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Parthasarathy S, Ayas NT, Bogan R, Hwang D, Kushida C, Lown JS, Ojile JM, Patel I, Prasad B, Rapoport DM, Strollo P, Vanderveken OM, Viviano J. Oral appliance therapy and hypoglossal nerve stimulation as non-positive airway pressure treatment alternatives for obstructive sleep apnea: a narrative expert review. SLEEP ADVANCES : A JOURNAL OF THE SLEEP RESEARCH SOCIETY 2024; 5:zpae035. [PMID: 38966620 PMCID: PMC11223066 DOI: 10.1093/sleepadvances/zpae035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 05/13/2024] [Indexed: 07/06/2024]
Abstract
This perspective on alternatives to positive airway pressure (PAP) therapy for the treatment of obstructive sleep apnea (OSA) summarizes the proceedings of a focus group that was conducted by the Sleep Research Society Foundation. This perspective is from a multidisciplinary panel of experts from sleep medicine, dental sleep medicine, and otolaryngology that aims to identify the current role of oral appliance therapy and hypoglossal nerve stimulation for the treatment of OSA with emphasis on the US practice arena. A secondary aim is to identify-from an implementation science standpoint-the various barriers and facilitators for adoption of non-PAP treatment that includes access to care, multidisciplinary expertise, reimbursement, regulatory aspects, current treatment guidelines, health policies, and other factors related to the delivery of care. The panel has contextualized the review with recent events-such as a large-scale PAP device recall compounded by supply chain woes of the pandemic-and emerging science in the field of OSA and offers solutions for multidisciplinary approaches while identifying knowledge gaps and future research opportunities.
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Affiliation(s)
- Sairam Parthasarathy
- Department of Medicine, University of Arizona Health Sciences Center for Sleep and Circadian Sciences, University of Arizona, Tucson, AZ, USA
| | - Najib T Ayas
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Richard Bogan
- Department of Psychaiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Dennis Hwang
- Division of Sleep Medicine, Kaiser Permanente Southern California, Fontana, CA, USA
| | - Clete Kushida
- Division of Sleep Medicine, Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | | | | | - Imran Patel
- Department of Medicine, University of Arizona Health Sciences Center for Sleep and Circadian Sciences, University of Arizona, Tucson, AZ, USA
- Dental Sleep Service Line, Banner University Medical Center - Tucson, Tucson, AZ, USA
| | - Bharati Prasad
- Department of Medicine, University of Illinois at Chicago and Jesse Brown VA Medical Center, Chicago, IL, USA
| | - David M Rapoport
- Mount Sinai Health System Integrative Sleep Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Patrick Strollo
- Division of Pulmonary, Allergy, and Critical Care Medicine University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Oliver M Vanderveken
- Department of ENT-HNS, Antwerp University Hospital, Edegem, Belgium and Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - John Viviano
- Sleep Disorders Dentistry Research and Learning Center, Mississauga, ON, Canada
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Xu X, Peng Q, Meng L, Yang H, Wang Y, Luo Y, Dong M, Wang C, Wang M. Quality assessment of clinical practice guidelines for adult obstructive sleep apnea: A systematic review. Sleep Med 2024; 118:16-28. [PMID: 38581804 DOI: 10.1016/j.sleep.2024.03.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 03/03/2024] [Accepted: 03/28/2024] [Indexed: 04/08/2024]
Abstract
OBJECTIVE Clinical Practice Guidelines (CPGs) are crucial in standardizing the management of obstructive sleep apnea (OSA) in adults. However, there has been insufficient evaluation of the overall quality of CPGs for adult OSA. This review aimed to comprehensively assess the overall quality of CPGs in the field of adult OSA. METHODS A systematic search was conducted on various literature databases, guideline-related databases, and academic websites from January 2013 to December 2023 to select CPGs relevant to adult OSA. The methodological and reporting quality of the eligible CPGs were thoroughly appraised by three reviewers using the AGREE II instrument and RIGHT checklist, respectively. RESULTS This review included 44 CPGs, consisting of 42 CPGs in English and 2 CPGs in Chinese. The assessment of methodological quality revealed that four domains attained an average standardized score above 60%. Among the domains, "clarity of presentation" received the highest standardized score of 85.10%, while the lowest standardized score was observed in the "rigor of development" domain with the value of 56.77%. The evaluation of reporting quality indicated an overall reporting rate of 51.30% for the eligible CPGs, with only three domains achieving an average reporting rate higher than 50%. The domain with the highest reporting rate was "basic information" at 60.61%, while the domain with the lowest reporting rate was "review and quality assurance" at 15.91%. Furthermore, a significantly positive correlation was found between the AGREE II standardized scores and the RIGHT reporting rates (r = 0.808, P < 0.001). CONCLUSIONS The overall quality of the currently available guidelines for adult OSA demonstrated considerable variability. Researchers should prioritize the utilization of evidence-based methods and adhere to the items listed in the RIGHT checklist when developing CPGs to enhance efficient clinical decision-making and promote the translation of evidence into practice.
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Affiliation(s)
- Xiaopan Xu
- Department of Respiratory and Critical Care Medicine, Lu'an Hospital of Anhui Medical University, Lu'an, China
| | - Qianqian Peng
- Department of Graduate School, Wannan Medical College, Wuhu, China
| | - Ling Meng
- Department of Nursing, Jining NO.1 People's Hospital, Jining, China
| | - Hualu Yang
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong Special Administrative Regions, China; Department of Nursing, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
| | - Yingzhen Wang
- Department of Nursing, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yan Luo
- School of Nursing, Zhuhai Campus of the Zunyi Medical University, Zhuhai, China
| | - Min Dong
- School of Nursing, Zhuhai Campus of the Zunyi Medical University, Zhuhai, China
| | - Changyu Wang
- Department of Respiratory and Critical Care Medicine, Lu'an Hospital of Anhui Medical University, Lu'an, China.
| | - Mian Wang
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong Special Administrative Regions, China.
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Khan S, Walters RK, Walker AM, Nguyen SA, Liu SY, Tremont TJ, Abdelwahab MA. The readability of online patient education materials on maxillomandibular advancement surgery. Sleep Breath 2024; 28:745-751. [PMID: 38062224 DOI: 10.1007/s11325-023-02952-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 10/05/2023] [Accepted: 11/20/2023] [Indexed: 05/31/2024]
Abstract
STUDY OBJECTIVES Maxillomandibular advancement (MMA) is an effective surgical option for patients suffering from obstructive sleep apnea (OSA). As a relatively new treatment option, patients may turn to the Internet to learn more. However, online patient education materials (OPEMs) on MMA may be written at a higher literacy level than recommended for patients. The aim of this study was to analyze the readability of OPEMs on MMA. METHODS A Google search of "maxillomandibular advancement" was performed, and the first 100 results were screened. Websites that met eligibility criteria were analyzed for their readability using the Automated Readability Index (ARI), Coleman-Liau Index (CLI), Flesch-Kincaid Grade Level (FKGL), Gunning Fog (GF), and Simple Measure of Gobbledygook (SMOG) and compared to the recommended sixth-grade reading level using one-tailed t tests. Readability scores were compared based on the type of website, including hospitals/universities or physician clinics, using ANOVA tests. RESULTS The mean (SD) for ARI, CLI, FKGL, GF, and SMOG was 11.91 (2.43), 13.42 (1.81), 11.91 (2.06), 14.32 (2.34), and 13.99 (1.56), respectively. All readability scores were significantly higher than a sixth-grade reading level (p < 0.001). After comparing readability scores between different website types (university/hospital, clinic, and other), there was no statistical difference found. CONCLUSIONS The available OPEMs on MMA surgery for OSA are above the recommended sixth-grade reading level. Identifying and reducing the gap between the reading levels of OPEMs and the reading level of the patient are needed to encourage a more active role, informed decisions, and better patient satisfaction.
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Affiliation(s)
- Sofia Khan
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue, MSC 500, Charleston, SC, 29425, USA.
| | - Rameen K Walters
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue, MSC 500, Charleston, SC, 29425, USA
| | - Angelica M Walker
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue, MSC 500, Charleston, SC, 29425, USA
| | - Shaun A Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue, MSC 500, Charleston, SC, 29425, USA
| | - Stanley Y Liu
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, CA, 94305, USA
| | - Timothy J Tremont
- Department of Orthodontics, Medical University of South Carolina, Charleston, SC, 29425, USA
| | - Mohamed A Abdelwahab
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue, MSC 500, Charleston, SC, 29425, USA
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Meyer EJ, Wittert GA. Approach the Patient With Obstructive Sleep Apnea and Obesity. J Clin Endocrinol Metab 2024; 109:e1267-e1279. [PMID: 37758218 PMCID: PMC10876414 DOI: 10.1210/clinem/dgad572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/31/2023] [Accepted: 09/25/2023] [Indexed: 10/03/2023]
Abstract
Obstructive sleep apnea (OSA) and obesity are highly prevalent and bidirectionally associated. OSA is underrecognized, however, particularly in women. By mechanisms that overlap with those of obesity, OSA increases the risk of developing, or having poor outcomes from, comorbid chronic disorders and impairs quality of life. Using 2 illustrative cases, we discuss the relationships between OSA and obesity with type 2 diabetes, dyslipidemia, cardiovascular disease, cognitive disturbance, mood disorders, lower urinary tract symptoms, sexual function, and reproductive disorders. The differences in OSA between men and women, the phenotypic variability of OSA, and comorbid sleep disorders are highlighted. When the probability of OSA is high due to consistent symptoms, comorbidities, or both, a diagnostic sleep study is advisable. Continuous positive airway pressure or mandibular advancement splints improve symptoms. Benefits for comorbidities are variable depending on nightly duration of use. By contrast, weight loss and optimization of lifestyle behaviors are consistently beneficial.
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Affiliation(s)
- Emily Jane Meyer
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA 5000, Australia
- Endocrine and Diabetes Services, The Queen Elizabeth Hospital, Woodville South, SA 5011, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, SA 5000, Australia
| | - Gary Allen Wittert
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA 5000, Australia
- Adelaide Medical School, University of Adelaide, Adelaide, SA 5000, Australia
- Freemasons Centre for Male Health and Wellbeing, South Australian Health and Medical Research Institute, Adelaide, SA 5000, Australia
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Lee PL, Wu YW, Cheng HM, Wang CY, Chuang LP, Lin CH, Hang LW, Yu CC, Hung CL, Liu CL, Chou KT, Su MC, Cheng KH, Huang CY, Hou CJY, Chiu KL. Recommended assessment and management of sleep disordered breathing in patients with atrial fibrillation, hypertension and heart failure: Taiwan Society of Cardiology/Taiwan Society of sleep Medicine/Taiwan Society of pulmonary and Critical Care Medicine joint consensus statement. J Formos Med Assoc 2024; 123:159-178. [PMID: 37714768 DOI: 10.1016/j.jfma.2023.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 07/23/2023] [Accepted: 08/23/2023] [Indexed: 09/17/2023] Open
Abstract
Sleep disordered breathing (SDB) is highly prevalent and may be linked to cardiovascular disease in a bidirectional manner. The Taiwan Society of Cardiology, Taiwan Society of Sleep Medicine and Taiwan Society of Pulmonary and Critical Care Medicine established a task force of experts to evaluate the evidence regarding the assessment and management of SDB in patients with atrial fibrillation (AF), hypertension and heart failure with reduced ejection fraction (HFrEF). The GRADE process was used to assess the evidence associated with 15 formulated questions. The task force developed recommendations and determined strength (Strong, Weak) and direction (For, Against) based on the quality of evidence, balance of benefits and harms, patient values and preferences, and resource use. The resulting 11 recommendations are intended to guide clinicians in determining which the specific patient-care strategy should be utilized by clinicians based on the needs of individual patients.
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Affiliation(s)
- Pei-Lin Lee
- Center of Sleep Disorder, National Taiwan University Hospital, Taipei, Taiwan; School of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yen-Wen Wu
- Division of Cardiology, Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Hao-Min Cheng
- Division of Faculty Development, Taipei Veterans General Hospital, Taipei, Taiwan; PhD Program of Interdisciplinary Medicine (PIM), National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan
| | - Cheng-Yi Wang
- Department of Internal Medicine, Cardinal Tien Hospital and School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Li-Pang Chuang
- Sleep Center, Department of Thoracic Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan; School of Medicine, Chang Gung University, Tauyan, Taiwan
| | - Chou-Han Lin
- Division of Respirology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Liang-Wen Hang
- School of Nursing & Graduate Institute of Nursing, China Medical University, Taichung, Taiwan; Sleep Medicine Center, China Medical University Hospital, Taichung, Taiwan
| | - Chih-Chieh Yu
- School of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chung-Lieh Hung
- Cardiovascular Center, MacKay Memorial Hospital, Taipei, Taiwan; Institute of Biomedical Sciences, Mackay Medical College, Taipei, Taiwan
| | - Ching-Lung Liu
- Division of Chest, Departments of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan; MacKay Medical College, New Taipei City, Taiwan
| | - Kun-Ta Chou
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Division of Clinical Respiratory Physiology, Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Mao-Chang Su
- Sleep Center, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan; Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi, Taiwan
| | - Kai-Hung Cheng
- Kao-Ho Hospital, Kaohsiung, Taiwan; Division of Cardiology, Department of Internal Medicine, E-Da Hospital, Kaohsiung, Taiwan
| | - Chun-Yao Huang
- Division of Cardiology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan; Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Charles Jia-Yin Hou
- Cardiovascular Center, MacKay Memorial Hospital, Taipei, Taiwan; MacKay Medical College, New Taipei City, Taiwan.
| | - Kuo-Liang Chiu
- Division of Chest Medicine, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan; School of Post-Baccalaureate Chinese Medicine, Tzu Chi University, Hualien, Taiwan.
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Pinczel AJ, Woods CM, Catcheside PG, Woodman RJ, Carney AS, Chai-Coetzer CL, Chia M, Cistulli PA, Hodge JC, Jones A, Lam ME, Lewis R, McArdle N, Ooi EH, Rea SC, Rees G, Singh B, Stow N, Yeo A, Antic N, McEvoy RD, Weaver EM, MacKay SG. Sleep apnea multi-level surgery trial: long-term observational outcomes. Sleep 2024; 47:zsad218. [PMID: 37607039 DOI: 10.1093/sleep/zsad218] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 08/02/2023] [Indexed: 08/24/2023] Open
Abstract
STUDY OBJECTIVES The sleep apnea multi-level surgery (SAMS) randomized clinical trial showed surgery improved outcomes at 6 months compared to ongoing medical management in patients with moderate or severe obstructive sleep apnea (OSA) who failed continuous positive airway pressure therapy. This study reports the long-term outcomes of the multi-level surgery as a case series. METHODS Surgical participants were reassessed >2 years postoperatively with the same outcomes reported in the main SAMS trial. Primary outcomes were apnea-hypopnea index (AHI) and Epworth sleepiness scale (ESS), with secondary outcomes including other polysomnography measures, symptoms, quality of life, and adverse events. Long-term effectiveness (baseline to long-term follow-up [LTFU]) and interval changes (6 month to LTFU) were assessed using mixed effects regression models. Control participants were also reassessed for rate of subsequent surgery and outcomes. RESULTS 36/48 (75%) of surgical participants were reevaluated (mean (standard deviation)) 3.5 (1.0) years following surgery, with 29 undergoing polysomnography. AHI was 41/h (23) at preoperative baseline and 21/h (18) at follow-up, representing persistent improvement of -24/h (95% CI -32, -17; p < 0.001). ESS was 12.3 (3.5) at baseline and 5.5 (3.9) at follow-up, representing persistent improvement of -6.8 (95% CI -8.3, -5.4; p < 0.001). Secondary outcomes were improved long term, and adverse events were minor. Interval change analysis suggests stability of outcomes. 36/43 (84%) of the control participants were reevaluated, with 25 (69%) reporting subsequent surgery, with symptom and quality of life improvements. CONCLUSION Multi-level upper airway surgery improves OSA burden with long-term maintenance of treatment effect in adults with moderate or severe OSA in whom conventional therapy failed. CLINICAL TRIAL Multi-level airway surgery in patients with moderate-severe obstructive sleep apnea (OSA) who have failed medical management to assess change in OSA events and daytime sleepiness; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366019&isReview=true; ACTRN12614000338662.
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Affiliation(s)
- Alison J Pinczel
- Adelaide Institute for Sleep Health, FHMRI Sleep Health, Flinders University, Adelaide, SA, Australia
| | - Charmaine M Woods
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- Department of Otolaryngology, Head and Neck Surgery, Flinders Medical Centre, Adelaide, SA, Australia
| | - Peter G Catcheside
- Adelaide Institute for Sleep Health, FHMRI Sleep Health, Flinders University, Adelaide, SA, Australia
| | - Richard J Woodman
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Andrew Simon Carney
- Adelaide Institute for Sleep Health, FHMRI Sleep Health, Flinders University, Adelaide, SA, Australia
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- Southern ENT and Adelaide Sinus Centre, Flinders Private Hospital, Adelaide, SA, Australia
| | - Ching Li Chai-Coetzer
- Adelaide Institute for Sleep Health, FHMRI Sleep Health, Flinders University, Adelaide, SA, Australia
- Respiratory and Sleep Service, Southern Adelaide Local Health Network, Adelaide, SA, Australia
| | - Michael Chia
- Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Peter A Cistulli
- Charles Perkins Centre, Faculty for Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - John-Charles Hodge
- Ear Nose and Throat Department, Royal Adelaide Hospital, Adelaide, SA, Australia
- ICON Cancer Centre, Adelaide, SA, Australia
- Department of Surgery, University of Adelaide, Adelaide, SA, Australia
| | - Andrew Jones
- Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
- Illawarra Sleep Medicine Centre, Wollongong, NSW, Australia
- Graduate School of Medicine, University of Wollongong, Wollongong, NSW, Australia
| | - Matthew E Lam
- Illawarra ENT Head and Neck Clinic, Wollongong, NSW, Australia
| | - Richard Lewis
- Head and Neck Surgery, Hollywood Medical Centre, Perth, WA, Australia
- Department of Otolaryngology, Royal Perth Hospital, Perth, WA, Australia
| | - Nigel McArdle
- West Australian Sleep Disorders Research Institute, Queen Elizabeth II Medical Centre, Perth, WA, Australia
- Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Eng H Ooi
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
- Department of Otolaryngology, Head and Neck Surgery, Flinders Medical Centre, Adelaide, SA, Australia
- Adelaide ENT Surgery, Flinders Private Hospital, Adelaide, SA, Australia
| | - Siobhan Clare Rea
- West Australian Sleep Disorders Research Institute, Queen Elizabeth II Medical Centre, Perth, WA, Australia
| | - Guy Rees
- ENT Surgeons, Memorial Hospital, North Adelaide, SA, Australia
- Department of Surgery, University of Adelaide, Adelaide, SA, Australia
| | - Bhajan Singh
- West Australian Sleep Disorders Research Institute, Queen Elizabeth II Medical Centre, Perth, WA, Australia
- Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
- Faculty of Human Sciences, University of Western Australia, Perth, WA, Australia
| | - Nicholas Stow
- Sydney Centre for Ear, Nose and Throat, Sydney, NSW, Australia
- Sleep Clinic, The Woolcock Clinic, Glebe, NSW, Australia
| | - Aeneas Yeo
- Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Nick Antic
- Adelaide Institute for Sleep Health, FHMRI Sleep Health, Flinders University, Adelaide, SA, Australia
| | - Ronald Doug McEvoy
- Adelaide Institute for Sleep Health, FHMRI Sleep Health, Flinders University, Adelaide, SA, Australia
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Edward M Weaver
- Department of Otolaryngology/Head and Neck Surgery, University of Washington, Seattle, WA, USA
- Surgery Service, Seattle Veterans Affairs Medical Center, Seattle, WA, USA
| | - Stuart G MacKay
- Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
- Graduate School of Medicine, University of Wollongong, Wollongong, NSW, Australia
- Illawarra ENT Head and Neck Clinic, Wollongong, NSW, Australia
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Sastow T, Moussa N, Zebovitz E. Controversies in Sleep Apnea. Dent Clin North Am 2024; 68:1-20. [PMID: 37951627 DOI: 10.1016/j.cden.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
This chapter discusses controversies in diagnosis and management of obstructive sleep apnea (OSA), with particular focus on surgical management to improve quality of life. Though OSA is a complex disorder that affects millions of people worldwide, its management remains controversial among clinicians. Gaps in understanding its pathophysiology, long-term health consequences, diagnostic methods, and treatment strategies exist. While continuous positive airway pressure (CPAP) therapy is considered the gold standard for moderate to severe obstructive sleep apnea (OSA), its adherence rate is often low, and its efficacy in improving outcomes beyond symptom reduction and quality of life improvement is uncertain. As such, surgical intervention may be an alternative for specific patient populations. Additionally, the type of surgical intervention may depend on individual patient needs, anatomic features, as well as preferences.
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Affiliation(s)
- Tal Sastow
- Oral and Maxillofacial Surgery, The Brooklyn Hospital Center, 155 Ashland Pl, Brooklyn, NY 11201, USA.
| | - Nabil Moussa
- Oral and Maxillofacial Surgery, Anne Arundel Medical Center, 4311 Northview Drive, Bowie, MD 20716, USA
| | - Edward Zebovitz
- Oral and Maxillofacial Surgery, Anne Arundel Medical Center, 4311 Northview Drive, Bowie, MD 20716, USA
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Hardin L. Hypoglossal nerve stimulation for adults with obstructive sleep apnea. JAAPA 2023; 36:24-29. [PMID: 37989167 DOI: 10.1097/01.jaa.0000991392.37494.b6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
ABSTRACT Obstructive sleep apnea (OSA) is a common chronic condition in which upper airway collapse interferes with breathing during sleep, reducing sleep quality. Untreated OSA can impair a patient's health and quality of life. The recommended first-line treatment for OSA in adults is positive airway pressure, but difficulty tolerating this device limits adherence to treatment for many patients. Treatment with an implanted hypoglossal nerve stimulation (HNS) device is a relatively new second-line option for these patients, and is gaining more widespread use. Clinicians who treat OSA or provide other healthcare services to patients with HNS implants should be familiar with these devices. This article reviews HNS technology and relevant OSA pathophysiology, along with device candidacy criteria, efficacy, risks, and considerations related to use of other medical technologies for patients with HNS implants.
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Affiliation(s)
- Laura Hardin
- Laura Hardin practices in otolaryngology at Texas ENT Specialists in Houston, Tex. The author has disclosed no potential conflicts of interest, financial or otherwise
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Wu CS, Chen DHK, Ko YC, Bai CH, Chen PY, Liu WT, Lin YC. The firstly visited department affects the acceptance of CPAP in patients with obstructive sleep apnea: a cohort study. J Otolaryngol Head Neck Surg 2023; 52:71. [PMID: 37898803 PMCID: PMC10613393 DOI: 10.1186/s40463-023-00676-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 10/18/2023] [Indexed: 10/30/2023] Open
Abstract
BACKGROUND Continuous positive airway pressure (CPAP) therapy is the first-line treatment for obstructive sleep apnea (OSA). However, the low acceptance rate of CPAP remains a challenging clinical issue. This study aimed to determine the factors that influence the acceptance rate of CPAP. METHODS This retrospective cohort study was conducted at the sleep center of Shuang-Ho Hospital. Initially, 1186 OSA patients who received CPAP therapy between December 2013 and December 2017 were selected, and finally, 1016 patients were analyzed. All patients with OSA received CPAP therapy for at least 1 week, and their acceptance to treatment was subsequently recorded. Outcome measures included patients' demographic and clinical characteristics (sex, age, BMI, comorbidities, history of smoking, and the medical specialist who prescribed CPAP treatment), polysomnography (PSG) results, and OSA surgical records. RESULTS Patients with a lower CPAP acceptance rate were referred from otolaryngologists (acceptance rate of otolaryngology vs. others: 49.6% vs. 56.6%, p = .015), in addition to having a lower apnea-hypopnea index (AHI) (acceptance vs. non-acceptance: 55.83 vs. 40.79, p = .003), rapid eye movement AHI (REM-AHI) (acceptance vs. non-acceptance: 51.21 vs. 44.92, p = .014), and arousal index (acceptance vs. non-acceptance: 36.80 vs. 28.75, p = .011). The multiple logistic regression model showed that patients referred from otolaryngology had a lower CPAP acceptance rate (odds ratio 0.707, p = .0216) even after adjusting for age, sex, BMI, AHI, REM-AHI, arousal index, comorbidities, and smoking status. CONCLUSIONS Before their initial consultation, patients may already have their preferred treatment of choice, which is strongly linked to the type of medical specialists they visit, and consequently, affects their rate of acceptance to CPAP therapy. Therefore, physicians should provide personalized care to patients by exploring and abiding by their preferred treatment choices.
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Affiliation(s)
- Chung-Sheng Wu
- Department of Primary Care Medicine, Shuang-Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - David Hsin-Kuang Chen
- Department of Medical Education, Shuang-Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Yuan-Chun Ko
- Department of Primary Care Medicine, Wan-Fang Hospital, Taipei Medical University, Taipei City, Taiwan
| | - Chyi-Huey Bai
- School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan
- Department of Public Health, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Nutrition Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - Po-Yueh Chen
- Department of Otolaryngology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Otolaryngology, Wan-Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Wen-Te Liu
- Sleep Center, Shuang-Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang-Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Yi-Chih Lin
- School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan.
- Department of Otolaryngology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
- Sleep Center, Shuang-Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.
- Department of Otolaryngology, Shuang-Ho Hospital, Taipei Medical University, No. 291, Zhongzheng Rd., Zhonghe District, New Taipei City, 23561, Taiwan.
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10
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Ho JPTF, Zhou N, van Riet TCT, Schreurs R, Becking AG, de Lange J. Assessment of Surgical Accuracy in Maxillomandibular Advancement Surgery for Obstructive Sleep Apnea: A Preliminary Analysis. J Pers Med 2023; 13:1517. [PMID: 37888128 PMCID: PMC10608325 DOI: 10.3390/jpm13101517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/14/2023] [Accepted: 10/18/2023] [Indexed: 10/28/2023] Open
Abstract
This retrospective study aimed to: (1) investigate the surgical accuracy of maxillomandibular advancement (MMA) in obstructive sleep apnea (OSA) patients, with a specific focus on maxillary and mandibular advancement and counter-clockwise rotation and (2) investigate the correlation between the amount of achieved advancement and the reduction in the relative apnea hypopnea index (AHI). Sixteen patients, for whom a three-dimensional virtual surgical plan was generated preoperatively and a computed tomography scan (CT) or cone-beam computer tomography (CBCT) was acquired postoperatively, were included. The postoperative CT or CBCT was compared to the virtual surgical plan, and differences in the mandibular and maxillary advancement and counter-clockwise rotation were assessed. Maxillary and mandibular advancement (median 3.1 mm, p = 0.002 and 2.3 mm, p = 0.03, respectively) and counter-clockwise rotation (median 3.7°, p = 0.006 and 4.7°, p = 0.001, respectively) were notably less than intended. A significant correlation was found between the planned maxillary advancement and the difference between the planned and actual maxillary advancement (p = 0.048; adjusted R2 = 0.1979) and also between the planned counter-clockwise rotation and the difference between the planned and actual counter-clockwise rotation for the mandible (p = 0.012; adjusted R2 = 0.3261). Neither the maxilla-first nor the mandible-first surgical sequence proved to be superior in terms of the ability to achieve the intended movements (p > 0.45). Despite a significant reduction (p = 0.001) in the apnea hypopnea index (AHI) from a median of 62.6 events/h to 19.4 events/h following MMA, no relationship was found between the extent of maxillary or mandibular advancement and AHI improvement in this small cohort (p = 0.389 and p = 0.387, respectively). This study underlines the necessity for surgeons and future research projects to be aware of surgical inaccuracies in MMA procedures for OSA patients. Additionally, further research is required to investigate if sufficient advancement is an important factor associated with MMA treatment outcome.
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Affiliation(s)
- Jean-Pierre T. F. Ho
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (N.Z.); (T.C.T.v.R.); (R.S.); (J.d.L.)
- Academic Centre for Dentistry of Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, 1081 LA Amsterdam, The Netherlands
- Department of Oral and Maxillofacial Surgery, Northwest Clinics, Wilhelminalaan 12, 1815 JD Alkmaar, The Netherlands
| | - Ning Zhou
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (N.Z.); (T.C.T.v.R.); (R.S.); (J.d.L.)
| | - Tom C. T. van Riet
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (N.Z.); (T.C.T.v.R.); (R.S.); (J.d.L.)
- Academic Centre for Dentistry of Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, 1081 LA Amsterdam, The Netherlands
| | - Ruud Schreurs
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (N.Z.); (T.C.T.v.R.); (R.S.); (J.d.L.)
| | - Alfred G. Becking
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (N.Z.); (T.C.T.v.R.); (R.S.); (J.d.L.)
- Academic Centre for Dentistry of Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, 1081 LA Amsterdam, The Netherlands
| | - Jan de Lange
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (N.Z.); (T.C.T.v.R.); (R.S.); (J.d.L.)
- Academic Centre for Dentistry of Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, 1081 LA Amsterdam, The Netherlands
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11
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Sisson CB. A clinical review of obstructive sleep apnea. JAAPA 2023; 36:10-15. [PMID: 37751250 DOI: 10.1097/01.jaa.0000977668.78287.0c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
ABSTRACT Symptoms of obstructive sleep apnea (OSA) often are overlooked or misinterpreted, but without treatment, patients are at increased risk for potentially life-threatening conditions including stroke and heart failure. Clinician awareness of the risk factors for and treatment of OSA can prevent the development or progression of these complications in patients.
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Affiliation(s)
- Caroline B Sisson
- Caroline B. Sisson is an assistant professor in the PA program at Wake Forest School of Medicine in Winston-Salem, N.C. The author has disclosed no potential conflicts of interest, financial or otherwise
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12
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Every JD, Mackay SG, Sideris AW, Do TQ, Jones A, Weaver EM. Mean disease alleviation between surgery and continuous positive airway pressure in matched adults with obstructive sleep apnea. Sleep 2023; 46:zsad176. [PMID: 37395677 DOI: 10.1093/sleep/zsad176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 05/19/2023] [Indexed: 07/04/2023] Open
Abstract
STUDY OBJECTIVES Polysomnography parameters measure treatment efficacy for obstructive sleep apnea (OSA), such as reduction in apnea-hypopnea index (AHI). However, for continuous positive airway pressure (CPAP) therapy, polysomnography measures do not factor in adherence and thus do not measure effectiveness. Mean disease alleviation (MDA) corrects polysomnography measures for CPAP adherence and was used to compare treatment effectiveness between CPAP and multilevel upper airway surgery. METHODS This retrospective cohort study consisted of a consecutive sample of 331 patients with OSA managed with multilevel airway surgery as second-line treatment (N = 97) or CPAP (N = 234). Therapeutic effectiveness (MDA as % change or as corrected change in AHI) was calculated as the product of therapeutic efficacy (% or absolute change in AHI) and adherence (% time on CPAP of average nightly sleep). Cardinality and propensity score matching was utilized to manage confounding variables. RESULTS Surgery patients achieved greater MDA % than CPAP users (67 ± 30% vs. 60 ± 28%, p = 0.04, difference 7 ± 3%, 95% confidence interval 4% to 14%) in an unmatched comparison, despite a lower therapeutic efficacy seen with surgery. Cardinality matching demonstrated comparable MDA % in surgery (64%) and CPAP (57%) groups (p = 0.14, difference 8 ± 5%, 95% confidence interval -18% to 3%). MDA measured as corrected change in AHI showed similar results. CONCLUSIONS In adult patients with OSA, multilevel upper airway surgery and CPAP provide comparable therapeutic effectiveness on polysomnography. For patients with inadequate CPAP use, surgery should be considered.
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Affiliation(s)
- James D Every
- Department of Otolaryngology, Head and Neck Surgery, The Wollongong Hospital, Wollongong, NSW. Australia
| | - Stuart G Mackay
- Department of Otolaryngology, Head and Neck Surgery, The Wollongong Hospital, Wollongong, NSW. Australia
- Illawarra ENT Head and Neck Clinic, Wollongong, NSW, Australia
- School of Medicine, University of Wollongong, Wollongong, NSW, Australia
| | - Anders W Sideris
- Department of Otolaryngology, Head and Neck Surgery, The Wollongong Hospital, Wollongong, NSW. Australia
| | - Timothy Q Do
- Department of Otolaryngology, Head and Neck Surgery, The Wollongong Hospital, Wollongong, NSW. Australia
| | - Andrew Jones
- Department of Respiratory Medicine, The Wollongong Hospital, Wollongong, NSW. Australia
- School of Medicine, University of Wollongong, Wollongong, NSW, Australia
| | - Edward M Weaver
- Department of Otolaryngology, University of Washington, Seattle, Washington, USA
- Surgery Service, Seattle Veterans Affairs Medical Center, Seattle, Washington, USA
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13
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Sabatino L, Moffa A, Iafrati F, Di Giovanni S, De Benedetto L, Giorgi L, Baptista P, Vicini C, De Vito A, Casale M. A New Lighting System for Surgical Vision Optimization in Barbed Pharyngoplasty for OSA. J Pers Med 2023; 13:1320. [PMID: 37763089 PMCID: PMC10532610 DOI: 10.3390/jpm13091320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 08/21/2023] [Accepted: 08/24/2023] [Indexed: 09/29/2023] Open
Abstract
Obstructive sleep apnea (OSA) surgery is now a viable solution in selected patients and the "remodeling" palatopharyngeal surgery is the most common one. Recently, it has become less invasive with the introduction of barbed sutures (BS). An optimization of surgical techniques is represented by barbed pharyngoplasty (BP), which requires surgical precision and needs efficient and precise oropharyngeal visualization. Consequently, the lighting system is of pivotal importance in BP. The aim of this work is to describe the first experience on the use of a new lighting system, called KLAROTM in BP for OSA. We evaluated the KLARO™ system in 15 consecutives BP for OSA in comparison with conventional headlamp illumination. The visualization of palatopharyngeal muscle in the bottom of the tonsillar fossa, entry and exit needle, such as needle tip, were statistically better with KLAROTM than headlamp illumination for both the surgeon and resident (p < 0.05). No significant differences for the visualization of the posterior pharyngeal wall and uvula were reported. The KLAROTM lighting system allows a satisfied illumination of oral cavity and oropharynx in the majority of cases. We encourage the use of KLAROTM not only in BP for OSA, but in all oral and pharyngeal surgeries, including tonsillectomy and oncological surgery.
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Affiliation(s)
- Lorenzo Sabatino
- Integrated Therapies in Otolaryngology, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy
| | - Antonio Moffa
- Integrated Therapies in Otolaryngology, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy
- School of Medicine, Università Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - Francesco Iafrati
- Integrated Therapies in Otolaryngology, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy
- School of Medicine, Università Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - Simone Di Giovanni
- Integrated Therapies in Otolaryngology, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy
- School of Medicine, Università Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - Luigi De Benedetto
- Integrated Therapies in Otolaryngology, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy
| | - Lucrezia Giorgi
- Integrated Therapies in Otolaryngology, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy
- Unit of Measurements and Biomedical Instrumentation, Università Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - Peter Baptista
- ENT Department, Al Zahra Private Hospital Dubai, Dubai 23614, United Arab Emirates
- Department of Otorhinolaryngology, Clinica Universidad de Navarra, 31008 Pamplona, Spain
| | - Claudio Vicini
- ENT Department, Morgagni Pierantoni Hospital, 47121 Forli, Italy
- ENT Department, University of Ferrara, 44121 Ferrara, Italy
| | - Andrea De Vito
- Otolaryngology and Head-Neck Surgery Unit, Department of Surgery, Ravenna & Lugo Hospitals, Health Local Agency of Romagna, 48121 Ravenna, Italy
| | - Manuele Casale
- Integrated Therapies in Otolaryngology, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy
- School of Medicine, Università Campus Bio-Medico di Roma, 00128 Rome, Italy
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14
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Bae E. Preoperative risk evaluation and perioperative management of patients with obstructive sleep apnea: a narrative review. J Dent Anesth Pain Med 2023; 23:179-192. [PMID: 37559666 PMCID: PMC10407451 DOI: 10.17245/jdapm.2023.23.4.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/19/2023] [Accepted: 07/22/2023] [Indexed: 08/11/2023] Open
Abstract
Obstructive sleep apnea (OSA) is a common sleep-breathing disorder associated with significant comorbidities and perioperative complications. This narrative review is aimed at comprehensively overviewing preoperative risk evaluation and perioperative management strategies for patients with OSA. OSA is characterized by recurrent episodes of upper airway obstruction during sleep leading to hypoxemia and arousal. Anatomical features, such as upper airway narrowing and obesity, contribute to the development of OSA. OSA can be diagnosed based on polysomnography findings, and positive airway pressure therapy is the mainstay of treatment. However, alternative therapies, such as oral appliances or upper airway surgery, can be considered for patients with intolerance. Patients with OSA face perioperative challenges due to difficult airway management, comorbidities, and effects of sedatives and analgesics. Anatomical changes, reduced upper airway muscle tone, and obesity increase the risks of airway obstruction, and difficulties in intubation and mask ventilation. OSA-related comorbidities, such as cardiovascular and respiratory disorders, further increase perioperative risks. Sedatives and opioids can exacerbate respiratory depression and compromise airway patency. Therefore, careful consideration of alternative pain management options is necessary. Although the association between OSA and postoperative mortality remains controversial, concerns exist regarding adverse outcomes in patients with OSA. Understanding the pathophysiology of OSA, implementing appropriate preoperative evaluations, and tailoring perioperative management strategies are vital to ensure patient safety and optimize surgical outcomes.
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Affiliation(s)
- Eunhye Bae
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong-si, Republic of Korea
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15
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Genioglossus Advancement: Technique Modification for Improved Chin Contour. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4846. [PMID: 36910733 PMCID: PMC9995103 DOI: 10.1097/gox.0000000000004846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/17/2023] [Indexed: 03/14/2023]
Abstract
Genioglossus advancement plays an important role in the armamentarium of the obstructive sleep apnea surgeon and has gone through many iterations over several decades. A recently described technique involves creating a box osteotomy, which is carried through the inferior border of the mandible in order to increase recruitment of the suprahyoid musculature. Here we introduce a further modification of the technique that uses virtual planning to improve the safety and accuracy of genial tubercle capture. In addition, angulation of the lateral osteotomies enhances bone to bone contact. Before the osteotomy, the surgeon has the opportunity to drill the buccal plate to reduce the chin profile. This approach is particularly valuable in the patient who is prognathic at baseline or who becomes prognathic after simultaneous maxillomandibular advancement. Here we discuss this unique approach, demonstrating how the patient profile may be balanced even as the genial tubercle is advanced.
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16
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Svensson M, Ekström M, Sundh J, Ljunggren M, Grote L, Palm A. Adherence to CPAP therapy in Down syndrome: the population-based DISCOVERY study. J Clin Sleep Med 2023; 19:453-458. [PMID: 36458740 PMCID: PMC9978440 DOI: 10.5664/jcsm.10364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 10/20/2022] [Accepted: 10/20/2022] [Indexed: 12/04/2022]
Abstract
STUDY OBJECTIVES Persons with Down syndrome (DS) have an increased risk of obstructive sleep apnea (OSA) needing continuous positive airway pressure (CPAP), but data on the therapy and outcomes in this population are scarce. We aimed to compare patient characteristics and outcomes of CPAP treatment for patients with OSA with and without DS. METHODS This was a population-based, longitudinal study on patients initiating CPAP therapy between July 2010 and March 2018 in Sweden and a population-based sex- and age-matched control group (control:case ratio 5:1), with linked data from the Swedish National Patient Registry and the Prescribed Drug Registry (DISCOVERY study cohort). RESULTS Patients with DS (n = 64) had a higher apnea-hypopnea index (51.7 ± 30.3 vs 36.8 ± 29.1 events/h, P < .001), Epworth Sleepiness Scale score (13.7 ± 5.9 vs 11.0 ± 4.9, P = .001), rate of previous surgery of tonsils and/or adenoids (21.9% vs 8.2%, P = .001), and more thyroid replacement hormone therapy (45.3% vs 7.8%, P < .001), but lower use of cardiovascular drugs (7.8% vs 22.3%, P = .003) compared with controls. At follow-up after 1.3 ± 0.9 years, there were no differences in nocturnal CPAP usage time (5.6 ± 2.4 vs 5.5 ± 2.0 hours, P = .77), CPAP adherence ≥ 4 hours/night (62% vs 65%, P = .93), or improvement in Epworth Sleepiness Scale score (-5.4 ± 6.8 vs -5.0 ± 2.0, P = .84) between DS and non-DS patients. CONCLUSIONS OSA severity was substantially higher in patients with DS despite an increased rate of tonsil surgery. Treatment outcomes in terms of adherence and improved daytime sleepiness were comparable between groups, underlining the importance of both OSA diagnosis and treatment in patients with DS. CITATION Svensson M, Ekström M, Sundh J, Ljunggren M, Grote L, Palm A. Adherence to CPAP therapy in Down syndrome: the population-based DISCOVERY study. J Clin Sleep Med. 2023;19(3):453-458.
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Affiliation(s)
- Malin Svensson
- Centre for Research and Development, Uppsala University, Region of Gävleborg, Gävle Hospital, Gävle, Sweden
- Department of Otorhinolaryngology, Head and Neck Cancer, Uppsala University, Uppsala, Sweden
| | - Magnus Ekström
- Department of Clinical Sciences, Respiratory Medicine, Allergology and Palliative Medicine, Faculty of Medicine, Lund University, Lund, Sweden
| | - Josefin Sundh
- Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro Sweden
| | - Mirjam Ljunggren
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Ludger Grote
- Pulmonary Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Center for Sleep and Wake Disorders, Institute for Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Andreas Palm
- Centre for Research and Development, Uppsala University, Region of Gävleborg, Gävle Hospital, Gävle, Sweden
- Department of Otorhinolaryngology, Head and Neck Cancer, Uppsala University, Uppsala, Sweden
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
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17
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González González A, Montero J, Gómez Polo C. Sleep Apnea-Hypopnea Syndrome and Sleep Bruxism: A Systematic Review. J Clin Med 2023; 12:910. [PMID: 36769558 PMCID: PMC9918154 DOI: 10.3390/jcm12030910] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/12/2023] [Accepted: 01/16/2023] [Indexed: 01/26/2023] Open
Abstract
The aim of this study was o determine the relationship between sleep bruxism (SB) and sleep apnea-hypopnea syndrome (SAHS) at the pathophysiological level, the risk factors, as well as the common signs and symptoms. A search was carried out using the databases PubMed, Web of Science, Scopus, and the Cochrane Library together with the Boolean equation "bruxism" AND "sleep apnea" AND "relation*"; the systematic search strategy limited the results to English language articles published from 2013 until December 2021. This review was conducted in accordance with the PRISMA statement. Nine articles were reviewed to relate SAHS and SB at different levels: two were systematic reviews (22%) and seven were research studies (78%). According to the literature reviewed, SB and SAHS occur simultaneously in 21.0% to 41.3% of cases. There are signs and symptoms that are common to both SAHS and SB. Rhythmic masticatory muscle activity (RMMA) precedes an SAHS event in 25% of subjects with SB, in contrast to 55% of the general population. SB and SAHS seem to have a certain concomitance, ranging between 20% and 40%, and they also share some risk factors such as advanced age, obesity, smoking, and alcohol consumption. Dentists should be aware of this relationship, as part of a multidisciplinary team, for early diagnosis.
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Affiliation(s)
| | | | - Cristina Gómez Polo
- Department of Surgery, School of Medicine, University of Salamanca, 37007 Salamanca, Spain
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18
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Ikeda AK, McShay C, Marsh R, Saini S, Sardesai M, Boss EF, Weaver EM. Barriers and communication behaviors impacting referral to sleep surgery: qualitative patient perspectives. J Clin Sleep Med 2023; 19:111-117. [PMID: 36591793 PMCID: PMC9806776 DOI: 10.5664/jcsm.10260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 08/19/2022] [Accepted: 08/23/2022] [Indexed: 02/01/2023]
Abstract
STUDY OBJECTIVES Physician-patient interactions influence the immediate encounter and leave lasting impressions for future health care encounters. We aimed to understand patient experiences and decision-making for considering sleep surgery, in terms of barriers and communication behaviors that facilitate or hinder referral for consideration of sleep surgery management of obstructive sleep apnea (OSA) when continuous positive airway pressure (CPAP) therapy has failed. METHODS We employed qualitative methods, using semistructured interviews of adults with OSA who presented for sleep surgery consultation after unsatisfactory therapy with CPAP. Open-ended questions traced symptoms and progression of sleep apnea burden, trials of noninvasive OSA therapies, outcomes, and patient expectations and concerns. The interviews were audio-recorded, transcribed, and analyzed using content analysis to identify themes. RESULTS Ten adult patients with OSA were enrolled March through April 2021 and reached predominant thematic saturation. Barriers to sleep surgery consultation included: (1) delays in OSA diagnosis due to limited OSA awareness among patients or primary providers and patients' perceived inconvenience of sleep testing, (2) patients faulted for slow progress, (3) patient-reported lack of urgency by providers in troubleshooting noninvasive management options, (4) scheduling delays and waitlists, and (5) cost. Patients were receptive to noninvasive treatment options, but inadequate improvement led to frustration after multiple encounters. Patients appreciated empathetic providers who shared information through transparent and understandable explanations and who presented multiple treatment options. CONCLUSIONS Experiences of patients with OSA highlight the need for shared decision-making through improved communication of unresolved concerns and alternative management options, including timely referral for sleep surgery consultation when indicated. CITATION Ikeda AK, McShay C, Marsh R, et al. Barriers and communication behaviors impacting referral to sleep surgery: qualitative patient perspectives. J Clin Sleep Med. 2023;19(1):111-117.
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Affiliation(s)
- Allison K. Ikeda
- University of Washington, Department of Otolaryngology–Head and Neck Surgery, Seattle, Washington
| | - Crystina McShay
- University of Washington, Department of Human Centered Design and Engineering, Seattle, Washington
| | - Robin Marsh
- University of Washington, Department of Human Centered Design and Engineering, Seattle, Washington
| | - Shireen Saini
- University of Washington, Department of Human Centered Design and Engineering, Seattle, Washington
| | - Maya Sardesai
- University of Washington, Department of Otolaryngology–Head and Neck Surgery, Seattle, Washington
| | - Emily F. Boss
- Johns Hopkins University, Department of Otolaryngology–Head and Neck Surgery, Baltimore, Maryland
| | - Edward M. Weaver
- University of Washington, Department of Otolaryngology–Head and Neck Surgery, Seattle, Washington
- Seattle Veterans Affairs Medical Center, Surgery Service, Seattle, Washington
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19
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Weiner JS, Munhall CC, Kent DT. Supine Pharyngeal Width Is Associated With Complete Concentric Palatal Collapse During Drug-Induced Sleep Endoscopy and Hypoglossal Nerve Stimulator Outcomes. EAR, NOSE & THROAT JOURNAL 2022:1455613221148313. [PMID: 36583238 DOI: 10.1177/01455613221148313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE Hypoglossal nerve stimulation (HNS) implantation in the US requires preoperative drug-induced sleep endoscopy (DISE) screening for complete concentric palatal collapse (CCC) to establish treatment candidacy. We hypothesized that supine pharyngeal width (SPW) in awake patients is associated with CCC and HNS therapy outcomes. METHODS Adults with moderate to severe obstructive sleep apnea underwent awake measurement of SPW followed by DISE screening for CCC. Eligible patients electing for HNS implantation underwent postoperative polysomnography per standard of care. RESULTS SPW was measured in 73 patients. For SPW >20 mm, the positive likelihood ratio for absence of CCC was 6.67 with pre- and post-test odds of 6.3 and 42.0, respectively. Postoperative PSG data were available from 31 of 44 (70.5%) patients subsequently implanted with HNS. Patients with SPW >20 mm had a greater rate of HNS response than those with SPW ≤20 (62 vs 30%; P < .05). Only SPW and BMI were significantly associated with CCC and HNS response in regression models. CONCLUSION In a retrospective cohort study, SPW was significantly associated with CCC and postoperative apnea-hypopnea index following HNS implantation. SPW may be a viable screening tool for HNS candidacy.
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Affiliation(s)
| | | | - David T Kent
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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20
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Surgical Treatment Options for Epiglottic Collapse in Adult Obstructive Sleep Apnoea: A Systematic Review. LIFE (BASEL, SWITZERLAND) 2022; 12:life12111845. [PMID: 36430980 PMCID: PMC9698204 DOI: 10.3390/life12111845] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/06/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022]
Abstract
The critical role of epiglottis in airway narrowing contributing to obstructive sleep apnoea (OSA) and continuous positive airway pressure (CPAP) intolerance has recently been revealed. This systematic review was conducted to evaluate available surgical treatment options for epiglottic collapse in adult patients with OSA. The Pubmed and Scopus databases were searched for relevant articles up to and including March 2022 and sixteen studies were selected. Overall, six different surgical techniques were described, including partial epiglottectomy, epiglottis stiffening operation, glossoepiglottopexy, supraglottoplasty, transoral robotic surgery, maxillomandibular advancement and hypoglossal nerve stimulation. All surgical methods were reported to be safe and effective in managing selected OSA patients with airway narrowing at the level of epiglottis. The surgical management of epiglottic collapse can improve OSA severity or even cure OSA, but can also improve CPAP compliance. The selection of the appropriate surgical technique should be part of an individualised, patient-specific therapeutic approach. However, there are not enough data to make definitive conclusions and additional high-quality studies are required.
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Katz D, DeMaria S, Heckman S, Lin F, Kushida C. Use of the Complete Airway Repositioning and Expansion (CARE) approach in 220 patients with Obstructive Sleep Apnea (OSA): A retrospective cohort study. Sleep Med 2022; 99:18-22. [DOI: 10.1016/j.sleep.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/30/2022] [Accepted: 07/04/2022] [Indexed: 11/26/2022]
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Gambino F, Zammuto MM, Virzì A, Conti G, Bonsignore MR. Treatment options in obstructive sleep apnea. Intern Emerg Med 2022; 17:971-978. [PMID: 35460431 PMCID: PMC9135849 DOI: 10.1007/s11739-022-02983-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 03/29/2022] [Indexed: 11/29/2022]
Abstract
Treatment of OSA with CPAP is currently the recommended treatment and has the greatest evidence of efficacy on AHI, symptoms and comorbidities. Symptomatic patients with moderate-severe OSA generally have good adherence to CPAP therapy, while those with mild OSA, female, young and generally paucisymptomatic, have lower CPAP adherence, especially in the medium and long term. The recent identification of different clinical and pathophysiological phenotypes of OSA has paved the way for alternative treatments to CPAP, leading to an increasingly personalized therapy. Weight loss and lifestyle modifications are highly recommended in all obese or overweight patients. Mandibular advancement devices (MAD), positional therapy (PT) and hypoglossal nerve stimulation (HSN) are recent and personalized alternative therapies on which there is promising and encouraging data but with still little strong scientific evidence. The purpose of this review is to compare the efficacy, adherence and costs of various therapeutic options for OSA patients in the light of recent evidence and to provide useful guidance for specialists.
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Affiliation(s)
- Francesco Gambino
- Division of Pulmonary Medicine, Ospedali Riuniti Villa Sofia-Cervello, Via Trabucco 180, 90146, Palermo, Italy
| | - Marta Maria Zammuto
- Division of Pulmonary Medicine, Ospedali Riuniti Villa Sofia-Cervello, Via Trabucco 180, 90146, Palermo, Italy
| | - Alessandro Virzì
- Division of Pulmonary Medicine, Ospedali Riuniti Villa Sofia-Cervello, Via Trabucco 180, 90146, Palermo, Italy
| | - Giosafat Conti
- Division of Pulmonary Medicine, Ospedali Riuniti Villa Sofia-Cervello, Via Trabucco 180, 90146, Palermo, Italy
| | - Maria Rosaria Bonsignore
- Division of Pulmonary Medicine, Ospedali Riuniti Villa Sofia-Cervello, Via Trabucco 180, 90146, Palermo, Italy.
- PROMISE Department, University of Palermo, Palermo, Italy.
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Weaver EM. Sleep Surgery Improves Blood Pressure: How Can It Be? Sleep Med Rev 2022; 62:101619. [DOI: 10.1016/j.smrv.2022.101619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 02/22/2022] [Indexed: 10/19/2022]
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Kent D, Stanley J, Aurora RN, Levine CG, Gottlieb DJ, Spann MD, Torre CA, Green K, Harrod CG. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med 2021; 17:2507-2531. [PMID: 34351849 PMCID: PMC8726364 DOI: 10.5664/jcsm.9594] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 08/03/2021] [Accepted: 08/03/2021] [Indexed: 11/13/2022]
Abstract
INTRODUCTION This systematic review provides supporting evidence for the accompanying clinical practice guideline on the referral of adults with obstructive sleep apnea (OSA) for surgical consultation. METHODS The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies that compared the use of upper airway sleep apnea surgery or bariatric surgery to no treatment as well as studies that reported on patient-important and physiologic outcomes pre- and postoperatively. Statistical analyses were performed to determine the clinical significance of using surgery to treat obstructive sleep apnea in adults. Finally, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process was used to assess the evidence for making recommendations. RESULTS The literature search resulted in 274 studies that provided data suitable for statistical analyses. The analyses demonstrated that surgery as a rescue therapy results in a clinically significant reduction in excessive sleepiness, snoring, blood pressure (BP), apnea-hypopnea index (AHI), respiratory disturbance index (RDI), and oxygen desaturation index (ODI); an increase in lowest oxygen saturation (LSAT) and sleep quality; and an improvement in quality of life in adults with OSA who are intolerant or unaccepting of positive airway pressure (PAP) therapy. The analyses demonstrated that surgery as an adjunctive therapy results in a clinically significant reduction in optimal PAP pressure and improvement in PAP adherence in adults with OSA who are intolerant or unaccepting of PAP due to side effects associated with high pressure requirements. The analyses also demonstrated that surgery as an initial treatment results in a clinically significant reduction in AHI/RDI, sleepiness, snoring, BP, and ODI and an increase in LSAT in adults with OSA and major anatomical obstruction. Analysis of bariatric surgery data showed a clinically significant reduction in BP, AHI/RDI, sleepiness, snoring, optimal PAP level, BMI, and ODI and an increase in LSAT in adults with OSA and obesity. Analyses of very limited evidence suggested that upper airway surgery does not result in a clinically significant increase in risk of serious persistent adverse events and suggested that bariatric surgery may result in a clinically significant risk of iron malabsorption that may be managed with iron supplements. The task force provided a detailed summary of the evidence along with the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations. CITATION Kent D, Stanley J, Aurora RN, et al. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med. 2021;17(12):2507-2531.
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Affiliation(s)
- David Kent
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - R. Nisha Aurora
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | | | - Daniel J. Gottlieb
- VA Boston Healthcare System, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Carlos A. Torre
- University of Miami, Miller School of Medicine, Miami, Florida
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