Comprehensive review of surgeries for obstructive sleep apnea syndrome

Epiglottopexy Is a Treatment of Choice for Obstructive Sleep Apnea Caused by a Collapsing Epiglottis

Drug-induced sleep endoscopy (DISE) reveals epiglottic collapse to be a frequent cause of obstructive sleep apnea (OSA) and intolerance of positive airway pressure (PAP). These patients require different management. This prospective study aimed to compare transoral laser epiglottopexy outcomes in patients with OSA caused by epiglottic collapse with the patients’ previous PAP outcomes. Fifteen consecutive adult patients with OSA and epiglottic collapse during DISE were included; ten were analyzed. Before inclusion, PAP was indicated and ineffective in six patients, one of whom underwent unsuccessful uvulopalatopharyngoplasty. PAP was performed during DISE in all patients before epiglottopexy and was uniformly ineffective. ENT control was performed at 1 week and 1 month, and control limited polygraphy to 6 months after surgery. The apnea−hypopnea index (AHI) and Epworth Sleepiness Scale (ESS) were significantly improved (p < 0.001 and p = 0.003, respectively) in all patients after epiglottopexy. Surgery was successful in 9/10 patients; the remaining patient had a significantly decreased AHI and could finally tolerate PAP. Transoral laser epiglottopexy is used to treat OSA in patients with epiglottic collapse. Unlike other methods, it significantly reduces both AHI and ESS and should be considered for these patients. An active search for OSA patients with epiglottic collapse is recommended to prevent treatment failure.

Obstructive sleep apnea: personalizing CPAP alternative therapies to individual physiology

Introduction The recent continuous positive airway pressure (CPAP) crisis has highlighted the need for alternative obstructive sleep apnea (OSA) therapies. This article serves to review OSA pathophysiology and how sleep apnea mechanisms may be utilized to individualize alternative treatment options.Areas covered: The research highlighted below focuses on 1) mechanisms of OSA pathogenesis and 2) CPAP alternative therapies based on mechanism of disease. We reviewed PubMed from inception to July 2022 for relevant articles pertaining to OSA pathogenesis, sleep apnea surgery, as well as sleep apnea alternative therapies.Expert opinion: Although the field of individualized OSA treatment is still in its infancy, much has been learned about OSA traits and how they may be targeted based on a patient's physiology and preferences. While CPAP remains the gold-standard for OSA management, several novel alternatives are emerging. CPAP is a universal treatment approach for all severities of OSA. We believe that a personalized approach to OSA treatment beyond CPAP lies ahead. Additional research is needed with respect to implementation and combination of therapies longitudinally, but we are enthusiastic about the future of OSA treatment based on the data presented here.

Progression of Obstructive Sleep Apnea Syndrome in Pediatric Patients with Prader-Willi Syndrome

Obstructive sleep apnea syndrome (OSAS) is one of the most common comorbidities in patients with Prader-Willi syndrome (PWS) and causes significant consequences. This observational study was conducted to investigate the progression of OSAS in pediatric patients with PWS, who had not undergone upper airway surgery, through a longitudinal follow-up of their annual polysomnography results. Annual body mass index (BMI), BMI z-score, sleep efficiency and stages, central apnea index (CAI), obstructive apnea-hypopnea index (OAHI), and oxygen saturation nadir values were longitudinally analyzed. At enrollment, of 22 patients (10 boys and 12 girls) aged 11.7 ± 3.9 years, 20 had OSAS. During the 4-year follow-up, only two patients had a spontaneous resolution of OSAS. The average BMI and BMI z-score increased gradually, but CAI and OAHI showed no significant differences. After statistical adjustment for sex, age, genotype, growth hormone use, and BMI z-score, OAHI was associated with the BMI z-score and deletion genotype. In conclusion, OSAS is common in patients with PWS, and rarely resolved spontaneously. Watchful waiting may not be the best OSAS management strategy. Weight maintenance and careful selection of surgical candidates are important for OSAS treatment in patients with PWS.

Treatment of sleep apnoea with tonsillectomy: a retrospective analysis using long-term follow-up data

PURPOSE

This single-group, retrospective, pre-test-post-test study was performed to examine clinical outcomes in treating obstructive sleep apnoea (OSA) with tonsillectomy alone and had the longest follow-up periods to date.

METHODS

We analysed 151 tonsillectomies in our district between the years 2004 and 2018 that had either sleep apnoea or snoring listed as a diagnosis. Twenty-one patients met our criteria and were included. Patient records were analysed for home sleep apnoea test and Epworth Sleepiness Scale (ESS) scores.

RESULTS

We defined success as a > 50% reduction of the Apnoea-Hypopnea Index (AHI) and a total AHI of < 20 post-surgery. The averages before surgery were an AHI of 22.3 and an ESS of 7.22. The success rate was 47.6% after tonsillectomy as the sole treatment for obstructive sleep apnoea in our adult population. Eleven patients were non-responders. The average ESS score reduction was 0.69 and did not reach statistical significance. With follow-up times ranging from 1.8 to 171 months, this study had the longest follow-up period compared to other existing studies. No patient with a follow-up longer than one year was a responder.

CONCLUSION

Our results support that tonsillectomy is an effective treatment for obstructive sleep apnoea in adults with tonsillar hypertrophy. With less severe OSA than those reported on previously, our patients also had less severe daytime sleepiness before surgery, and daytime sleepiness score reductions did not reach statistical significance. In the future, long-term results should be further analysed.

Myofunctional therapy for OSA: a meta-analysis

INTRODUCTION

Myofunctional therapy (MT) improves obstructive sleep apnea (OSA) in patients.

AREAS COVERED

We systematically reviewed publications to evaluate MT as a treatment for OSA. We identified relevant articles and performed a meta-analysis on apnea-hypopnea index (AHI) scores, lowest oxygen saturation (LSAT), and Epworth Sleepiness Scale (ESS). Search databases were retained as primary data sources with the search performed through 18 June 2021.

EXPERT OPINION

Fifteen studies with 237 patients provided OSA outcomes before and after MT, which were analyzed for this meta-analysis. The mean AHI scores decreased from 28.0 ± 16.2/h to 18.6 ± 13.1/h. The AHI standard mean difference (SMD) is -1.34 (large effect) [95% CI -0.84, -1.85], (P < 0.00001). LSAT (197 patients) improved from 83.18 ± 6.10% to 85.13 ± 7.01%. The LSAT SMD is 0.44 [95% CI 0.75, 0.12], (P < 0.007). Sleepiness measured via ESS (156 patients) demonstrated a decrease from 12.71 ± 5.73 to 8.78 ± 5.80. The ESS SMD is -1.0 [95% CI -0.50, -1.50], (P < 0.0001).

Obstructive Sleep Apnea in Patients with Head and Neck Cancer—More than Just a Comorbidity?

Obstructive sleep apnea is the most common type of sleep-disordered breathing with growing prevalence. Its presence has been associated with poor quality of life and serious comorbidities. There is increasing evidence for coexisting obstructive sleep apnea in patients suffering from head and neck cancer, a condition that ranks among the top ten most common types of cancer worldwide. Routinely, patients with head and neck cancer are treated with surgery, radiation therapy, chemotherapy, immunotherapy or a combination of these, all possibly interfering with the anatomy of the oral cavity, pharynx or larynx. Thus, cancer treatment might worsen already existing obstructive sleep apnea or trigger its occurrence. Hypoxia, the hallmark feature of obstructive sleep apnea, has an impact on cancer biology and its cure. Early diagnosis and sufficient treatment of coexisting obstructive sleep apnea in patients with head and neck cancer may improve quality of life and could also potentially improve oncological outcomes.

Dynamic sleep MRI in obstructive sleep apnea: a systematic review and meta-analysis

Purpose

The objective of this study is to systematically review the international literature for dynamic sleep magnetic resonance imaging (MRI) as a diagnostic tool in obstructive sleep apnea (OSA), to perform meta-analysis on the quantitative data from the review, and to discuss its implications in future research and potential clinical applications.

Study design

A comprehensive review of the literature was performed, followed by a detailed analysis of the relevant data that has been published on the topic.

Methods

Clinical key, Uptodate, Ovid, Ebscohost, Pubmed/MEDLINE, Scopus, Dynamed, Web of Science and The Cochrane Library were systematically searched. Once the search was completed, dynamic sleep MRI data were analyzed.

Results

Nineteen articles reported on 410 OSA patients and 79 controls that underwent dynamic sleep MRI and were included in this review. For meta-analysis of dynamic sleep MRI data, eight articles presented relevant data on 160 OSA patients. Obstruction was reported as follows: retropalatal (RP) 98%, retroglossal (RG) 41% and hypopharyngeal (HP) in 5%. Lateral pharyngeal wall (LPW) collapse was found in 35/73 (48%) patients. The combinations of RP + RG were observed in 24% and RP + RG + LPW in 16%. If sedation was used, 98% of study participants fell asleep compared to 66% of unsedated participants.

Conclusions

Dynamic sleep MRI has demonstrated that nearly all patients have retropalatal obstruction, retroglossal obstruction is common and hypopharyngeal obstruction is rare. Nearly all patients (98%) who are sedated are able to fall asleep during the MRI. There is significant heterogeneity in the literature and standardization is needed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00405-021-06942-y.

Surgical Algorithm for Obstructive Sleep Apnea: An Update

Sleep surgery is part of a continuum of care for obstructive sleep apnea (OSA) that involves medical, pharmacologic, and behavioral therapy. Upper airway surgery for OSA can significantly improve stability by way of modulating the critical negative closing pressure. This is the same mechanism of action as positive airway pressure or oral appliance therapy. The updated surgical algorithm in this review adds precision in three areas: patient selection, identification of previously unaddressed anatomic phenotypes with associated treatment modality, and improved techniques of previously established procedures. While the original Riley and Powell phase 1 and 2 approach to sleep surgery has focused on individual surgical success rate, this algorithm strives for an overall treatment success with multi-modal and patient-centric treatments.

Continuous positive airway pressure can improve depression in patients with obstructive sleep apnoea syndrome: a meta-analysis based on randomized controlled trials

Objective

Substantial research indicates a clear relationship between obstructive sleep apnoea syndrome (OSAS) and depression. The study aim was to quantitatively evaluate whether continuous positive airway pressure (CPAP) therapy improves mood symptoms in OSAS patients.

Methods

PubMed and Embase databases were systematically searched up to 2017 for publications on the impact of CPAP on mood symptoms in OSAS patients.

Results

For the final analysis, nine randomized controlled trials comprising 1,052 patients were selected. The pooled standard mean difference (SMD) of the effect of CPAP on depression was 0.31 (95% confidence interval 0.18, 0.43). A subgroup analysis showed that when CPAP use was greater than 4 hours per night, it tended to be effective in improving patients’ mood symptoms (SMD = 0.38; confidence interval 0.23, 0.54). Analysis of publication bias using Egger’s test found no evidence of publication bias.

Conclusion

CPAP treatment can improve depression in OSAS patients.

The Role of the Revised Stanford Protocol in Today's Precision Medicine

Whereas the original Stanford protocol relied on a tiered approach to care to avoid unnecessary surgery, it did not address the issue of surgical relapse, a common concern among sleep medicine specialists. With 3 decades of experience since the original 2-tiered Powell-Riley protocol was introduced and the role of evolving skeletal techniques and upper airway stimulation, we are pleased to present our current protocol. This update includes emphasis on the facial skeletal development with impact on function including nasal breathing, and the incorporation of upper airway stimulation. The increased versatility of palatopharyngoplasty as an adjunctive procedure is also discussed.

Tissue-Sparing Uvulopalatopharyngoplasty for OSA: Conservative, Compassionate and Possibly just as Effective

A common surgical treatment for obstructive sleep apnea (OSA) is uvulopalatopharyngoplasty (UPPP). Unfortunately, traditional UPPP can cause a foreign body sensation, chronic discomfort and in rare cases, nasopharyngeal stenosis or velopharyngeal insufficiency. Modifications to traditional UPPP have been developed over the years to help decrease side effects, while trying to maintain or improve OSA outcomes. Conservative, tissue-sparing UPPP techniques include preservation of soft palate tissues (muscle and/or mucosa), avoidance of plication or conservative plication of the uvula, partial instead of complete uvulectomy, and suture plication of the palatopharyngeus-superior pharyngeal constrictor-palatoglossus muscles with complete preservation of surrounding tissues after tonsillectomy.

Inflammatory cytokines tumor necrosis factor-α, interleukin-8 and sleep monitoring in patients with obstructive sleep apnea syndrome

The present study investigated the changes of tumor necrosis factor-α (TNF-α), interleukin-8 (IL-8) and sleep ability in patients with obstructive sleep apnea hypopnea syndrome (OSAHS). A total of 684 patients who were admitted to Xuzhou Central Hospital between June 2012 and June 2016 were enrolled to serve as the experimental group and 192 healthy subjects were selected as the control group. Polysomnography was performed on both groups, and serum TNF-α and IL-8 levels were measured by ELISA. Pearson's correlation analysis was used to analyze correlations between factors. Compared with control group, the levels of TNF-α and IL-8, the morning systolic and diastolic pressure in OSAHS group were significantly higher (P<0.01). Furthermore, the mean oxygen saturation (MSaO2) and lowest oxygen saturation (LSaO2) of the OSAHS group were significantly lower compared with those in control group (P<0.01). Results also indicated that TNF-α was positively correlated with apnea-hypopnea index (AHI), morning systolic and diastolic pressure (r=0.621, 0.464, 0.539; P<0.05), and negatively correlated with MSaO₂ and LSaO₂ (r=−0.526, −0.466; P<0.05). Notably, IL-8 was positively correlated with AHI, morning systolic and diastolic pressure (r=0.337, 0.413 and 0.629; P<0.05), and negatively correlated with MSaO₂ and LSaO₂ (r=−0.329 and −0.417; P<0.05). Therefore, it was concluded that TNF-α and IL-8 may be involved in the occurrence and development of OSAHS, are closely related to OSAHS and may be important risk factors for cardiovascular disease in patients with OSAHS. The present findings suggest that TNF-α and IL-8 can be used to assess the degree of OSAHS.

Myofunctional Therapy: Role in Pediatric OSA

Myofunctional therapy (MFT) has been reported to be an alternative treatment to obstructive sleep apnea (OSA), but compliance and long-term outcome in the children were considered as an issue. A prospective study was performed on age-matched children submitted to MFT or to a functional oral device used during sleep (passive MFT) and compared with no-treatment control group. Compliance is a major problem of MFT, and MFT will have to take into consideration the absolute need to have continuous parental involvement in the procedure for pediatric OSA.

A Comparative Study on Efficacy and Safety of Propofol versus Dexmedetomidine in Sleep Apnea Patients undergoing Drug-Induced Sleep Endoscopy: A CONSORT-Prospective, Randomized, Controlled Clinical Trial

The aim of this study is to compare the efficacy and safety of propofol with dexmedetomidine in patients with obstructive sleep apnea hypopnea syndrome (SAHS) undergoing drug-induced sleep endoscopy (DISE). The 88 patients diagnosed with SAHS in the Affiliated Hospital of Xuzhou Medical University were randomly allocated into 2 groups (n = 44). Patients in the group dexmedetomidine (group D) received continuous intravenous infusion of dexmedetomidine 1 μg/kg over 15 minutes before the endoscopy, and propofol 2 mg/kg was intravenously administrated in the group propofol (group P). Cardiopulmonary parameters of patients were recorded. The time to fall asleep, duration of endoscopic examination, the wakeup time of patients, the number of mask ventilations for patients, the satisfaction of patients and endoscopic performers, and false positive cases of SAHS of patients were compared between the two groups. Compared with group D, mean arterial pressure (MAP) and blood oxygen saturation (SPO₂) of patients in the P group were lower at the time point of T1 (P < 0.05), the duration of endoscopic examination and wakeup time of patients were obviously prolonged, the incidence of mask ventilation for patients and false positive cases of SAHS of patients was observably higher, and the satisfaction of endoscopic performers was markedly lower, but the time to fall asleep was significantly shortened (P < 0.05). Dexmedetomidine served as a novel sleep induced drug and can provide satisfactory conditions and be safely and effectively applied for endoscopy in patients with SAHS, without adverse hemodynamic effects.

First Successful Mechanical Splint for Obstructive Sleep Apnea With an Orally Administrable Pharyngeal Stenting Device

We report the case of obstructive sleep apnea in a 19-year-old, otherwise healthy male presenting with persistent daytime sleepiness and nonrestorative sleep after velo- and uvuloplasty. An individually tailored prototype of an orally inserted pharyngeal stenting device was proposed in the framework of a first clinical feasibility trial. The noninvasive, easily self-administered device is mounted on a simple inferior dental guard. Baseline total apnea-hypopnea index (AHI) was 15.5 and 24.4 per hour of rapid eye movement (REM) sleep. With the device, total AHI dropped to 6.7 per hour (56.8% reduction) and 1.4 per hour of REM (94.3% reduction). Recorded sleep efficiency during treatment was excellent at 96.5%. Laryngoscope, 129:1945-1948, 2019.

Sleep-Disordered Breathing

PURPOSE OF REVIEW

Sleep-disordered breathing encompasses a broad spectrum of sleep-related breathing disorders, including obstructive sleep apnea (OSA), central sleep apnea, as well as sleep-related hypoventilation and hypoxemia. Diagnostic criteria have been updated in the International Classification of Sleep Disorders, Third Edition and the American Academy of Sleep Medicine Manual for Scoring Sleep and Associated Events. Neurologic providers should have basic knowledge and skills to identify at-risk patients, as these disorders are associated with substantial morbidity, the treatment of which is largely reversible.

RECENT FINDINGS

OSA is the most common form of sleep-disordered breathing and is highly prevalent and grossly underdiagnosed. Recent studies suggest that prevalence rates in patients with neurologic disorders including epilepsy and stroke exceed general population estimates. The physiologic changes that occur in OSA are vast and involve complex mechanisms that play a role in the pathogenesis of cardiovascular and metabolic disorders and, although largely unproven, likely impact brain health and disease progression in neurologic patients. A tailored sleep history and examination as well as validated screening instruments are effective in identifying patients with sleep-disordered breathing, although sleep testing is necessary for diagnostic confirmation. While continuous positive airway pressure therapy and other forms of noninvasive positive pressure ventilation remain gold standard treatments, newer therapies, including mandibular advancement, oral appliance devices, and hypoglossal nerve stimulation, have become available. Emerging evidence of the beneficial effects of treatment of sleep-disordered breathing on neurologic outcomes underscores the importance of sleep education and awareness for neurologic providers.

SUMMARY

Sleep-disordered breathing is highly prevalent and grossly underrecognized. The adverse medical and psychosocial consequences of OSA and other sleep-related breathing disorders are considerable. The impact of sleep therapies on highly prevalent neurologic disorders associated with substantial morbidity and health care costs is becoming increasingly recognized.

Effectiveness of oral appliances versus continuous positive airway pressure in treatment of OSA patients: An updated meta-analysis

Objective: To update the meta-analysis comparing the effectiveness of oral appliance (OA) with continuous positive airway pressure (CPAP) in treating patients with obstructive sleep apnea (OSA). Methods: PubMed, ISI Web of Knowledge, Ovid, EBSCO Dentistry & Oral Science Source, The Cochrane Library, and Embase database were searched for RCTs until 23 May 2017. Meta-analyses were performed using RevMan 5.3. Results: Sixteen RCTs were included. Compared with OA, CPAP significantly decreased AHI, min SaO2, ARI, ESS (p < 0.05), with no significant difference in REM%, FOSQ, BP (p ≥ 0.05). OA significantly improved REM% in the severe groups and ESS in the adjustable OA group (p < 0.05). OA shared greater preference. Conclusion: Even though CPAP can better decrease the severity of OSA, more patients opted for OA, which showed better results in severe patients, especially adjustable OA.

Oropharyngeal and tongue exercises (myofunctional therapy) for snoring: a systematic review and meta-analysis

PURPOSE

Oropharyngeal and tongue exercises (myofunctional therapy) have been shown to improve obstructive sleep apnea. However, to our knowledge, a systematic review has not been performed for snoring. The study objective is to perform a systematic review, with a meta-analysis, dedicated to snoring outcomes after myofunctional therapy.

METHODS

PubMed/MEDLINE and three other databases were searched through November 25, 2017. Two authors independently searched the literature. Eligibility (1) patients: children or adults with snoring, (2) intervention: oropharyngeal and/or tongue exercises, (3) comparison: pre and post-treatment data for snoring, (4) outcomes: snoring frequency and snoring intensity, (5) study design: publications of all study designs.

RESULTS

A total of 483 articles were screened, 56 were downloaded in their full text form, and nine studies reported outcomes related to snoring. There were a total of 211 patients (all adults) in these studies. The snoring intensity was reduced by 51% in 80 patients from pre-therapy to post-therapy visual analog scale values of 8.2 ± 2.1 (95% CI 7.7, 8.7) to 4.0 ± 3.7 (95% CI 3.2, 4.8). Berlin questionnaire snoring intensity reduced by 36% in 34 patients from 2.5 ± 1.0 (95% CI 2.2, 2.8) to 1.6 ± 0.8 (95% CI 1.3, 1.9). Finally, time spent snoring during sleep was reduced by 31% in 60 patients from 26.3 ± 18.7% (95% CI 21.6, 31.0) to 18.1 ± 20.5% (95% CI 12.9, 23.3) of total sleep time.

CONCLUSIONS

This systematic review demonstrated that myofunctional therapy has reduced snoring in adults based on both subjective questionnaires and objective sleep studies.

Tratamiento quirúrgico por otorrinolaringología en el síndrome de apnea-hipopnea obstructiva del sueño (SAHOS)

El síndrome de apnea-hipopnea obstructiva del sueño (SAHOS) se caracteriza por la obstrucción parcial o el colapso total de la vía aérea superior, de manera intermitente y repetitiva, por lo que, en un principio, se vio el manejo quirúrgico como una alternativa curativa para esta patología. Sin embargo, en la actualidad se reconoce que la cirugía, aun sin lograr tasas de efectividad muy altas de manera consistente, sí mejora la tolerancia y adaptación a la terapia de presión positiva, la cual sigue siendo la primera línea de manejo.Así, el primer paso antes de pensar en cualquier procedimiento quirúrgico es un adecuado diagnóstico topográfico, de modo que siempre se debe realizar una nasofibrolaringoscopia para identificar el o los sitios de obstrucción. Además, se sabe que el 75% de los pacientes presentan obstrucciones en múltiples niveles y que, cuando el abordaje se hace multinivel, se logra corregir el SAHOS hasta en un 95%. Entre los procedimientos vigentes se encuentran cirugías de nariz, paladar blando, amígdalas, base de lengua, estimulación del nervio hipogloso y procedimientos del esqueleto facial, así como procedimientos coadyuvantes, entre los que están radiofrecuencia e implantes de paladar.

Hyoid myotomy and suspension without simultaneous palate or tongue base surgery for obstructive sleep apnea

Objective

Determine the effects of hyoid myotomy and suspension (HMS) without concurrent palatal or tongue base sleep surgery for obstructive sleep apnea (OSA).

Method

Patients with OSA treated with HMS were identified using CPT code (21685) at an academic and private sleep surgery clinic. Those who underwent concurrent palatal or tongue base sleep surgery were excluded. Outcomes included simultaneous procedures, apnea-hypopnea index (AHI), lowest oxyhemoglobin saturation (LSAT), and Epworth Sleepiness Scale (ESS).

Results

Nineteen patients with OSA underwent HMS without palatal or tongue base sleep surgery. The average age at surgery was (55.3 ± 13.5) years with a majority of patients being male (71%). Concurrent procedures included the following: torus mandibularis excision (n = 1), endoscopic sinus surgery (n = 4), septoplasty (n = 10), inferior turbinate reduction (n = 12), and nasal valve repair (n = 2). AHI improved significantly from (39.7 ± 21.2) events/h to (22.6 ± 22.7) events/h after HMS (P < 0.01), which represented a 43% reduction. LSAT significantly increased from (82.2% ± 9.9%) to (86.6% ± 6.2%), P < 0.01. There was no improvement in ESS after surgery (8.2 ± 4.4) to (8.3 ± 5.2), P = 0.904. A subset of patients with severe OSA (AHI > 30 events/h) had an improvement in AHI from (49.9 ± 16.6) events/h to (29.1 ± 24.9) events/h, P < 0.01.

Conclusion

HMS without palatal or tongue base sleep surgery improves OSA severity. It can be considered as a valid option in the treatment of OSA in appropriately-selected patients.

Tongue retaining devices for obstructive sleep apnea: A systematic review and meta-analysis

OBJECTIVE

Tongue Retaining Devices (TRD) anteriorly displace the tongue with suction forces while patients sleep. TRD provide a non-surgical treatment option for patients with Obstructive Sleep Apnea (OSA). Our objective was to conduct a systematic review of the international literature for TRD outcomes as treatment for OSA.

METHODS

Three authors independently and systematically searched four databases (including PubMed/MEDLINE) through June 26, 2016. We followed guidelines set within the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

RESULTS

Sixteen studies with 242 patients met criteria. The overall means±standard deviations (M±SD) for apnea-hypopnea index (AHI) decreased from 33.6±21.1/h to 15.8±16.0/h (53% reduction). Seven studies (81 patients) reported lowest oxygen saturation (LSAT), which improved from 79.8±17.5% to 83.9±8.6%. Four studies (93 patients) reported Epworth sleepiness scale (ESS), which decreased from 10.8±4.8 to 8.2±4.5, p <0.0001. Four studies (31 patients) reported Oxygen Desaturation Index (ODI) which decreased from 29.6±32.1 to 12.9±8.7, a 56.4% reduction.

CONCLUSION

Current international literature demonstrates that tongue retaining devices reduce apnea-hypopnea index by 53%, increase lowest oxygen saturation by 4.1 oxygen saturation points, decrease oxygen desaturation index by 56% and decrease Epworth sleepiness scale scores by 2.8 points. Tongue retaining devices provide a statistically effective alternative treatment option for obstructive sleep apnea.

Sleep surgery tool: A medical checklist to review prior to operating

OBJECTIVE

The objective of this study was to systematically review the international literature for studies providing a preoperative checklist for medical disorders to be evaluated or treated before performing sleep surgery. If no checklist exists, then studies providing recommendations would be used to develop a checklist de novo.

STUDY DESIGN

Systematic review combined with expert opinion.

METHODS

Four databases, including PubMed/Medline were searched through August 10, 2016.

RESULTS

453 potentially relevant studies were screened, 32 were downloaded for full review. No study included a preoperative checklist. No study provided guidance for specific medical disorders to evaluate or screen for prior to sleep surgery. Therefore, we reviewed articles in adults that provided recommendations such as: (1) labs to review, (2) non-operative disorders to evaluate and treat, and (3) comorbidities to optimize prior to performing sleep surgery. These articles were utilized in conjunction with expert opinion to develop a preoperative checklist for surgical guidance.

CONCLUSION

There are several items to review prior to performing sleep surgery on obstructive sleep apnea patients. This systematic review and expert opinion-based checklist provides over twenty items for reviewing prior to performing sleep surgery to reduce the chance of operating prematurely.

Rapid maxillary expansion for pediatric obstructive sleep apnea: A systematic review and meta-analysis

OBJECTIVES/HYPOTHESIS

To perform a systematic review with meta-analysis for sleep study outcomes in children who have undergone rapid maxillary expansion (RME) as treatment for obstructive sleep apnea (OSA).

DATA SOURCES

PubMed/MEDLINE and eight additional databases.

REVIEW METHODS

Three authors independently and systematically reviewed the international literature through February 21, 2016.

RESULTS

Seventeen studies reported outcomes for 314 children (7.6 ± 2.0 years old) with high-arched and/or narrow hard palates (transverse maxillary deficiency) and OSA. Data were analyzed based on follow-up duration: ≤3 years (314 patients) and >3 years (52 patients). For ≤3-year follow-up, the pre- and post-RME apnea-hypopnea index (AHI) decreased from a mean ± standard deviation (M ± SD) of 8.9 ± 7.0/hr to 2.7 ± 3.3/hr (70% reduction). The cure rate (AHI <1/hr) for 90 patients for whom it could be calculated was 25.6%. Random effects modeling for AHI standardized mean difference (SMD) is -1.54 (large effect). Lowest oxygen saturation (LSAT) improved from 87.0 ± 9.1% to 96.0 ± 2.7%. Random effects modeling for LSAT SMD is 1.74 (large effect). AHI improved more in children with previous adenotonsillectomy or small tonsils (73-95% reduction) than in children with large tonsils (61% reduction). For >3-year follow-up (range = 6.5-12 years), the AHI was reduced from an M ± SD of 7.1 ± 5.7/hr to 1.5 ± 1.8/hr (79% reduction).

CONCLUSIONS

Improvement in AHI and lowest oxygen saturation has consistently been seen in children undergoing RME, especially in the short term (<3-year follow-up). Randomized trials and more studies reporting long-term data (≥3-year follow-up) would help determine the effect of growth and spontaneous resolution of OSA. Laryngoscope, 2016 Laryngoscope, 127:1712-1719, 2017.

Adenoidectomy can improve obstructive sleep apnoea in young children: systematic review and meta-analysis

Objective:

To systematically search for studies reporting outcomes for adenoidectomy alone as a treatment for paediatric obstructive sleep apnoea and use the data to perform a meta-analysis.

Methods:

Nine databases, including PubMed and Medline, were systematically searched through to 1 April 2016. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was followed.

Results:

A total of 1032 articles were screened and 126 full texts were reviewed. Three paediatric studies (47 patients) reported outcomes. Overall, apnoea–hypopnoea index values decreased from 18.1 ± 16.8 to 3.1 ± 5.5 events per hour (28 patients). Random-effects modelling demonstrated a mean difference of −14.43 events per hour (I2 = 23 per cent (low inconsistency)). The apnoea–hypopnoea index standardised mean difference was −1.14 (large magnitude of effect). The largest reduction in apnoea–hypopnoea index was observed in children aged less than 12 months (reduction of 56.6−94.9 per cent). Lowest oxygen saturation values improved from 80.0 ± 9.5 to 85.5 ± 6.0 per cent (13 children).

Conclusion:

Adenoidectomy alone has improved obstructive sleep apnoea in children, especially in those aged less than 12 months; however, given the low number of studies, isolated adenoidectomy remains an area for additional research.

Genial tubercle advancement and genioplasty for obstructive sleep apnea: A systematic review and meta-analysis

OBJECTIVE

To perform a systematic review and meta-analysis for studies evaluating genioplasty alone, genial tubercle advancement (GTA) alone, and GTA with hyoid surgery (GTA-HS) to treat obstructive sleep apnea (OSA).

DATA SOURCES

Ten databases.

REVIEW METHODS

Three authors searched through November 15, 2015.

RESULTS

1,207 studies were screened; 69 were downloaded; and 13 studies met inclusion criteria. A total of 111 patients were included, with 27 standard genioplasty, 10 modified genioplasty, 24 GTA, and 50 GTA-HS patients. For standard genioplasty, the apnea-hypopnea index (AHI) reduced from a mean ± standard deviation (M ± SD) of 18.8 ± 3.8 (95% confidence interval [CI] 17.6, 20.0) to 10.8 ± 4.0 (95% CI 9.5, 12.1) events/hour (relative reduction 43.8%), P value = 0.0001. Genioplasty improved lowest oxygen saturation (LSAT) from 82.3 ± 7.3% (95% CI 80.0, 84.7) to 86.8 ± 5.2% (95% CI 85.1, 88.5), P value = 0.0032. For modified genioplasty AHI increased by 37.3%. For GTA, the AHI reduced from an M ± SD of 37.6 ± 24.2 (95% CI 27.9, 47.3) to 20.4 ± 15.1 (95% CI 14.4, 26.4) events/hour (relative reduction 45.7%), P value = 0.0049. GTA improved LSAT from 83.1 ± 8.3% (95% CI 79.8, 86.4) to 85.5 ± 6.8% (95% CI 82.8, 88.2), P value = 0.2789. For GTA-HS, the AHI reduced from an M ± SD of 34.5 ± 22.1 (95% CI 28.4, 40.6) to 15.3 ± 17.6 (95% CI 10.4, 20.2) events/hour (relative reduction 55.7%), P value < 0.0001; GTA-HS improved LSAT from 80.1 ± 16.6% (95% CI 75.5, 84.7) to 88.3 ± 6.9% (95% CI 86.4, 90.2), P value = 0.0017.

CONCLUSION

Standard genioplasty, GTA and GTA-HS can improve OSA outcomes such as AHI and LSAT. Given the low number of studies, these procedures remain as an area for additional OSA research. Laryngoscope, 127:984-992, 2017.

Five-Minute Awake Snoring Test for Determining CPAP Pressures (Five-Minute CPAP Test): A Pilot Study

Objective. To develop a quick, simple, bedside test for determining continuous positive airway pressures (CPAP) for obstructive sleep apnea (OSA) patients. Study Design. Prospective case series at a tertiary medical center. Methods. The Five-Minute Awake Snoring Test for Determining CPAP (Five-Minute CPAP Test) was developed and tested. Patients wear a soft-gel nasal triangle mask while holding a tongue depressor with the wide section (1.75 cm) between the teeth. Fixed pressure nasal CPAP is applied while the patient simulates snoring at 4 centimeters of water pressure. The pressure is incrementally titrated up and then down to determine the lowest pressure at which the patient cannot snore (Quiet Pressure). Results. Overall, thirty-eight patients participated. All could simulate snoring. Correlation coefficients were statistically significant between Quiet Pressures and body mass index (r s = 0.60 [strong positive relationship], p = 0.0088), apnea-hypopnea index (r s = 0.49 [moderate positive relationship], p = 0.039), lowest oxygen saturation (r s = -0.47 [moderate negative relationship], p = 0.048), and oxygen desaturation index (r s = 0.62 [strong positive relationship], p = 0.0057). Conclusion. This pilot study introduces a new concept, which is the final product of over one year of exploration, development, and testing. Five-Minute CPAP Test is a quick, inexpensive, and safe bedside test based on supine awake simulated snoring with nasal CPAP.

Mini Tracheostomy for Obstructive Sleep Apnea: An Evidence Based Proposal

Objective. To search for articles evaluating the use of tracheostomies (either permanent stomas or tracheostomy tubes) in adult obstructive sleep apnea (OSA) patients and to evaluate the potential for the use of mini tracheostomies as treatment for OSA. Study Design. Systematic review. Methods. Nine databases were searched from inception through July 21, 2015. Results. The overall tracheostomy search yielded 516 articles, of which eighteen studies provided polysomnographic data. No study was identified (empty review) for the use of mini tracheostomies for treating OSA. The mini tracheostomy search yielded ninety-five articles which describe findings for either mini tracheostomy kits (inner cannula diameter of 4 mm) or the performance of mini tracheotomies. Six articles described the use of mini tracheostomies as a temporary procedure to relieve acute upper airway obstruction and none described the use for OSA. For tracheostomy stomal sites, suturing the skin directly to the tracheal rings with defatting can minimize stomal site collapse. The smallest tracheostomy stomal size that can successfully treat OSA has not been described. Conclusion. Mini tracheostomies as small as 4 mm have been successfully used in the short term to relieve upper airway obstruction. Given that polysomnography data are lacking, additional research is needed.

Variable Findings for Drug-Induced Sleep Endoscopy in Obstructive Sleep Apnea with Propofol versus Dexmedetomidine

OBJECTIVE

To compare VOTE classification findings (velum, oropharyngeal-lateral walls, tongue base, and epiglottis) for drug-induced sleep endoscopy (DISE) among patients with obstructive sleep apnea (OSA) using 2 sedation protocols.

STUDY DESIGN

Case series with chart review.

SETTING

Single tertiary institution.

SUBJECTS

Patients with OSA who underwent DISE.

METHODS

A total of 216 patients underwent DISE between November 23, 2011, and May 1, 2015. DISE findings based on VOTE classification were compared between patients receiving the propofol- and dexmedetomidine-based sedation protocols.

RESULTS

Patients with OSA (N = 216; age, 44.3 ± 11.7 years; body mass index, 27.9 ± 4.8 kg/m(2)) underwent DISE with intravenous administration of propofol (n = 52) or dexmedetomidine (n = 164). There were no statistically significant differences between the 2 groups in baseline apnea-hypopnea index, oxygen desaturation index, Mallampati score, tonsil size, Epworth Sleepiness Scale score, peripheral oxygen saturation nadir, age, sex, or body mass index. Patients in the propofol group had a significantly increased likelihood of demonstrating complete tongue base obstruction (75%, 39 of 52) versus partial or no obstruction (25%, 13 of 52) in the anterior-posterior dimension, as compared with the dexmedetomidine group (complete obstruction: 42.7%, 70 of 164; partial or no obstruction: 57.3%, 94 of 164; odds ratio: 4.0; 95% confidence interval: 2.0-8.1; P = .0001). Obstruction of other airway subsites was not significantly different.

CONCLUSION

Use of propofol versus dexmedetomidine to induce sedation may have a significant effect on the pattern of upper airway obstruction observed during DISE. Randomized prospective studies are indicated to confirm these initial findings.

Mathematical Equations to Predict Positive Airway Pressures for Obstructive Sleep Apnea: A Systematic Review

Objective. To systematically review the international literature for mathematical equations used to predict effective pressures for positive airway pressure (PAP) devices. Methods. Google Scholar, PubMed, Scopus, Embase, Web of Science, CINAHL, and The Cochrane Library were searched through June 27, 2015. The PRISMA statement was followed. There was no language limitation. Results. 709 articles were screened, fifty were downloaded, and twenty-six studies presented equations that met the inclusion and exclusion criteria. In total, there were 4,436 patients in the development phases and 3,489 patients in the validation phases. Studies performed multiple linear regressions analyses as part of the equation(s) development and included the following variables: physical characteristics, polysomnography data, behavioral characteristics, and miscellaneous characteristics, which were all predictive to a variable extent. Of the published variables, body mass index (BMI) and mean oxygen saturation are the most heavily weighted, while BMI (eighteen studies), apnea-hypopnea index (seventeen studies), and neck circumference (eleven studies) were the variables most frequently used in the mathematical equations. Ten studies were from Asian countries and sixteen were from non-Asian countries. Conclusion. This systematic review identified twenty-six unique studies reporting mathematical equations which are summarized. Overall, BMI and mean oxygen saturation are the most heavily weighted.

Myofunctional Therapy to Treat Obstructive Sleep Apnea: A Systematic Review and Meta-analysis

OBJECTIVE

To systematically review the literature for articles evaluating myofunctional therapy (MT) as treatment for obstructive sleep apnea (OSA) in children and adults and to perform a meta-analysis on the polysomnographic, snoring, and sleepiness data.

DATA SOURCES

Web of Science, Scopus, MEDLINE, and The Cochrane Library.

REVIEW METHODS

The searches were performed through June 18, 2014. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement was followed.

RESULTS

Nine adult studies (120 patients) reported polysomnography, snoring, and/or sleepiness outcomes. The pre- and post-MT apneahypopnea indices (AHI) decreased from a mean ± standard deviation (M ± SD) of 24.5 ± 14.3/h to 12.3 ± 11.8/h, mean difference (MD) -14.26 [95% confidence interval (CI) -20.98, -7.54], P < 0.0001. Lowest oxygen saturations improved from 83.9 ± 6.0% to 86.6 ± 7.3%, MD 4.19 (95% CI 1.85, 6.54), P = 0.0005. Polysomnography snoring decreased from 14.05 ± 4.89% to 3.87 ± 4.12% of total sleep time, P < 0.001, and snoring decreased in all three studies reporting subjective outcomes. Epworth Sleepiness Scale decreased from 14.8 ± 3.5 to 8.2 ± 4.1. Two pediatric studies (25 patients) reported outcomes. In the first study of 14 children, the AHI decreased from 4.87 ± 3.0/h to 1.84 ± 3.2/h, P = 0.004. The second study evaluated children who were cured of OSA after adenotonsillectomy and palatal expansion, and found that 11 patients who continued MT remained cured (AHI 0.5 ± 0.4/h), whereas 13 controls had recurrent OSA (AHI 5.3 ± 1.5/h) after 4 y.

CONCLUSION

Current literature demonstrates that myofunctional therapy decreases apnea-hypopnea index by approximately 50% in adults and 62% in children. Lowest oxygen saturations, snoring, and sleepiness outcomes improve in adults. Myofunctional therapy could serve as an adjunct to other obstructive sleep apnea treatments.

Volumetric MRI analysis pre- and post-Transoral robotic surgery for obstructive sleep apnea

OBJECTIVES/HYPOTHESIS

To quantitatively measure volumetric changes in upper airway soft tissue structures using magnetic resonance imaging (MRI) pre- and post transoral robotic surgery for obstructive sleep apnea (OSA-TORS).

STUDY DESIGN

Prospective, nonrandomized, institutional board-approved study.

METHODS

Apneics undergoing OSA-TORS, which included bilateral posterior hemiglossectomy with limited pharyngectomy and uvulopalatopharyngoplasty, had upper airway MRIs pre- and postoperatively. Changes (percent and absolute values) in upper airway and surrounding soft tissue volumes were calculated. We assessed whether there were significant volumetric changes and if changes correlated with apnea-hypopnea index (AHI) changes.

RESULTS

Nineteen MRIs and 18 polysomnograms were analyzed pre- and postoperation. Total airway volume increased by 19.4% (P = 0.030). Soft palate and tongue volumes decreased by 18.3% (P = 0.002) and 5.8% (P = 0.013), respectively. Retropalatal and total lateral wall volumes decreased by 49.8% (P = 0.0001) and 17.9% (P = 0.008), respectively. Changes in other structures were not significant. Eleven patients had surgical success, with a mean AHI decrease of 52.9; six were nonsuccesses with a mean AHI decrease of 4.5 (P =0.006). Decreased retropalatal lateral wall volume correlated with decreased AHI.

CONCLUSION

Airway, tongue, soft palate, and lateral wall volumes change significantly after OSA-TORS. Changes in the volume of the lateral walls correlated with changes in AHI. Volumetric upper airway MRI may be a helpful tool to better understand reasons for surgical success.

LEVEL OF EVIDENCE

4.

Maxillomandibular Advancement and Tracheostomy for Morbidly Obese Obstructive Sleep Apnea

Objective

The objective of this study is to systematically review polysomnography data and sleepiness in morbidly obese (body mass index [BMI] ≥40 kg/m2) patients with obstructive sleep apnea (OSA) treated with either a maxillomandibular advancement (MMA) or a tracheostomy and to evaluate the outcomes.

Data Sources

MEDLINE, Scopus, Web of Science, and the Cochrane Library.

Review Methods

A search was performed from inception through April 8, 2014, in each database.

Results

Six maxillomandibular advancement studies (34 patients, age 42.42 ± 9.13 years, mean BMI 44.88 ± 4.28 kg/m2) and 6 tracheostomy studies (14 patients, age 52.21 ± 10.40 years, mean BMI 47.93 ± 7.55 kg/m2) reported individual patient data. The pre- and post-MMA means ± SDs for apnea-hypopnea indices were 86.18 ± 33.25/h and 9.16 ± 7.89/h ( P < .00001), and lowest oxygen saturations were 66.58% ± 16.41% and 87.03% ± 5.90% ( P < .00001), respectively. Sleepiness following MMA decreased in all 5 patients for whom it was reported. The pre- and posttracheostomy mean ± SD values for apnea indices were 64.43 ± 41.35/h and 1.73 ± 2.68/h ( P = .0086), oxygen desaturation indices were 69.20 ± 26.10/h and 41.38 ± 36.28/h ( P = .22), and lowest oxygen saturations were 55.17% ± 16.46% and 79.83% ± 4.36% ( P = .011), respectively. Two studies reported outcomes for Epworth Sleepiness Scale for 5 patients, with mean ± SD values of 18.80 ± 4.02 before tracheostomy and 2.80 ± 2.77 after tracheostomy ( P = .0034).

Conclusion

Data for MMA and tracheostomy as treatment for morbidly obese, adult OSA patients are significantly limited. We caution surgeons about drawing definitive conclusions from these limited studies; higher level studies are needed.