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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.

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.

Australasian Sleep Association position statement on consensus and evidence based treatment for primary snoring

Primary snoring impacts a significant portion of the adult population and has the potential to significantly impair quality of life. The purpose of these guidelines is to provide evidence-based recommendations to assist Australasian practitioners in the management of adult patients who present with primary snoring without significant obstructive sleep apnoea. The Timetable, Methodology and Standards by which this Position Statement has been established is outlined in the Appendix S1. The main recommendations are: Weight loss, and reduced alcohol consumption should be recommended, where appropriate If clinical judgement dictates, benzodiazepine and opioid reduction or avoidance may be advised Positional therapy should be considered in supine dominant snorers In dentate patients, Mandibular advancement devices (MAD) should be recommended as a first line treatment following assessment by both an appropriate Dentist and Sleep physician Continuous positive airway pressure (CPAP) devices may be recommended in patients with primary snoring in those already committed to their use or willing to try Surgical treatment of primary snoring by an appropriately credentialled surgeon may be advised and includes nasal (adjunctive), palatal and other interventions This position statement has been designed based on the best available current evidence and our combined expert clinical experience to facilitate the management of patients who present with primary snoring. It provides clinicians with a series of both non-surgical and surgical options with the aim of achieving optimal symptom control and patient outcomes. This is the first such set of recommendations to be established within Australasia and has also been reviewed and endorsed by the Australasian Sleep Association.

Incidence of allergen-specific and total immunoglobulin E positivity in children undergoing adenotonsillectomy

AIM

To conduct a prospective, consecutive cohort study to evaluate the incidence of allergen-specific and total immunoglobulin E (IgE) in a paediatric population undergoing adenotonsillectomy for sleep-disordered breathing.

METHODS

A total of 64 consecutive patients presenting for adenotonsillectomy at a single centre were recruited over a period of 3 months. All patients underwent adenotonsillectomy and had allergen-specific and total IgE serum testing at the time of anaesthesia induction. Pre-operative history and examination were conducted to determine clinical allergy. Caregivers completed the Sleep-Related Breathing Disorder scale of the Paediatric Sleep Questionnaire and the Mini Rhinoconjunctivitis Quality of Life Questionnaire at baseline and at 6 weeks post-operatively.

RESULTS

A total of 37 (57.8%) patients had either allergen-specific or total IgE positivity. House dust mite was the most prevalent allergen-specific IgE finding, being present in moderate to high levels in 14 (21.9%) patients. A total of 17 (26.6%) patients had a history of atopy, while 34 (53.1%) had examination findings suggestive of allergy. Neither serum IgE testing nor clinical history and examination were independently associated with residual symptoms post adenotonsillectomy. Patients with concomitant serum IgE positivity and clinical allergy had higher residual symptom scores compared to those who did not using both Sleep-Related Breathing Disorder scale of the Paediatric Sleep Questionnaire (P = 0.035) and Mini Rhinoconjunctivitis Quality of Life Questionnaire (P = 0.02) questionnaires.

CONCLUSIONS

Our prospective, consecutive cohort of patients reflect a greater incidence of serum IgE positivity compared to historical figures. When utilised with clinical findings on history and examination, serum IgE is a useful adjunct that is associated with greater residual symptoms post-adenotonsillectomy.

Surgical management of obstructive sleep apnoea: A position statement of the Australasian Sleep Association. Respirology 2020;25:1292-1308. [PMID: 33190389 PMCID: PMC7839593 DOI: 10.1111/resp.13967]

Surgery for adult obstructive sleep apnoea (OSA) plays a key role in contemporary management paradigms, most frequently as either a second‐line treatment or in a facilitatory capacity. This committee, comprising two sleep surgeons and three sleep physicians, was established to give clarity to that role and expand upon its appropriate use in Australasia. This position statement has been reviewed and approved by the Australasian Sleep Association (ASA) Clinical Committee.

0665 Bilateral Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea

Introduction

Hypoglossal Nerve Stimulation (HGNS) decreases obstructive sleep apnea (OSA) severity by contracting the tongue and decreasing upper airway collapsibility. This study assessed the safety and effectiveness of a new implantable device that delivers bilateral HGNS: the Genio™ system.

Methods

The BLAST OSA study (BiLAteral Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea), was a prospective, open-label, non-randomized, single arm treatment study conducted at eight centres in three countries (Australia, France, UK). Primary outcomes were the incidence of device-related Serious Adverse Events (SAEs) and change in the Apnea-Hypopnea Index (AHI). The secondary outcome was change in the 4% Oxygen Desaturation Index (ODI). Additional outcomes included measures of sleepiness, quality of life, snoring, and device use. Participants were eligible if: 21-75 years old; BMI ≤ 32 kg/m2; obstructive AHI 20-60 events/hr and combined central and mixed AHI &lt; 10 events/hr; no positional OSA; no Complete Concentric Collapse of the soft palate during Drug Induced Sleep Endoscopy; and failed to tolerate or accept Positive Airway Pressure treatments.

Results

27 participants were implanted (63% male, aged 55.9±12.0 years, BMI 27.4±3.0 kg/m2). 22 completed the protocol. At 6 months, AHI decreased from 23.7±12.2 to 12.9±10.1 events/hr [p&lt;0.001]; and ODI decreased from 19.1±11.2 to 9.8±6.9 events/hr [p&lt;0.001]. Daytime sleepiness (ESS, p=0.011) and sleep-related quality of life (FOSQ-10, p=0.016) both significantly improved. 91% of participants reported using their device &gt;5 days per week, and 77% used it &gt;5 hours per night. The number of bed partners reporting disruptive snoring decreased from 96% to 35%. No device-related SAE occurred.

Conclusion

In a targeted population of individuals with moderate-to-severe OSA, the Genio system reduced OSA severity and sleepiness, improved quality of life, and was associated with high adherence and an acceptable safety profile.

Support

This study trial was funded by Nyxoah S.A. This trial was registered with ClinicalTrials.gov, number NCT03048604.

Modeling the upper airway: A precursor to personalized surgical interventions for the treatment of sleep apnea

An accurate benchtop model was developed to mimic the different forms of human upper airway collapse in adult sleep apnea patients. This was done via modeling the airway through digital imaging. Airway representative models were then produced in two steps via a customized pneumatic extrusion 3D printing system. This allowed the pressure of collapse and planes of collapse to be manipulated to accurately represent those seen in sleep apnea patients. The pressure flow relationships of the collapsible airways were then studied by inserting the collapsible airways into a module that allowed the chamber pressure (P_c ) around the airways to be increased in order to cause collapse. Airways collapsed at physiologically relevant pressures (5.32-9.58 cmH₂ O). Nickel and iron magnetic polymers were then printed into the airway in order to investigate the altering of the airway collapse. The introduction of the nickel and iron magnetic polymers increased the pressure of collapse substantially (7.38-17.51 cmH₂ O). Finally, the force produced by the interaction of the magnetic polymer and the magnetic module was studied by measuring a sample of the magnetic airways. The peak force in (48.59-163.34 cN) and the distance over which the forces initially registered (6.8-9.7 mm) were measured using a force transducer. This data set may be used to inform future treatment of sleep apnea, specifically the production of an implantable polymer for surgical intervention.

Bilateral hypoglossal nerve stimulation for treatment of adult obstructive sleep apnoea

BACKGROUND AND AIM

Hypoglossal nerve stimulation (HNS) decreases obstructive sleep apnoea (OSA) severity via genioglossus muscle activation and decreased upper airway collapsibility. This study assessed the safety and effectiveness at 6 months post-implantation of a novel device delivering bilateral HNS via a small implanted electrode activated by a unit worn externally, to treat OSA: the Genio™ system.

METHODS

This prospective, open-label, non-randomised, single-arm treatment study was conducted at eight centres in three countries (Australia, France and the UK). Primary outcomes were incidence of device-related serious adverse events and change in the apnoea-hypopnoea index (AHI). The secondary outcome was the change in the 4% oxygen desaturation index (ODI). Additional outcomes included measures of sleepiness, quality of life, snoring and device use. This trial was registered with ClinicalTrials.gov, number NCT03048604.

RESULTS

22 out of 27 implanted participants (63% male, aged 55.9±12.0 years, body mass index (BMI) 27.4±3.0 kg·m^-2) completed the protocol. At 6 months BMI was unchanged (p=0.85); AHI decreased from 23.7±12.2 to 12.9±10.1 events·h^-1, a mean change of 10.8 events·h^-1 (p<0.001); and ODI decreased from 19.1±11.2 to 9.8±6.9 events·h^-1, a mean change of 9.3 events·h^-1 (p<0.001). Daytime sleepiness (Epworth Sleepiness Scale; p=0.01) and sleep-related quality of life (Functional Outcomes of Sleep Questionnaire-10; p=0.02) both improved significantly. The number of bed partners reporting loud, very intense snoring, or leaving the bedroom due to participant snoring decreased from 96% to 35%. 91% of participants reported device use >5 days per week, and 77% reported use for >5 h per night. No device-related serious adverse events occurred during the 6-month post-implantation period.

CONCLUSIONS

Bilateral HNS using the Genio™ system reduces OSA severity and improves quality of life without device-related complications. The results are comparable with previously published HNS systems despite minimal implanted components and a simple stimulation algorithm.

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.

Radiofrequency ablation of the lateral palatal space for snoring

Objective

Pilot study to examine the effect of radiofrequency ablation (RFA) of the lateral palatal fat pad in patients with socially-disruptive snoring.

Method

Snoring outcomes and complications were compared between a group of patients with treated with RFA ablation of the lateral soft palate fat pad with or without inferior turbinate reduction (8 patients) and another group undergoing inferior turbinate reduction alone (12 patients).

Results

Snoring loudness and bothersomeness improved in the palate but not inferior turbinate group. Pain was mild and no major complications were observed.

Conclusion

The study supports RFA ablation of the lateral palatal space as a potential low morbidity procedure for snoring.

Surgical Approaches to Obstructive Sleep Apnea

Surgery in adult obstructive sleep apnea (OSA) has undergone significant advancement in recent years and continues to evolve. It is a modality of treatment used in the context of failed device use, specifically, failed continuous positive airway pressure or mandibular advancement splint. In this context, the role of surgery is either as salvage therapy or to facilitate better tolerance of device use. Other treatments such as weight loss, adjuvant nasal therapy (medical ± prephase nasal surgery) and positional devices may be combined with airway surgery. In general, patients with OSA are managed with in-hospital monitoring perioperatively.

AHI Outcomes Are Superior after Upper Airway Reconstructive Surgery in Adult CPAP Failure Patients

Objective

This study aims to evaluate Apnea-Hypopnea Index (AHI) outcomes of upper airway adult obstructive sleep apnea (OSA) reconstructive surgery, as compared with outcomes of suboptimal continuous positive airway pressure (CPAP) therapy, in response to reviews claiming unreliable surgical AHI reduction.

Study Design

Prospective cohort study.

Setting

Single-surgeon series at medical centers within Wollongong, Australia.

Subjects and Methods

Adult patients with OSA who were partial device users or who refused CPAP were considered candidates for upper airway surgery (N = 48). Subjects underwent physical examination and polysomnography before and after surgery. Three groups were delineated on the nature of their suboptimal CPAP therapy: group 1, partially using CPAP or refusing long-term CPAP despite adherence (with available download data); group 2, unable or refusing to use CPAP with 2 sleep studies over time; group 3, unable or refusing to use CPAP with 1 sleep study over time. Collected data included demographics and AHI outcomes.

Results

Average AHI across all 3 groups with suboptimal CPAP therapy before surgery was 30.24 ± 17.17 events per hour sleep, as compared with the average postoperative AHI of 7.65 ± 6.59 events per hour sleep. This decrease was shown to be statistically significant with Wilcoxon signed-rank test ( P < .0001).

Conclusions

AHI outcomes are superior with surgery in untreated or suboptimally treated adult OSA patients prescribed CPAP.

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.

Modified uvulopalatopharyngoplasty and coblation channeling of the tongue for obstructive sleep apnea: a multi-centre Australian trial

STUDY OBJECTIVES

To investigate the surgical outcomes and efficacy of modified uvulopalatopharyngoplasty (mod UPPP) and Coblation channelling of the tongue (CCT) as a treatment for obstructive sleep apnea (OSA).

METHODS

Adult patients with simple snoring or obstructive sleep apnea were treated with combined modified UPPP, bilateral tonsillectomy, and CCT (N = 48). Full polysomnography was performed preoperatively and 3 months postoperatively. Postoperative clinical assessment, sleep questionnaires, and patient demographics including body mass index were compared to preoperative data. All polysomnograms were re-scored to AASM recommended criteria by 2 sleep professionals.

RESULTS

The preoperative AHI (median and interquartile range) of 23.1 (10.4 to 36.6) was lowered to a postoperative AHI of 5.6 (1.9 to 10.4) (p < 0.05). The Epworth Sleepiness Scale score fell from 10.5 (5.5 to 13.5) to 5.0 (3.09 to 9.5) (p < 0.05). Morbidity of the surgery was low, with no long-term complications recorded.

CONCLUSIONS

Modified UPPP combined with CCT is a highly efficacious intervention for OSA with minimal morbidity. It should be considered for individuals who fail or are intolerant of CPAP or other medical devices.

The need for a better prognostic staging system in patients with metastatic cutaneous squamous cell carcinoma of the head and neck

PURPOSE OF REVIEW

A validated and universal staging system for metastatic cutaneous head and neck squamous cell carcinoma that accurately describes its clinical behaviour is vital for prognostication and management. The current clinical staging system is not specific for the head and neck and makes no allowances for disease extent. The lack of an improved staging system prevents any meaningful research into improved treatment strategies in patients with head and neck cutaneous squamous cell carcinoma.

RECENT FINDINGS

Contemporary evidence supports surgery and adjuvant radiotherapy as current best practice for patients with operable metastatic head and neck cutaneous squamous cell carcinoma. Despite this, patients with poor-prognosis disease are still at risk of locoregional relapse and may benefit from collaborative research. The modified staging system proposed by O'Brien is an important aspect of any further research and is discussed in this article.

SUMMARY

The present clinical staging for head and neck cutaneous squamous cell carcinoma is inadequate and the evidence to date supports a recommendation for changing the current system to reflect the heterogeneity and complexity of this disease.