Current surgical concepts for treating obstructive sleep apnea syndrome

Treating obstructive sleep apnea: can an intraoral prosthesis help?

The author studied the effectiveness of an intraoral airway maintenance prosthesis in treating obstructive sleep apnea syndrome. He found that the prosthesis, which can be constructed and modified easily by a dentist, significantly reduced the number of apneas per night and the syndrome's severity in his subjects.

Morphology of the viscerocranium in obstructive sleep apnoea syndrome--cephalometric evaluation of 400 patients

The aim of this study was the cephalometric evaluation of patients with obstructive sleep apnoea in order to see whether certain craniofacial characteristics exist. Additional to known skeletal facial parameters cephalometric analysis has been used to establish pharyngeal dimensions. Surprisingly, many patients with obstructive sleep apnoea (nearly 40%) showed certain craniofacial characteristics which apparently predispose to pharyngeal obstruction and to obstructive sleep apnoea. More than one third of 400 patients prove to have pharyngeal narrowing combined with more or less distinct maxillary and mandibular deficiency. Cephalometric evaluation helps to identify sleep apnoea patients, in whom maxillomandibular advancement surgery might be effective in the treatment of obstructive sleep apnoea. According to our results, an indication for surgical treatment by maxillomandibular advancement exists in patients with maxillary and especially mandibular deficiency combined with pharyngeal narrowing.

Uvulopalatopharyngoplasty: The Leicester experience

Twenty-nine patients undergoing uvulopalatopharyngoplasty (UPPP) for snoring are presented. Ninety per cent expressed an overall improvement in their symptoms: 21 per cent had complete abolition of snoring. Post-operative complications included nasal regurgitation of food/fluids and hyponasal speech development.

Pulmonary dysfunction secondary to mandibular retrognathia in Marfan's syndrome

Referrals to pulmonary physicians for polysomnography to evaluate snoring or the possibility of sleep apnea syndrome often evolve into a multidisciplinary clinical problem. We present a young woman with two congenital abnormalities (Marfan's syndrome and retrognathism) which both may affect her decreased exercise tolerance, daytime hypersomnolence, and fatigue. Polysomnography and pulmonary exercise testing documented improvement in her upper airway diameter and exercise capacity. Her improved sleep pattern and her understanding of her exercise performance limitations afforded her a new outlook on life.

Nasal continuous positive airway pressure in decompensated hypercapnic respiratory failure as a complication of sleep apnea

Cardiopulmonary failure resulting from progression of obstructive sleep apnea (OSA) is treated with endotracheal intubation and mechanical ventilation. This study was conducted to determine whether the use of nasal continuous positive airway pressure (CPAP) would rapidly reverse changes in mental status and hypercapnic acidosis in such patients with decompensated hypercapnic respiratory failure resulting from OSA. Six morbidly obese patients (mean weight, 159 +/- 19 kg) were treated with nasal CPAP and supplemental oxygen. Within 24 h of this treatment, there was a significant increase in pH, from a baseline mean of 7.23 +/- 0.03 to 7.35 +/- 0.01 (p < 0.01), and the mean PaCO2 fell from 80 +/- 4 mm Hg to 64 +/- 4 mm Hg (p < 0.01). In addition, there was a dramatic improvement in mental status within 24 h of therapy with nasal CPAP. None of the patients required intubation and mechanical ventilation. There were no complications attributable to the CPAP delivered by nasal mask. We conclude that CPAP delivered by nasal mask can be safe and effective in rapidly reversing changes in mental status and hypercapnic acidosis in this group of patients with severe respiratory failure, and nasal CPAP obviates the need for endotracheal intubation and mechanical ventilation.

Obstructive sleep apnea syndrome: a surgical protocol for dynamic upper airway reconstruction

A surgical protocol for dynamic upper airway reconstruction in the treatment of obstructive sleep apnea syndrome is presented. Two hundred thirty-nine consecutively treated patients were evaluated. All patients underwent a presurgical evaluation that included a physical examination, fiberoptic pharyngoscopy, cephalometric analysis, and polygraphic monitoring. The goal of the presurgical evaluation was to document sleep apnea and isolate the area of obstruction. The treatment was then directed to the obstructive site. The surgical protocol included two phases. Phase 1 was a conservative approach and included uvulopalatopharyngoplasty and/or mandibular osteotomy with genioglossus advancement-hyoid myotomy and suspension. Polysomnography was repeated at 6 months and patients with unsuccessful surgical results were offered maxillary-mandibular advancement osteotomy. Results were based on the postoperative polysomnograms, and included assessing changes in both sleep architecture and sleep-disordered breathing. The surgical results were compared with results in patients who were using nasal continuous positive airway pressure. The surgical success rate for the 239 patients entered into phase 1 therapy was 61% (145 patients). Twenty-four patients who failed phase 1 treatment elected phase 2 treatment. The surgical success rate of this phase was 100%.

Obstructive sleep apnea syndrome: a review of 306 consecutively treated surgical patients

Three hundred six consecutively treated surgical patients with obstructive sleep apnea syndrome were evaluated from a group of 415 patients. One hundred nine patients were excluded because they failed to obtain a postoperative polysomnogram or were lost to followup. All patients received a physical examination, cephalometric analysis, fiberoptic examination, and polysomnography before treatment to document OSAS and determine the areas of obstruction. A two-phase surgical protocol was used for the reconstruction of the upper airway. Phase I surgery consisted of a uvulopalatopharyngoplasty (UPPP) for palatal obstruction and genioglossus advancement with hyoid myotomy-suspension for base of tongue obstruction. Failures of phase I were offered phase 2 reconstruction, which consisted of maxillary-mandibular advancement osteotomy. One hundred twenty-one patients were treated with nasal continuous positive airway pressure (CPAP) before surgery and this was the primary method of evaluating surgical success. Results were reported on the polysomnogram performed a minimum of 6 months after surgery and compared to the preoperative polysomnogram and the second night nasal CPAP study. The polysomnographic results included respiratory disturbance index (RDI), lowest oxyhemoglobin saturation (LSAT), and sleep architecture parameters. Surgery was considered a success if it was equivalent to nasal CPAP or the postoperative RDI was less than 20 with normal oxygenation. The overall success rate, which included patients that dropped from the protocol, was 76.5%, with a mean followup of 9.3 months (SD, 6.7). The preoperative RDI, nasal CPAP RDI, and postoperative RDI were 55.8 (SD, 26.7), 7.2 (SD, 5.4), and 9.2 (SD, 7.5), respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Sleep apnea syndrome symptoms and automobile driving in a general population

Automobile accidents are reported as being overrepresented in those suffering from the obstructive sleep apnea syndrome (SAS), evident by snoring, sleep disturbances and diurnal hypersomnia. An estimation of the prevalence of these symptoms amongst an adult population, predominantly automobile drivers, was assessed by using a one-stage questionnaire procedure. From a national random sample of 1214 persons a weighted reply rate of 76% was achieved. Snoring, breath cessations, mid-sleep awakenings, and diurnal hypersomnia were reported in 24, 3.8, 27 and 9.1%, respectively. The maximum prevalence of SAS was estimated as 2.8-5.5% among men, aged 30-69 years, depending on definition used. Driving frequency in potential sleep apneics was similar to that of the entire population studied. Diurnal hypersomnia, considered a consequence of SAS, was reported as an overall 2.2%, corresponding to 100,000 automobile drivers in Sweden.

Pressure recordings--a method for detecting site of upper airway obstruction in obstructive sleep apnea syndrome

Polysomnography is the method of choice in diagnosis of obstructive sleep apnea syndrome (OSAS) establishing whether a patient has apneas or not. It does not, however, give any indications of where the obstructions occur. This is reflected in the limited success rate of current surgical procedures used in the treatment of this disorder. We have developed a simple method for simultaneous determination of OSAS and site of obstruction. The method implies continuously recording of pressure at different sites in pharynx. A catheter with five pressure transducers and corresponding markings is put into the pharynx through the nasal cavity and interfaced with a polygraph. Continuous pressure registrations were made in 12 patients. We have found characteristic patterns of pressure-changes which clearly indicate the level of obstruction. This may be of importance in selecting patients for further treatment.

Glossopexia--evaluation of a new surgical method for treating obstructive sleep apnea syndrome

Uvulopalatopharyngoglossoplasty, UPPGP, is a modification of the uvulopalatopharyngoplasty, UPPP, technique, originally used for surgical treatment of the obstructive sleep apnea syndrome. The first method seems to be the more successful. However, polysomnography performed after UPPGP showed that about 35% of the patients still had obstructive apnea periods during sleep. Eight of these patients were reoperated with a new technique which is a combination of partial tongue resection and anterior suspension of the tongue (glossopexia). After glossopexia all the patients were subjectively relieved of their symptoms. However, polysomnography carried out postoperatively demonstrated that only 2 patients were objectively cured. The authors want to stress the necessity of meticulous polysomnographical registration pre- and postoperatively. Subjective and objective parameters recorded before and after surgery are discussed.

Uvulopalatopharyngoglossoplasty (UPPGP) in the treatment of the obstructive sleep apnea syndrome

Out-patient polysomnography was conducted prior to surgery in 26 male, obstructive sleep apnea patients. Resection of lateral aspects of the tongue base and conservation of the proximal part of the uvula muscle were carried out in addition to conventional palatopharyngoplasty. At a minimum of 6 months after surgery, the patients were given a questionnaire for assessment of treatment. At the same time, polysomnography was repeated for objective evaluation of the results of surgery. More than 90% of the patients were satisfied with the outcome of treatment. The objective results by means of apnea index and oxygen desaturation index matched the patients' personal experiences, which is not usual in this kind of treatment. Sixty-seven percent of the obstructive sleep apnea patients achieved more than a 50% reduction in apnea index and oxygen desaturation index. No more side effects than for similar surgical intervention (PPP) were encountered. Safety and efficiency lead us to recommend this procedure as standard whenever oropharyngeal surgery is indicated.

Hallermann-Streiff syndrome: a review

The Hallermann-Streiff syndrome is characterized by dyscephaly, hypotrichosis, microphthalmia, cataracts, beaked nose, micrognathia, and proportionate short stature. Cause is unknown; sporadic occurrence is the rule. Data presented in this review include the characteristics of pregnancy, growth and development, principal manifestations, radiographic and ophthalmological characteristics, and the results of cephalometric study. Potential complications in the syndrome are related to the narrow upper airway associated with the craniofacial configuration. Severe complications may include early pulmonary infection, respiratory embarrassment, obstructive sleep apnea, and anesthetic risk. Topics for future study are suggested.

Uvulopalatorrhaphy in a case of obstructive sleep apnoea

A reversible uvulopalatorrhaphy is reported in a case of obstructive sleep apnoea. The patient had an abnormally long uvula but no skeletal abnormality.

Obstructive sleep apnea: a comparison of continuous positive airway pressure and surgical treatment

Since earlier descriptions of the syndrome of obstructive sleep apnea (OSA), various treatment alternatives have included a variety of medical regimens, continuous positive airway pressure (CPAP), tracheostomy, and other surgical options. A lack of acceptable criteria for surgical intervention remains an important concern for the surgeon. in an attempt to resolve some of the controversies pertaining to various therapeutic modalities, we performed a retrospective analysis--from 1983 to the present--of posttreatment results in patients who underwent surgical therapy and those who were treated primarily with CPAP at this institution. Of 400 patients diagnosed with OSA, only 66 underwent surgical treatment, including uvulopalatopharyngoplasty. CPAP was the mainstay of treatment in the majority of our patients. Post-treatment data were available for 50 patients treated with CPAP and for 45 patients treated surgically. A comparative analysis of polysomnographic studies revealed superior cures with CPAP, although long-term compliance remains a significant problem. We advocate CPAP as initial therapy in patients with no clinically apparent causes for obstruction (e.g., nasal polyps, deviated nasal septum, or obstructive tonsillar hypertrophy) because of the predictability of success, and lower costs and complication rates. Long-term followup of OSA patients is indicated, regardless of treatment modality.

Sleep apnoea syndrome associated with maxillofacial abnormalities

Four cases with Obstructive Sleep Apnoea Syndrome (OSAS) are presented. They consisted of two cases with TMJ ankylosis with micrognathia, one case with Treacher Collins Syndrome, and one case with the Long Face Syndrome. Standard and specific cephalometric parameters were obtained to detect the site of the obstruction. Polysomnographic studies yielded information regarding the patient's sleep-wake state, respiratory and cardiac functioning, pre- and post-operatively. A temporary tracheostomy corrected the symptoms in one patient but the syndrome recurred when it was closed. Surgical correction of the maxillofacial anomalies will re-establish normal sleep patterns preventing OSAS.

Maxillofacial surgery and nasal CPAP. A comparison of treatment for obstructive sleep apnea syndrome

Nasal continuous positive airway pressure (CPAP) is the primary therapy for obstructive sleep apnea syndrome (OSAS). Recent reports have indicated, however, that there is a small but significant number of failures related to patient compliance. Primary surgical treatment, which has been uvulopalatopharyngoplasty (UPPP), has declined because of poor results. A reviewed of UPPP failures has shown that while UPPP eliminated palatal obstruction, it failed to eliminate base of tongue obstruction. Maxillofacial surgery has been reported as treatment of OSAS by correcting base of tongue obstruction. Thirty patients with severe OSAS were evaluated to compare nasal CPAP and maxillofacial surgery. The goal was to determine if our surgical protocol was as effective as nasal CPAP. All patients initially underwent baseline diagnostic polysomnography to document OSAS. A nasal CPAP study was performed to determine the appropriate positive end-expiratory pressure. The patients in this study were using nasal CPAP, but they found it unacceptable as long-term treatment and elected surgery. Maxillofacial surgery consisted of maxillary, mandibular, and hyoid advancement. Polysomnography was performed six months following surgery and compared with the night 2 CPAP results. The parameters included in the investigation were the respiratory disturbance index (RDI), lowest SaO2, number of SaO2 falls below 90 percent, total sleep time (TST), REM sleep percent, stage 3-4 sleep percent, and wake after sleep onset. The mean RDI before treatment was 72.0 (SD 25.7). After completing therapy, the RDI from surgery and CPAP was 8.8 (SD 6.0) and 8.6 (SD 4.1), respectively. The mean low SaO2 prior to treatment was 61.0 (SD 13.5), and the CPAP results and postsurgical results were 86.2 (SD 5.5) and 86.1 (SD 4.2), respectively. An analysis of variance was used to examine the results, and there was no statistical difference between nasal CPAP and surgery for all respiratory variables.

Cephalometric analysis of long-term airway space changes with maxillary osteotomies

The cephalometric radiographs of 13 patients without sleep apnea who had undergone isolated maxillary surgery were studied. The authors found increases in both the nasopharyngeal and hypopharyngeal airway spaces 3 to 5 years after surgery. The results suggest that adaptive processes occur in both the upper and lower jaw, which contribute to an enlarged airway after surgery.

Maxillary, mandibular, and hyoid advancement for treatment of obstructive sleep apnea: a review of 40 patients

Forty patients with documented obstructive sleep apnea syndrome (OSAS) were evaluated following maxillary and mandibular osteotomies (MMO). All patients were evaluated before and after surgery by a physical examination, fiberoptic pharyngoscopy, cephalometric analysis, and polysomnography. Ninety-seven percent of the patients responded to the surgical treatment, based on the polysomnogram. The present indications for MMO are severe OSAS, morbid obesity, and severe mandibular deficiency.

Speech status following uvulopalatopharyngoplasty

The purpose of this study was to evaluate the adequacy of speech following uvulopalatopharyngoplasty surgery. Twenty UPPP subjects, all of whom exhibited obstructive sleep apnea syndrome, and 15 non-UPPP control subjects participated in the study. Evaluation included measures of nasal airflow, speech recordings with listener judgments, and a questionnaire survey. Nasal resonance in the UPPP subjects was found not to be deviant by a panel of four experienced judges. The UPPP subjects were differentiated from their non-UPPP pairs on the basis of significant phonation (voice) problems, and to a lesser extent, their articulation problems. It is suggested that dryness problems that remained in many subjects postoperatively may be related to the observed voice problems.

Maxillomandibular advancement surgery in 23 patients with obstructive sleep apnea syndrome

Twenty-three patients with obstructive sleep apnea syndrome (OSAS) documented by polysomnography underwent maxillomandibular advancement via Le Fort I, and sagittal ramus split osteotomies followed by rigid fixation with miniplates and bicortical screws. Partial turbinectomies and septal reconstruction were simultaneously performed. Pre- and post-operative cephalometric radiographs were analyzed by computer. Hyoid position and posterior airway space changes did not correlate with clinical success. The surgical success (respiratory disturbance index less than 10) with maxillomandibular advancement was 65%. The total desaturations below 90% greatly decreased. Ninety-six percent of patients were subjectively and objectively improved.