (p = 0.04) was shown in the TORS Group. Delta-AHI (-23.7 ± 14.3 vs. -31.7 ± 15.6; p = 0.001) and Delta-ODI (-24.5 ± 9.5 vs. -29.4 ± 10.5; p = 0.001) showed better values in the CPAP group. Therapeutic success rate of the Multilevel TORS Group was 73.1% and 91% in the CPAP group (p = 0.01), respectively. Multilevel TORS and CPAP have a positive effect on the quality of life of OSA patients. Greater social support has been reported in the CPAP group and better physical health status in the TORS group. No statistical difference emerged in the reduction in daytime sleepiness between both groups.

Prevention of Incident Hypertension in Patients With Obstructive Sleep Apnea Treated With Uvulopalatopharyngoplasty or Continuous Positive Airway Pressure: A Cohort Study

Purpose

To determine whether treatment with uvulopalatopharyngoplasty (UPPP) or continuous positive airway pressure (CPAP) in patients with obstructive sleep apnea (OSA) prevents hypertension, compared to those not receiving any treatment.

Methods

A retrospective cohort study was conducted among 413 patients with OSA (age ≥ 35 years) at the Shuang Ho Hospital between 2009 and 2016. The patients were divided into three groups: UPPP, CPAP, and non-treatment groups. Data about the personal characteristics, history of comorbidities, and polysomnography (PSG) reports were collected at baseline. A Cox model with inverse probability of treatment weighting was used to adjust for confounders and baseline diversity.

Results

After multivariate adjustment and weighting for incident hypertension, patients in both the CPAP and UPPP groups showed a significant preventive effect on hypertension than in the non-treatment group. Moreover, patients in the CPAP group had lower event rates than those in the UPPP group.

Conclusion

UPPP can prevent the development of new-onset hypertension in patients with OSA. CPAP had a better preventive effect than UPPP. UPPP might be a good alternative for reducing the risk of the onset of hypertension when compliance to CPAP is poor.

Barbed pharyngoplasty for obstructive sleep apnea: A meta-analysis

PURPOSE

The purpose of this study was to perform a meta-analysis of barbed pharyngoplasty (BP) in the treatment of obstructive sleep apnea (OSA).

METHODS

Databases included PubMed, Ovid MEDLINE, Cochrane Library, Web of Science and Scopus, and reference lists. Relevant articles were searched through August 2021, following the PRISMA guidelines.

RESULTS

Twenty articles with 762 participants were included. The mean success in BP as a single-level surgery was 85.2% (MD, 95% CI 77.6%, 92.7%). There was a significant reduction of oxygen desaturation index (ODI) of -11.7 (MD 95% CI -16, -7.4). The lowest oxygen saturation (LSAT) improved 8.9% (MD, 95% CI 1.3%, 16.7%). Epworth Sleepiness Scale (ESS) and snoring score significantly decreased -6.8 (MD 95% CI -8.3, -5.2) and -5.3 (MD 95% -7.9, -2.7), respectively. The apnea-hypopnea index (AHI) significantly decreased -23.9 events/h (MD, 95% CI -25.5, -22.9) with a 69% reduction. The mean surgical time was 23 min. A significant improvement of AHI, ODI, ESS, and LSAT was also revealed in BP as a multilevel surgery. Complications included suture extrusion (18%), dysphagia (20%), velopharyngeal insufficiency (15%), and dysgeusia (3%) without serious consequences. The median follow-up period was 6 months, ranged 1 to 26 months.

CONCLUSION

Barbed pharyngoplasty as a single-level or multilevel surgery is a safe and effective procedure with significant objective and subjective outcomes for OSA patients with palatal obstruction. However, randomized clinical controlled trials with multicenter cooperation and long-term study are necessary.

Obstructive Sleep Apnea Syndrome: From Symptoms to Treatment

Obstructive sleep apnea (OSA) syndrome is a respiratory sleep disorder characterized by partial or complete recurrent episodes of upper airway collapse that occur during the night. The OSA manifests with a reduction (hypopnea) or complete cessation (apnea) of airflow in the upper airways, associated with breathing effort. OSA is a frequent and often underestimated pathology affecting between 2 and 5% of the middle-aged population. Typical nocturnal symptoms are the persistent snoring and awakenings with dyspnea sensation. On the other hand, diurnal symptoms could be sleepiness, headaches, asthenia, neurological disorders, and impaired personal relationships. Surgery of the velo-pharyngeal region had a huge evolution going from ablative techniques (UP3 and LAUP) to remodeling techniques of the pharyngeal lateral walls.

Lateral pharyngoplasty vs. traditional uvulopalatopharyngoplasty for patients with OSA: systematic review and meta-analysis

OBJECTIVES

To compare the efficacy and success rates of lateral pharyngoplasty techniques (LP) vs. uvulopalatopharyngoplasty (UPPP) among adult patients surgically treated for obstructive sleep apnea.

METHODS

A systematic literature review of the last 20 years' papers was conducted using PubMed/Medline, Embase, Web of Science, Scholar, and the Cochrane Library until April 2021. Only full-text English articles comparing LP and UPPP outcomes in adult patients with objective outcomes were included in the study.

RESULTS

We included 9 articles for a total of 312 surgically treated patients with OSA. LP techniques for obstructive sleep apnea were used on 186 (60%) subjects, while 126 patients (40%) were treated with UPPP. Both surgical procedures resulted in significant improvements in apnea-hypopnea index (AHI), Epworth Sleepiness Scale (ESS) score, and lowest oxygen saturation (LOS) (p < 0.001 in all cases). Although better outcomes were reported with lateral pharyngoplasty, the differences were not significant compared to UPPP post-operative results (p > 0.05 in all cases).

CONCLUSIONS

UPPP and LP are both effective surgical procedures in treating OSA in adults. Although not significant, LPs demonstrated improved post-operative outcomes. However, further evidence comparing the surgical effect on patients with OSA is needed to discriminate post-operative outcomes.

Barbed reposition pharyngoplasty (BRP) in obstructive sleep apnea treatment: State of the art

PURPOSE

In this paper, we perform a systematic review that discusses the state of the art and evolution on the barbed reposition pharyngoplasty (BRP) in the velo-pharyngeal surgery. Clinical evidence and published outcomes of this surgical technique are reported and discussed.

MATERIALS AND METHODS

We performed a systematic review of the current literature through the analysis of the last 10 years of literature on barbed palate surgery. Study design, number of patients enrolled, inclusion criteria, pre- and posttreatment outcomes (AHI, ODI), surgical success rate, follow-up time and complication has been collected and reported.

RESULTS

15 studies for a total of 1531 patients, out of which 1061 underwent barbed reposition pharyngoplasty. Five trials were uncontrolled prospective studies (215 patients, 14% of total), nine were retrospective studies (1266 patients, 82,6% of total), and one randomized prospective clinical trial (RCT) (50 patients, 3,32% of total). All analyzed studies reported good outcomes after BRP surgery. Average preoperative values of AHI and ODI reduced in all studies considered with a significative statistical difference between preoperative and postoperative values (p < 0.05 in all cases). The postoperative surgical success rate ranged between 65.4 and 93% of cases. There were no significant intra-operative or post-operative complications in all studies considered in this systematic review.

CONCLUSIONS

Barbed reposition pharyngoplasty has proven to be an easy to learn, quick, safe and effective new palatopharyngeal procedure, that can be used in a single level surgery or as a part of multilevel procedures.

Effectiveness of drug-induced sleep endoscopy in improving outcomes of barbed pharyngoplasty for obstructive sleep apnea surgery: a prospective randomized trial

PURPOSE

To observe the effectiveness of preoperative drug-induced sleep endoscopy in improving surgical results of patients undergoing single-level barbed pharyngoplasty surgery for OSA, using a prospective randomized model.

METHODS

A single-center randomized controlled trial with two prospective arms was carried out to compare functional results in patients treated with barbed reposition pharyngoplasty (BRP) surgery without a preoperative drug-induced sleep endoscopy (DISE) evaluation vs patients treated with BRP surgery performed after DISE evaluation of sites/patterns of collapse.

RESULTS

We compared 50 patients who underwent BRP without a preoperative DISE evaluation (Group A) and 42 patients (Group B) treated with BRP surgery but preoperatively selected by means of a preoperative DISE. In this second group of patients, after DISE evaluation, 70% of patients were selected for single-level BRP surgery because they showed an isolated velopharyngeal collapse at the DISE evaluation, without obstruction at other upper airway levels evaluated. Both groups of patients showed a statistically significant difference between preoperative and postoperative values of AHI, ODI, and LOS (p<0.05 in all cases). Comparing Group A and Group B patients, the therapeutic success rate was found to be 60% in patients treated without preoperative DISE evaluation and 83% in patients treated with preoperative DISE (p = 0.02).

CONCLUSION

DISE appears to improve the surgical results of single-level velopharyngeal surgery due to the possibility of excluding patients with obstruction of the base of the tongue, the hypopharynx, and the epiglottis/larynx.

OSA Upper Airways Surgery: A Targeted Approach

Obstructive sleep apnea syndrome (OSA) is a multi-factorial disorder, with quite complex endotypes, consisting of anatomical and non-anatomical pathophysiological factors. Continuous positive airway pressure (CPAP) is recognized as the first-line standard treatment for OSA, whereas upper airway (UA) surgery is often recommended for treating OSA patients who have refused or cannot tolerate CPAP. The main results achievable by the surgery are UA expansion, and/or stabilization, and/or removal of the obstructive tissue to different UA levels. The site and pattern of UA collapse identification is of upmost importance in selecting the customized surgical procedure to perform, as well as the identification of the relation between anatomical and non-anatomical factors in each patient. Medical history, sleep studies, clinical examination, UA endoscopy in awake and drug-induced sedation, and imaging help the otorhinolaryngologist in selecting the surgical candidate, identifying OSA patients with mild UA collapsibility or tissue UA obstruction, which allow achievement of the best surgical outcomes. Literature data reported that the latest palatal surgical procedures, such as expansion sphincter palatoplasty or barbed reposition palatoplasty, which achieve soft palatal and lateral pharyngeal wall remodeling and stiffening, improved the Apnea Hypopnea Index, but the outcome analyses are still limited by methodological bias and the limited number of patients' in each study. Otherwise, the latest literature data have also demonstrated the role of UA surgery in the improvement of non-anatomical factors, confirming that a multidisciplinary and multimodality diagnostic and therapeutical approach to OSA patients could allow the best selection of customized treatment options and outcomes.

Barbed suture Extrusion and Exposure in palatoplasty for OSA: What does it mean?

PURPOSE

Analyze Extrusion&Exposion (E&E), its implications in the functional, anatomical results and subjective discomfort in OSA patients treated with Barbed Reposition Pharyngoplasty (BRP).

MATERIALS AND METHODS

488 patients treated with BRP or multilevel TORS. Stratafix wire was used in 230 patients, V-Loc in 258. E&E, timing and localization evaluated at follow-up. Polygraphy used to assess the impact of E&E on functional results, PPOPS questionnaire used for subjective discomfort.

RESULTS

E&E in the entire group was 18,4%, with significant difference between Stratafix and V-Loc wire (p = 0,002), but not between BRP alone and multilevel surgery (p = 0,68). 28,9% of extrusion happened within the first seven days, 76,7% between seven days and two months, 5,5% after two months. Symptomatic clinical profile has been seen in 62,2%, asymptomatic one in 37,8% of patients. 35,5% of E&E were localized in tonsillar bed, 46,7% in soft palate and 20% in other sites. Mean delta-AHI of E&E patients was -15,87 ± 16.82 compared with one of those who did not have E&E was -16.34 ± 22,77 (p = 0,38). Mean PPOPS of 183 patients analyzed was 12,32 ± 4,96. Mean PPOPS of extruded group was 12,94 ± 4,68 and 11,92 ± 5,11 in not extruded one (p = 0,166).

CONCLUSIONS

E&E are suture-type sensitive (V-Loc > Stratafix), reported more frequent when BRP is performed alone than BRP-TORS with no statistical significance. 76,7% of the E&E occur after patient discharge and within 2 months. About half of the E&E were localized in soft palate. There is no need to fear Extrusion&Exposition because it does not affect in a negative way subjective and PSG outcome.

Obstructive sleep apnoea/hypopnoea syndrome: relationship with obesity and management in obese patients

Obstructive sleep apnoea/hypopnoea syndrome (OSAHS) is a disease characterised by upper airway obstruction during sleep, quite frequent in the general population, even if underestimated. Snoring, sleep apnoea and diurnal hypersomnia are common in these patients. Central obesity plays a key role: it reduces the size and changes the conformation of the upper airways, besides preventing lung expansion, with consequent reduction of lung volumes. Furthermore, obese people are also resistant to leptin, which physiologically stimulates ventilation; as a result, this causes scarce awakening during apnoea. OSAHS diagnosis is based on the combination of clinical parameters, such as apnoea/hypopnoea index (AHI), medical history, physical examination and Mallampati score. The first objective reference method to identify OSAHS is polysomnography followed by sleep endoscopy. Therapy provides in the first instance reduction of body weight, followed by continuous positive airway pressure (CPAP), which still remains the treatment of choice in most patients, mandibular advancement devices (MAD) and finally otolaryngology or maxillofacial surgery. Among surgical techniques, central is barbed reposition pharyngoplasty (BRP), used in the field of multilevel surgery.

Functional Upper Airway Space Endoscopy: A Prognostic Indicator in Obstructive Sleep Apnea Treatment with Mandibular Advancement Devices

PURPOSE

The use of a mandibular advancement device (MAD) in the treatment of obstructive sleep apnea (OSA) is a consolidated therapy. This study aimed to evaluate the predictive value of awake upper airways (UA) functional endoscopy in identifying the outcome of MAD therapy.

METHODS

This observational prospective study included 30 adult OSA patients, all patients underwent pre-treatment awake UA functional endoscopy, during the exam subjects were instructed to advance their mandible maximally, and they were divided into three different groups according to the response of the soft tissue, group A (expansion), group B (stretch), group C (unchanged). The results of this test were used in combination with other noninvasive indexes to predict the treatment outcome in terms of apnea-hypopnea index (AHI) reduction.

RESULTS

We found that a substantial AHI reduction occurred in group A and group B while e slight AHI reduction was measured in group C.

CONCLUSION

Based on our experience the awake UA endoscopy is a valid prognostic exam for discriminating responder and non-responder patients; in addition our results indicate the possibility of predicting a range of post-treatment AHI index values.

Oxidative Stress and Inflammation Biomarker Expression in Obstructive Sleep Apnea Patients

Obstructive Sleep Apnea Syndrome (OSAS) is a respiratory sleep disorder characterised by repeated episodes of partial or complete obstruction of the upper airway during the night. This obstruction usually occurs with a reduction (hypopnea) or complete cessation (apnea) of the airflow in the upper airways with the persistence of thoracic-diaphragmatic respiratory movements. During the hypopnea/apnea events, poor alveolar ventilation reduces the oxygen saturation in the arterial blood (SaO₂) and a gradual increase in the partial arterial pressure of carbon dioxide (PaCO₂). The direct consequence of the intermittent hypoxia is an oxidative imbalance, with reactive oxygen species production and the inflammatory cascade’s activation with pro and anti-inflammatory cytokines growth. Tumour necrosis factors, inflammatory cytokines (IL2, IL4, IL6), lipid peroxidation, and cell-free DNA have been found to increase in OSAS patients. However, even though different risk-related markers have been described and analysed in the literature, it has not yet been clarified whether specified inflammatory bio-markers better correlates with OSAS diagnosis and its clinical evolution/comorbidities. We perform a scientific literature review to discuss inflammatory and oxidative stress biomarkers currently tested in OSAS patients and their correlation with the disease’s severity and treatment.

Barbed Reposition Pharyngoplasty versus Expansion Sphincter Pharyngoplasty: A Meta-Analysis

OBJECTIVE

This study was to compare barbed reposition pharyngoplasty (BRP) and expansion sphincter pharyngoplasty (ESP) in the treatment of obstructive sleep apnea (OSA).

METHODS

Relevant 907 articles were searched from various databases until August 2020, including PubMed, MEDLINE, EMBASE, Cochrane Library, Web of Science and Scopus, and reference lists.

RESULTS

Four studies with a total of 208 participants were included. The mean reduction of apnea-hypopnea index (AHI) in the BRP group was 74.03% and the mean reduction of AHI in the ESP group was 60.17%. The mean success rate in the BRP group and the ESP group was 84.96% and 79.87%, respectively. The mean difference (MD) of the change in AHI between groups was not significantly different (MD = -1.24 event/hr, 95% CI [-11.86, 9.36], P = .82). There was no significant difference in postoperative AHI, postoperative Epworth Sleepiness Scale, pain, hospital stay, time to oral diet, and the change in oxygen desaturation index in both groups whereas the analgesic requirement was lower in the BRP group. Operative time was lower in the BRP group (MD = 21.72 minutes, 95% CI [18.85, 24.60], P < .0001).

CONCLUSION

The outcomes in both procedures are comparable in the improvement of OSA with palatal collapse. BRP is superior to ESP in term of surgical time. However, randomized clinical controlled trials with multicenter cooperation and long-term follow-up are essential to further demonstrate the efficacy of these procedures. Laryngoscope, 131:1420-1428, 2021.

Olfactory function in patients with obstructive sleep apnea: a meta-analysis study

PURPOSE

This meta-analysis study was designed to analyze the olfactory function in obstructive sleep apnea patients (OSA).

METHODS

A comprehensive review of the English language literature regarding OSA patients and olfactory function/dysfunction was performed. The papers assessing olfactory dysfunction with Sniffin' Sticks test were taken into consideration.

RESULTS

A total of 420 OSA patients were judged eligible for the study. The average TDI score was found to be 24.3 ± 5.6. The olfactory identification (OD), the olfactory discrimination (OD), and the olfactory threshold (OT) average values were calculated resulting 9.9 ± 2.1, 9.8 ± 1.5, and 5.3 ± 2, respectively. There were 161 healthy control subjects in this meta-analysis. The average TDI of the control group was 30.7 ± 6.0 showing a statistical difference with the group of OSA patients (p = 0.03). A linear correlation between Apnea-Hypopnea Index (AHI) increase and TDI decrease (R² = 0.1, p = 0.05) was detected. Finally, the average values of TDI of 151 patients classified as mild-moderate OSA and 159 patients considered as severe OSA were calculated. The difference between these two groups resulted not statistically significant (p = 0.3).

CONCLUSION

The comparison between OSA patients and healthy subjects using Sniffin' Sticks test showed lower values of the various olfactory parameters. Although a linear correlation between AHI increase and olfactory dysfunction was observed, no statistical difference between mild-moderate and severe OSA patients in terms of the severity of olfactory dysfunction could be proved.