Obstructive sleep apnea after radial forearm free flap reconstruction of the oral tongue

Oral Cancer and Sleep Disturbances: A Narrative Review on Exploring the Bidirectional Relationship

Oral cancer is a common malignant tumor, and its incidence has steadily increased in recent years. Sleep disturbances, including insomnia and obstructive sleep apnea, are prevalent among patients with oral cancer and significantly impact their quality of life. Emerging research suggests a bidirectional relationship between oral cancer and sleep disorders. This article reviews how oral cancer induces or exacerbates sleep disorders, particularly obstructive sleep apnea (OSA), through factors such as pain, psychological stress, and treatment-related side effects (e.g., upper airway damage caused by chemotherapy, radiotherapy, or surgical interventions). Furthermore, it analyzes how sleep disorders may promote oral cancer progression via chronic inflammation, intermittent hypoxia, oxidative stress, and disruption of circadian rhythms. By elucidating these interactions, this review provides a theoretical foundation for optimizing clinical treatment plans through a holistic understanding of their shared pathophysiological mechanisms.

Prevalence and assessment of sleep-disordered breathing in head and neck cancer patients: a systematic review

STUDY OBJECTIVES

Sleep-disordered breathing (SDB) is a very common and underdiagnosed condition in head and neck cancers (HNC) patients. If untreated, SDB can lead to negative health consequences. The identification of SDB in HNC patients is crucial to ensure appropriate treatment and to improve outcomes. The purpose of the study was to investigate the incidence of coexisting SDB in HNC patients and to evaluate methods of assessing SDB in the population.

METHODS

A systematic search of PubMed, Embase, CINAHL, Cochrane Database, the Web of Science, and Scopus was performed for studies related to SDB in HNC patients. In total, 1713 articles were identified. 19 articles were selected for qualitative synthesis. The studies involved 584 subjects.

RESULTS

The prevalence of SDB ranged from 57 to 90% before cancer treatment and from 12 to 96% after. When using an apnea-hypopnea index (AHI) cut-off ≥ 5/h to diagnosis SDB, the prevalence of SDB was 57-90% before cancer treatment and 12-94% after treatment. Sleep studies using polysomnography are the most commonly used assessment tools, but thresholds for diagnosis have been inconsistent.

CONCLUSIONS

There is a high prevalence of SDB in HNC patients. However, the diagnostic and thresholds methods used for detecting SDB vary widely. To determine the accurate prevalence of SDB, prospective, systematic studies of SDB in unselected cohorts of HNC participants are required.

A narrative review of the relationship between head and neck cancer and obstructive sleep apnea: Clinical studies and statistical analysis

Obstructive sleep apnea (OSA) is an underestimated and overlooked comorbidity in head and neck cancer (HNC) care. Refining HNC-OSA management requires an improved grasp of the HNC-OSA relationship. Thus, this paper reviews the current course of HNC therapy, causal and associative relationships before and after treatment, and statistical methods quantifying HNC-OSA interactions. This evaluation serves a dual purpose: to support oncologists and sleep physicians in improving the treatment outcomes of patients undergoing HNC treatment by considering OSA as a comorbidity and to assist researchers in selecting suitable analytical models for investigating the correlation between OSA and HNC. The investigation confirms a positive correlation between the apnea-hypopnea index (AHI) and primary tumor size, consistent with prior findings. Case studies also reported new evidence of lipoma and head-neck tumors triggering OSA, and sleep apnea surgery prompting tumor development. This paper provides an overview of existing statistical models and offers suggestions for model selection and a framework for designing experiments that delve into research questions surrounding the link between OSA and HNC across various stages of cancer treatment. Despite progress, understanding the HNC-OSA interplay remains incomplete due to limited histological, molecular, and clinical data. Future studies with longitudinal data are crucial for comprehensive insights.

Preoperative sleep-disordered breathing and craniofacial abnormalities are risk factors for postoperative sleep-disordered breathing in patients undergoing skin-flap oropharyngeal reconstruction surgery for oral cavity cancer: a prospective case-control study

PURPOSE

After oropharyngeal reconstruction surgery, excessive flap volume within the oral cavity may increase the risk of pharyngeal obstruction during sleep. This prospective observational study aimed to test a hypothesis that the skin-flap oropharyngeal reconstructive surgery increases nocturnal apnea-hypopnea index (nAHI, primary variable) after surgery.

METHODS

Adult patients undergoing oropharyngeal reconstruction surgery participated in this study. The hypothesis was tested by comparing the results of portable type 4 sleep study and craniofacial assessments with lateral head and neck computed tomography scout image before and after surgery. Multiple linear regression analyses were performed to identify predictors for nAHI increase after the surgery.

RESULTS

In 15 patients, a postoperative sleep study was performed at 41 (27, 59) (median (IQR)) days after the surgery. nAHI did not increase after the surgery (mean (95% CI), 13.0 (7.2 to 18.7) to 18.4 (10.2 to 26.6) events.hour-1, p = 0.277), while apnea index significantly increased after the surgery (p = 0.026). Use of the pedicle flap for the oropharyngeal reconstruction (p = 0.051), small mandible (p = 0.008), longer lower face (0.005), and larger tongue size (p = 0.008) were independent predictors for worsening of nAHI after surgery. Hospital stay was significantly longer in patients with the pedicle flap (n = 8) than in those with the free flap (n = 7) (p = 0.014), and the period of hospital stay was directly associated with increase of nAHI after surgery (r = 0.788, p < 0.001, n = 15).

CONCLUSIONS

Oropharyngeal reconstruction surgery worsens sleep-disordered breathing in some patients with craniofacial and surgical risk factors.

TRIAL REGISTRATION

UMIN Clinical Trial Registry (UMIN000036260, March 22, 2019), https://rctportal.niph.go.jp/s/detail/um?trial_id=UMIN000036260.

Prevalence of obstructive sleep apnea after treatment for advanced T-stage head and neck cancer

PURPOSE

Treatment of head and neck cancer (HNC) may lead to obstructive sleep apnea (OSA), but conclusive results on the prevalence of OSA are lacking. The objective of this study is to investigate the prevalence of OSA in a cohort of patients treated for advanced T-stage HNC.

METHODS

A cross-sectional study was conducted in two tertiary cancer care centers including patients at least 1 year after treatment with curative intent with surgery and/or (chemo)radiotherapy ((C)RT) for advanced T-staged (T3-4) cancer of the oral cavity, oropharynx, hypopharynx, or larynx. A polysomnography (PSG) was performed in all participants. OSA was defined as an apnea-hypopnea index (AHI) of 15 events/h or higher or an AHI of 5 events/h and higher with OSA related symptoms, such as sleeping problems, daytime dysfunction and/or cardiac/metabolic comorbidities collected through file review and questionnaires.

RESULTS

Of the 67 participants, 48 (72%, 95% CI 59-82%) were diagnosed with OSA. Possible risk factors are male gender, higher BMI, greater neck circumference, more nicotine pack years, cardiometabolic comorbidities, use of medication with sleepiness as side effect, present tonsils, lower T-stage (T3 vs. T4 stage), higher AJCC stage and a HPV-negative tumor.

CONCLUSION

In this population of advanced T-stage HNC patients, the prevalence of OSA was 72%, which is considerably higher than in the general population (2-50%). Given the high prevalence, screening of this entire subgroup for OSA may be indicated. Future studies to identify high risk factors and develop an OSA screening protocol are needed.

Risk of obstructive sleep apnea after treatment of head and neck squamous cell carcinoma: a cross-sectional study

STUDY OBJECTIVES

Head and neck squamous cell carcinoma (HNSCC) or its treatment may be associated with an increased risk of obstructive sleep apnea (OSA). However, reported relationships between OSA risk factors and HNSCC are inconsistent. This study examined associations between tumor variables and risk of OSA at least 1 year after completion of treatment for HNSCC.

METHODS

This cross-sectional study included HNSCC patients of a large academic medical center. Inclusion criteria were age ≥ 18 years, cancer free for at least 1 year, and absence of tracheostomy or mental impairment. The STOP-BANG questionnaire, with a threshold ≥ 3, was used to classify HNSCC patients into elevated and low OSA risk. Tumor characteristics and treatment types were obtained from medical records. Descriptive statistics were used to compare characteristics between OSA risk groups. Unadjusted and age-adjusted logistic and linear regression models were used to explore associations between exposures and OSA risk.

RESULTS

Among 67 participants, 85% were males, mean age was 62.0 years (8.0 standard deviation), mean body mass index was 28.7 kg/m2 (4.6 standard deviation), and mean neck circumference was 16.3 inches (1.2 standard deviation). Three-quarters of participants received chemoradiation only. Elevated OSA risk was observed in 60% of the participants. Tumor location, tumor stage, and type of cancer treatment were not different between OSA risk groups. Hyperlipidemia was more common in the elevated OSA risk group vs the low-risk group (n = 16, 40% vs n = 2, 7%, P = .004). Age-adjusted analysis showed a trend toward 2-fold increased odds of elevated OSA risk in patients with tumors at the base of the tongue in comparison to other locations (odds ratio = 2.3, 95% confidence interval 0.9, 6.4). No associations between tumor stage, cancer treatment, and elevated OSA risk were observed.

CONCLUSIONS

Elevated OSA risk was common after HNSCC treatment. However, measured HNSCC characteristics generally were not different between elevated and low OSA risk groups. Given the high frequency of OSA that appears likely to exist in HNSCC patients, clinicians should inquire about OSA features in patients with a history of HNSCC.

CITATION

Gavidia R, Dunietz GL, O'Brien LM, et al. Risk of obstructive sleep apnea after treatment of head and neck squamous cell carcinoma: a cross-sectional study. J Clin Sleep Med. 2022;18(6):1681-1686.

Probable Change of Sleep Parameters after Resection and Reconstruction Surgeries in Patients with Oral Cavity or Oropharyngeal Cancers

In patients of oral cavity or oropharyngeal cancers, resection of the tumor and reconstruction of the defect may reduce the framework, add a bulky flap, alter the tissue flexibility, and contribute to postoperative obstructive sleep apnea (OSA). Postoperative OSA and the potential consequences may decrease the survival rate and reduce patients' quality of life. It is unclear whether the surgery is associated with postoperative OSA. Here, we compared the polysomnographies (PSGs) before and after the surgery in 15 patients of oral cavity or oropharyngeal cancers (out of 68 patients of head and neck cancers) without a chemo- or radio-therapy. Each patient received the second PSG before the start of any indicated adjuvant therapy to prevent its interference. There were 14 men and 1 woman, with a mean age and a standard deviation (SD, same in the following) of 56.2 ± 12.8 years. There were 6 tongue cancers, 5 buccal cancers, 2 tonsil cancer, 1 lower gum cancer, and 1 trigone cancer. The results show that the surgery changed sleep parameters insignificantly in apnea-hypopnea index (AHI), mean oxyhemoglobin saturation of pulse oximetry (SpO2), minimum SpO2, mean desaturation, and desaturation index but increased mean heart rate in the patients with free flaps. These results hint that the effect of surgery on developing OSA was small in this sample, with a longer plate or a larger framework for a bulkier free flap. It needs future studies with a large sample size to generalize this first observation.

Obstructive sleep apnea in patients with head and neck cancer: a systematic review

STUDY OBJECTIVES

Head and neck cancers (HNCs) may modify the upper airway anatomy and thereby increase the risk for obstructive sleep apnea (OSA). If untreated, OSA is associated with adverse outcomes. Identification of risk factors for OSA in patients with HNC is essential to promote proper evaluation, treatment, and improvement of sleep-related outcomes. In this review, we assessed associations between tumor stage, cancer treatment, and OSA in the population with HNC.

METHODS

A systematic search of PubMed, EMBASE (Embase.com), Cochrane Library (Cochranelibrary.com), Scopus, and Web of Science was conducted to identify articles related to OSA in patients with HNC. A total of 215 articles were identified, of which 14 were included in the qualitative synthesis. These studies included 387 participants.

RESULTS

The most common cancer type, tumor location, and cancer therapy were squamous cell carcinoma, oropharynx, and surgery, respectively. Three of six articles reported an association between surgical treatment and OSA. Conversely, associations between tumor stage, radiotherapy, and OSA were found in only a minority of studies (15%). The prevalence of OSA was between 57% and 76% pre-cancer therapy and 12% and 96% afterward.

CONCLUSIONS

This review suggests a potential association between HNC surgery and OSA. An association between tumor stage, radiotherapy to the head and neck, and OSA is inconclusive. Further research is needed to examine the relationship between HNC and OSA.

Obstructive Sleep Apnoea in Patients Treated for Head and Neck Cancer: A Systematic Review of the Literature

Background and objectives: Obstructive sleep apnoea (OSA) is clinically defined by signs of daytime sleepiness and objective measures of disordered breathing during sleep. The literature is still controversial on the incidence and aetiology of OSA secondary to head and neck cancer treatment. The aim of this systematic review is to evaluate and discuss the prevalence of OSA in patients treated with surgery and/or chemo/radiotherapy for head and neck cancer. Materials and methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search was performed on May 2020 using the MEDLINE database, Scopus, and Google Scholar. The searches were conducted using combinations of the following terms: head and neck cancer, OSA, radiotherapy, chemotherapy, partial laryngectomy, laryngeal cancer, neoplasm, tumour, carcinoma, and oropharyngeal cancer. Results: Our results suggest that head and neck cancer patients have a higher incidence of OSA (59.78%) compared to the general population; differences may occur based on the type of treatment. Conclusions: Clinicians should recognise the higher prevalence of OSA in patients treated for head and neck cancer and should consider a comprehensive sleep history as part of the evaluation and management of these patients. Further research is needed to evaluate the exact prevalence, aetiology, and correct management of OSA after treatment for head and neck cancer.

Obstructive sleep apnea and cardiovascular comorbidities: a large epidemiologic study

Obstructive sleep apnea (OSA) is a common disorder, characterized by cyclic cessation of airflow for 10 seconds or more. There is growing awareness that OSA is related to the development and progression of cardiovascular disease. However, only a few studies have associated OSA directly to major cardiovascular events. The aim of this study was to evaluate the relationship between OSA and cardiovascular morbidity in a well defined population of patients.The electronic database of the central district of a major health management organization was searched for all patients diagnosed with OSA in 2002-2010. For each patient identified, an age- and sex-matched patient was randomly selected from the members of the same health management organization who did not have OSA. Data on demographics, socioeconomic status, and relevant medical parameters were collected as well.The study population included 2797 patients, average age 58.1, in which 76.6% were males. There was a significant correlation between OSA and the presence of ischemic heart disease (P < 0.001), pulmonary hypertension (P < 0.001), congestive heart failure (P < 0.001), cardiomyopathy (P = 0.003), and arrhythmia (P < 0.001). OSA was also significantly correlated with low socioeconomic status (P < 0.001).OSA and cardiovascular disease were strongly correlated. As such, early diagnosis and treatment of OSA may change the course of both diseases. We suggest that sleep disordered breathing should be routinely assessed in patients with cardiovascular problems. An ear-nose-throat evaluation may also be important to rule out anatomic disorders that cause upper airway obstruction.