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Changes in behavioral and cognitive abilities after rapid maxillary expansion in children affected by persistent snoring after long-term adenotonsillectomy: A noncontrolled study

INTRODUCTION

The objective of this study was to verify changes in behavioral abilities and cognitive functions after rapid maxillary expansion (RME) in children with refractory sleep-disordered breathing (SDB) in the long term after adenotonsillectomy.

METHODS

A prospective clinical trial study using RME therapy was conducted. Participant inclusion criteria were children who had adenotonsillectomy with maxillary transverse deficiency and persistent SDB (obstructive apnea-hypopnea index ≥1). The study included 24 children aged 5-12 years, and of these 24 children, 13 had primary snoring and 11 had obstructive sleep apnea. The patients underwent laryngeal nasofibroscopy and a complete polysomnography. In addition, patients completed the Obstructive Pediatric Sleep Questionnaire and Obstructive Sleep Apnea 18-Item Quality-of-Life Questionnaire. Behavioral and neurocognitive tests were also completed before and after RME.

RESULTS

The Obstructive Pediatric Sleep Questionnaire and Obstructive Sleep Apnea 18-Item Quality-of-Life scores showed a statistically significant decrease in both groups (P <0.001) after RME. The results showed that neurocognitive and behavioral parameters (Child Behavior Checklist scale) were similar in primary snoring and obstructive sleep apnea (OSA) groups before RME. In the OSA group, the mean scores of the "Somatic" and "Aggressiveness" domains decreased significantly (P <0.05). The cognitive functions did not register significant differences pre- and post-RME in any of the cognitive functions, except for visuospatial function in the OSA group.

CONCLUSIONS

The noncontrolled design was a major limitation of our study. The need for treatment for SDB should consider the association of symptoms and behavioral disturbances with the child's obstructive apnea-hypopnea index. RME might prove to be an alternative treatment for children with SDB refractory to adenotonsillectomy, improving quality of life and behavioral aspects. However, a larger sample size with a control group is needed to substantiate these claims.

Clinical Characteristics of Primary Snoring vs Mild Obstructive Sleep Apnea in Children: Analysis of the Pediatric Adenotonsillectomy for Snoring (PATS) Randomized Clinical Trial

Importance

It is unknown whether children with primary snoring and children with mild obstructive sleep apnea (OSA) represent populations with substantially different clinical characteristics. Nonetheless, an obstructive apnea-hypopnea index (AHI) of 1 or greater is often used to define OSA and plan for adenotonsillectomy (AT).

Objective

To assess whether a combination of clinical characteristics differentiates children with primary snoring from children with mild OSA.

Design, Setting, and Participants

Baseline data from the Pediatric Adenotonsillectomy Trial for Snoring (PATS) study, a multicenter, single-blind, randomized clinical trial conducted at 6 academic sleep centers from June 2016 to January 2021, were analyzed. Children aged 3.0 to 12.9 years with polysomnography-diagnosed (AHI <3) mild obstructive sleep-disordered breathing who were considered candidates for AT were included. Data analysis was performed from July 2022 to October 2023.

Main Outcomes and Measures

Logistic regression models were fitted to identify which demographic, clinical, and caregiver reports distinguished children with primary snoring (AHI <1; 311 patients [67.8%]) from children with mild OSA (AHI 1-3; 148 patients [32.2%]).

Results

A total of 459 children were included. The median (IQR) age was 6.0 (4.0-7.5) years, 230 (50.1%) were female, and 88 (19.2%) had obesity. A total of 121 (26.4%) were Black, 75 (16.4%) were Hispanic, 236 (51.5%) were White, and 26 (5.7%) were other race and ethnicity. Black race (odds ratio [OR], 2.08; 95% CI, 1.32-3.30), obesity (OR, 1.80; 95% CI, 1.12-2.91), and high urinary cotinine levels (>5 µg/L) (OR, 1.88; 95% CI, 1.15-3.06) were associated with greater odds of mild OSA rather than primary snoring. Other demographic characteristics, clinical examination findings, and questionnaire reports did not distinguish between primary snoring and mild OSA. A weighted combination of the statistically significant clinical predictors had limited ability to differentiate children with mild OSA from children with primary snoring.

Conclusions and Relevance

In this analysis of baseline data from the PATS randomized clinical trial, primary snoring and mild OSA were difficult to distinguish without polysomnography. Mild OSA vs snoring alone did not identify a clinical group of children who may stand to benefit from AT for obstructive sleep-disordered breathing.

Trial Registration

ClinicalTrials.gov Identifier: NCT02562040.

Adenotonsillectomy for Snoring and Mild Sleep Apnea in Children: A Randomized Clinical Trial

Importance

The utility of adenotonsillectomy in children who have habitual snoring without frequent obstructive breathing events (mild sleep-disordered breathing [SDB]) is unknown.

Objectives

To evaluate early adenotonsillectomy compared with watchful waiting and supportive care (watchful waiting) on neurodevelopmental, behavioral, health, and polysomnographic outcomes in children with mild SDB.

Design, Setting, and Participants

Randomized clinical trial enrolling 459 children aged 3 to 12.9 years with snoring and an obstructive apnea-hypopnea index (AHI) less than 3 enrolled at 7 US academic sleep centers from June 29, 2016, to February 1, 2021, and followed up for 12 months.

Intervention

Participants were randomized 1:1 to either early adenotonsillectomy (n = 231) or watchful waiting (n = 228).

Main Outcomes and Measures

The 2 primary outcomes were changes from baseline to 12 months for caregiver-reported Behavior Rating Inventory of Executive Function (BRIEF) Global Executive Composite (GEC) T score, a measure of executive function; and a computerized test of attention, the Go/No-go (GNG) test d-prime signal detection score, reflecting the probability of response to target vs nontarget stimuli. Twenty-two secondary outcomes included 12-month changes in neurodevelopmental, behavioral, quality of life, sleep, and health outcomes.

Results

Of the 458 participants in the analyzed sample (231 adenotonsillectomy and 237 watchful waiting; mean age, 6.1 years; 230 female [50%]; 123 Black/African American [26.9%]; 75 Hispanic [16.3%]; median AHI, 0.5 [IQR, 0.2-1.1]), 394 children (86%) completed 12-month follow-up visits. There were no statistically significant differences in change from baseline between the 2 groups in executive function (BRIEF GEC T-scores: -3.1 for adenotonsillectomy vs -1.9 for watchful waiting; difference, -0.96 [95% CI, -2.66 to 0.74]) or attention (GNG d-prime scores: 0.2 for adenotonsillectomy vs 0.1 for watchful waiting; difference, 0.05 [95% CI, -0.18 to 0.27]) at 12 months. Behavioral problems, sleepiness, symptoms, and quality of life each improved more with adenotonsillectomy than with watchful waiting. Adenotonsillectomy was associated with a greater 12-month decline in systolic and diastolic blood pressure percentile levels (difference in changes, -9.02 [97% CI, -15.49 to -2.54] and -6.52 [97% CI, -11.59 to -1.45], respectively) and less progression of the AHI to greater than 3 events/h (1.3% of children in the adenotonsillectomy group compared with 13.2% in the watchful waiting group; difference, -11.2% [97% CI, -17.5% to -4.9%]). Six children (2.7%) experienced a serious adverse event associated with adenotonsillectomy.

Conclusions

In children with mild SDB, adenotonsillectomy, compared with watchful waiting, did not significantly improve executive function or attention at 12 months. However, children with adenotonsillectomy had improved secondary outcomes, including behavior, symptoms, and quality of life and decreased blood pressure, at 12-month follow-up.

Trial Registration

ClinicalTrials.gov Identifier: NCT02562040.

[New Swedish National care process for pediatric obstructive sleep disordered breathing]

Obstructive sleep disordered breathing (OSDB) is a spectrum from habitual snoring and labored breathing to obstructive sleep apnea (OSA), which is common and potentially serious in children. The process contains a new question at child care centers, directed at caretakers with children at age 18 months and 3 years, concerning habitual snoring (3 times a week or more). A primary care doctor verifies the suspicion of OSDB in case of a positive answer to one of 7 additional questions or 4 status findings (e.g. tonsil hypertrophy). The process starts with the suspicion of OSDB, from the age of 18 months to 18 years, and ends when symptoms are improved after watchful waiting or upper airway surgery. National equality is a goal, with increased access to nocturnal respiratory recordings of children with comorbidities or doubtful cases. Also, with short waiting time to first visit at ORL department, and to surgery. Children with comorbidities or severe symptoms get postoperative follow-ups with a nurse after 6 months. The new ICD code for OSDB is R06.8A.

[Effects of orofacial myofunctional therapy on postoperative outcomes of upper airway surgery for adults with severe obstructive sleep apnea]

Objective:To investigate the effect of orofacial myofunctional therapy on the clinical efficacy of upper airway surgery for adults with severe obstructive sleep apnea（OSA）. Methods:A total of 48 patients with OSA who underwent upper airway surgery in the Shenzhen Second People's Hospital from June 2020 to September 2021 were included in this study. These patients were randomly divided into the combination group（21 cases） and the surgery group（27 cases）. The effective rate, AHI, minimum blood oxygen saturation, snoring events and Epworth sleepiness scale scores at 6 months after operation were compared and analyzed between the two groups. Results:The proportions of AHI, LSaO2, snoring events, and total snoring time in the combined group at 6 months after operation were（14.77±9.15） times/h, （81.19±6.52）%, （172.43±73.67） times, and（13.16±6.02）%. The proportion of AHI, LSaO2, snoring events, and total snoring time in surgical group at 6 months after operation was（23.87±10.6） times/h, （80.78±4.88）%, （235.81±83.23） times, （17.58±5.94）%. Compared with preoperative 6 months after operation, the proportion of AHI, snoring events, and total snoring time was significantly decreased, and LSaO2was significantly increased, and the differences were statistically significant（P<0.05）. The time of snoring and the proportion of snoring to time were significantly improved compared with those in the simple operation group, and the differences were statistically significant（P<0.05）. Conclusion:This study verified that orofacial myofunctional therapy can improve the clinical efficacy after upper airway surgery for adults with severe obstructive sleep apnea.

Measurement of snoring and stertor using the Sonomat to assess effectiveness of upper airway surgery in children

STUDY OBJECTIVES

The success of surgical treatment for pediatric sleep-disordered breathing is typically assessed using the mixed and obstructive apnea-hypopnea index (MOAHI). Although an important metric, previous work has shown that snoring and stertor are also associated with sleep disruption. Our aim was to assess the efficacy of surgery using the Sonomat (Sonomedical Pty Ltd), a noncontact sleep assessment system, that accurately records complete and partial upper airway obstruction.

METHODS

Forty children (< 18 years) had a Sonomat study, in their own beds, before and after surgery. As an MOAHI ≥ 1 event/h is considered abnormal, the same threshold was applied to snore/stertor runs. Median (interquartile range) values are reported.

RESULTS

Respiratory event-induced movements decreased from 12.0 (8.7-19.0) to 0.5 (0.1-3.2) events/h (P < .01), with no significant change in spontaneous movements: 12.8 (9.8-17.9) to 16.5 (13.7-26.1) events/h (P = .07). The MOAHI decreased from 4.5 (1.9-8.6) to 0.0 (0.0-0.4) events/h (P < .01). Snoring and/or stertor runs decreased from 32.8 (23.4-44.4) to 3.0 (0.2-14.6) events/h (P < .01). Thirty-four children had an MOAHI < 1 event/h following surgery; however, 20 had snore and/or stertor runs ≥ 1 event/h and 11 had snore and/or stertor runs ≥ 5 events/h. Only 14 (35%) children had a postsurgery MOAHI < 1 event/h combined with snoring and/or stertor < 1 runs/h.

CONCLUSIONS

Although surgery is effective in improving breathing, success rates are overestimated using the MOAHI. Our results indicate that snoring and/or stertor are still present at levels that may disrupt sleep despite a normalization of the MOAHI and that when obstructed breathing was objectively measured, there was a large variation in its response to surgery.

CITATION

Norman MB, Harrison HC, Sullivan CE, Milross MA. Measurement of snoring and stertor using the Sonomat to assess effectiveness of upper airway surgery in children. J Clin Sleep Med. 2022;18(6):1649-1656.

Neurobehavioral morbidity of pediatric mild sleep-disordered breathing and obstructive sleep apnea

STUDY OBJECTIVES

Obstructive sleep apnea is associated with neurobehavioral dysfunction, but the relationship between disease severity as measured by the apnea-hypopnea index and neurobehavioral morbidity is unclear. The objective of our study is to compare the neurobehavioral morbidity of mild sleep-disordered breathing versus obstructive sleep apnea.

METHODS

Children 3-12 years old recruited for mild sleep-disordered breathing (snoring with obstructive apnea-hypopnea index < 3) into the Pediatric Adenotonsillectomy Trial for Snoring were compared to children 5-9 years old recruited for obstructive sleep apnea (obstructive apnea-hypopnea 2-30) into the Childhood Adenotonsillectomy Trial. Baseline demographic, polysomnographic, and neurobehavioral outcomes were compared using univariable and multivariable analysis.

RESULTS

The sample included 453 participants with obstructive sleep apnea (median obstructive apnea-hypopnea index 5.7) and 459 participants with mild sleep-disordered breathing (median obstructive apnea-hypopnea index 0.5). By polysomnography, participants with obstructive sleep apnea had poorer sleep efficiency and more arousals. Children with mild sleep-disordered breathing had more abnormal executive function scores (adjusted odds ratio 1.96, 95% CI 1.30-2.94) compared to children with obstructive sleep apnea. There were also elevated Conners scores for inattention (adjusted odds ratio 3.16, CI 1.98-5.02) and hyperactivity (adjusted odds ratio 2.82, CI 1.83-4.34) in children recruited for mild sleep-disordered breathing.

CONCLUSIONS

Abnormal executive function, inattention, and hyperactivity were more common in symptomatic children recruited into a trial for mild sleep-disordered breathing compared to children recruited into a trial for obstructive sleep apnea. Young, snoring children with only minimally elevated apnea-hypopnea levels may still be at risk for deficits in executive function and attention.

TRIAL REGISTRATION

Pediatric Adenotonsillectomy for Snoring (PATS), NCT02562040; Childhood Adenotonsillectomy Trial (CHAT), NCT00560859.

Variations in Polysomnographic Indices of Obstructive Sleep Apnea following Lingual Tonsil Hypertrophy Excision: Is the Difference Significant?

Background and Objectives: Obstructive sleep apnea (OSA) is a sleep-related respiratory disorder that affects between 5% and 20% of the population. In obstructive sleep apnea, lingual tonsillar hypertrophy (LTH) has been suggested as a contributing factor to airway blockage. Objectives: The aim of this work is to demonstrate the polysomnographic indices and their values in OSA patients with LTH before and after the surgical intervention. Materials and Methods: The study was conducted on eighteen patients endoscopically diagnosed as having LTH, with the main complaints being snoring, sleep apnea, and/or sleep disturbance. Clinical examination, grading of LTH, body mass index (BMI), endoscopic assessment using Muller’s maneuver, and sleep endoscopy were recorded for all patients. The Epworth Sleepiness Scale (ESS) and overnight sleep polysomnography (PSG) were conducted before and after the surgical removal of LTH. All data were submitted for statistical analysis. Results: The mean ± SD of the AHI decreased from 33.89 ± 26.8 to 20.9 ± 19.14 postoperatively, and this decrease was of insignificant statistical value. The average SpO2 (%) mean ± SD was 91.14 ± 5.96, while the mean ± SD of the desaturation index was 34.64 ± 34.2. Following surgery, these indices changed to 96.5 ± 1.47 and 9.36 ± 7.58, respectively. The mean ± SD of the ESS was changed after the surgery, from 17.27 ± 6.48 to 7.16 ± 3.56. The mean ± SD of sleep efficacy was 71.2 ± 16.8 and the snoring index mean ± SD was 277.6 ± 192.37, and both improved postoperatively, to become 88.17 ± 9.1 and 62.167 ± 40.01, respectively. Conclusions: The AHI after lingual tonsillectomy showed no statistically significant change. The changes in the average SpO2 (%), desaturation index, sleep efficiency, snoring index, and Epworth Sleepiness Scale following the surgery were statistically significant.

The effects of adeno/tonsillectomy on cardiopulmonary function based on echocardiography indices in children with primary snoring and mild obstructive sleep apnea

BACKGROUND

The goal of this study was to evaluate the effects of adenotonsillectomy on heart function based on echocardiography indices in children with primary snoring (PS) and mild obstructive sleep apnea due to adenotonsillar hypertrophy (ATH).

METHODS

55 children (aged 7 to 11 years old) with PS and ATH who were a candidate for adenotonsillectomy from August 2018 to June 2019 evaluated. A history of Upper Respiratory Tract Obstruction was obtained, clinical examination was performed and the cases suspicious for moderate to severe degrees of Obstructive Sleep Apnea Syndrome were excluded. Echocardiography was performed one week before and 3-6 months after surgery. All data were analyzed by SPSS version 19 and P-value<0.05 was considered significant.

RESULTS

From 55 enrolled cases, 42 [30 boys (71.5%) and 12 girls (28.5%)] completed the study course. Tricuspid Annular Plane Systolic Excursion (TAPSE), Ejection Fraction (EF), Right Ventricular Peak Systolic Myocardial Velocity (RVSM), Right Ventricular Fractional Area Change (RVFAC) were increased significantly and Isovolumic Contraction Time (IVCT) index was decreased significantly after surgery (P-value<0.05). The difference of indices between the two sexes was not significant after surgery (P-value>0.05).

CONCLUSION

Adenotonsillectomy can improve cardiac function indices in patients with PS due to ATH especially in terms of right ventricle (RV) function and reduction in pulmonary artery pressure. So, although "subclinical", it is better to be considered PS not just as annoying noise for roommates before significant clinical cardiac problems happen.

Barbed pharyngoplasty for obstructive sleep apnea: A meta-analysis

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Evaluation of the clinical efficacy of nasal surgery in the treatment of obstructive sleep apnoea

STUDY OBJECTIVES

The aim of the study was to evaluate the clinical efficacy of nasal surgery in the treatment of obstructive sleep apnoea (OSA) by comparing the improvement of subjective symptoms and objective metrics before surgery and after 6 months of surgery.

METHODS

Patients with the main complaint of nasal congestion combined with habitual snoring who were hospitalized and treated were selected. Patients underwent subjective symptom tests and objective indicator monitoring both before surgery and 6 months after surgery. Comparisons between groups were performed using the independent samples t-test.

RESULTS

Subjective scale evaluations demonstrated that nasal congestion, daytime sleepiness, snoring, nose-related symptoms, and sleep symptoms in patients with simple snoring or with OSA were improved after nasal surgery. Additionally, vitality was improved in all groups except for the patients with simple snoring and emotional consequence was improved in patients with simple snoring and mild OSA. Objective evaluations indicated the apnoea-hypopnoea index (AHI), the thickness of the soft palate, and the maximum cross-sectional area of the sagittal plane of the soft palate decreased after surgery in patients with mild OSA. The lowest blood oxygen concentration (LSaO₂) and anteroposterior diameter of the soft palate increased after surgery in patients with mild OSA. The arousal index also significantly decreased in patients with mild and moderate OSA. The nasal cavity volumes (NCVs) and the nasal minimal cross-sectional areas (NMCAs) of all groups showed significant differences after surgery.

CONCLUSIONS

Nasal surgery can effectively improve nose and sleep symptoms in patients with simple snoring or with OSA. It can significantly reduce the nasal resistance and increase the ventilation volume.

STATEMENT OF SIGNIFICANCE

Obstructive sleep apnoea (OSA) is becoming a global health problem. OSA is associated with several coexisting conditions, reduced health-related quality of life, and impaired work productivity. This study performed nasal surgery on OSA patients with the main complaint of nasal congestion combined with snoring and patients with simple snoring to compare the improvement of subjective symptoms and objective metrics before and after surgery. We found that: (1) symptoms such as nasal congestion, daytime sleepiness or snoring were improved after nasal surgery; (2) the apnoea-hypopnoea index (AHI) and arousal index decreased after surgery in patients with OSA; (3) the nasal and oropharyngeal cavity volumes increased after surgery. These findings suggest that patients with OSA or with simple snoring could benefit from nasal surgery.

[Influence of the soft palate structure in patients with snoring and obstructive sleep apnea syndrome on the results of surgical treatment]

OBJECTIVE

To evaluate the variants of the anatomical structure of the soft palate in patients with snoring and obstructive sleep apnea (OSA) syndrome and their relationship with the severity of OSA syndrome.

MATERIAL AND METHODS

The study included patients (n=71) with snoring and sleep apnea. For the purpose of treatment, patients underwent reconstructive interventions on the soft palate. All patients underwent a comprehensive examination, including the collection of complaints and anamnesis, examination of the upper respiratory tract, night respiratory monitoring. There are 5 types of soft palate structure, depending on which all patients are divided into 5 groups. The 1st and 2nd groups mainly included patients with simple snoring and mild OSA syndrome, the 3rd and 5th groups were evenly distributed with all degrees of severity of the same pathology, and the 4th group consisted mainly of patients with severe OSA syndrome. The procedure of the operation varied in different groups. 1 month after surgical treatment, there was a decrease in the anpoe/hypopnea index compared with preoperative values in patients of the 1st and 2nd groups by 71.9% and 76.2%, respectively, in patients of the 3rd group by 51.4%, in patients of the 5th group by 65.3%, in patients of the 4th group by 39.6%.

CONCLUSIONS

The presented original classification of anatomical variants of the soft palate in patients with snoring and OSA syndrome makes it possible to determine the scope of intervention, predict the feasibility of surgery and can be recommended for practical use. Surgical treatment is indicated for types 1, 2, 3 and 5 of the structure of the soft palate. In patients with type 4, reconstructive operations on the soft palate do not lead to a satisfactory result and can only be used in combination with other methods of treatment.

Post-tonsillectomy respiratory complications in children with sleep disordered breathing

OBJECTIVE

A common indication for tonsillectomy in children is clinically diagnosed sleep disordered breathing (SDB) without confirmation of obstructive sleep apnea (OSA) by polysomnography (PSG). Our goal was to review rates of post-tonsillectomy respiratory complications in children with SDB without prior PSG in order to develop recommendations for postoperative monitoring and safe hospital discharge in this population.

METHODS

Following Institutional Review Board (IRB) approval at Penn State Milton S. Hershey Medical Center, a database query using Current Procedural Terminology (CPT) codes for tonsillectomy with or without adenoidectomy (42820, 42821, 42825, 42826) between January 1, 2012 and December 31, 2017 was performed. International Classification of Diseases (ICD) codes for sleep disordered breathing (G47.30), snoring (R06.83), and obstructive sleep apnea (G47.33) were applied for further selection. Charts were individually reviewed to confirm the inclusion criteria of pediatric patients (≤18 years) who underwent tonsillectomy without prior PSG and were monitored overnight. Demographic, operative, and relevant postoperative hospital course data (including desaturations, supplemental oxygen requirements, and upgraded level of care) were collected.

RESULTS

A total of 1874 unique patient encounters were identified by our database search and 364 children met inclusion criteria. The average age of the patient population was 6.5 ± 3.1 years and 52.2% of children were female. Mean z-score for the population was 0.6. The rate of overnight oxygen desaturation events (<95%) was 2.2%, with no severe complications found in this population. Children with desaturation events were supplemented with oxygen and resolved prior to hospital discharge. Only race was found to be significantly related to risk of mild overnight desaturations (P = 0.023).

CONCLUSION

A lack of significant postoperative respiratory complications or alterations in the clinical management of children with SDB without prior PSG supports the idea that such patients may safely be discharged from the hospital following tonsillectomy without overnight oxygen monitoring.

Pediatric Adenotonsillectomy Trial for Snoring (PATS): protocol for a randomised controlled trial to evaluate the effect of adenotonsillectomy in treating mild obstructive sleep-disordered breathing

INTRODUCTION

Mild obstructive sleep-disordered breathing (oSDB), characterised by habitual snoring without frequent apnoeas and hypopnoeas on polysomnography, is prevalent in children and commonly treated with adenotonsillectomy (AT). However, the absence of high-level evidence addressing the role of AT in improving health and behavioural outcomes has contributed to significant geographical variations in care and potential for surgery to be both overused and underused.

METHODS AND ANALYSIS

The Pediatric Adenotonsillectomy Trial for Snoring (PATS) is a single-blinded, multicentre randomised controlled trial designed to evaluate the effect of AT in treating mild oSDB. Four hundred sixty eligible children, aged 3.0-12.9 years old, will be randomised to either early adenotonsillectomy or to watchful waiting with supportive care (WWSC) with a 1:1 ratio. The study's coprimary endpoints are (1) change from baseline in executive behaviour relating to self-regulation and organisation skills as measured by the Behavioural Rating Inventory of Executive Function (BRIEF) Global Composite Score (GEC); and (2) change from baseline in vigilance as measured on the Go-No-Go (GNG) signal detection parameter (d-prime). A mixed effects model will be used to compare changes in the BRIEF GEC score and GNG score at 6 and 12 months from baseline between the AT arm and the WWSC arm.

ETHICS AND DISSEMINATION

The study protocol was approved by the institutional review board (IRB) at Children's Hospital of Philadelphia (CHOP) on 3 October 2014 (14-0 11 214). The approval of CHOP as the central IRB of record was granted on 29 February 2016. The results will be published in peer-reviewed journals and presented at academic conferences. The data collected from the PATS study will be deposited in a repository (National Sleep Research Resource, sleepdata.org) after completion of the study to maximise use by the scientific community.

TRIAL REGISTRATION NUMBER

NCT02562040; Pre-results.

Partial resection of hypertrophic torus tubarius for recurred snoring: Case series

Sleep-disordered breathing symptoms may recur in some children after successful adenoidectomy. A potential etiology that warrants consideration is torus tubarius hypertrophy (TTH) as well as residual or recurrent adenoid hypertrophy. Here, we report our experience and the treatment outcomes with microscopic coblator-assisted partial resection of TTH.Seven children who had undergone coblator-assisted partial resection of TTH under microscopy from April 2000 through January 2017 were retrospectively reviewed. The patient age at the time of initial adenotonsillectomy and the interval between the first operation and partial resection of TTH were identified. Lateral cephalometry and scores on the Korean version of the obstructive sleep apnea-18 (KOSA-18) questionnaire were reviewed.The median age at the time of the first operation was 3.0 years and the average time interval between the first operation and subsequent tubal tonsillectomy was 44.0 months. The average width between the torus tubarius was 2.1 mm preoperatively. Symptoms of sleep-disordered breathing were relieved in all patients after operation. Preoperative and postoperative KOSA-18 scores were 73.5 and 35.5, respectively (P = .024). On polysomnography, the preoperative and postoperative apnea-hypopnea index scores were 22.9 and 4.7, respectively (P = .068). The patients were followed up for an average of 1.3 years. One patient developed a recurrence of symptoms and underwent a revision operation. Complications such as bleeding and nasopharyngeal stenosis were not observed.Otorhinolaryngologists should keep TTH in mind as one of the differential diagnoses for recurrent upper airway obstruction symptoms after adenoidectomy. Microscopic coblator-assisted partial resection of TTH is likely to be safe and effective.

Complications of Palatal Pillar Implants: An analysis of the MAUDE database and literature review

PURPOSE

The Pillar Palatal Implant System is a minimally invasive procedure for the treatment of obstructive sleep apnea and snoring. Prior studies have examined the effectiveness of this procedure, however no prior study has thoroughly evaluated its complications. We anticipate that this analysis will provide valuable insight into these procedures which can be used in patient education and post-operative follow-up.

MATERIALS AND METHODS

The Manufacturer and User Facility Device Experience (MAUDE) database was queried for cases reporting injury related to the pillar procedure. The case narratives were individually analyzed and categorized by type of complication. A comparison of extruding parts and select complications was also performed using chi-square analysis.

RESULTS

Of the 261 cases reported, 73.6% reporting extruding parts, 47.5% described patient pain, and 38.7% included patients describing a foreign body sensation. Infection was reported in 7.7% of the cases with cellulitis and abscess formation specifically mentioned in one case. Cases describing pain and difficulty swallowing were significantly more likely to have reported extruding parts (p < 0.05).

CONCLUSIONS

This study describes various complications associated with this procedure. The description of these complications and accompanying literature review may provide healthcare professionals and patients with an understanding of the scope of adverse events related to this procedure.

Diagnosis and treatment of the pharyngeal glial choristoma accompanied with incomplete cleft palate: A case report

INTRODUCTION

A choristoma formed by heterotopic tissue rarely occurs in the throat, especially one accompanied with cleft palate in a new-born baby.

PATIENT CONCERNS

An 18-month-old female patient was admitted to the hospital for apparent snoring symptoms accompanied by mouth breathing and sleep apnea. In addition, the patient presented with weak aspiration and nasal leakage during fluid intake.

DIAGNOSIS

The patient received routine physical examination and endoscopy showing that there was a wide fissure which split from the palate vertical anterior cleft to 1/3 of the hard palate. Meanwhile, we found an unclear-bordered uplift in the left palate and a soft mass. The radiographs revealed a mass with inhomogeneous density convex to the pharyngeal cavity.

INTERVENTIONS

The patient was subsequently referred for surgical resection and tissue diagnosis of choristoma was confirmed by pathological examination. H&E staining showed well demarcated mature brain tissue with scattered sand-like calcification.

OUTCOMES

According to the diagnosis, the patient suffered from pharyngeal glial choristoma and incomplete cleft palate. The surgical resection and repair were performed together. The postoperative recovery was very good.

LESSONS

Choristoma rarely occurs in the head and neck, especially if accompanied by cleft palate. Early diagnosis for choristoma relies heavily on clinical examination and radiological imaging. Complete resection of choristoma remains the gold standard for treatment of these patients.

Long-term results of palatal implantation for severe obstructive sleep apnea patients with prominent retropalatal collapse

BACKGROUND

Most previous reports on palatal implantation for patients with severe obstructive sleep apnea have been anecdotal. Our objective in this study was to assess the long-term outcomes of palatal implantations from objective as well as subjective perspectives when applied to patients with severe obstructive sleep apnea and prominent retropalatal collapse.

METHODS

This retrospective review was conducted in a single institution using subjective data (Epworth Sleepiness Scale and visual analog scales of snoring sounds and sleep quality) and objective data (respiratory disturbance index, minimum O₂ saturation, sleep efficiency, and snoring index using a polysomnograph) before and after surgery. A total of ten patients were enrolled in this study. The median time between pre-operative sleep-related tests and the operation date was 1.0 months and the median time between operation date and post-operative sleep-related tests was 33.0 months.

RESULTS

Significant improvements were observed in the visual analog scale scores of snoring (p = 0.004), visual analog scale scores of sleep quality (p = 0.005), and Epworth Sleepiness Scale (p = 0.012). Eight of the ten patients reported a reduction of at least 50% on the visual analog scale of snoring sounds, which was the criterion of subjective surgical success. We also observed significant improvements in the respiratory disturbance index (p = 0.009) and minimum O₂ saturation (p = 0.033). Two of the ten patients presented a reduction in respiratory disturbance index of ≥50% and a subsequent respiratory disturbance index of <20, which were the criteria of objective surgical success. A percentage change in respiratory disturbance index was negatively associated with prominent retrolingual collapse and the length of the soft palate.

CONCLUSION

Patients with severe obstructive sleep apnea and prominent retropalatal collapse may benefit from palatal implantation from a subjective perspective. Palatal implantation could be considered an alternate form of treatment for some cases of severe obstructive sleep apnea, due to the likelihood of improvement in clinical symptoms and the normalization of sleep quality.

Smoking and Improvement after Nasal Surgery in Snoring Men

Background

The aim of this study was to compare subgroups of smokers and nonsmokers undergoing nasal surgery and to evaluate improvement of nasal stuffiness, snoring, and symptoms related to sleep-disordered breathing after nasal surgery.

Methods

A cross-sectional prospective study was performed. The study population included 40 consecutive snoring men scheduled for surgical treatment of nasal obstruction. The patients completed nasal and sleep questionnaires, an Epworth sleepiness scale, and a visual analog scale of snoring intensity. They underwent polysomnography, anterior rhinomanometry, acoustic rhinometry, and cephalometric analysis.

Results

The smokers were younger, they snored longer and louder, and they had higher nasal resistance with decongestion and longer soft palates than the nonsmokers. Nasal stuffiness improved well after surgery, but a decrease of nasal resistance was not related to improvement of subjective snoring.

Conclusion

Smoking was associated with increased snoring, nasal obstruction, and pharyngeal soft tissue volume. Expectations of patients may influence subjective assessment of snoring after nasal surgery.

Assessment of Chronic Snorers

Snorers represent a heterogenous group that require adequate assessment before recommending surgical treatment. There are unfortunately no specific features either in the history or physical examination that might predict those chronic snorers with obstructive sleep apnoea. We have used trained observation together with pulse oximetry ('sleep screening') and fibreoptic nasendoscopy with Muller manoeuvre in our unit to assess snorers. This combination is a reliable means of distinguishing apnoeic patients from simple snorers and determining the level of the obstructing segment. We report our experience in using these methods in the management of 71 chronic snorers. We stress the value of conservative management, and emphasize that obesity, habitual alcohol ingestion and nasal obstruction should be corrected before embarking on pharyngeal surgery.

The Uvulopalatopharyngoplasty Operation: The Edinburgh Experience

The experience of the uvulopalatopharyngoplasty operation, performed on 24 patients for the relief of loud or heroic snoring, is presented. The operation successfully reduced the severity of snoring in 96% of patients. Postoperative complications were uncommon but included nasal regurgitation and intrapharyngeal adhesions in one patient. The role of the uvulopalatopharyngoplasty operation in the treatment of obstructive sleep apnoea is undecided but the authors do not perform this operation on such patients.

Clinical research on airway intervention before tracheal extubation after general anesthesia on snoring children

OBJECTIVE

To analyze the method and the effect of airway intervention before tracheal extubation in post-anesthesia cure unit (PACU) after anesthesia when removing the tonsil under general anesthesia and adenoidectomy under nasal endoscope on children with snoring.

PATIENTS AND METHODS

46 cases diagnosed as snoring were executively selected in this study. The cases were randomly divided into the control group (n = 22) and the observation group (n = 24). For airway intervention after general anesthesia during the recovery period, the control group was treated with intravenous injection of 0.5 μg/kg remifentanil, whereas the observation group was treated with atomization inhalation of 15 mg ambroxol hydrochloride and 0.5 mg budesonide suspension.

RESULTS

The clinical effects of both methods were compared and analyzed for statistical analysis. The blood pressure, heart rate and blood oxygen saturation at 30 min and 10 min after extubation in the control group was significantly more stable than those in the observation group (p < 0.05). The alertness/sedation (OAA/S) score in the observation group was significantly higher than that in the control group (p < 0.05). The prevalence rate of complications after extubation in the two groups was not statistically significant (p > 0.05). The levels of serum cortisol (Cor) and IL-8 in the control group were significantly lower than those in the observation group (p < 0.05).

CONCLUSIONS

Both methods are effective for treatment of airway intervention concerned with snoring children after general anesthesia during the recovery period. The effect of remifentanil on hemodynamics is relatively huge compared with that of atomization inhalation.

Updated Nasal Surgery for Obstructive Sleep Apnea

Numerous studies report that difficulty breathing through the nose is associated with reduced sleep quality, increased daytime dysfunction, and increased risk of snoring and obstructive sleep apnea (OSA). Additionally, chronic nasal obstruction often complicates and limits successful medical device therapy for OSA, particularly with continuous positive airway pressure (CPAP). When medical evaluation and management of the nose is inadequate, surgical therapy to lower nasal resistance has been shown to substantially improve sleep and breathing outcome measures. Although nasal surgery in isolation does not have a consistent effect on the apnea-hypopnea index in OSA patients, it does have robust evidence on improving snoring, subjective sleep quality, daytime sleepiness, sleep-related quality of life measures, and other important OSA outcome measures. Furthermore, in OSA patients with sinonasal disease who are struggling with CPAP and other medical devices, sinonasal surgery also has the potential to lower pressure requirements and improve adherence rates. Nasal surgery plays a key adjunctive role in the management of an OSA patient population.

The History of Sleep Surgery

Snoring and the subsequent diagnosis of obstructive sleep apnea (OSA) was a life-threatening medical condition with no available treatment until the late 20th century. An early description of OSA was provided by Charles Dickens in his 1836 novel Pickwick Papers with the description of a "fat boy" who was thought to be lazy and always falling asleep but likely displayed hypersomnolence from OSA. It was not until 1976 that Ikematsu first described uvulopalatopharyngoplasty (UPPP) as an alternative surgical treatment of "snoring," with a reported cure rate of 81%. The only other surgical procedure for OSA was permanent tracheostomy, but patients suffered from social stigma from the visible stoma with skin flaps and complications such as tracheal granulomas and tracheitis. UPPP was introduced in the USA as an alternative to permanent tracheostomy by Fujita in 1981. Since then, multiple surgical approaches and combinations of approaches have surfaced, with variable success rates.

Parent Experience of Care and Decision Making for Children Who Snore

Importance

Sleep-disordered breathing (SDB) is prevalent and has an impact on the physical and behavioral health of children. Adenotonsillectomy (AT), the primary treatment, is subject to unexplained variation in utilization, which may be reduced by improving physician-patient communication and decision quality for this elective procedure.

Objective

To identify factors are associated with parental experience and decision making in pediatric SDB and AT surgery.

Design, Setting, and Participants

In this qualitative study, parents of children with prior SDB evaluation participated in semistructured, audiorecorded interviews. Open-ended questions regarded experiences of having a child with SDB, communication with pediatric clinicians and surgeons, and experiences with AT surgery. Recordings were transcribed and analyzed for emergent themes using grounded theory methodology. Eleven parents of children ages 2 to 17 years who had previously been diagnosed or treated for SDB were identified via purposive sampling and interviewed between January and April 2015. Interviews were conducted at locations convenient for the participants and separate from the pediatric clinic. A goal of this study was to ascertain how parents perceived sharing decisions with their physicians.

Main Outcomes and Measures

Themes of parental experiences and treatment decision-making processes with pediatric SDB.

Results

Overarching themes were inclusive of (1) clinical factors of SDB and AT and (2) clinician interpersonal behaviors and communication. Parents described an urgency that led them to seek evaluation or treatment, including fear that the child would stop breathing, or behavioral and/or cognitive delays. Parents often viewed surgery as a "last resort" and had explored alternate therapies prior to seeing the surgeon. Nearly all parents feared anesthesia more than AT surgery itself. Parents described satisfaction when physicians provided them with options, engaged their child in conversation, depicted SDB visually, and were responsive or accessible to questions. Parents regarded a trusting relationship with their pediatrician, confidence in the surgeon, and inclusion in decision making as important.

Conclusions and Relevance

While clinical factors were influential for decision making, interpersonal factors helped parents feel comfortable and influenced their overall experience. Shared decision making, in which parents receive evidence-based information allowing them to accurately perceive risks, benefits, and alternatives about SDB treatment in the setting of trusting clinician-family relationships, may reduce parental decision conflict and improve decision quality toward AT surgery.

Surgical treatments for snoring

Surgical treatments for snoring.

OBJECTIVES

To compare the results on snoring and sleepiness of different surgical treatments for sleep disordered breathing (SDB) including uvulopalatopharyngoplasty (UPPP), functional expansion pharyngoplasty (FEP), osteotomy, septoplasty with turbinoplasty, and somnoplasty.

METHODOLOGY

Between May 2011 and December 2015, 329 patients presenting with SDB underwent a dedicated clinical examination, drug-induced sleep endoscopy (DISE), and polysomnography (PSG). Of these, 84 patients underwent surgical treatment. Treatments were evaluated through 4 questionnaires (snoring intensity, snoring severity, Epworth Sleepiness Scale [ESS], and global snoring score) before and 6 weeks and 6 months after treatment. Treatment success was defined as a global snoring visual analog scale score (VAS) ≤3 at 6 months.

RESULTS

The average age of the surgical group was 43 ± 11 years; the mean body mass index was 26 ±3 kg/m; and 88% were male. The snoring scores decreased significantly for every surgical technique at 6 weeks and 6 months. A higher reduction in the median snoring scores was observed in patients receiving UPPP/FEP and osteotomy compared to somnoplasty and septoplasty. Treatment was successful in 88% of the UPPP/FEP group, 92% of the osteotomy group, 61% of the septoplasty group, and 64% of the somnoplasty group.

CONCLUSIONS

All surgical treatments effectively and persistently reduced snoring and sleepiness symptom scores. The highest rates of success were observed with osteotomies and UPPP/FEP procedures.

Radiofrequency Soft Palate Procedure in Snoring: Influence of Energy Delivered

OBJECTIVE: We conducted a retrospective study to evaluate the influence of amount of energy delivered during radiofrequency procedure for soft palate reduction in snoring, to improve the cure rate.

METHODS: Consecutive patients with chronic disruptive snoring presenting to our department were successively treated in an outpatient procedure. A visual analog scale was used to assess the severity of snoring by the bed partner and the pain by the patient, before treatment and after each treatment session. The soft palate was divided into 3 treatment sites: middle, lateral right, and lateral left. Any mucosal injury of the soft palate was classified as a complication.

RESULTS: Forty-3 patients were classified into 2 groups according to energy assignment. The total amount of energy delivered was 1250 J in group 1 (n = 15) and 1500 J in group 2 (n = 28). Energy was predominantly distributed in the middle of the soft palate in group 1 (550 J) and group 2 (800 J). After each treatment session, the 1500-J delivery of radiofrequency energy (total per session) led to a better snoring grading reduction in comparison with the 1250-J delivery with a significant difference after 2 treatment sessions ( P < 0.05). The mean pain score and the incidence rate of complications per treatment were not statistically different in comparing both groups.

CONCLUSION: Better snoring scores can be expected by increasing radiofrequency energy applied to the soft palate. Further randomized long-term investigations are required to confirm that the cure rate can be improved when increasing energy with a suitable distribution and good clinical tolerance.

Transoral Radiofrequency Treatment of Snoring

OBJECTIVES/HYPOTHESIS: Radiofrequency ablation (RFA) may effectively treat snoring with acceptable patient tolerance.

STUDY DESIGN: A cohort of patients with unacceptable snoring underwent RFA to the soft palate between October 1997 and May 2000. Before the therapy, a family member or significant other person was interviewed to rate snoring loudness.

METHODS: Snoring was rated on a visual analog scale of 0 to 10 (in which 0 was no snoring and 10 was horrific snoring) before and after therapy. All patients were treated with transoral RFA administered under local anesthesia at 6-week intervals.

RESULTS: Complete data were available for 60 of the 75 treated patients. The average number of treatment sessions per patient was 1.8. These patients received an average energy of 1845 J. Overall the average snoring score was 8.9 before therapy and 3.5 after therapy. Fifty-one patients (85%) were considered to have major improvement in snoring loudness. A total of 9 patients (15%) were nonresponders.

CONCLUSIONS: RFA to the soft palate is a viable option to treat socially unacceptable snoring. Inadequate response to therapy may reflect misdiagnosis or delivery of an insufficient amount of energy.

Midline Radiofrequency Tissue Reduction of the Palate for Bothersome Snoring and Sleep-Disordered Breathing: A Clinical Trial

This study is a prospective, nonrandomized clinical trial initiated to assess the safety and efficacy of radiofrequency tissue reduction of the palate for the treatment of bothersome snoring and sleep-disordered breathing. Twelve healthy volunteers with socially disruptive snoring underwent a baseline polysomnogram along with a battery of visual analog scales (VASs) to measure daytime sleepiness, snoring level, pain, and disturbances of speech and swallowing. After radiofrequency tissue reduction of the palate, they were re-evaluated with a mean follow-up after the final procedure of 15.7 ± 5.1 (mean ± SD) weeks. As rated by the bed partner, a significant reduction in the level of snoring occurred in all 12 patients, with a mean pretreatment snoring level of 8.3 ± 2.1 to a mean posttreatment snoring level of 2.1 ± 1.4. (Student t test, P < 0.0001) These patients required an average of 2.3 treatment sessions each. Nine of 12 had a reduction in snoring from a bothersome level (VAS range 5–10) to a nonbothersome level (VAS range 0–3). Daytime sleepiness as measured by the Epworth Sleepiness Scale (0–24) decreased from 10.8 ± 4.4 to 8.3 ± 4.1 ( P = 0.011). Posttreatment pain was considered absent or minimal in 11 of 12 patients and was managed with acetaminophen. No significant adverse events or complications were reported.

Randomized study comparing inflammatory response after tonsillectomy versus tonsillotomy

To determine if there was a difference in the inflammatory reaction after tonsil surgery with "traditional" techniques (tonsillectomy and adenoidectomy or TA) compared to partial intracapsular tonsillectomy and adenoidectomy (PITA).

DESIGN

Randomized, double-blind study.

SETTING

tertiary care academic hospital. Children under the age of 16 years with a diagnosis of obstructive sleep disordered breathing were randomly allocated into three study groups: TA with electrocautery (n = 34), PITA with CO₂ laser (n = 30) and PITA with debrider (n = 28). All of the children underwent adenoidectomy with a current at the same surgical procedure.

MAIN OUTCOME MEASURE

c-reactive protein level (CRP) was the primary endpoint. In addition, the following were assessed: white blood cells (WBC), neutrophils (NEU), interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α). Pre- and post-procedure measurements were compared between the groups. Parents filled out a questionnaire daily during the first postoperative week assessing pain, swallowing and snoring. CRP levels ascended higher in the PITA groups after surgery (p = 0.023), WBC and NEU showed the same pattern, IL-6 levels were higher in PITA group and there was no difference in TNF-alpha levels between the two types of procedures. Postoperative pain and postoperative hemorrhage were significantly lower in the PITA groups as compared to the TA group (p = 0.01 and 0.048). PITA in comparison to TA is associated with lower morbidity; however, the inflammatory response does not differ significantly in the first 24 h after surgery. Additional long-term studies assessing efficacy of PITA are warranted.

LEVEL OF EVIDENCE

Level 1, prospective randomized controlled trial.

Evaluation of Potential Predictors of Outcome of Laser-Assisted Uvulopalatoplasty for Snoring

OBJECTIVE: Laser-assisted uvulopalatoplasty (LAUP) is a common treatment for snoring, but up to 50% of patients obtain little or no sustained benefit. We investigated whether pre-operative measurements from lateral cephalometry, acoustic rhinometry, analysis of snoring sounds, and body mass index (BMI) could predict which snorers benefited from LAUP.

STUDY DESIGN AND SETTING: Fifty-five snoring patients were assessed pre- and 6 months post-LAUP. Snoring severity was assessed by objective sound level recorded during polysomnography, and a Snoring Symptoms Inventory (SSI) questionnaire.

RESULTS: The outcome of surgery was assessed by changes in objective sound measurements and in SSI, 6 months after LAUP.

CONCLUSIONS: Relationships between the predictive measurements and outcome were at best only weak and none had sufficient predictive value to be useful in clinical practice.

EBM rating: C-4

Palatal Implants for the Treatment of Snoring: Long-Term Results

OBJECTIVE: To evaluate the safety and long-term effectiveness of a new treatment for snoring using permanent palatal implants.

STUDY DESIGN: Prospective study with 35 patients referred to the clinic for the treatment of snoring. The patients were followed for 1 year, and a sleep analysis was performed and repeated at 360 days. During the procedure, 3 braided polyethylene terephthalate implants were placed in the palate of each patient.

RESULTS: The average duration for nonnarcotic analgesics was 1.3 days. No adverse events were observed. The mean snoring intensity was reduced from 7.1 at baseline to 4.8 at 1 year ( P < 0.001). Bed partner satisfaction rate was very high at 70.6% after 1 year. Six patients (17.8%) experienced a total of 9 partial extrusions.

CONCLUSIONS: The palatal implant system is safe, and the effectiveness in treating snoring is comparable to other surgical methods. Advantages are virtually no tissue damage and minimal patient discomfort as a result of one standardized, low-cost procedure.

Palatal implants for primary snoring: Short-term results of a new minimally invasive surgical technique

OBJECTIVE:

To determine the safety and efficacy of a new soft palate implant procedure for the reduction of snoring.

STUDY DESIGN AND SETTING:

Fifteen healthy patients with primary snoring due to palatal flutter were enrolled into this prospective study after clinical and endoscopic examination and polysomnography. The average age of the patients was 41.2 ± 8.6 years with a body mass index of 26.2 ± 2.5 kg/m 2 . The Anti-Snoring Device consists of a delivery tool with a cylindrical implant of braided polyester filaments. Under local anesthesia, three implants intended for permanent implantation were placed into the soft palate. Snoring-related symptoms were assessed by visual analogue scales (VAS), polysomnography, and the SNAP system at baseline and 90 days postoperatively.

RESULTS:

All implants were placed without complications. Only minor discomfort was reported in four cases within the first three days postprocedure. At the 90-day follow-up snoring was reduced from 7.3 ± 1.6 to 2.5 ± 2.1 (VAS, P < 0.01) and from 347 ± 239 to 264 ± 168 snoring sounds/hour (SNAP, P > 0.05). Polysomnography did not show any deterioration of sleep or breathing. Speech, swallowing, and taste were unchanged.

CONCLUSION:

The Anti-Snoring Device is a new surgical tool offering a simple and minimally invasive procedure. Our data demonstrate that the treatment is safe and effective with good patient acceptance. Further patient follow-ups are needed to evaluate the long-term results.

The Development of a Snoring Symptoms Inventory

OBJECTIVES: To develop a patient-derived snoring questionnaire, the Snoring Symptoms Inventory (SSI), and explore its structure and relationship to the Epworth Sleepiness Scale (ESS); and to assess the sensitivity of the SSI to change.

STUDY DESIGN AND SETTING: The SSI was developed from an open-ended questionnaire given to 120 habitual snorers. The 25 symptoms reported compose the SSI. This study examines 261 subsequent snorers assessed between April 1998 and August 2002, who completed both the SSI and the ESS. Fifty-five of them underwent laser uvulopalatoplasty and their preoperative and postoperative SSI results were compared.

RESULTS: The total SSI score is the key outcome derived. Principal component analysis identified two further dimensions, one contrasting family/social with work-related problems and another comparing physical problems with embarrassment. The total score correlated weakly with the ESS. Laser uvulopalatoplasty significantly reduced patients' overall symptom severity and family and socially related problems.

CONCLUSION: The SSI is a comprehensive and sensitive measure for assessing snoring, making it a useful clinical outcome tool for snoring treatment.

SIGNIFICANCE: The SSI is a new, useful snoring questionnaire.

EBM rating: B-2b

Acoustical analysis of snoring: Can the probability of success be predicted?

Purpose

Palatal flutter snoring is the most common form of snoring. However, other types of snoring do exist. Does identifying palatal snoring beforehand translate into improved subjective treatment success with palatal stiffening procedures?

Methods

Fifty-three patients presenting with snoring were evaluated with a commercially available device. The proportion (%) and magnitude of palatal flutter (dB) were quantified. Patients then underwent a palatal stiffening procedure and subjective success/failure was assessed.

Results

Overall subjective treatment success was 85% (45 of 53). The percent palatal flutter was the most predictive of success (area under ROC = 0.8556, 95% CI = .7428-.9683). Patients exceeding 68% palatal flutter had a 95% (39 of 41) success rate ( P = 0.001, Fisher's exact) and an adjusted odds ratio of treatment success of 25.2 (95% CI = 3.22-196, P = 0.002).

Conclusion

Palatal stiffening treatments are successful in the majority of patients. However, identifying patients with predominant palatal flutter snoring significantly increases the probability of subjective treatment success. EBM rating: B-2b

Acoustic parameters of snoring sound to assess the effectiveness of sleep nasendoscopy in predicting surgical outcome

Objective

To assess the effectiveness of two grading systems used to predict surgical outcome in nonapneic snorers.

Study Design

A prospective observational study. Prior to undergoing palatal surgery, 20 patients completed a sleep nasendoscopic examination involving sequential steady-state sedation with intravenous propofol. Using a combination of acoustic parameters of snoring sound as an objective outcome measurement, and the answers to a specifically designed questionnaire as a subjective outcome measurement, the effectiveness of each grading system in predicting surgical outcome was examined.

Results

Depending on the outcome measurement used, sensitivity in predicting success of surgery for snoring varied from 16.7% to 50.0% and specificity from 38.5% to 62.5% for the Pringle and Croft system, while sensitivity varied from 91.7% to 100% and specificity from 30.8% to 31.5% for the Camilleri system.

Conclusion

Sleep nasendoscopy using these classifications cannot be recommended as a reliable predictor of surgical outcome in nonapneic snorers. EBM rating: C-4

Is the difference in the volume of the pharyngeal space, as measured by acoustic pharyngometry, before and after tonsillectomy proportional to the volume of the excised tonsils?

OBJECTIVE

Adenotonsillectomy is recognized as an effective therapy for snoring and sleep disorders in children. It is important to understand whether adenotonsillectomy significantly increases the volume of the pharyngeal space. The goal of this study was to evaluate the change in oropharyngeal volume after adenotonsillectomy and the correlation of this change with the objective volume of the tonsils and body mass index.

METHODS

We included 27 subjects (14 males) with snoring caused by tonsil and adenoid hypertrophy. The mean age of the subjects was 7.92 (±2.52) years. Children with craniofacial malformations or neuromuscular diseases or syndromes were excluded. The parents/caregivers answered an adapted questionnaire regarding sleep-disordered breathing. All patients were subjected to weight and height measurements and body mass index was calculated. The subjects underwent pharyngometry before and after adenotonsillectomy and the volume of both excised tonsils together was measured in cm3 in the operating room.

RESULTS

Pharyngometric analysis showed that the mean pharyngeal volume was 28.63 (±5.57) cm3 before surgery and 31.23 (±6.76) cm3 after surgery; the volume of the oropharynx was significantly increased post-surgery (p=0.015, Wilcoxon test). No correlation was found between the objective tonsil volume and the post-surgical volume increase (p=0.6885). There was a fair correlation between the oropharyngeal volume and body mass index (p=0.0224).

CONCLUSION

Adenotonsillectomy increases the volume of the pharyngeal space, but this increase does not correlate with the objective tonsil size. Furthermore, greater BMI was associated with a smaller increase in the pharyngeal volume. Oropharyngeal structures and craniofacial morphology may also play a role in the increase in oropharyngeal volume.

Olfactory and Gustatory Functions after Anterior Palatoplasty in Patients with Primary Snoring

OBJECTIVE

In this study, we investigated the chemical senses (namely, olfaction), the 4 basic tastes, and umami taste in patients who underwent anterior palatoplasty (AP) for primary snoring.

STUDY DESIGN

Prospective clinical study.

SETTING

Multicenter, tertiary care hospitals.

SUBJECTS AND METHODS

The age range of the 28 participants was 22 to 47 years, and all had been diagnosed with primary snoring by polysomnography. Orthonasal and retronasal olfactory testing was performed using the respective "Sniffin' Sticks." Tests for the 4 basic tastes (sweet, sour, salty, and bitter) and umami were performed before and 6 months after AP.

RESULTS

The changes between the preoperative and postoperative results for the 4 basic tastes, which were applied to the anterior tongue region, were not significant. Retronasal olfactory function improved significantly 6 months after AP (P = .007). After AP, umami scores for the soft palate but not those of the anterior and posterior tongue decreased significantly (P = .001).

CONCLUSION

Patients scheduled for AP should be properly informed about potential postoperative taste and flavor changes. They should also be warned of a possible loss of appetite due to a postoperative decrease in the umami taste sensation of the soft palate.

Pang-Rotenberg sign--snoring surgery prognosticator: A prospective clinical trial of 153 patients

OBJECTIVES/HYPOTHESIS

To illustrate the reliability of the Pang-Rotenberg (PR) sign as a prognosticator of snoring surgery. Our hypothesis was that patients who are PR-positive have better snoring reduction scores and outcomes than PR-negative patients after nose and palate surgery.

STUDY DESIGN

A multicenter prospective series of 153 patients with snoring.

METHODS

All patients graded the snoring intensity on a visual analog scale (VAS). All 137 patients enrolled had both the nose surgery and palate surgery. The control group consisted of 16 patients who underwent nasal surgery alone.

RESULTS

There were 122 men and 15 women, the mean age was 44.6 years old, and mean body mass index was 26.1. There were 15 simple snorers and 122 obstructive sleep apnea patients. Patients who were PR-positive showed significantly better postoperative snoring VAS reduction (from 9.04 to 1.02) compared to those patients who were PR-negative (from 8.91 to 3.14) (P < .001). The mean follow-up time was 7.4 months. The control group had poor snoring VAS reduction from 9.21 to 6.72. After adjusting for covariates that influence the snoring VAS change due to surgery, we found that PR-negative patients achieved an average of 5.78 improvement in snoring VAS, whereas PR-positive patients achieved an average of 8.02 improvement in snoring VAS (P < .001).

CONCLUSIONS

The PR sign is a reliable prognosticator of snoring reduction, after combined nose and palate surgery, for patients with troublesome snoring.

Comparative effects of snoring sound between two minimally invasive surgeries in the treatment of snoring: a randomized controlled trial

Background

Minimally invasive surgeries of the soft palate have emerged as a less-invasive treatment for habitual snoring. To date, there is only limited information available comparing the effects of snoring sound between different minimally invasive surgeries in the treatment of habitual snoring.

Objective

To compare the efficacy of palatal implant and radiofrequency surgery, in the reduction of snoring through subjective evaluation of snoring and objective snoring sound analysis.

Patients and Method

Thirty patients with habitual snoring due to palatal obstruction (apnea-hypopnea index ≤15, body max index ≤30) were prospectively enrolled and randomized to undergo a single session of palatal implant or temperature-controlled radiofrequency surgery of the soft palate under local anesthesia. Snoring was primarily evaluated by the patient with a 10 cm visual analogue scale (VAS) at baseline and at a 3-month follow-up visit and the change in VAS was the primary outcome. Moreover, life qualities, measured by snore outcomes survey, and full-night snoring sounds, analyzed by a sound analytic program (Snore Map), were also investigated at the same time.

Results

Twenty-eight patients completed the study; 14 received palatal implant surgery and 14 underwent radiofrequency surgery. The VAS and snore outcomes survey scores were significantly improved in both groups. However, the good response (postoperative VAS ≤3 or postoperative VAS ≤5 plus snore outcomes survey score ≥60) rate of the palatal implant group was significantly higher than that of the radiofrequency group (79% vs. 29%, P = 0.021). The maximal loudness of low-frequency (40–300 Hz) snores was reduced significantly in the palatal implant group. In addition, the snoring index was significantly reduced in the radiofrequency group.

Conclusions

Both palatal implants and a single-stage radiofrequency surgery improve subjective snoring outcomes, but palatal implants have a greater effect on most measures of subjective and objective snoring. Multi-stage radiofrequency surgery was not tested.

Trial Registration

ClinicalTrials.gov NCT01955083

[Nasal surgery and upper airway radiofrequency ablation in patients with obstructive sleep apnea hypopnea syndrome]

OBJECTIVE

To investigate the efficacy and related factors of nasal surgery combined with upper air way radiofrequency ablation(RFA) for treatment of obstructive sleep apnea hypopnea syndrome (OSAHS) with chronic nasal blockage.

METHOD

One hundred and three mild or moderate OSAHS patients with chronic nasal blockage were recruited, all cases had nasal surgery and upper airway RFA. All patients were evaluated by body mass index (BMI), Epworth sleep scale (ESS), snoring scale, and nocturnal polysomnography (PSG). Eighty-nine patients were reevaluated at least 6 months after surgery with the preoperative methods.

RESULT

After operation, the apnea and hypopnea index (AHI) decreased from (18.67 +/- 9.48)/h to (9.22 +/- 7.18)/h; the lowest artery oxygen saturation (LSaO2) increased from (0.83 +/- 0.08) to (0.92 +/- 0.06); the Epworth sleep scale(ESS) decreased from (8.74 +/- 5.67) to (5.12 +/- 3.74); the snoring scale decreased from (7.16 +/- 2.85) to (3.56 +/- 2.26), the percentage of time with oxyhemoglobin saturation below 0.90 (CT90) decreased from (18.64 +/- 12.98) to (10.73 +/- 8.29). All of the differences were obvious (P<0.01). Success was defined as a postoperative apnea-hypopnea in dex < 10 events per hour and at least 50% less than the preoperative value. The surgical success rate was 75.3% (67/89). No major perioperative complications occurred.

CONCLUSION

Our findings suggest that nasal surgery combined with upper airway RFA can improve snoring and disease-specific quality of life in patients with anatomic na sal obstruction with mild or moderate OSAHS.

[Effects of bupivacaine versus lidocaine infiltration on postoperative analgesia in pediatric tonsillectomy patients]

OBJECTIVE

To compare the effects of bupivacaine, lidocaine and saline injections in alleviating post tonsillectomy pain.

METHOD

We recruited 60 patients into the study. All subjects were randomly allocated into 3 groups. Group 1 received 0.9% sodium chloride (saline group), group 2 received 0.25% bupivacaine (bupivacaine group) and group 3 received 2% lidocaine (lidocaine group), infiltrated around each tonsil. Pain was evaluated with McGrath's face scale.

RESULT

The postoperative pain scores at 2 and 6 hours were similar among the groups (P>0.05). The pain scores in the bupivacaine group were lower than those in the saline group at 12 h (P<0.05). The pain scores in the bupivacaine and lidocaine groups were significantly lower than those in the saline group from 18 to 24 hours until day 7 (P<0.05). There was no difference between the bupivacaine and lidocaine groups (P> 0.05).

CONCLUSION

Local infiltration of bupivacaine is a relatively and safe effective method and is equivalent to use of lidocaine for post tonsillectomy pain.

[Effects of nasal cavity enlarging surgery on snoring in obstructive sleep apnea hypopnea syndrome patients]

OBJECTIVE

To explore the efficacies of nasal cavity enlarging surgery in obstructive sleep apnea hypopnea syndrome (OSAHS) patients with nasal obstruction.

METHODS

From April 2011 to October 2012, a total of 22 OSAHS patient with nasal obstruction underwent nasal cavity enlargement. Natural overnight snoring was digitally recorded, polysomnography (PSG) performed simultaneously and nasal resistance measured at pre- and post-operation. Body mass index (BMI), Epworth sleepiness scale (ESS), apnea-hypopnea index (AHI), minimum oxygen saturation SaO2, total nasal resistance, peak frequency, maximal frequency, mean frequency, central frequency and power ratio 800 Hz of snores were recorded and compared.

RESULTS

BMI and SaO2 rose while AHI and ESS declined post-operatively. No statistical difference existed between pre-operation and post-operation. The total nasal resistance was (0.39 ± 0.15) and (0.29 ± 0.11) Pa·cm(-3)·s(-1) at pre- and post-operation. And there was significant statistical difference (P < 0.01) . The snores at pre- and post-operation exhibited different patterns in time and power spectrum distribution domains. And fmax, fpeak and fmean declined while fc and PR800 rose at post-operation. Significant statistical differences existed in the change of fpeak and PR800 at pre- and post-operation (P < 0.01) .

CONCLUSION

Nasal cavity enlargement can lessen nasal resistance and change the acoustic characteristics of snoring in OSAHS patients. The postoperative snoring focus of lower frequency suggests that acoustic parameters of snores may be used to evaluate the efficacy of OSAHS surgery.

Pediatric polysomnography for sleep-disordered breathing prior to tonsillectomy: a guideline review

Snoring and other signs of sleep-disordered breathing (SDB) represent a common management challenge for the pediatrician, pulmonologist, anesthesiologist, and otolaryngologist. In 2011, the American Academy of Otolaryngology-Head and Neck Surgery published a clinical practice guideline for the treatment of patients with SDB. This guideline provides indications for polysomnography use in patients with SDB. In this article, we discuss the management of SDB in pediatric patients, which relies on the accurate assessment of symptoms of SDB, identification of comorbidities known to increase the severity of SDB, and appropriate preoperative assessment of the patient.

Radiofrequency uvulopalatoplasty for primary snoring

Simple snoring is a social problem, one that can gravely affect the patient's married life. About 40% of men and 20% of women are affected, and it often goes along with sleep-disordered breathing. Up to now various surgical techniques have been defined such as UPPP(uvulopalatopharyngo plasty), and laser-assisted uvulopalatoplasty (LAUP). Among the surgical methods, RAUP (radiofrequency assisted uvulopalatoplasty) is a minimal invasive, an easy performed, and time and cost effective one. We designed a before and after a clinical trial. The inclusion criteria were age >18 years, complaint of nocturnal snoring, have a bed partner to assess snoring, AHI<5 events per hour in the polysomnography, malampathy score (soft palate position) I or II, an elongated uvula, grade I and II of pharyngeal webbing and patient consent was needed too. A 10-score visual analog scale (VAS) of snoring severity was completed by bed partner. All of 35 included patients underwent RAUP under local anesthesia by the same expert surgeon. After 3 months, 6 months and one year, subjective snoring decreased significantly compared to the preoperative period. The decline in VAS in 6 month compared to 3 months postoperatively, was not significant (P=0.223). When comparing 1 year and 6 months after treatment, the VAS scores were increased, but they were not significant (From 1.8 to 1.9, P=0.78). Three months after treatment minor complications consisted of: nasal regurgitation in 2 patients (5.7%), nasal speech in 2 (5.7%) and exacerbation of snoring in 2 (5.7%) patients.There was no major complication including mucosal laceration, uvular damage and obstruction of the airway. The rate of snoring decrease did not correlate with age, sex and BMI. Based on this study and literature review, it seems RAUP is a safe surgery, which may decrease symptoms of snoring, at least, in short-term follow-up.

[Comparison the applications of tracheal intubation with GlideScope video laryngoscope and Macintosh direct laryngoscope in snoring patients]

OBJECTIVE

To compare the efficacy and safety of applications of GlideScope video laryngoscope (GSVL) and Macintosh direct laryngoscope (MDLS) during endotracheal intubation under general anesthesia of abdominal snoring surgeries.

METHOD

Forty patients ranged from American Society of Anesthesiologists I to II scheduled for snoring surgery under general anesthesia with endotracheal intubation were randomly divided into GSVL group and MDLS group (20 cases in each group), After traditional induction, endotracheal intubation (ETT) performed by GSVL or MDLS. Glottic exposure, the time of endotracheal intubation(from mask ventilation ending to successful intubation), the times of tracheal intubation operation were recorded in both groups. The mean artery pressure(MAP), heart rate(HR) were monitored before induction (basic value T0), before tracheal intubation (T1), after tracheal intubation (T2), 1 min after tracheal intubation (T3), 3 mins after tracheal intubation (T4).

RESULT

The glottic exposure of GSVL group is superior to that of MDLS group. There was no significant difference in the time of tracheal intubation between MDLS group (27 +/- 11)s and GSVL group (26 +/- 11)s (P < 0.05). Compared with T0, MAP of T1 was lower in two groups (P < 0.05), while HR were similar both in two groups (P > 0.05). MAP of T2 and T3 increased and HR became faster (P < 0.05). MAP of T4 declined, but HR still increased (P < 0.05). Between the two groups, there was no significant difference of MAP or HR (P > 0.05).

CONCLUSION

Compared with MDLS,the GSVL is of benefit to improve the glottic exposure in endotracheal intubation to the snoring patients,so as to improve the success rate of tracheal intubation. But there is no obvious advantages via GSVL in preventing hemodynamic reaction during tracheal intubation.

[Tonsillotomy]

In tonsillotomy, only the obstructive tonsillar tissue is removed without touching the surrounding tissue of the palatine tonsil. Tonsillotomies have been mainly performed for children due to tonsillar hypertrophy. Less postoperative pain is recorded after tonsillotomy compared with tonsillectomy. In addition, recovery is quicker and there are fewer complications. Tonsillotomy is an effective method in cases where the indication for surgery is tonsillar hypertrophy and associated symptoms such as snoring or difficulties in swallowing.