Sleep apnea multi-level surgery trial: long-term observational outcomes

STUDY OBJECTIVES

The sleep apnea multi-level surgery (SAMS) randomized clinical trial showed surgery improved outcomes at 6 months compared to ongoing medical management in patients with moderate or severe obstructive sleep apnea (OSA) who failed continuous positive airway pressure therapy. This study reports the long-term outcomes of the multi-level surgery as a case series.

METHODS

Surgical participants were reassessed >2 years postoperatively with the same outcomes reported in the main SAMS trial. Primary outcomes were apnea-hypopnea index (AHI) and Epworth sleepiness scale (ESS), with secondary outcomes including other polysomnography measures, symptoms, quality of life, and adverse events. Long-term effectiveness (baseline to long-term follow-up [LTFU]) and interval changes (6 month to LTFU) were assessed using mixed effects regression models. Control participants were also reassessed for rate of subsequent surgery and outcomes.

RESULTS

36/48 (75%) of surgical participants were reevaluated (mean (standard deviation)) 3.5 (1.0) years following surgery, with 29 undergoing polysomnography. AHI was 41/h (23) at preoperative baseline and 21/h (18) at follow-up, representing persistent improvement of -24/h (95% CI -32, -17; p < 0.001). ESS was 12.3 (3.5) at baseline and 5.5 (3.9) at follow-up, representing persistent improvement of -6.8 (95% CI -8.3, -5.4; p < 0.001). Secondary outcomes were improved long term, and adverse events were minor. Interval change analysis suggests stability of outcomes. 36/43 (84%) of the control participants were reevaluated, with 25 (69%) reporting subsequent surgery, with symptom and quality of life improvements.

CONCLUSION

Multi-level upper airway surgery improves OSA burden with long-term maintenance of treatment effect in adults with moderate or severe OSA in whom conventional therapy failed.

CLINICAL TRIAL

Multi-level airway surgery in patients with moderate-severe obstructive sleep apnea (OSA) who have failed medical management to assess change in OSA events and daytime sleepiness; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366019&isReview=true; ACTRN12614000338662.

Mean disease alleviation between surgery and continuous positive airway pressure in matched adults with obstructive sleep apnea

STUDY OBJECTIVES

Polysomnography parameters measure treatment efficacy for obstructive sleep apnea (OSA), such as reduction in apnea-hypopnea index (AHI). However, for continuous positive airway pressure (CPAP) therapy, polysomnography measures do not factor in adherence and thus do not measure effectiveness. Mean disease alleviation (MDA) corrects polysomnography measures for CPAP adherence and was used to compare treatment effectiveness between CPAP and multilevel upper airway surgery.

METHODS

This retrospective cohort study consisted of a consecutive sample of 331 patients with OSA managed with multilevel airway surgery as second-line treatment (N = 97) or CPAP (N = 234). Therapeutic effectiveness (MDA as % change or as corrected change in AHI) was calculated as the product of therapeutic efficacy (% or absolute change in AHI) and adherence (% time on CPAP of average nightly sleep). Cardinality and propensity score matching was utilized to manage confounding variables.

RESULTS

Surgery patients achieved greater MDA % than CPAP users (67 ± 30% vs. 60 ± 28%, p = 0.04, difference 7 ± 3%, 95% confidence interval 4% to 14%) in an unmatched comparison, despite a lower therapeutic efficacy seen with surgery. Cardinality matching demonstrated comparable MDA % in surgery (64%) and CPAP (57%) groups (p = 0.14, difference 8 ± 5%, 95% confidence interval -18% to 3%). MDA measured as corrected change in AHI showed similar results.

CONCLUSIONS

In adult patients with OSA, multilevel upper airway surgery and CPAP provide comparable therapeutic effectiveness on polysomnography. For patients with inadequate CPAP use, surgery should be considered.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Patient Factors and Preferences in Choosing Sleep Surgery for Obstructive Sleep Apnea: A Qualitative Study

OBJECTIVE

There are several obstructive sleep apnea (OSA) treatment options available to patients, including surgery and less invasive therapies. Little is known about the factors that influence patient preferences for treatment. We aimed to understand factors influencing patient experience and decision making for undergoing sleep surgery.

STUDY DESIGN

Retrospective qualitative study.

SETTING

Tertiary sleep surgery clinic.

METHODS

We conducted semistructured interviews with adults who previously underwent any nasal and/or pharyngeal sleep surgery. We asked open-ended questions about their decision-making process within a preconceived thematic framework of chief OSA symptoms, expectations for recovery, and sources of information. The interviews were audio recorded and transcribed, and content was analyzed for defined, emergent, and prevalent themes.

RESULTS

Ten patients were interviewed from December 11, 2020 through January 29, 2021. Six patients underwent nasal surgery, 1 underwent pharyngeal surgery, and 3 underwent staged nasal and pharyngeal procedures. All patients were beyond the acute recovery phase. Reasons for pursuing surgical consultation varied from sleep apnea burden to external factors, such as recommendations from significant others. Duration of sleep surgery consideration varied from months to years. Major concerns about sleep surgery involved anesthesia and postoperative pain. External factors influencing patients' decisions to pursue sleep surgery included family and friend support. Postoperative outcomes of surgery included patient satisfaction with decision for surgery, given OSA improvements.

CONCLUSION

Understanding patient factors that influence decision making for sleep surgery may guide clinicians in patient-centered counseling that engages patients in decision making, aligning with clinical symptoms and patient preferences.

Barriers and communication behaviors impacting referral to sleep surgery: qualitative patient perspectives

STUDY OBJECTIVES

Physician-patient interactions influence the immediate encounter and leave lasting impressions for future health care encounters. We aimed to understand patient experiences and decision-making for considering sleep surgery, in terms of barriers and communication behaviors that facilitate or hinder referral for consideration of sleep surgery management of obstructive sleep apnea (OSA) when continuous positive airway pressure (CPAP) therapy has failed.

METHODS

We employed qualitative methods, using semistructured interviews of adults with OSA who presented for sleep surgery consultation after unsatisfactory therapy with CPAP. Open-ended questions traced symptoms and progression of sleep apnea burden, trials of noninvasive OSA therapies, outcomes, and patient expectations and concerns. The interviews were audio-recorded, transcribed, and analyzed using content analysis to identify themes.

RESULTS

Ten adult patients with OSA were enrolled March through April 2021 and reached predominant thematic saturation. Barriers to sleep surgery consultation included: (1) delays in OSA diagnosis due to limited OSA awareness among patients or primary providers and patients' perceived inconvenience of sleep testing, (2) patients faulted for slow progress, (3) patient-reported lack of urgency by providers in troubleshooting noninvasive management options, (4) scheduling delays and waitlists, and (5) cost. Patients were receptive to noninvasive treatment options, but inadequate improvement led to frustration after multiple encounters. Patients appreciated empathetic providers who shared information through transparent and understandable explanations and who presented multiple treatment options.

CONCLUSIONS

Experiences of patients with OSA highlight the need for shared decision-making through improved communication of unresolved concerns and alternative management options, including timely referral for sleep surgery consultation when indicated.

CITATION

Ikeda AK, McShay C, Marsh R, et al. Barriers and communication behaviors impacting referral to sleep surgery: qualitative patient perspectives. J Clin Sleep Med. 2023;19(1):111-117.

Use of computational fluid dynamics (CFD) to model observed nasal nitric oxide levels in human subjects

BACKGROUND

Upper airway nitric oxide (NO) is physiologically important in airway regulation and defense, and nasal NO (nNO) levels typically exceed those in exhaled breath (fractional exhaled NO [FeNO]). Elevated concentrations of NO sampled from the nose, in turn, reflect even higher concentrations in the paranasal sinuses, suggesting a "reservoir" role for the latter. However, the dynamics of NO flux within the sinonasal compartment are poorly understood.

METHODS

Data from 10 human subjects who had previously undergone both real-time nNO sampling and computed tomography (CT) scanning of the sinuses were analyzed using computational fluid dynamics (CFD) methods. Modeled and observed nNO values during the initial 2-s transient ("spike") during nasal exhalation were then compared.

RESULTS

Examining the initial 2-s transient spike for each subject (as well as the pooled group), there was a statistically significant correlation between modeled and observed nNO levels, with r values ranging from 0.43 to 0.89 (p values ranging from <0.05 to <0.0001). Model performance varied between subjects, with weaker correlations evident in those with high background (FeNO) levels. In addition, the CFD simulation suggests that ethmoid sinuses (>60%) and diffusion process (>54%) contributed most to total nasal NO emissions.

CONCLUSION

Analysis of this dataset confirms that CFD is a valuable modeling tool for nNO dynamics, and highlights the importance of the ethmoid sinuses, as well as the role of diffusion as an initiating step in sinonasal NO flux. Future model iterations may apply more generally if baseline FeNO is taken into account.

Association of Laryngeal Botulinum Neurotoxin Injection With Work Productivity for Patients With Spasmodic Dysphonia

Importance

A disordered voice can affect an individual across both work and non-work-related life domains. There is insufficient research on the effect of spasmodic dysphonia or its treatment with botulinum neurotoxin (BoNT) injections on work productivity.

Objective

To assess whether employed patients with spasmodic dysphonia experience voice-related work productivity impairment before BoNT injection, and had a 10% or greater improvement in productivity 1 month after treatment with BoNT injection.

Design, Setting, and Particpants

This prospective case series carried out in 2 laryngology outpatient clinics from November 1, 2015, to August 30, 2018 included a consecutive sample of adult employed patients diagnosed with spasmodic dysphonia. Analysis was conducted between November 1, 2015, to July 31, 2018.

Exposures

Treatment with BoNT injection into the intrinsic laryngeal musculature.

Main Outcomes and Measures

Eligible participants completed the following validated outcomes instruments immediately before and 1 month after outpatient laryngeal BoNT injection: the Work Productivity and Activity Impairment instrument (WPAI), Voice Handicap Index (VHI), and WorkHoarse. Demographic, comorbidity, and occupational voice use data were also collected at baseline. The changes in outcome measures (primary, WPAI Work Productivity Impairment domain) were tested using a paired 2-tailed t test. Exploratory subgroup analyses were analyzed with multivariable linear regression, adjusting for demographic, comorbidity, and voice use variables.

Results

Of the 101 patients enrolled, 75 completed the study. The mean (SD) age of the 75 completing participants was 55.7 (11.8) years and 53 (71%) were women. The participants who completed the study had mean (SD) voice-related work productivity impairment of 43% (27%) at baseline and 22% (23%) at 1 month after BoNT injection (difference, 20% [27%] improvement; 95% CI, 14%-27%; effect size, 0.74).

Conclusions and Relevance

This case series study found that employed patients with spasmodic dysphonia reported voice-related work productivity impairment, which improved significantly 1 month after treatment with BoNT injection. The association of spasmodic dysphonia with voice-related work productivity appeared greater in women than men with comparable outcomes with BoNT treatment, but this exploratory sex-associated difference requires independent validation.

Volumetric MRI analysis of Multilevel Upper Airway Surgery effects on pharyngeal structure

STUDY OBJECTIVES

The Sleep Apnea Multilevel Surgery (SAMS) trial found that modified uvulopalatopharyngoplasty with tonsillectomy (if tonsils present) combined with radiofrequency tongue ablation reduced obstructive sleep apnea (OSA) severity and daytime sleepiness in moderate-severe OSA. This study aimed to investigate mechanisms of effect on Apnoea-Hypopnoea Index (AHI) reduction by assessing changes in upper airway volumes (airway space, soft palate, tongue, and intra-tongue fat).

METHODS

This is a case series analysis of forty-three participants of 51 randomized to the surgical arm of SAMS trial who underwent repeat magnetic resonance imaging (MRI). Upper airway volume, length, and cross-sectional area, soft palate and tongue volumes and tongue fat were measured. Relationships between changes in anatomical structures and apnea-hypopnea index (AHI) were assessed.

RESULTS

The participant sample was predominantly male (79%); mean ± SD age 42.7 ± 13.3 years, body mass index 30.8 ± 4.1 kg.m 2, and AHI 47.0 ± 22.3 events/hour. There were no, or minor, overall volumetric changes in the airway, soft palate, total tongue, or tongue fat volume. Post-surgery there was an increase in the minimum cross-sectional area by 0.1 cm 2 (95% confidence interval 0.04-0.2cm 2) in the pharyngeal airway, but not statistically significant on corrected analysis. There was no association with anatomical changes and AHI improvement.

CONCLUSIONS

This contemporary multi-level upper airway surgery has been shown to be an effective OSA treatment. The current anatomical investigation suggests there are not significant post-operative volumetric changes associated with OSA improvement six-months post-surgery. This suggests that effect on OSA improvement is achieved without notable deformation of airway volume. Reduced need for neuromuscular compensation during wake following anatomical improvement via surgery could explain lack of measurable volume change. Further research to understand the mechanisms of action of multilevel surgery is required.

Association of Allergic Rhinitis With Change in Nasal Congestion in New Continuous Positive Airway Pressure Users

Importance

Nasal congestion occurring after continuous positive airway pressure (CPAP) treatment initiation impairs CPAP adherence. Allergic rhinitis is associated with worsening nasal congestion in patients who are exposed to nonallergic triggers. Use of CPAP presents potential nonallergic triggers (eg, humidity, temperature, pressure, and airflow).

Objective

To compare nasal congestion among CPAP users with allergic rhinitis, nonallergic rhinitis, and no rhinitis. We hypothesize that CPAP patients with baseline allergic rhinitis are more likely to experience a worsening of nasal congestion (or less improvement in nasal congestion) compared with patients with no baseline rhinitis.

Design, Setting, and Participants

This prospective cohort study included consecutive patients newly diagnosed with obstructive sleep apnea in a tertiary sleep center who were using CPAP therapy 3 months after diagnosis. Baseline rhinitis status was assigned as allergic rhinitis, nonallergic rhinitis, or no rhinitis, based on questionnaire responses and past allergy testing. Data were collected from 2004 to 2008 and analyzed from July 2019 to February 2020.

Main Outcomes and Measures

At baseline before CPAP exposure and again 3 months later, subjective nasal congestion was measured with the Nasal Obstruction Symptom Evaluation (NOSE) scale and a visual analog scale (VAS), each scored from 0 to 100 (100 = worst congestion). Changes in nasal congestion were tested over 3 months for the whole cohort, within each rhinitis subgroup (paired t test), and between rhinitis subgroups (multivariate linear regression).

Results

The study cohort comprised 102 participants, of whom 61 (60%) were male and the mean (SD) age was 50 (13). The study included 23 (22.5%) participants with allergic rhinitis, 67 (65.7%) with nonallergic rhinitis, and 12 (11.8%) with no rhinitis. Nasal congestion improved from baseline to 3 months in the whole cohort (mean [SD] NOSE score, 38 [26] to 27 [23], mean [SD] change, -10 [23]; 95% CI, -15 to -6; mean [SD] VAS score, 41 [27] to 32 [28]; mean [SD] change, -10 [26]; 95% CI, [-15 to -4]) and in each rhinitis subgroup. Adjusted improvement in nasal congestion at 3 months was significantly less in the allergic rhinitis subgroup compared with the no rhinitis subgroup (positive difference means less improvement) compared with baseline: NOSE score 14 (95% CI, 1 to 28) and VAS score 15 (95% CI, 0 to 30).

Conclusions and Relevance

Initiation of CPAP was associated with improved subjective nasal congestion, but less improvement in patients with baseline allergic rhinitis. Baseline allergic rhinitis may predict which patients are more vulnerable to potential congestive effects of CPAP.

Effect of Multilevel Upper Airway Surgery vs Medical Management on the Apnea-Hypopnea Index and Patient-Reported Daytime Sleepiness Among Patients With Moderate or Severe Obstructive Sleep Apnea: The SAMS Randomized Clinical Trial

IMPORTANCE

Many adults with obstructive sleep apnea (OSA) use device treatments inadequately and remain untreated.

OBJECTIVE

To determine whether combined palatal and tongue surgery to enlarge or stabilize the upper airway is an effective treatment for patients with OSA when conventional device treatment failed.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, parallel-group, open-label randomized clinical trial of upper airway surgery vs ongoing medical management. Adults with symptomatic moderate or severe OSA in whom conventional treatments had failed were enrolled between November 2014 and October 2017, with follow-up until August 2018.

INTERVENTIONS

Multilevel surgery (modified uvulopalatopharyngoplasty and minimally invasive tongue volume reduction; n = 51) or ongoing medical management (eg, advice on sleep positioning, weight loss; n = 51).

MAIN OUTCOMES AND MEASURES

Primary outcome measures were the apnea-hypopnea index (AHI; ie, the number of apnea and hypopnea events/h; 15-30 indicates moderate and >30 indicates severe OSA) and the Epworth Sleepiness Scale (ESS; range, 0-24; >10 indicates pathological sleepiness). Baseline-adjusted differences between groups at 6 months were assessed. Minimal clinically important differences are 15 events per hour for AHI and 2 units for ESS.

RESULTS

Among 102 participants who were randomized (mean [SD] age, 44.6 [12.8] years; 18 [18%] women), 91 (89%) completed the trial. The mean AHI was 47.9 at baseline and 20.8 at 6 months for the surgery group and 45.3 at baseline and 34.5 at 6 months for the medical management group (mean baseline-adjusted between-group difference at 6 mo, -17.6 events/h [95% CI, -26.8 to -8.4]; P < .001). The mean ESS was 12.4 at baseline and 5.3 at 6 months in the surgery group and 11.1 at baseline and 10.5 at 6 months in the medical management group (mean baseline-adjusted between-group difference at 6 mo, -6.7 [95% CI, -8.2 to -5.2]; P < .001). Two participants (4%) in the surgery group had serious adverse events (1 had a myocardial infarction on postoperative day 5 and 1 was hospitalized for observation following hematemesis of old blood).

CONCLUSIONS AND RELEVANCE

In this preliminary study of adults with moderate or severe OSA in whom conventional therapy had failed, combined palatal and tongue surgery, compared with medical management, reduced the number of apnea and hypopnea events and patient-reported sleepiness at 6 months. Further research is needed to confirm these findings in additional populations and to understand clinical utility, long-term efficacy, and safety of multilevel upper airway surgery for treatment of patients with OSA.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12614000338662.

Development of a Sleep Apnea-Specific Health State Utility Algorithm

Importance

With the increasing emphasis on economic evaluations, there is a need for additional methods of measuring patient utility in the obstructive sleep apnea population.

Objective

To develop and validate a utility scoring algorithm for a sleep apnea-specific quality-of-life instrument.

Design, Setting, and Participants

Development and validation were conducted at 2 tertiary referral sleep centers and associated sleep clinics and included patients with newly diagnosed obstructive sleep apnea from a randomized clinical trial and an associated observational cohort study. Baseline participants were randomly divided into a model development group (60%) and a cross-validation group (40%).

Main Outcomes and Measures

Utility scoring of the Symptoms of Nocturnal Obstruction and Related Events (SNORE-25) was mapped from the SF-6D utility index through multiple linear regression in the development sample using the Akaike information criterion to determine the best model.

Results

A total of 500 participants (development, n = 300; validation, n = 200) were enrolled; the analyzed sample of 500 participants included 295 men (59%), and the mean (SD) age was 48.6 (12.8) years, with a range of 18 to 90 years. The mean (SD) SF-6D utility among participants with untreated sleep apnea was 0.61 (0.08; range, 0.40-0.85) with similar utility across sleep apnea severity groups. The best-fit model (the SNORE Utility Index) was the natural log conversion of the instrument subscales (r2 = 0.32 in the development sample). The SNORE Utility Index retained this association within the validation sample (r2 = 0.33).

Conclusions and Relevance

The SNORE Utility Index provides a validated, disease-specific, preference-weighted utility instrument that can be used in future studies of patients with obstructive sleep apnea.

The Association of Sleep Apnea and Cancer in Veterans

Objective

To test the association between preexisting obstructive sleep apnea (OSA) and subsequent cancer in a large long-term cohort of veteran patients.

Study Design

Retrospective matched cohort study.

Setting

The Veterans Affairs Health Care System.

Subjects and Methods

All veteran patients diagnosed with OSA between 1993 and 2013 by International Classification of Diseases, Ninth Revision ( ICD-9) codes in any Veterans Affairs facility and veteran patients without an OSA diagnosis, matched to patients with OSA by age and index year. Cancer diagnoses were identified by ICD-9 codes for the time period at least 2 years after OSA diagnosis or index date. We tested the association between OSA and cancer using multivariate Cox regression with time since cohort entry as the time axis, adjusting for potential confounders.

Results

The cohort included 1,377,285 patients (726,008 with and 651,277 without an OSA diagnosis) with mean age of 55 years, predominantly male (94%), a minority obese (32%), and median follow-up of 7.4 years (range, 2.0-25.2). The proportion of patients diagnosed with cancer was higher in those with vs without an OSA diagnosis (8.3% vs 3.6%; mean difference 4.8%; 95% confidence interval [CI], 4.7%-4.8%; P < .001). After adjusting for age, sex, year of cohort entry, smoking status, alcohol use, obesity, and comorbidity, the hazard of incident cancer was nearly double in patients with vs without an OSA diagnosis (hazard ratio, 1.97; 95% CI, 1.94-2.00; P < .001).

Conclusion

Preexisting OSA was strongly associated with subsequent cancer in this veteran cohort, independent of several known cancer risk factors. These findings suggest that OSA may be a strong, independent risk factor for subsequent cancer development.

Obstructive sleep apnea in obese minipigs

Objective:

Obesity has reached epidemic proportions and is a strong risk factor for obstructive sleep apnea (OSA). However, the underlying mechanisms are poorly understood and current treatment strategies for OSA and obesity have critical limitations. Thus, establishment of an obesity-related large animal model with spontaneous OSA is imperative.

Materials and methods:

Natural and sedated sleep were monitored and characterized in 4 obese (body mass index - BMI>48) and 3 non-obese (BMI<40) minipigs. These minipigs were instrumented with the BioRadio system under sedation for the wireless recording of respiratory airflow, snoring, abdominal and chest respiratory movements, electroencephalogram, electrooclulogram, electromyogram, and oxygen saturation. After instrumentation, the minipigs were placed in a dark room with a remote night-vision camera for monitoring all behaviors. Wakefulness and different sleep stages were classified, and episodes of apneas and/or hypopneas were identified during natural and/or sedated sleep.

Results:

No hypopnea episodes were observed in two of the non-obese minipigs, but one non-obese minipig had 5 hypopnea events. Heavy snoring and 27-58 apnea and/or hypopnea episodes were identified in all 4 obese minipigs. Most of these episodes occurred in the rapid eye movement stage during natural sleep and/or sedated sleep in Yucatan minipigs.

Conclusions:

Obese minipigs can experience naturally occurring OSA, thus are an ideal large animal model for obese-related OSA studies.

Sleep Apnea Multilevel Surgery (SAMS) trial protocol: a multicenter randomized clinical trial of upper airway surgery for patients with obstructive sleep apnea who have failed continuous positive airway pressure

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is a serious and costly public health problem. The main medical treatment, continuous positive airway pressure, is efficacious when used, but poorly tolerated in up to 50% of patients. Upper airway reconstructive surgery is available when medical treatments fail but randomized trial evidence supporting its use is limited. This protocol details a randomized controlled trial designed to assess the clinical effectiveness, safety, and cost-effectiveness of a multilevel upper airway surgical procedure for OSA.

METHODS

A prospective, parallel-group, open label, randomized, controlled, multicenter clinical trial in adults with moderate or severe OSA who have failed or refused medical therapies. Six clinical sites in Australia randomly allocated participants in a 1:1 ratio to receive either an upper airway surgical procedure consisting of a modified uvulopalatopharyngoplasty and minimally invasive tongue volume reduction, or to continue with ongoing medical management, and followed them for 6 months.

RESULTS

Primary outcomes: difference between groups in baseline-adjusted 6 month OSA severity (apnea-hypopnea index) and subjective sleepiness (Epworth Sleepiness Scale). Secondary outcomes: other OSA symptoms (e.g. snoring and objective sleepiness), other polysomnography parameters (e.g. arousal index and 4% oxygen desaturation index), quality of life, 24 hr ambulatory blood pressure, adverse events, and adherence to ongoing medical therapies (medical group).

CONCLUSIONS

The Sleep Apnea Multilevel Surgery (SAMS) trial is of global public health importance for testing the effectiveness and safety of a multilevel surgical procedure for patients with OSA who have failed medical treatment.

CLINICAL TRIAL REGISTRATION

Multilevel airway surgery in patients with moderate-severe Obstructive Sleep Apnea (OSA) who have failed medical management to assess change in OSA events and daytime sleepiness. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366019&isReview=true Australian New Zealand Clinical Trials Registry ACTRN12614000338662, prospectively registered on 31 March 2014.

Predictors of Obtaining Polysomnography Among Otolaryngologists Prior to Adenotonsillectomy for Childhood Sleep-Disordered Breathing

STUDY OBJECTIVES

(1) To assess the predictors for obtaining polysomnography (PSG) in children undergoing adenotonsillectomy (AT) for sleep-disordered breathing, and (2) to estimate the adherence to the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guideline recommendations for pre-AT PSG.

METHODS

This was a retrospective cohort study of children who were seen in the Pediatric Otolaryngology Clinic and underwent AT for sleep-disordered breathing over a 13-month period at a single tertiary care children's hospital. Patients with and without pre-AT PSG were compared using bivariate and logistic regression analysis to identify predictors for PSG. Electronic medical records were reviewed for demographic variables, medical comorbidities, and PSG data. Adherence to AAO-HNS guideline recommendations was estimated by calculating the proportion of patients who had a PSG among those who met the recommended criteria for pre-AT PSG.

RESULTS

Mean age was 6.6 ± 3.6 years with 53% male. A total of 65 of 324 children (20%) underwent PSG prior to AT. The only factor significantly associated with pre-AT PSG was age 1 to 3 years (odds ratio 4.5, 95% confidence interval [2.2, 9.0], P < .001). Among patients who met AAO-HNS criteria for pre-AT PSG, 28 of 128 (20%) underwent PSG compared to 35 of 186 (19%) who did not meet criteria (odds ratio 1.0, 95% confidence interval [0.6, 1.9], P = .87).

CONCLUSIONS

Among children who underwent AT, the only significant predictor of obtaining pre-AT PSG was age 1 to 3 years. The rate of adherence to the AAO-HNS guideline recommendations was low (20%), which represents an educational opportunity.

Association of Continuous Positive Airway Pressure Treatment With Sexual Quality of Life in Patients With Sleep Apnea: Follow-up Study of a Randomized Clinical Trial

Importance

Obstructive sleep apnea reduces sexual quality of life (QOL) as a result of reduced libido and intimacy, erectile dysfunction, and several other mechanisms. Treatment for obstructive sleep apnea may improve sexual QOL.

Objective

To test the association of long-term continuous positive airway pressure (CPAP) treatment with sexual QOL for patients with obstructive sleep apnea.

Design, Setting, and Participants

Prospective cohort study at a single, tertiary medical center of patients with newly diagnosed obstructive sleep apnea who were prescribed CPAP treatment from September 1, 2007, through June 30, 2010 (follow-up completed June 30, 2011). The statistical analysis was performed from February 1 through December 31, 2017.

Exposures

Use of CPAP treatment objectively measured by the number of hours per night. Users of CPAP were defined as patients who used CPAP treatment for more than 4 hours per night, and nonusers were defined as patients who used CPAP treatment for fewer than 0.5 hours per night.

Main Outcomes and Measures

Data were collected from eligible patients before CPAP treatment was prescribed and 12 months later by using the validated Symptoms of Nocturnal Obstruction and Related Events-25 (SNORE-25) QOL instrument. The 2 sex-specific items used to create the sexual QOL domain were taken from the SNORE-25. The sexual QOL domain was scored in a range from 0 to 5 (higher score is worse). The difference in sexual QOL between CPAP users and nonusers was analyzed using a paired, 2-tailed t test and multivariable linear regression adjusted for potential confounders.

Results

Of the 182 participants in the cohort, 115 (63.2%) were men (mean [SD] age, 47.2 [12.3] years) with severe OSA (mean [SD] apnea-hypopnea index, 32.5 [23.8] events per hour). At the 12-month follow-up, 72 CPAP users (mean [SD] use, 6.4 [1.2] hours per night) had greater improvement than 110 nonusers (0 [0] hours per night) in sexual QOL scores (0.7 [1.2] vs 0.1 [1.1]; difference, 0.54; 95% CI, 0.18-0.90; effect size, 0.47). A moderate treatment association was observed after adjustment for age, sex, race/ethnicity, marital status, income level, educational level, body mass index, apnea-hypopnea index, and the Functional Comorbidity Index (adjusted difference, 0.49; 95% CI, 0.09-0.89; effect size, 0.43). Subgroup analysis revealed a large treatment association for women (adjusted difference, 1.34; 95% CI, 0.50-2.18; effect size, 0.87) but not for men (adjusted difference, 0.16; 95% CI, -0.26 to 0.58; effect size, 0.19).

Conclusions and Relevance

Successful CPAP use may be associated with improved sexual QOL. Subgroup analysis revealed a large improvement in women but no improvement in men. Further study is warranted to test other measures of sexual QOL and other treatments.

Trial Registration

ClinicalTrials.gov Identifier: NCT00503802.

Surgical specialty and preoperative medical consultation based on commercial health insurance claims

Background

Surgical patients are sometimes referred for preoperative evaluations by consultants in other medical specialties, although consultations are unnecessary for many patients, particularly for healthy patients undergoing low-risk surgeries. Surgical specialty has been shown to predict usage of preoperative consultations. However, evidence is generally limited regarding factors associated with preoperative consultations. This study evaluates surgical specialty and other predictors of preoperative consultations.

Methods

This retrospective cohort study analyzed surgery claims of 7400 privately insured patients in Washington, United States, from eight surgical specialties. We estimated log-Poisson generalized estimating equation models that regress whether a patient received a consultation on surgical specialty and covariates accounting for the data’s hierarchical structure with patients nesting within surgeons, and surgeons nesting within provider organizations. Covariates include age, gender, Deyo comorbidity index, surgical risk, and geographic factors.

Results

Overall, 485 (6.6%) patients had a preoperative consultation. The incidence of preoperative consultation varied significantly by surgical specialty. Orthopedics, neurosurgery, and ophthalmology had 3.9 (95% CI 2.4, 6.5), 2.3 (95% CI 1.1, 4.5), and 2.3 (95% CI 1.1, 4.6) times greater adjusted likelihoods of preoperative consultation than general surgery, respectively. The adjusted likelihoods of consultation for gynecology, urology, otolaryngology, and vascular surgery were not statistically different from general surgery. The following covariates were associated with greater likelihood of preoperative consultation: greater age, higher surgical risk, having one or more comorbidities vs. none, and small rural towns vs. urban areas. More than 75% of all consultations were provided to patients with a Deyo comorbidity index of 0 or 1. Low surgical risk patients had 0.3 (95% CI 0.3, 0.5) times the likelihood of preoperative consultation of intermediate and high-risk patients overall.

Conclusions

The likelihood of preoperative consultation varied fourfold (an absolute 9% points) across surgical specialties. Most consultations were provided to patients with low comorbidity and with low or intermediate surgical risk. To improve usage of preoperative consultations as an evidence-based practice, future research should determine how the health outcomes effects of preoperative consultations vary depending on comorbidity burden and surgical risk.

Association of palatine tonsil size and obstructive sleep apnea in adults

OBJECTIVE

The relationship between palatine tonsil (PT) size and obstructive sleep apnea (OSA) has not been well established in adults. The purpose of this study was to test the association between PT grade, PT volume, and OSA severity in U.S. adult patients.

STUDY DESIGN

Cross-sectional study of all patients (age ≥ 18 years) who underwent pharyngeal surgery for OSA that included palatine tonsillectomy with tonsil volume measurement from January 2011 to June 2016.

METHODS

Medical records were reviewed for PT grade (measured on clinical exam by the Brodsky tonsil grading scale), PT volume (measured intraoperatively by water displacement), and apnea-hypopnea index (AHI). Associations were evaluated with multivariate linear regression adjusting for age, sex, body mass index (BMI), smoking status, lingual tonsil volume (AHI models only), and multilevel surgery aside from lingual tonsillectomy (PT volume vs. AHI model only).

RESULTS

The cohort (N = 83) was middle-aged (mean age 43 ± 12 years), predominantly male (61%), obese (mean BMI 33 ± 7 kg/m² ), and had severe OSA (mean AHI 32 ± 28). After adjustment for confounders, PT grade was strongly associated with PT volume (beta = 1.8, 95% confidence interval [CI]: [1.0, 2.6], P < 0.001) and with AHI (beta = 13.5, 95% CI: [3.5, 23.6], P = 0.01); PT volume was not associated with AHI (beta = -0.2, 95% CI: [-2.2, 1.9], P = 0.89).

CONCLUSION

In contrast to past studies, subjective PT grade (vs. objective PT volume) was more strongly associated with AHI. These data suggest the space that the tonsils occupy within the oropharyngeal airway, instead of their actual measured volume, may be more predictive of OSA severity in a cohort of U.S. adult patients.

LEVEL OF EVIDENCE

2c. Laryngoscope, 128:1002-1006, 2018.

Association between Snoring and High-Risk Carotid Plaque Features

Objectives Previous studies have demonstrated an association between snoring and carotid disease independent of sleep apnea. The aim of this study was to quantify the association between self-reported snoring and high-risk carotid plaque features on magnetic resonance imaging (MRI) that predict stroke. Study Design Cross-sectional. Setting Tertiary care university hospital and affiliated county hospital. Methods We surveyed 133 subjects with asymptomatic carotid artery disease that had been previously evaluated with high-resolution MRI. The survey captured data on self-reported snoring (exposure) and covariates (age, sex, body mass index, and sleep apnea via the STOP-Bang questionnaire). A subset of patients underwent home sleep apnea testing. High-risk carotid plaque features were identified on the high-resolution MRI and included thin/ruptured fibrous cap and intraplaque hemorrhage (outcomes). We quantified the association between snoring and high-risk carotid plaque features with the chi-square test (unadjusted analysis) and multivariate logistic regression adjusting for the covariates. Results Of 133 subjects surveyed, 61 (46%) responded; 32 (52%) reported snoring. Significantly higher proportions of snorers than nonsnorers had a thin/ruptured fibrous cap (56% vs 25%, P = .01) and intraplaque hemorrhage (63% vs 29%, P < .01). In multivariate analysis, snoring was associated with thin/ruptured fibrous cap (odds ratio, 4.4; 95% CI, 1.1-16.6; P = .04) and intraplaque hemorrhage (odds ratio, 8.2; 95% CI, 2.1-31.6; P < .01) after adjusting for age, sex, body mass index, and sleep apnea. Conclusion This pilot study suggests a significant independent association between snoring and high-risk carotid plaque features on MRI. Further study is warranted to confirm these results in a larger cohort of subjects.

Multilevel Obstructive Sleep Apnea Surgery

Continuous positive airway pressure (CPAP) is the primary treatment of obstructive sleep apnea/hypopnea syndrome (OSA). Most sleep physicians are in agreement that a certain number of OSA patients cannot or will not use CPAP. Although other conservative therapies, such as oral appliance, sleep hygiene, and sleep positioning, may help some of these patients, there are many who fail all conservative treatments. As sleep surgeons, we have the responsibility to screen patients for both symptoms and signs of OSA. As experts of upper airway diseases, we often view an airway clearly and help the patient understand the importance of assessment and treatment for OSA. Surgery for OSA is not a substitute for CPAP but is a salvage treatment for those who failed CPAP and other conservative therapies and therefore have no other options. Most early studies and reviews focused on the efficacy of uvulopalatopharyngoplasty, a single-level procedure for the treatment of OSA. Since OSA is usually caused by multilevel obstructions, the true focus on efficacy should be on multilevel surgical intervention. The purpose here is to provide an updated overview of multilevel surgery for OSA patients.

Predicting CPAP Use and Treatment Outcomes Using Composite Indices of Sleep Apnea Severity

STUDY OBJECTIVES

Measures of baseline sleep apnea disease burden (apnea-hypopnea index, Epworth Sleepiness Scale) predict continuous positive airway pressure (CPAP) adherence, but composite indices of sleep apnea severity (Sleep Apnea Severity Index, Modified Sleep Apnea Severity Index) may be more robust measures of disease burden. We tested the relative prognostic ability of each measure of sleep apnea disease burden to predict subsequent CPAP adherence and subjective sleep outcomes.

METHODS

Prospective cohort study at a tertiary academic sleep center. Patients (n = 323) underwent initial diagnostic polysomnography for suspected obstructive sleep apnea and 6 mo of subsequent CPAP therapy.

RESULTS

Baseline apnea-hypopnea index and both composite indices predicted adherence to CPAP therapy at 6 mo in multivariate analyses (all p ≤ 0.001). Baseline Epworth Sleepiness Scale did not predict CPAP adherence (p = 0.22). Both composite indices were statistically stronger predictors of CPAP adherence at 6 mo than apnea-hypopnea index (p < 0.001). In multivariate analyses, baseline apnea-hypopnea index (p < 0.05) and both composite indices (both p < 0.04) predicted change in Pittsburgh Sleep Quality Index, whereas only the composite indices predicted changes in Sleep Apnea Quality of Life Index (both p < 0.001). Adjustment for treatment adherence did not affect the relationship of the composite indices with change in Sleep Apnea Quality of Life Index (both p ≤ 0.005).

CONCLUSIONS

Composite indices of baseline sleep apnea severity better predict objective CPAP adherence and subjective treatment outcomes than baseline apnea-hypopnea index and baseline Epworth Sleepiness Scale.

Multilevel Temperature-Controlled Radiofrequency for Obstructive Sleep Apnea: Extended Follow-Up

OBJECTIVE: To determine long-term effectiveness of multilevel (tongue and palate) temperature-controlled radiofrequency tissue ablation (TCRFTA) for patients with obstructive sleep apnea syndrome (OSAS).

STUDY DESIGN AND SETTING: Prospective, 2-institution case series. Twenty-nine subjects with mild to moderate OSAS and who were at least 1 year from completion of multilevel TCRFTA were included, representing a subset of subjects who were enrolled in a previously published controlled trial. Exclusion criteria for this extended follow-up study included any additional treatment for OSAS after completion of TCRFTA.

RESULTS: Median follow-up was 23 months. Daytime sleepiness and OSAS-related quality of life were significantly improved at extended follow-up (both P 0.001). Median reaction time testing and apnea-hypopnea index (AHI) were also significantly improved at long-term follow-up ( P = 0.03 and 0.01). Body mass index was unchanged ( P = 0.94).

CONCLUSIONS: Multilevel TCRFTA treatment of mild to moderate OSAS resulted in prolonged improvement in daytime somnolence, OSAS-related quality of life, psychomotor vigilance, and AHI in this group of subjects at extended follow-up.

Polysomnography indexes are discordant with quality of life, symptoms, and reaction times in sleep apnea patients

OBJECTIVE: We tested whether polysomnography (PSG) indexes were associated with sleepiness, quality of life, or reaction times at baseline and as outcome measures following surgical or sham treatment for patients with obstructive sleep apnea syndrome (OSAS).

STUDY DESIGN AND METHODS: Mild-moderate OSAS subjects were measured before and 8 weeks after surgical or sham treatment in this prospective longitudinal study. Measures included standard PSG indexes, sleepiness, quality of life, and reaction times. Associations were examined with Spearman correlations and multivariate linear regression.

RESULTS: Correlations between baseline PSG and non-PSG measures ranged from −0.22 to 0.25 (n, 87 subjects; mean correlation, 0.00 ± 0.11), with one positive association significant of 56 tested (arousal index and SF36 Mental Component Summary, r, 0.25; P = 0.03). Correlations between change in PSG and non-PSG measures ranged from −0.37 to 0.35 (n, 54 subjects; mean correlation, −0.05 ± 0.19), with no significant positive association of 56 tested. Regression analyses confirmed these results.

CONCLUSIONS: PSG indexes are not consistently associated with sleepiness, quality of life, or reaction time, both at baseline and as outcome measures in patients with mild-moderate OSAS. PSG indexes may not quantify some important aspects of OSAS disease burden or treatment outcome. Clinically important outcomes should be measured directly. EBM rating: A.

Development and Validation of the Nasal Obstruction Symptom Evaluation (NOSE) Scale

OBJECTIVE

The study goal was to validate a disease-specific health status instrument for use in patients with nasal obstruction.Design, settings, and patients The study consisted of a prospective instrument validation conducted at 4 academic medical centers with 32 adults with nasal septal deformity.

METHODS

Prospective instrument validation occurred in 2 stages. Stage 1 was the development of a preliminary (alpha-version) instrument of potential items. Stage 2 was a test of the alpha-version for item performance, internal consistency, and test-retest reliability; construct, discriminant, criterion validity, and responsiveness; and creation of the final instrument.

RESULTS

Items with poor performance were eliminated from the alpha-version instrument. In testing the final instrument, test-retest reliability was adequate at 0.702; internal consistency reliability was also adequate at 0.785. Validity was confirmed using correlation and comparison analysis, and response sensitivity was excellent.

CONCLUSIONS

The Nasal Obstruction Symptom Evaluation Scale is a valid, reliable, and responsive instrument that is brief and easy to complete and has potential use for outcomes studies in adults with nasal obstruction.

Assessment of pediatric obstructive sleep apnea using a drug-induced sleep endoscopy rating scale

OBJECTIVES/HYPOTHESIS

Assess the reliability of a Sleep Endoscopy Rating Scale (SERS) and its relationship with pediatric obstructive sleep apnea (OSA) severity.

STUDY DESIGN

Retrospective case series of pediatric patients who underwent drug-induced sleep endoscopy (DISE) at the time of surgery for OSA from January 1, 2013 to May 1, 2014.

METHODS

Three blinded otolaryngologists scored obstruction on DISE recordings as absent (0), partial (+1), or complete (+2) at six anatomic levels: nasal airway, nasopharynx, velopharynx, oropharynx, hypopharynx, and arytenoids. Ratings were summed for a SERS total score (range, 0-12). Reliability was calculated using a κ statistic with linear weighting. SERS ratings and obstructive apnea-hypopnea index (OAHI) were compared using Spearman correlation. A receiver operating characteristic (ROC) analysis determined the ability of the SERS total score to predict severe OSA (OAHI >10).

RESULTS

Thirty-nine patients were included (mean age, 8.3 ± 5.1 years; 36% obese; mean OAHI, 19.1 ± 23.7). Intrarater and inter-rater reliability was substantial-to-excellent (κ = 0.61-0.83) and fair-to-substantial (κ = 0.33-0.76), respectively. Ratings correlated best with OAHI for the oropharynx (r = 0.54, P = .02), hypopharynx (r = 0.48, P = .04), and SERS total score (r = 0.75, P = .002). In ROC analysis, a SERS total score ≥6 demonstrated sensitivity/specificity of 81.8%/87.5%, respectively, and correctly classified 84% of patients.

CONCLUSIONS

The SERS can be applied reliably in children undergoing DISE for OSA. Ratings of the oropharynx, hypopharynx, and SERS total score demonstrated significant correlation with OSA severity. A SERS total score ≥6 was an accurate predictor of severe OSA.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:1492-1498, 2016.

Relationship between Clinical and Polysomnography Measures Corrected for CPAP Use

OBJECTIVES

The changes in patient-reported measures of obstructive sleep apnea (OSA) burden are largely discordant with the change in apnea-hypopnea index (AHI) and other polysomnography measures before and after treatment. For patients treated with continuous positive airway pressure (CPAP), some investigators have theorized that this discordance is due in part to the variability in CPAP use. We aim to test the hypothesis that patient-reported outcomes of CPAP treatment have stronger correlations with AHI when it is corrected for mean nightly CPAP use.

METHODS

This was a cross-sectional study of 459 adults treated with CPAP for OSA. Five patient-reported measures of OSA burden were collected at baseline and after 6 months of CPAP therapy. The correlations between the change in each patient-reported measure and the change in AHI as well as mean nightly AHI (corrected for CPAP use with a weighted average formula) were measured after 6 months of treatment. The same analysis was repeated for 4 additional polysomnography measures, including apnea index, arousal index, lowest oxyhemoglobin saturation, and desaturation index.

RESULTS

The change in AHI was weakly but significantly correlated with change in 2 of the 5 clinical measures. The change in mean nightly AHI demonstrated statistically significant correlations with 4 out of 5 clinical measures, though each with coefficients less than 0.3. Similar results were seen for apnea index, arousal index, lowest oxyhemoglobin saturation, and desaturation index.

CONCLUSIONS

Correction for CPAP use yielded overall small but significant improvements in the correlations between patient-reported measures of sleep apnea burden and polysomnography measures after 6 months of treatment.

Excessive Dynamic Airway Collapse of the Lower Airway: A Cause for Persistent Sleep Disordered Breathing after Tracheostomy

ABSTRACT

Tracheostomy has demonstrated effectiveness in the control of obstructive sleep apnea (OSA) in most patients; however, current evidence suggests significant sleep disordered breathing may persist, particularly in morbidly obese individuals. While several mechanisms have been proposed to explain this phenomenon, we demonstrate evidence of a previously unidentified pathophysiology: excessive dynamic airway collapse (EDAC) of the lower airway. We present the case of a 62-year-old woman status post tracheostomy with persistent dyspnea in the supine position. Both radiographic and bronchoscopic images demonstrate prolapse of the posterior membranous trachea at the level of the trachea and mainstem bronchi with partial or complete obstruction. The prolapse was completely relieved with upright positioning or positive airway pressure. This case illustrates a novel mechanism of post-tracheostomy sleep disordered breathing in obese individuals and emphasizes the need to consider follow-up polysomnography after tracheostomy in this patient population, especially those with persistent symptoms related to sleep or the supine position.

Functional Comorbidity Index in chronic rhinosinusitis

BACKGROUND

The Functional Comorbidity Index is a promising tool to predict general health status and adjust for comorbidity confounding in outcomes studies of chronic conditions, but it has been tested as a predictor of general health status only in a sleep apnea cohort. We tested it in a chronic rhinosinusitis cohort with 2 objectives: (1) measure the association between the Functional Comorbidity Index (range, 0 to 18) and general health status (SF-36 Physical Component Score and Mental Component Score); and (2) test if the Functional Comorbidity Index is more strongly associated (a better predictor) than the well-known Charlson Comorbidity Index (range, 0 to 37) with these SF-36 outcome measures.

METHODS

In a cross-sectional study of chronic rhinosinusitis patients, we obtained scores for the Functional Comorbidity Index, Charlson Comorbidity Index, and the SF-36. We calculated Spearman correlations and adjusted coefficients of determination (R(2)) using multiple linear regression, adjusted for demographic covariates. Bootstrapping generated R(2) distributions for statistical comparison.

RESULTS

In the cohort (N = 97), the Functional Comorbidity Index scores (mean ± standard deviation: 2.2 ± 1.9) were more widely distributed than Charlson Comorbidity Index scores (0.6 ± 1.2). The Functional Comorbidity Index significantly correlated with the SF-36 Physical Component Score (-0.49, p < 0.001) and Mental Component Score (-0.37, p < 0.001). The Functional Comorbidity Index was a better predictor than the Charlson Comorbidity Index of SF-36 Physical Component Score (R(2) mean ± standard error: 0.21 ± 0.09 vs 0.15 ± 0.05; p < 0.001) and Mental Component Score (0.16 ± 0.10 vs 0.01 ± 0.06; p < 0.001).

CONCLUSION

The Functional Comorbidity Index is a more robust predictor of general health status than the Charlson Comorbidity Index in chronic rhinosinusitis patients.

Association between Drug-Induced Sleep Endoscopy and Measures of Sleep Apnea Burden

OBJECTIVE

To test the following associations: (1) complete obstruction on drug-induced sleep endoscopy (DISE) and polysomnographic and subjective measures of obstructive sleep apnea; (2) tongue base/epiglottic obstruction and apnea index.

STUDY DESIGN

Retrospective cohort.

SETTING

Academic medical center.

SUBJECTS AND METHODS

Subjects included surgically naïve adult patients with DISE. Chart extraction included demographics, polysomnography, and Epworth Sleepiness Scale and SNORE25 (Symptoms of Nocturnal Obstruction and Related Events 25) scores. Each DISE video was examined for complete obstruction at velum, oropharynx, tongue, epiglottis (VOTE system). Student's t test, correlation, and multivariate linear regression were performed.

RESULTS

Among 65 subjects, complete obstruction was observed at 0 (3%), 1 (46%), 2 (48%), and 3 (3%) subsites, respectively. Subjects with 0-1 subsites vs 2-4 subsites of complete obstruction had similar apnea indexes (13 ± 24 vs 12 ± 17, P = .78, 83% power to detect difference of 15), apnea-hypopnea indexes (30 ± 25 vs 31 ± 28, P = .96, 54% power to detect difference of 15), Epworth Sleepiness Scale scores (11 ± 7 vs 12 ± 5, P = .34, 91% power to detect difference of 5), and SNORE25 scores (2.0 ± 1.1 vs 1.9 ± 1.0, P = .70, 96% power to detect difference of 1.0), with similar results after adjusting for age, sex, body mass index, and tonsil status. Neither tongue base nor epiglottic obstruction was associated with apnea index.

CONCLUSION

The number of subsites with complete obstruction on DISE was not associated with polysomnographic, subjective sleepiness, and quality-of-life measures. Tongue base and epiglottic obstruction were not associated with apnea index. Larger detailed analyses are needed to determine the importance of each site and degree of obstruction seen on DISE.

The Lymphatic Malformation Function (LMF) Instrument

OBJECTIVE

The Lymphatic Malformation Function (LMF) instrument is a preliminary parent-report assessment designed to measure outcomes in children with cervicofacial lymphatic malformation (LM). This study aimed to assess the measurement properties of the LMF, refine it, test criterion validity, and evaluate the test-retest reliability.

STUDY DESIGN

Cross-sectional.

SETTING

Two pediatric tertiary referral centers.

SUBJECTS

Parents of 60 children from 6 months to 15 years old with cervicofacial LM.

METHODS

Parents were recruited via mail and online. The LMF was administered on paper or online initially and again within 21 days. Response distributions and interitem correlations were examined for item reduction. Exploratory factor analysis was conducted on retained items. Cronbach's α, Spearman correlation, and intraclass correlation (ICC) coefficients were calculated to test internal consistency, criterion validity (compared to stage), and test-retest reliability, respectively.

RESULTS

One item was removed due to a floor effect. The response scale was collapsed from a 5-point scale to a 3-point scale due to skewness. Six items were discarded due to redundancy (interitem correlations >0.7); 2 items were discarded due to factor loadings <0.4. Exploratory factor analysis revealed a 2-factor structure explaining 84% of variance, and the domains Signs and Impacts had good internal consistency (all Cronbach's α >0.80 and <0.90), significant association with stage (P < .05), and good overall test-retest reliability (ICC, 0.82).

CONCLUSION

The LMF has been refined into a 12-item, 2-domain instrument measuring LM-specific signs and impacts with internal consistency, criterion validity, and test-retest reliability.

Change in Quality of Life with Velopharyngeal Insufficiency Surgery

OBJECTIVES

(1) To define the minimal clinically important difference (MCID) of the Velopharyngeal Insufficiency (VPI) Effects on Life Outcomes (VELO) instrument, and (2) to test for the change in quality of life (QOL) after VPI surgery.

STUDY DESIGN

Prospective observational cohort.

SETTING

VPI clinic at a tertiary pediatric medical center.

SUBJECTS AND METHODS

Children with VPI and their parents completed the VELO instrument (higher score is better QOL) at enrollment and then underwent VPI surgery (Furlow palatoplasty or sphincter pharyngoplasty, n = 32), other treatments (obturator or oronasal fistula repair, n = 7), or no treatment (n = 18). They completed the VELO instrument again and an instrument of global rating of change in QOL at 1 year. The MCID was anchored to the global change instrument scores corresponding to "a little" or "somewhat" better. Within-group (paired t test) and between-group (Student t test) changes in VELO scores were tested for the VPI surgery and no treatment groups. The association between treatment group and change in VELO scores was tested with multivariate linear regression, adjusting for confounders.

RESULTS

Follow-up was obtained for 37 of 57 (65%) patients. The mean (±standard deviation) change in VELO scores corresponding to the MCID anchor was 15 ± 13. The VELO score improved significantly more in the VPI surgery group (change, 22 ± 15; P < .001) than in the no treatment group (change, 9 ± 12; P = .04), after adjusting for confounders (P = .007 between groups).

CONCLUSION

VPI surgery using the Furlow palatoplasty or sphincter pharyngoplasty improves VPI-specific QOL, and the improvement is clinically important.

A review of multiple hypothesis testing in otolaryngology literature

OBJECTIVES/HYPOTHESIS

Multiple hypothesis testing (or multiple testing) refers to testing more than one hypothesis within a single analysis, and can inflate the type I error rate (false positives) within a study. The aim of this review was to quantify multiple testing in recent large clinical studies in the otolaryngology literature and to discuss strategies to address this potential problem.

DATA SOURCES

Original clinical research articles with >100 subjects published in 2012 in the four general otolaryngology journals with the highest Journal Citation Reports 5-year impact factors.

REVIEW METHODS

Articles were reviewed to determine whether the authors tested greater than five hypotheses in at least one family of inferences. For the articles meeting this criterion for multiple testing, type I error rates were calculated, and statistical correction was applied to the reported results.

RESULTS

Of the 195 original clinical research articles reviewed, 72% met the criterion for multiple testing. Within these studies, there was a mean 41% chance of a type I error and, on average, 18% of significant results were likely to be false positives. After the Bonferroni correction was applied, only 57% of significant results reported within the articles remained significant.

CONCLUSIONS

Multiple testing is common in recent large clinical studies in otolaryngology and deserves closer attention from researchers, reviewers, and editors. Strategies for adjusting for multiple testing are discussed.

Procedure Selection with Drug-Induced Sleep Endoscopy

Program Description:

Drug-induced sleep endoscopy (DISE) is a novel technique to identify sites of anatomic obstruction that may be amenable to surgery. Although the technical aspect of the procedure is straight forward, the interpretation and management is not. The science of DISE is rapidly expanding, but there are still many gaps. This miniseminar will present a variety of DISE videos. After audience polling, an expert panel will provide their interpretation and management. Both the art and science behind the decision process will be discussed.

Educational Objectives:

(1) Evaluate a DISE video and classify the obstruction. (2) Formulate a management plan for a variety of anatomic sites of obstruction. (3) Predict the best OSA surgical candidates.

Ask the Experts: Sleep Surgery Potpourri

Program Description:

Modification of uvulopalatopharyngoplasty (UPPP) as well as variation in treatment of hypopharyngeal obstruction are numerous. Selecting the right technique for the right patient often becomes the most difficult decision in treatment planning. It is often unclear if the proponents of a particular technique apply their “modifications” for every case or if there is a selection process. The purpose of this miniseminar is to present specific cases and hear the opinion of 5 experts on how they would treat the same patient.

Educational Objectives:

(1) Use the appropriate patient selection for a classic UPPP. (2) Determine when uvula preservation techniques are appropriate. (3) Examine the current thinking in tongue base reduction.

Preoperative consultations for medicare patients undergoing cataract surgery

IMPORTANCE

Low-risk elective surgical procedures are common, but there are no clear guidelines for when preoperative consultations are required. Such consultations may therefore represent a substantial discretionary service.

OBJECTIVE

To assess temporal trends, explanatory factors, and geographic variation for preoperative consultation in Medicare beneficiaries undergoing cataract surgery, a common low-risk elective procedure.

DESIGN, SETTING, AND PARTICIPANTS

Cohort study using a 5% national random sample of Medicare part B claims data including a cohort of 556,637 patients 66 years or older who underwent cataract surgery from 1995 to 2006. Temporal trends in consultations were evaluated within this entire cohort, whereas explanatory factors and geographic variation were evaluated within the 89,817 individuals who underwent surgery from 2005 to 2006.

MAIN OUTCOMES AND MEASURES

Separately billed preoperative consultations (performed by family practitioners, general internists, pulmonologists, endocrinologists, cardiologists, nurse practitioners, or anesthesiologists) within 42 days before index surgery.

RESULTS

The frequency of preoperative consultations increased from 11.3% in 1998 to 18.4% in 2006. Among individuals who underwent surgery in 2005 to 2006, hierarchical logistic regression modeling found several factors to be associated with preoperative consultation, including increased age (75-84 years vs 66-74 years: adjusted odds ratio [AOR], 1.09 [95% CI, 1.04-1.13]), race (African American race vs other: AOR, 0.71 [95% CI, 0.65-0.78]), urban residence (urban residence vs isolated rural town: AOR, 1.64 [95% CI, 1.49-1.81]), facility type (outpatient hospital vs ambulatory surgical facility: AOR, 1.10 [95% CI, 1.05-1.15]), anesthesia provider (anesthesiologist vs non-medically directed nurse anesthetist: AOR, 1.16 [95% CI, 1.10-1.24), and geographic region (Northeast vs South: AOR, 3.09 [95% CI, 2.33-4.10]). The burden of comorbidity was associated with consultation, but the effect size was small (<10%). Variation in frequency of consultation across hospital referral regions was substantial (median [range], 12% [0-69%]), even after accounting for differences in patient-level, anesthesia provider-level, and facility-level characteristics.

CONCLUSIONS AND RELEVANCE

Between 1995 and 2006, the frequency of preoperative consultation for cataract surgery increased substantially. Referrals for consultation seem to be primarily driven by nonmedical factors, with substantial geographic variation.

Functional comorbidity index in sleep apnea

OBJECTIVES

(1) Measure the association between the Functional Comorbidity Index (range, 0-18) and physical function health status (SF-36 Physical Function domain), general physical health status (SF-36 Physical Component Score), and general mental health status (SF-36 Mental Component Score) outcome measures in a cohort of sleep apnea patients. (2) Test if the Functional Comorbidity Index is more strongly associated (a better predictor) than the well-known Charlson Comorbidity Index (range, 0-37) with these SF-36 outcome measures.

STUDY DESIGN

Cross-sectional study.

SETTING

University of Washington Sleep Center.

SUBJECTS AND METHODS

In a cohort of newly diagnosed obstructive sleep apnea patients (N = 233), we obtained scores for the Functional Comorbidity Index, Charlson Comorbidity Index, and SF-36. We calculated Spearman correlations and adjusted coefficients of determination (R2) with multiple linear regression, adjusted for demographic and health covariates. Bootstrapping generated R2 distributions for statistical comparison.

RESULTS

Functional Comorbidity Index scores (mean ± standard deviation 2.4 ± 1.7) were more widely distributed than Charlson Comorbidity Index scores (0.7 ± 1.4). The Functional Comorbidity Index was significantly correlated with SF-36 Physical Function (-0.53, P < .001), Physical Component Score (-0.44, P < .001), and Mental Component Score (-0.38, P < .001). The Functional Comorbidity Index was a better predictor than the Charlson Comorbidity Index of SF-36 Physical Function (R (2) mean ± standard error 0.27 ± 0.05 vs. 0.17 ± 0.05, P < .001), Physical Component Score (0.23 ± 0.05 vs. 0.17 ± 0.05, P < .001), and Mental Component Score (0.23 ± 0.05 vs. 0.13 ± 0.05, P < .001).

CONCLUSION

The Functional Comorbidity Index is a more robust predictor of general health status than the Charlson Comorbidity Index in obstructive sleep apnea patients.

Surgery for adult obstructive sleep apnoea

Surgery rarely cures OSA, but the lack of cure should not be judged as failure. New higher-level evidence shows excellent clinical outcomes with surgery, in long-term health, short-term symptoms and quality of life, even when complete cure is not achieved. It is unrealistic and inappropriate to expect that surgery must result in a cure to be considered worthwhile. Evaluating surgical treatments is complicated because placebo control is usually not feasible with invasive therapies, randomisation to or away from invasive therapy may limit patient enrolment and generalisability, and surgery is a heterogeneous array of procedures and combinations of procedures. Despite these testing challenges, well controlled studies are showing important benefits of surgery and, moreover, of combinations of surgical procedures.

An official American Thoracic Society statement: continuous positive airway pressure adherence tracking systems. The optimal monitoring strategies and outcome measures in adults

BACKGROUND

Continuous positive airway pressure (CPAP) is considered the treatment of choice for obstructive sleep apnea (OSA), and studies have shown that there is a correlation between patient adherence and treatment outcomes. Newer CPAP machines can track adherence, hours of use, mask leak, and residual apnea-hypopnea index (AHI). Such data provide a strong platform to examine OSA outcomes in a chronic disease management model. However, there are no standards for capturing CPAP adherence data, scoring flow signals, or measuring mask leak, or for how clinicians should use these data.

METHODS

American Thoracic Society (ATS) committee members were invited, based on their expertise in OSA and CPAP monitoring. Their conclusions were based on both empirical evidence identified by a comprehensive literature review and clinical experience.

RESULTS

CPAP usage can be reliably determined from CPAP tracking systems, but the residual events (apnea/hypopnea) and leak data are not as easy to interpret as CPAP usage and the definitions of these parameters differ among CPAP manufacturers. Nonetheless, ends of the spectrum (very high or low values for residual events or mask leak) appear to be clinically meaningful.

CONCLUSIONS

Providers need to understand how to interpret CPAP adherence tracking data. CPAP tracking systems are able to reliably track CPAP adherence. Nomenclature on the CPAP adherence tracking reports needs to be standardized between manufacturers and AHIFlow should be used to describe residual events. Studies should be performed examining the usefulness of the CPAP tracking systems and how these systems affect OSA outcomes.

Development and Validation of a Health-Related Quality-of-Life Comorbidity Index

Objectives:

Comorbidity indexes adjust for comorbidity confounding on a specific outcome, but no index is designed specifically for a quality of life (QOL) outcome. The Functional Comorbidity Index was previously designed to predict physical function. The goals of this study: 1) Develop a Quality of Life Comorbidity Index (QOLI) designed specifically to predict QOL (measured using SF-36 component scores) in sleep apnea patients; 2) Compare the ability to predict QOL between the QOLI, the Functional Comorbidity Index, and another commonly used index.

Methods:

A random sample of 300 subjects, selected from prospectively enrolled sleep apnea patients between 2004-07, was split into a model-development cohort (n=200) and a validation cohort (n=100). Additional comorbidities suspected to impact QOL were selected as candidate variables to add to the Functional Comorbidity Index. Multivariate linear regression using predictive stepwise modeling was applied to determine which candidate variables maximized the ability to predict QOL (adjusted R2). The resultant QOLI was tested in the validation cohort, and the ability to predict QOL was compared to other comorbidity indexes.

Results:

The QOLI model that best predicted QOL added smoking, illicit drug use, migraine, fibromyalgia, allergies, and sinusitis to the Functional Comorbidity Index. The ability to predict QOL (adjusted R2) was better in the QOLI by 10% compared to the Functional Comorbidity Index and by 18% compared to the Charlson Comorbidity Index.

Conclusions:

The QOLI is useful to predict quality of life and is a more robust predictor of QOL than other comorbidity indexes in obstructive sleep apnea patients.

Optimize Patient Education for Patient Satisfaction

Program Description:

This miniseminar will discuss various modalities for providing patient education in otolaryngology practice, highlighting some evidence, relevant educational concepts, and otolaryngologists’ experiences. Patient education is a critical component of patient-centered care in today’s outcomes-focused environment, in which patients obtain information from various educational media, and in which patient satisfaction is an increasingly-emphasized metric. Speakers will use combinations of literature evidence, educational theory, and critical, reflective “How I do it” descriptions to highlight different approaches to patient education. Short overview didactic sessions will be followed by a panel discussion with input from the audience.

Educational Objectives:

1) Describe selected relevant concepts in medical education, and apply these in developing strategies for patient education; summarize the literature evidence for written materials in patient education. 2) Interpret techniques for use of seminars and simulation for patient education, and recognize their benefits and limitations. 3) Consider when educating medical staff and trainees is best to provide patient education.

Palate Surgery in Obstructive Sleep Apnea: How to Choose among the Options

Program Description:

Palate surgery is the primary surgical approach for treatment of OSA. Although uvulopalatopharyngoplasty (UPPP) was described 30 years ago, the past 10-15 years have witnessed the development of alternative palatoplasty techniques. This miniseminar draws from leading surgeons who have developed these procedures and/or performed clinical trials related to them. Findings from published studies will enable attendees to learn more about selection from among the procedures for their patients.

Educational Objectives:

1) Interpret evidence regarding the range of palatoplasty techniques: UPPP, palate stiffening, modified expansion sphincter pharyngoplasty, relocation pharyngoplasty, lateral pharyngoplasty, Z-palatoplasty, and palatal advancement. 2) Differentiate between the various palatoplasty techniques for different types of patients.