Current surgical concepts for treating obstructive sleep apnea syndrome

Useful Genioplasty for Repeated Recurrent Sleep Apnea of Congenital Anomalies and Its Evaluation

Congenital facial anomalies with hypoplasia of the midface or lower face are associated with obstructive apnea syndrome. Although such patients underwent bone advancement surgery and their sleep apnea improved in the short term, it often recurred several years after surgery. It is difficult to perform another major osteotomy because of impairment of the facial contour or prior orthodontic treatment. Genioplasty was performed for genioglossus muscle advancement in patients with congenital anomalies and repeated sleep apnea. In this study, we evaluated the usefulness of this procedure and the mechanism for the improvement of sleep apnea.

Methods

Six patients were included: three with syndromic craniosynostosis, two with Treacher-Collins syndrome, and one with micrognathia by Goldenhar syndrome. Patients who had recurrence of sleep apnea after previous maxillomandibular osteotomies, or advancement and orthodontic treatment, received genioplasty for genioglossus muscle advancement. The patients were evaluated by body mass index, simple polysomnography, hyoid bone position on cephalogram, and the airway area on computed tomography images pre- and postoperatively.

Results

Polysomnography showed a significant improvement in the apnea-hypopnea index. Cephalometric measurement showed significant results of the hyoid bone position from point B and the ramus plane. However, no significant results were obtained in the airway area assessment.

Conclusions

Genioplasty for genioglossus muscle advancement can improve apnea-hypopnea index by moving the hyoid bone forward. Genioplasty was useful in patients with congenital anomalies who had a recurrence of sleep apnea after several procedures.

A combined orthodontic / orthognathic approach in the management of obstructive sleep apnoea: Balancing treatment efficacy and facial aesthetics

Obstructive sleep apnoea (OSA) is a prevalent condition and has been extensively managed with orthognathic surgery using a variety of surgical techniques. This case report describes the successful management of a 56-year-old Caucasian woman with a bimaxillary retrusive profile and macroglossia complicated by OSA and the combined use of orthodontics and orthognathic surgery to improve Apnoea-Hypopnoea Index while maintaining facial aesthetics. The non-extraction treatment plan included: (1) pre-surgical orthodontic treatment to maximise aesthetics and functional occlusion after surgery; (2) maxillomandibular advancement using down fracture of the maxilla (Le Fort 1 osteotomy) with counter-clockwise rotation as well as bilateral sagittal split osteotomy with septoplasty to aid increase in airway function; and (3) post-surgical orthodontic finishing and alignment with self-ligating fixed appliances. Optimum aesthetic and functional results as well as an increase in the airway volume were achieved, without compromising facial aesthetics, with the cooperation of two specialties and the use of state-of-the-art technology during the surgical planning stages.

Tongue volume in adults with skeletal Class III dentofacial deformities

Background

The size of the tongue is implicated as an essential etiological factor in the development of malocclusions. The aim of our study was to assess tongue size in skeletal Class III (SCIII) patients in comparison to adults with normal occlusion, using three-dimensional (3D) ultrasound.

Methods

The SCIII group consisted of 54 subjects; 34 females and 20 males and the control group contained 36 subjects, 18 from each gender with Class I relationship. 3D ultrasound images of the tongues were acquired, and then the tongues’ volumes were assessed.

Results

The males in both the SCIII and control groups had significantly larger tongue volumes than the female subjects (mean SCIII 100.8 ± 6.3 and control 92.4 ± 9.8 cm³ in males vs. SCIII 77.4 ± 10.2 and control 67.2 ± 5.6 cm³ in females). The highly significantly larger tongue volumes were in SCIII patients of both genders (p were less than 0.01 for female and 0.03 for male). The tongue volumes within the whole SCIII group were significantly larger with more negative Wits values.

Conclusion

The tongue volumes are significantly bigger in SCIII subjects than normal. Larger tongues correlate with more severe SCIII. The clinical importance of this data is that limited mandibular setback planning is necessary to prevent narrowing of respiratory airways.

Lateral Pharyngeal Wall Tension After Maxillomandibular Advancement for Obstructive Sleep Apnea Is a Marker for Surgical Success: Observations From Drug-Induced Sleep Endoscopy

PURPOSE

The efficacy of maxillomandibular advancement (MMA) for obstructive sleep apnea (OSA) with anatomic airway changes has previously been studied using static imaging and endoscopy in awake subjects. The aim of the present study was to use drug-induced sleep endoscopy (DISE) to evaluate the dynamic upper airway changes in sleeping subjects before and after MMA and their association with the surgical outcome.

PATIENTS AND METHODS

This was a retrospective cohort study of subjects with OSA who had undergone MMA at the Stanford University Sleep Surgery Division from July 2013 to July 2014. The subjects were included if perioperative polysomnography and DISE had been performed. The predictor variable was the perioperative DISE velum-oropharynx-tongue-epiglottis score. The outcome variables were the apnea-hypopnea index (AHI), oxygen-desaturation index (ODI), and Epworth Sleepiness Scale (ESS). A subgroup analysis was performed for the subjects who had undergone primary and secondary MMA. The statistical analyses included Cronbach's α coefficient, the McNemar test, and the independent Student t test. The P value was set at <.01.

RESULTS

A total of 16 subjects (15 males, 1 female) were included in the present study, with an average age of 47 ± 10.9 years and body mass index of 29.4 ± 5.1 kg/m(2). Significant post-MMA decreases were found in the AHI (from 59.8 ± 25.6 to 9.3 ± 7.1 events/hr) and ODI (from 45 ± 29.7 to 5.7 ± 4.1 events/hr; P < .001). Greater improvement in the AHI occurred in the primary MMA group (P = .022). The post-MMA change in airway collapse was most significant at the lateral pharyngeal wall (P = .001). The subjects with the most improvement in lateral pharyngeal wall collapsibility demonstrated the largest changes in the AHI (from 60.0 ± 25.6 events/hr to 7.5 ± 3.4 events/hr) and ODI (from 46.7 ± 29.8 to 5.3 ± 2 events/hr; P = .002).

CONCLUSIONS

Using DISE, we observed that after MMA, the greatest reduction in upper airway collapsibility is seen at the lateral pharyngeal wall of the oropharynx, followed by the velum, and then the tongue base. The stability of the lateral pharyngeal wall is a marker of surgical success after MMA using the AHI, ODI, and ESS.

Linear and volumetric airway changes after maxillomandibular advancement for obstructive sleep apnea

PURPOSE

Maxillomandibular advancement (MMA) surgery is a well-established treatment of obstructive sleep apnea (OSA). Although many studies have assessed the efficacy of MMA in treating OSA, very few studies have quantified the magnitude of its changes to airway morphology. Therefore, the present study investigated the linear and volumetric morphologic changes that occur in the pharyngeal airway after treatment of OSA using MMA.

MATERIALS AND METHODS

A retrospective cohort study of patients with OSA treated from May 2010 to February 2014 was performed. Each patient underwent preoperative clinical and fiberoptic nasopharyngoscopic examinations. Pre- and postoperative polysomnograms, lateral cephalograms, and cone-beam computed tomography scans were acquired. The radiographic images were used to determine the linear and volumetric airway measurements. The time and magnitude of skeletal movement were used as the independent variables. The dependent variables included assessment of success or cure, apnea hypopnea index (AHI), cephalometric changes, Epworth score, rapid eye movement sleep, body mass index, and various airway morphologic parameters.

RESULTS

A total of 15 patients (13 men and 2 women) participated in the present study. The surgical success and cure rate was 73.33% and 40.00%, respectively. Statistically significant improvements were found in the airway total volume, minimal cross-sectional area, anteroposterior and lateral dimensions, airway index, airway length, posterior airway space morphology, AHI, and Epworth sleepiness score.

CONCLUSIONS

MMA is a highly successful surgical treatment of OSA that improves airway morphology and sleep quality. MMA results in a shorter and broader airway and associated improvements in the AHI.

Cephalometric and three-dimensional assessment of the posterior airway space and imaging software reliability analysis before and after orthognathic surgery

PURPOSE

This study aimed to compare the reliability of three different imaging software programs for measuring the PAS and concurrently to investigate the morphological changes in oropharyngeal structures in mandibular prognathic patients before and after orthognathic surgery by using 2D and 3D analyzing technique.

MATERIAL AND METHODS

The study consists of 11 randomly chosen patients (8 females and 3 males) who underwent maxillomandibular treatment for correction of Class III anteroposterior mandibular prognathism at the University Hospital in Zurich. A set of standardized LCR and CBCT-scans were obtained from each subject preoperatively (T0), 3 months after surgery (T1) and 3 months to 2 years postoperatively (T2). Morphological changes in the posterior airway space (PAS) were evaluated longitudinally by two different observers with three different imaging software programs (OsiriX(®) 64-bit, Switzerland; Mimics(®), Belgium; BrainLab(®), Germany) and manually by analyzing cephalometric X-rays.

RESULTS

A significant increase in the upper airway dimensions before and after surgery occurred in all measured cases. All other cephalometric distances showed no statistically significant alterations. Measuring the volume of the PAS showed no significant changes in all cases. All three software programs showed similar outputs in both cephalometric analysis and 3D measuring technique.

CONCLUSION

A 3D design of the posterior airway seems to be far more reliable and precise phrasing of a statement of postoperative gradients than conventional radiography and is additionally higher compared to the corresponding manual method. In case of Class III mandibular prognathism treatment with bilateral split osteotomy of the mandible and simultaneous maxillary advancement, the negative effects of PAS volume decrease may be reduced and might prevent a developing OSAS.

Computerized cephalometric study of the pharyngeal airway space in patients submitted to orthognathic surgery

INTRODUCTION

Pharynx is a muscular organ with is sustained by craniofacial bones. It is divided into nasal, oral and hipopharynx, and can be considered as a tube that serves both respiratory and digestive systems. Its anatomical morphology permits that factors facilitate its obstruction, leading to the sleep apnea syndrome. One of the treatment consists of surgical mandibular advancement, increasing pharyngeal dimensions. The aim of this study was evaluate the cephalometric changes in the pharyngeal airway space after orthognathic surgery procedures for correction of mandibular prognathism.

MATERIALS AND METHODS

Pre and post-operative cephalometric analysis was performed on 19 patients submitted to mandibular setback by mandibular bilateral sagittal split osteotomy associated with maxillary advancement by Le Fort I osteotomy, using the Dolphin Imaging 10.0 software.

RESULTS

Results did not reveal statistically significant changes in the upper (nasopharyngeal), middle (oropharyngeal) and lower (hypopharyngeal) airway spaces, but showed increase in the nasal pharynx due the maxillary advancement and a lower position of the hyoid bone due the mandibular setback.

DISCUSSION

Maxillomandibular orthognathic surgery for correction of mandibular prognathism does not seem to statistically significantly change the pharyngeal airway space, but it increases the maxillary airway.

CONCLUSION

It seems to be important to consider the double jaw surgery in cases of mandibular prognathism, aiming prevention of a possible reduction of whole upper airway.

Impact of mandibular distraction osteogenesis on the oropharyngeal airway in adult patients with obstructive sleep apnea secondary to retroglossal airway obstruction

AIM

To evaluate the impact of mandibular advancement by distraction osteogenesis on the oropharyngeal airway in adult patients with retroglossal airway obstruction using two different techniques of mandibular distraction.

MATERIALS AND METHODS

13 adult patients with mandibular hypoplasia secondary to TMJ ankylosis with OSAS and radiographic, CT and polysomnographic evidence of OSAS were included in the study. MDO was performed (corpus distraction in 8 cases and morphometric distraction in 5 patients). Post-operatively the patients were followed up by radiographs, CT and polysomnography after 1 month and 6 months.

RESULTS

There was an increase in the linear dimension of mandible by 11.07 mm, the volume by 19.3% and a decrease in AHI from 44.8 to 13.2.

CONCLUSION

Mandibular distraction (corpus and orthomorphic-equivocal results) is an effective method of relieving the retroglossal airway obstruction in adult patients with OSAS.

Sleep Medicine Clinical and Surgical Training during Otolaryngology Residency

Objective. The authors sought to assess the otolaryngology residency training experiences in adult sleep medicine and sleep surgery in the United States.

Study Design. Internet survey.

Setting. US academic otolaryngology residency programs.

Subjects and Methods. This Internet survey was emailed to the program directors of 103 US Accreditation Council for Graduate Medical Education (ACGME)–approved otolaryngology residency programs in 2010.

Results. A total of 47 program directors responded, representing 46% of programs surveyed. In 59% of these programs, there was at least 1 faculty member with clinical practice dedicated to adult medicine. Most commonly, these clinicians spent less than 50% of their clinical time on adult sleep medicine. While most otolaryngology residents were reported being well trained in commonly performed procedures such as septoplasty and uvulopalatopharyngoplasty (UPPP), the training on hypopharyngeal or multilevel surgeries, such as partial glossectomy, tongue base resection, hyoid or tongue suspension, or geniotubercle advancement, was considered less frequent. The overall exposure to education regarding the interpretation of original data of laboratory-based sleep studies or portable home monitoring devices was infrequent. A significant portion of respondents indicated that they would like to expand their residents’ exposure to adult sleep medicine and sleep surgery.

Conclusion. This survey provides a starting point to further assess the rigor of sleep medicine/sleep surgery training in US residency programs. Continued assessment and strengthening of the current curriculum are crucial to keep residents up to date with this evolving field. This result calls attention to the importance of bolstering sleep medicine and surgery curriculum to meet the academic requirements of otolaryngology training.

Changes in upper airway width associated with Class II treatments (headgear vs activator) and different growth patterns

OBJECTIVE

To investigate the upper airways for anteroposterior width against different growth patterns and for alterations during various Class II treatments.

MATERIALS AND METHODS

Cephalograms from three treatment groups (headgear, activator, and bite-jumping appliance) were evaluated by a single investigator at baseline and at the end of orthodontic treatment. Cephalograms were used to determine upper airway width at different levels in the anteroposterior plane. Patients in the headgear group were additionally divided into six subsets on the basis of y-axis values to assess the influence of different growth patterns.

RESULTS

Small increases in pharyngeal width were noted at all vertical level segments, both at baseline and during orthodontic treatments. No significant differences in these small increases were noted across various treatment modalities and growth patterns.

CONCLUSION

Upper airway changes did not significantly vary with the different treatment modalities investigated in the present study. Nevertheless, reductions in pharyngeal width potentially triggering or exacerbating obstructive sleep apnea syndrome (OSAS) are always possible in the headgear phase.

Morphological examination of upper airway in obstructive sleep apnea

OBJECTIVES

An aim of this study was to assess the predictive power of an otorhinolaryngological examination of the upper airway to identify risk factors of obstructive sleep apnea syndrome (OSAS) in the patients.

METHODS

We examined 141 consecutive patients with OSAS. The morphological features were assessed by the designated otorhinolaryngologist while the subjects were sitting relaxedly with tidal breathing. The bilateral nasal resistance was measured using the active anterior rhinomanometry during daytime wakefulness.

RESULTS

The body mass index (BMI), fauces's narrowness, neck circumference, lowest oxygen saturation, tonsil size and modified Mallampati grade (MMP) showed the statistically significant correlations with the apnea-hypopnea index (AHI) of an index of apnoeseverity, however, the age, Epworth sleepiness scale (ESS), nasal resistance and retroglossal space were not significantly associated with the AHI.

CONCLUSIONS

The upper airway morphology significantly associated with AHI are fauces's narrowness, tonsil size, and MMP, but not nasal resistance and retroglossal space.

[Genioplasty: technique and applications]

The chin is an element as important in facial profile as the nose and the forehead. It is subject to morphological anomalies in the sagittal (retrogenius or progenius), vertical (excess or insufficient height), or transversal (laterogenius) axes. Genioplasty used alone or in complement to other maxillomandibular osteotomies, allows for the correction of these malformations by modifying the position of the chin bones in three planes. Many types of genioplasty may be used to reach the desire goal, such as advancement, retraction, or adjustment of height or of symmetry. This genioplasty also has functional applications, notably in the treatment of obstructive sleep apnoea disorders. The anatomic bases of genioplasty and the interest of cephalometric analysis in diagnosing chin position anomalies are reviewed as well as the different operative steps for horizontal advancement osteotomy and the specific principles and indications for other types of genioplasty.

Surgical management of obstructive sleep apnea

Obstructive sleep apnea (OSA) syndrome is a common disorder that has recently received much attention by the medical community due to its potentially serious physiological consequences. The clinical significance of OSA results from hypoxemia and sleep fragmentation caused by collapse of the airway, which leads to apnea or hypopnea during sleep. This paper reviews common surgical techniques used for clinical management of OSA patients, with emphasis on jaw advancement surgical procedures.

Sleep apnoea in the older adult : pathophysiology, epidemiology, consequences and management

Sleep apnoea is a breathing disorder in sleep usually caused by repetitive upper airway obstruction. Its primary symptoms include snoring, daytime sleepiness and decreased cognitive functioning. Risk factors for the condition include obesity, anatomical abnormalities, aging, and family history. It has been associated with hypertension, cardiovascular and pulmonary diseases and increased mortality. The prevalence of sleep apnoea increases with age, although the severity of the disorder, as well as the morbidity and mortality associated with it, may actually decrease in the elderly. A decline in cognitive functioning in older adults with sleep apnoea may resemble dementia. Medical management of sleep apnoea rarely relies on drug treatment, as the few drugs (antidepressants and respiratory stimulants) tested for treatment have been found to be ineffective, or cause tolerance or serious adverse effects and complications. The treatment of choice for sleep apnoea is continuous positive airway pressure, a device which generates positive air pressure through a nose mask, creating a splint which keeps the airway unobstructed throughout the night. Weight loss significantly decreases or eliminates apnoeas. Oral appliances are used to enlarge the airway at night by moving the tongue and mandible forward. Positional therapy involves avoiding the supine position during sleep in patients who mostly have apnoeas while lying on their back. Surgical management may also be considered, although with great caution in the elderly, because of their increased risk of complications related to surgery. Surgical procedures include nasal reconstruction, somnoplasty, laser-assisted uvuloplasty, uvulopalatopharyngoplasty, genioglossus advancement and hyoid myotomy, and maxillomandibular advancement for severe cases when other treatments have failed. As a last option, tracheostomy may be performed.

Evaluation of respiratory status and mandibular movement after total temporomandibular joint replacement in patients with rheumatoid arthritis

We performed total TMJ replacement to improve respiratory status and correct occlusion in six patients with destruction of the temporomandibular joint (TMJ) caused by rheumatoid arthritis. Morphological changes were evaluated on lateral cephalograms before and after surgery. Respiratory function and mandibular movement were assessed with the use of an apnea-monitor and an LED mandibular tracking device, respectively. After surgery, symptoms such as snoring and daytime sleepiness improved, and solid food could be masticated. Postoperative cephalograms showed that both the posterior airway space and ramal height were significantly improved by surgery. Postoperative records of mandibular movement indicated stability of the occlusion and improvement of mandibular movement, as compared with the preoperative records. Mean oxygen saturation significantly improved 1 month after surgery, whereas apnea and apnea-hypopnea indices did not change significantly.

Surgical strategies in the treatment of complex obstructive sleep apnoea in children

Complex OSA in children is a challenging problem that requires careful team management. Evaluation includes history, physical examination and appropriate radiological and endoscopic studies. Twelve-channel polysomnography, with or without a pH probe, is mandatory in children with OSA to determine the severity and to document the efficacy of treatment. A variety of individual problems and nuances arise and will continue to do so. Clinical experience and a high degree of suspicion in the craniofacial population is necessary to rule out the existence of OSA in a given patient. Newer treatment modalities, such as distraction osteogenesis of the mandible and midface, have revolutionised treatment of OSA during childhood. Although still the gold standard of care, tracheostomy is not a benign procedure and the toll on both the patient and family can be devastating.

Pharyngeal airway space changes after counterclockwise rotation of the maxillomandibular complex

The purpose of this study was to evaluate the effects of double-jaw surgery with counterclockwise rotation of the maxillomandibular complex on the pharyngeal airway space and velopharyngeal anatomy in patients with high occlusal plane facial morphology. Fifty patients (22 men, 28 women) with high occlusal plane facial morphology underwent double-jaw surgery with counterclockwise rotation of the maxillomandibular complex. The patients were divided into 2 groups: group 1, 30 patients (8 men, 22 women) who underwent maxillary and mandibular advancement and group 2, 20 patients (14 men, 6 women) who underwent maxillary advancement and mandibular setback. Presurgery and postsurgery lateral cephalometric radiographs were analyzed to correlate changes in pharyngeal airway space dimensions and velopharyngeal anatomy with maxillary and mandibular positional changes. The calibration showed a more than 0.94 correlation for both intra- and interoperator error. The average follow-up time was 29.6 months in group 1 and 22.2 months in group 2. Mean maxillary surgical change at point A was 4.15 mm in group 1 and 2.5 mm in group 2. Mean mandibular surgical change at the genial tubercles was 7.5 mm in group 1 and -4.95 mm in group 2. After surgery, group 1 patients had an increase in pharyngeal airway space of 47% at the soft palate and 76% at the base of the tongue relative to the amount of mandibular advancement. Group 2 patients had a decrease in pharyngeal airway space of 47% at the soft palate and 65% at the base of the tongue relative to the amount of mandibular setback. Double-jaw surgery with counterclockwise rotation of the maxillomandibular complex significantly affects the pharyngeal airway space and velopharyngeal anatomy in patients with high occlusal plane facial morphology, with both mandibular advancement and setback.

Selecting sleep-disordered-breathing appliances. Biomechanical considerations

BACKGROUND

Dentists who wish to provide sleep-disordered-breathing therapy have many different mandibular advancement devices, or MADs, from which to select. Documented research directly about the variations in MADs is sparse.

TYPES OF STUDIES REVIEWED

The author reviewed dental and medical literature dealing with biological and mechanical principles affecting the function of MADs.

RESULTS

The author found that MADs vary in four major areas: freedom of mandibular movement, amount and rigidity of dental coverage, amount of mandibular advancement and amount of bite opening. Each of these areas appears to affect the appliance's efficacy, safety or both. The main potential detrimental effect of MADs is occlusal shifting. The author presents biological and mechanical considerations in an attempt to determine the optimum parameters for each of the MAD variation areas. The MAD must be constructed in a manner and with material that secures the mandible in its optimum position. The optimum mandibular position needs to be captured and transferred to the articulator with an accurate construction bite.

CLINICAL IMPLICATIONS

MAD therapy may last a lifetime. Therefore, dentists must consider the efficacy and the safety of an MAD when selecting an appliance. Since occlusal shifting appears to be the main potential detrimental effect, dentists should consider all available means to monitor and minimize these changes.

Fiberoptic nasopharyngolaryngoscopy for airway monitoring after obstructive sleep apnea surgery

PURPOSE

This study evaluated the upper airway characteristics in the early postoperative period after reconstructive surgery for obstructive sleep apnea (OSA).

METHODS

During a 24-month period, the upper airway of patients who underwent uvulopalatopharyngoplasty (UPPP) with genioglossus advancement (GA) or hyoid myotomy (HM) or maxillomandibular advancement (MMA) were evaluated with fiberoptic nasopharyngolaryngoscopy (NPG) preoperatively and 24 to 72 hours postoperatively.

RESULTS

NPG was performed on 271 patients. One hundred seventy-three patients had UPPP with GA or HM, and the remainder had MMA. All of the patients who underwent UPPP with GA or HM were found to have varying degrees of soft tissue edema involving the soft palate and the tongue base. The patients who underwent tonsillectomies and UPPP with GA or HM had greater soft palate/pharyngeal wall edema. In contrast, patients who underwent MMA had minimal edema involving the soft palate and the base of tongue, but diffuse lateral pharyngeal wall edema throughout the upper airway was identified. Eighteen of the MMA patients had ecchymosis and edema involving the pyriform sinus and aryepiglottic fold; 4 of these patients also had a hypopharyngeal hematoma involving the pyriform sinus, aryepiglottic fold, arytenoid, and false vocal cord, which partially obstructed the airway. These 4 patients were closely monitored for 1 to 2 additional days, and all were discharged without problems. None of the patients in the study had postoperative airway obstruction.

CONCLUSION

NPG may be useful in postoperative airway monitoring and assist in discharge planning after upper airway reconstruction in the OSA patients.

Site of airway collapse in obstructive sleep apnea after uvulopalatopharyngoplasty

The objective of this prospective study was to determine the site and pattern of upper airway collapse by a multiple-catheter technique in subjects demonstrated to have obstructive sleep apnea (OSA) after uvulopalatopharyngoplasty (UPPP). Standard diagnostic nocturnal polysomnography (PSG) was done on all subjects. The PSG recordings included electroencephalogram, electrooculogram, electrocardiogram, chin and leg electromyograms, nasal and oral airflow, and abdominal effort. Polysomnography with a multiport flexible airway Gaeltec catheter was performed in 22 subjects. The Gaeltec flexible airway catheter has 4 high-fidelity pressure sensors to aid in determining the primary site of airway collapse. The primary site of airway collapse was determined by differential pressure gradients between pressure ports and by visual inspection of the pressure tracings. Forty-two subjects with prior UPPP from a total of 60 (39 men and 3 women, ages 33 to 61) agreed to be to studied by the standard PSG technique. Thirty-five subjects complained of excessive daytime sleepiness. Ten had mild OSA, 10 had moderate OSA, 12 had severe OSA, and 10 were "normal." Of the 22 subjects who had airway catheter monitoring, 3 of the normals were reclassified as having upper airway resistance (mean peak negative esophageal pressure of -28 cm H2O); 2 patients demonstrated airway obstruction in the nasopharynx, 2 at the oropharynx, and 11 at the level of the hypopharynx. Postoperative nocturnal PSG data were compared to data gathered prior to UPPP. The mean respiratory disturbance index (RDI) for the catheter group was 54 events per hour prior to UPPP, and the mean RDI after surgery was 44. There was no correlation between the severity of OSA and the stage of sleep. We conclude that the majority of patients who complain of excessive daytime sleepiness following UPPP have OSA with the primary site of obstruction at the level of the hypopharynx. The severity of airway collapse is variable during each stage of sleep. Esophageal pressure monitoring during sleep should be considered when evaluating symptoms of persistent OSA in patients who have had UPPP.

Maxillomandibular advancement surgery in a site-specific treatment approach for obstructive sleep apnea in 50 consecutive patients

OBJECTIVE

To report the efficacy of maxillomandibular advancement (MMA) surgery, with a description of several innovations, as a site-specific treatment of obstructive sleep apnea syndrome (OSAS) in selected cases with disproportionate velo-orohypopharyngeal anatomy.

DESIGN

Clinical series of 50 consecutive cases.

SETTING

Surgery was performed in a hospital operating room, and perioperative management was provided in an intensive care environment. Except for polysomnography (PSG), which was performed and interpreted by independent sleep facilities/physicians, all pre- and postoperative evaluations were accomplished in a solo office private practice setting.

PATIENTS

Patients were referred for MMA evaluation when applicable conservative therapies such as nasal continuous positive airway pressure (nCPAP) were not tolerated, refused, or unsuccessful. Case selection was based primarily on the sites of disproportionate upper airway anatomy.

INTERVENTIONS

MMA consisted of a Lefort I osteotomy, bilateral sagittal split ramus osteotomies, and a new modified procedure called an anterior inferior mandibular osteotomy with indirect hyoid suspension. Some patients also received concomitant adjunctive nonpharyngeal procedures.

MEASUREMENTS AND RESULTS

Obtained at a mean of 5.2 months postoperatively, revealed significant improvement in all cases. Mean BPs (n = 50) were lowered, subjective symptoms were ameliorated, and mean body mass index (n = 50) was reduced. Cephalometric analysis (n = 50), with several new modifications including standardization for phases of respiration, quantified structural changes in soft-tissue and bony landmarks. Postoperative PSG results (n = 50) showed dramatic improvement over preoperative data (n = 50), with therapeutic values similar to nCPAP (n = 42). Mean values improved from preoperative to postoperative vs nCPAP for apnea index (34.5 to 1.0 vs 2.0, respectively), apnea-hypopnea index (59.2 to 4.7 vs 5.4, respectively), lowest arterial oxyhemoglobin desaturations (72.7% to 88.6% vs 88.6%, respectively), and number of desaturations < 90% (118.8 to 6.6 vs 2.4, respectively). The success rate was 100%.

CONCLUSION

MMA is highly successful and safe and may be a definitive primary single-staged surgical treatment of selected OSAS cases with diffusely complex or multiple sites of disproportionate velo-orohypopharyngeal anatomy.

Overview of Phase II Surgery for Obstructive Sleep Apnea Syndrome

Maxillomandibular advancement is an extremely effective surgical procedure for the treatment of obstructive sleep apnea syndrome. When properly executed, it is associated with minimal morbidity and is well accepted by patients. It is a treatment option that achieves long-term cure.

Proposed cephalometric diagnosis for osteogenic obstructive sleep apnea (OSA): the mandibular/pharyngeal ratio

The purpose of this laboratory study is to devise a simple, diagnostic test to assess possible osteological deficiency as a probable cause of OSA. Modern day skulls of fifty males and forty eight females of Tuscan origin and an additional seventy-five skulls, from India, with their cephalograms were used for this study. Mandibular length and antero-posterior dimension of the nasopharynx--pharyngeal tubercle (PhT) to posterior nasal spine (PNS)--were measured on the Tuscan skulls. The nasopharynx was similarly measured on the Indian skulls and readings multiplied by 1.14, the magnification factor of the cephalometric apparatus used. The PhT-PNS distance was then plotted on the cephalogram of Indian skulls with point PhT at the basiocciput. The possible presence of an osteogenic etiology of OSA can be determined by comparison of the mandibular/pharyngeal ratio obtained from the skull cephalograms to that of the individual patient.

Mandibular posture during sleep in patients with obstructive sleep apnoea

Vertical mandibular posture is thought to be related to narrowing of the upper airway, because mouth opening is associated with an inferior-posterior movement of the mandible and the tongue which influences pharyngeal airway patency. To test whether the mandibular posture is related to the occurrence and/or termination of obstructive sleep apnoea (OSA), the vertical mandibular position was recorded intraorally using a magnet sensor during a standard sleep study in seven patients with OSA. Measurements were recorded during sleep both in the supine and lateral recumbent positions. The percentage of total sleep time spent with mandibular opening greater than 5 mm was significantly larger (p<0.001) in patients with OSA (69.3+/-23.3%) compared with our previous results obtained from healthy adults without OSA (11.1+/-11.6%). The stage of sleep affected the vertical mandibular posture during sleep in the supine position, but not in the lateral recumbent position in patients with OSA. In non-rapid eye-movement sleep, mandibular opening increased progressively during apnoeic episodes and decreased at the termination of apnoeic episodes. In contrast, no significant change in mandibular posture occurred in apnoeic episodes during rapid eye-movement sleep. It was concluded that the vertical mandibular posture is more open during sleep in patients with OSA than in healthy adults and that mandibular opening increases progressively during apnoeic episodes and decreases at the termination of those episodes.

Surgical management of obstructive sleep apnea

Obstructive sleep apnea syndrome (OSAS) is most commonly the result of unfavorable anatomic configuration of the pharyngeal airway. Although tracheostomy bypasses the pharyngeal airway, other surgical approaches to OSAS modify the pharyngeal airway by extirpation of soft tissue or modification of the underlying craniofacial skeleton. Frequently more than one anatomic alteration is required for effective therapy. The techniques applied are determined by radiological and endoscopic assessment. Multiple techniques may be required and may be applied either in one surgical session or in sequential sessions.

Alternatives to tracheostomy in infants and children with obstructive sleep apnea

PURPOSE

Since 1989, 70 children have been treated surgically with varying degrees of obstructive sleep apnea (OSA). Of these, 29 patients had completely failed conventional medical and surgical treatment and were considered tracheostomy (T) candidates, whereas five had previously undergone T for severe OSA as infants and did not respond to standard decannulation protocols. The preoperative diagnoses were cerebral palsy (n = 5), Down's syndrome (n = 5), hemifacial microsomia (n = 4), Pierre Robin sequence (n = 6), and a mixed group of craniofacial disorders (n = 14). The patients ranged in age from 2.5 weeks to > or =18 months (mean, 7.32 years). Preoperatively, four patients were on ventilators and one suffered a cardiac arrest, attesting to the severity of OSA.

METHODS

To enlarge the caliber of the airway, each patient underwent an aggressive surgical treatment protocol. All sites of upper airway obstruction were treated simultaneously by a combination of craniofacial skeletal expansion and soft-tissue reduction.

RESULTS

Tracheostomy was avoided in 90.4% of patients. Temporary or "permanent T" were required in three patients (9.6%). One patient with cerebral palsy had recurrent OSA and died. A second patient with severe laryngotracheomalacia and retrognathia who did not respond to apnea surgery underwent a tracheostomy and ultimately died of pulmonary causes. Four patients (7.8%) required supplemental home oxygen or continuous positive airway pressure. The average preoperative respiratory disturbance index, defined as the average number of apneic and hypopneic events per hour of sleep, dropped from 25.9 to 4.4 after surgery. The average lowest recorded oxygen saturation during overnight polysomnography rose from 61% to 92% after surgery. Of the five patients with permanent T, four had thus far been decannulated. Complications occurred in 10 patients, 50% of which were related to minor problems with mandibular distraction devices.

CONCLUSION

Our results confirm the efficacy of an aggressive surgical approach to the treatment of OSA in children, avoiding the necessity for tracheostomy or permitting decannulation of permanent T in the majority of cases.

Skeletal expansion combined with soft-tissue reduction in the treatment of obstructive sleep apnea in children: physiologic results

Twenty consecutive children, ranging in age from 6 days to 18 years, were treated with skeletal expansion, in addition to soft-tissue reduction, for medically refractory obstructive sleep apnea. The underlying diagnoses were craniofacial microsomia (n = 6), Down syndrome (n = 3), Pierre Robin syndrome (n = 3), cerebral palsy (n = 3), Nager's syndrome (n = 1), Treacher Collins syndrome (n = 1), cri du chat syndrome (n = 1), juvenile rheumatoid arthritis (n = 1), and temporomandibular joint ankylosis (n = 1). Fourteen children had severe medically refractory sleep apnea and were tracheostomy candidates; in the remaining six, tracheostomies were placed shortly after birth and could not be decannulated. Overnight, 12-channel polysomnography was obtained before and after surgery. The mean apnea index improved from 7.42 to 1.26, the mean respiratory disturbance index improved from 25.24 to 1.72, and the mean lowest apnea-related oxygen saturation improved from 68% to 88%. Of the 14 children with medically refractory obstructive sleep apnea, two required tracheostomies. Of the six patients with tracheostomies, five have been decannulated at the time of this writing. Skeletal expansion in conjunction with soft-tissue reduction in the pediatric population permits substantial increases in the volume of both the nasopharynx and oropharynx. Creative use of conventional osteotomies and the application of distraction osteogenesis have enabled surgeons to apply maxillofacial and craniofacial techniques in treating children with obstructive sleep apnea.

Mandibular distraction osteogenesis in the treatment of upper airway obstruction in children with craniofacial deformities

Over the past 3 years, 16 patients (12 males, 4 females) have undergone mandibular distraction osteogenesis in conjunction with soft-tissue procedures to treat medically refractory obstructive sleep apnea. Thirty distraction devices were placed for bilateral distraction in 14 children and unilateral distraction in 2. The mean age of treatment was 4 years and 8 months (range 14 weeks to 12 years and 8 months). Eight of the patients had failed conventional medical and surgical treatment of obstructive sleep apnea and were considered tracheostomy candidates, whereas the remaining eight had tracheostomies placed shortly after birth for upper airway obstruction. These eight children could not be decannulated by standard protocols. The average distraction distance was 25 mm (range 18 to 35 mm). To date, seven of the eight patients with tracheostomies have been decannulated, and one is still in progress. Clinical improvement in the signs and symptoms of sleep apnea and reduction or elimination of preoperative oxygen requirements occurred in seven of the eight children with medically refractory sleep apnea. Twelve-channel polysomnograms were obtained preoperatively and postoperatively in each of the eight patients without tracheostomies. Respiratory disturbance index decreased from a mean of 7.1 to 1.7 after surgery. Lowest oxygen saturation rose from a mean of 0.70 to 0.89 after surgery. Application of mandibular distraction osteogenesis is an important component in the treatment of obstructive sleep apnea and permits mandibular advancement in the younger child. As more experience is gained with distraction osteogenesis in the treatment of children with obstructive sleep apnea, the role of distraction will become better defined.

Obstructive sleep apnoea: the role of the oral and maxillofacial surgeon

Obstructive sleep apnoea is a relatively common sleep disorder that is popularly associated with snoring and excessive daytime sleepiness. It is a disorder with serious implications that has only in the last two decades received the attention of clinical specialists. The aim of this article is to review the role of the dental profession in the recognition and management of this disorder.

Hyoid myotomy and suspension for obstructive sleep apnea syndrome

Hyoid bone suspension with inferior myotomy has been shown to be a successful technique in the treatment of obstructive sleep apnea. However, little mention is made in the literature concerning the details of the surgical procedure. Anatomic details have been given even less attention. This article addresses the regional anatomy, surgical technique, and materials for suspension of the hyoid bone, along with newer modifications of the procedure. Potential risks and complications are also discussed.

Obstructive sleep apnoea: fact not fiction

Obstructive sleep apnoea (OSA) is a recognized clinical disorder in which periods of cessation of breathing occur in the presence of inspiratory effort. Because this may have serious cardio-vascular and pulmonary consequences, diagnosis, and adequate treatment are important. Apart from its medical repercussions, OSA adversely affects the quality of life of both the sufferer and his family. This paper aims to give an overview of the complaint, defining and describing the disorder, reporting its signs and symptoms, and discussing its diagnosis and treatment. Particular attention will be given to those areas in which the orthodontist may play an active role.

The functional palatorrhaphy in the treatment of obstructive sleep apnoea

We have developed a new operation for the surgical treatment of obstructive sleep apnoea, which we called functional palatorrhaphy. This preserves the posterior border of the soft palate and allows a controlled repair of the aponeurosis of the soft palate muscle. We combine the palatorrhaphy with a standard or a modified chin osteotomy with advancement of the base of tongue. In our first five treated and re-evaluated patients with severe obstructive sleep apnoea syndrome, who did not respond to conservative treatment, the operation was successful. All patients but one were considerably improved or cured of their symptoms.

The cranial base in obstructive sleep apnea

PURPOSE

The purpose of this investigation was to determine if there are cranial base differences in adults with obstructive sleep apnea (without identifiable craniofacial abnormalities) when compared with those of adults without airway problems.

METHODS

Cephalometric analysis of the cranial base of 52 patients with documented sleep apnea were compared with 96 normal adult patients. Each of the groups was subdivided based on skeletal profiles (Class I, II, III). Cephalometric measurements included cranial base flexure angle and anterior and posterior cranial base lengths. Standard analysis of variance and Students' t test were used to determine level of significance.

RESULTS

The cranial base flexure angle in patients with documented sleep apnea was significantly more acute than that found in the nonapnea group. Patients with a skeletal Class III profile had the most acute cranial base flexure whereas those with Class II profiles had the most obtuse angles. This pattern was true for apnea and nonapnea groups. No cranial base length differences could be found in either group.

CONCLUSION

The results of this study demonstrate that there were abnormalities of the cranial base in patients with obstructive sleep apnea. Abnormalities of the cranial base seen in "nonsyndrome" obstructive sleep apnea patients are similar to those seen in patients with certain identifiable syndromes. This may suggest that sleep apnea is a reflection of a form of craniofacial syndrome.