Treatment-emergent central sleep apnoea after surgery for obstructive sleep apnoea

Central sleep apnoea (CSA) is a lack of drive to breathe during sleep, which can occur in physiologic as well as in pathologic conditions. A particular type of CSA, defined treatment-emergent CSA (TECSA), may occur after the treatment of obstructive sleep apnoea syndrome (OSAS), either with CPAP or surgery. TECSA is transitory and seems to be related to the severity of OSAS. We describe a 51-year-old man affected by severe OSAS who developed severe, transient CSA immediately after upper airways surgery. We believe that CSA was triggered by the sudden variation in nocturnal arterial PCO₂, which decreased from 52.3 mmHg before surgery to 42.0 mmHg after surgery. It is conceivable that, due to long-lasting severe OSAS, our patient lowered his chemosensitivity to PCO₂. Consequently, the resolution of obstructive apnoeas and the restoration of normal nocturnal values of PCO₂ may have reduced the nocturnal PCO₂ to the point of being inadequate to stimulate ventilation.

Moderate OSAS and turbinate decongestion: surgical efficacy in improving the quality of life and compliance of CPAP using Epworth score and SNOT-20 score

SUMMARY

Drug-induced sleep endoscopy (DISE) is an important procedure in diagnostic pathway of patients affected by moderate OSAS. However, the Italian National Health System does not provide any compatible Diagnosis-related-group (DRG) code codification for DISE, which makes it impossible to obtain regional reimbursement. In order to overcome this problem, DISE is usually associated with other codified surgical procedures. The aim of our study is to assess the association of turbinate decongestion (TD) and DISE in order to combine in a single operating session diagnostic and therapeutic procedures. The objective of our work is to assess the role of nasal surgery on symptoms of moderate OSA. Recent studies have confirmed that isolated nasal surgery improves quality of life (QOL), but not the apnoea hypopnoea index (AHI) during polygraph registration. We enrolled 30 patients, aged between 29 and 64 years (mean 50.53 ± 9.20), 26 males and 4 females, with a mean BMI of 26.07 ± 2.81 kg/m², who were affected by moderate OSAS. All patients underwent otolaryngologycal pre-operative evaluation, home respiratory polygraph and subjective evaluation through Sino-Nasal-Outcome Test (SNOT-20) and Epworth Sleepiness Scale (ESS). During the same surgery session, they underwent DISE and TD. Patients were re-evaluated six months later using the same questionnaires. We observed a significant improvement (p #x003C; 0.05) in both the mean ESS index (6.03 ± 2.75 vs 4.16 ± 4.63) and total SNOT score (22.53 ± 12.16 vs 13.23 ± 10.82). Significant differences (p #x003C; 0.05) were also identified for partial SNOT questions 1-11 (9.1 ± 5.11 vs 6.13 ± 4.12) and 11-20 (13.36 ± 10.20 vs 7.13 ± 9.644). The results of the present study confirm that TD alone can improve sleepiness, QOL and nasal symptoms. Thus, in absence of a National Health System recognition for DISE, the association of this procedure with TD can be useful for diagnostic and therapeutic management of OSAS, improving CPAP compliance and adherence, reducing sleepiness, ameliorating nasal symptoms and therefore QOL.

Salivary biomarkers and proteomics: future diagnostic and clinical utilities

Saliva testing is a non-invasive and inexpensive test that can serve as a source of information useful for diagnosis of disease. As we enter the era of genomic technologies and -omic research, collection of saliva has increased. Recent proteomic platforms have analysed the human salivary proteome and characterised about 3000 differentially expressed proteins and peptides: in saliva, more than 90% of proteins in weight are derived from the secretion of three couples of "major" glands; all the other components are derived from minor glands, gingival crevicular fluid, mucosal exudates and oral microflora. The most common aim of proteomic analysis is to discriminate between physiological and pathological conditions. A proteomic protocol to analyze the whole saliva proteome is not currently available. It is possible distinguish two type of proteomic platforms: top-down proteomics investigates intact naturally-occurring structure of a protein under examination; bottom-up proteomics analyses peptide fragments after pre-digestion (typically with trypsin). Because of this heterogeneity, many different biomarkers may be proposed for the same pathology. The salivary proteome has been characterised in several diseases: oral squamous cell carcinoma and oral leukoplakia, chronic graft-versus-host disease Sjögren's syndrome and other autoimmune disorders such as SAPHO, schizophrenia and bipolar disorder, and genetic diseases like Down's Syndrome and Wilson disease. The results of research reported herein suggest that in the near future human saliva will be a relevant diagnostic fluid for clinical diagnosis and prognosis.

Drug-induced sleep endoscopy as a selection tool for mandibular advancement therapy by oral device in patients with mild to moderate obstructive sleep apnoea

Nowadays oral appliance therapy is recognised as an effective therapy for many patients with primary snoring and mild to moderate obstructive sleep apnoea (OSA), as well as those with more severe OSA who cannot tolerate positive airway pressure (PAP) therapies. For this reason, it is important to focus on objective criteria to indicate which subjects may benefit from treatment with a mandibular advancement device (MAD). Various anthropometric and polysomnographic predictors have been described in the literature, whereas there are still controversies about the role of drug-induced sleep endoscopy (DISE) and advancement bimanual manoeuvre as predictor factors of treatment outcome by oral device. Herein, we report our experience in treatment of mild moderate OSA by oral appliance selected by DISE. We performed a single institution, longitudinal prospective evaluation of a consecutive group of mild moderate patients with obstructive sleep apnoea syndrome who underwent DISE. During sleep endoscopy, gentle manoeuvre of mandibular advancement less than 5 mm was performed. In 30 of 65 patients (46.2%) we obtained an unsuccessful improvement of airway patency whereas in 35 of 65 patients (53.8%) the improvement was successful and patients were considered suitable for oral device application. Because 7 of 35 patients were excluded due to conditions interfering with oral appliance therapy, we finally treated 28 patients. After 3 months of treatment, we observed a significant improvement in the Epworth medium index [(7.35 ± 2.8 versus 4.1 ± 2.2 (p < 0.05)], in mean AHI [(21.4 ± 6 events per hour versus 8.85 ± 6.9 (p < 0.05)] and in mean ODI [(18.6 ± 8 events per hour to 7 ± 5.8 (p < 0.05)]. We observed that the apnoea/hypopnoea index (AHI) improved by up to 50% from baseline in 71.4% of patients selected after DISE for MAD therapy. In the current study, mandibular advancement splint therapy was successfully prescribed on the basis not only of severity of disease, as determined by the subject's initial AHI, but also by DISE findings combined with results of gentle mandibular advancement manoeuvre allowing direct view of the effects of mandibular protrusion on breathing spaces in obstruction sites, and showing good optimisation of selection of patients for oral device treatment.

Case report of patients treated with an orthodontic and myofunctional protocol

BACKGROUND

Occlusion alterations can be associated to bad habits (such as thumb sucking, oral breathing, atypical swallowing and labial interposition) which can lead to functional anomalies.

CASE REPORT

Three cases are reported with the good results of myofunctional and orthodontic therapy.

CONCLUSION

When there are bad habits, orthodontics should be combined with a myofunctional therapy.

Causal relationship between malocclusion and oral muscles dysfunction: a model of approach

AIM

Bad habits result in altered functions which with time can cause anomalies of the orofacial morphology. To solve these problems, orthodontic treatment can be supported by myofunctional therapy in order to recover the normal functionality of the oral muscles. The aim of this study is to assess the need to treat patients with neuromuscular disorders, from both the occlusion and the muscles condition approach in order to obtain the balance needed for the stability of treatment.

MATERIALS AND METHODS

A sample of 23 patients with atypical swallowing was included in this study, some of them presented thumb sucking and oral breathing. After case history collection, in order to make a correct orthodontic and functional diagnosis, correction of anomalies was carried out since they could compromise the success of the therapy (maxillary contraction, oral breathing, and short lingual fraenum). Then a different therapeutic approach was applied on the basis of the specific dental features.

RESULTS

Both from the diagnostic and therapeutic point of view, important results were achieved especially through muscle analysis with dynamometer and surface electromyography.

CONCLUSION

Orthodontic therapy, in the presence of bad habits, is not enough to solve orthodontic issues, it must be combined with a myofunctional treatment. The success of the therapy is granted only when patients and their family comply with the treatment and all factors which can prevent success of the therapy are removed.

Patients treated with orthodontic-myofunctional therapeutic protocol

The aim of this study is to report three cases that needed myofunctional and orthodontic treatment and the good results achieved after the therapy. Orthodontic treatment alone, in presence of bad habits, is not enough to solve the orthodontic issues, so it needs to be combined with myofunctional treatment.

Proteomics of saliva: personal experience

The salivary proteome is a complex protein mixture resulting from the activity of salivary glands with the contribution of other components that form the oral environment such as oral tissues and micro-organisms. For diagnosis purposes, saliva collection has the great advantage of being an easy and non-invasive technique. Human saliva proteomics have proven to be a novel approach in the search for protein biomarkers for detection of different local and systemic diseases. Currently, more than 1400 salivary proteins have been identified. In the last few years, our research group has extensively studied the salivary proteomics in order to analyse the salivary composition, investigating the major families of proteins present in human and mammalian saliva, the post-translational modifications, the different contributions of glands, the physiological and pathological modifications of saliva. The aim of this report is to present our personal experience in salivary proteomics. In conclusion, salivary proteome analysis represents an important field both for diagnosis and monitoring of various diseases and could be considered a novel approach to prevention of various pathological conditions.

Statherin levels in saliva of patients with precancerous and cancerous lesions of the oral cavity: a preliminary report

OBJECTIVE

The aim of this study was to measure concentration of human salivary statherin in patients with oral cavity pathologies and salivary gland diseases.

SUBJECTS AND METHODS

Levels of statherin were analysed with High Performance Liquid Chromatography (HPLC) in following groups of subjects: group A: 24 patients with neoplastic diseases of salivary glands, group B: 13 patients with inflammatory lesions of salivary glands, group C: 13 patients with precancerous and cancerous lesions of the oral cavity excluding salivary gland tumors, group D: 20 healthy volunteers (control group).

RESULTS

Our preliminary data indicated a sensible reduction of the statherin level in the saliva of patients with precancerous and cancerous lesions of the oral cavity (group C) compared with the healthy subjects (group D). The statherin levels are not significantly reduced either in the inflammatory (group B) or in the salivary glands tumours (group A), compared with the healthy subjects (group D).

CONCLUSION

Statherin could play a protective effect in oral cavity in association with its other functions.