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Chang CP, Poomkonsarn S, Giannakopoulos H, Ma Y, Riley R, Liu SY. Comparative Efficacy of Obstructive Sleep Apnea Patients Undergoing Multilevel Surgery Followed by Upper Airway Stimulation Versus Isolated Upper Airway Stimulation. J Oral Maxillofac Surg 2022; 81:557-565. [PMID: 36539190 DOI: 10.1016/j.joms.2022.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 11/21/2022] [Accepted: 11/24/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE Upper Airway Stimulation (UAS) of the hypoglossal nerve is a rapidly growing management option for patients with obstructive sleep apnea (OSA). Our study compares the treatment efficacy of UAS between those who were initially ineligible for UAS but subsequently met eligibility after multilevel surgery versus those who underwent isolated UAS for the treatment of moderate to severe OSA. METHODS The investigators implemented a retrospective single-center cohort study of patients aged 18+ years who presented for surgical evaluation of OSA from 2016-2019 and underwent UAS implantation. The predictor variable was eligibility status for UAS. Initially ineligible subjects were defined as having an apnea-hypopnea (AHI) > 65 events/hr, body mass index (BMI) > 32 kg/m2, or complete concentric collapse (CCC) on drug-induced sleep endoscopy. Eligible subjects were defined as having an AHI between 15 and 65, with no CCC on drug-induced sleep endoscopy. The primary outcome was change in AHI which was measured preoperatively and 6 months post UAS implantation. Secondary outcomes were change in Epworth sleepiness scale and Fatigue severity scale. Covariates were age, sex, and BMI. Data analysis involved descriptive statistics and multivariable statistical models; P < .05 was considered significant. RESULTS Thirty six patients underwent UAS implantation from 2016-2019. Eighteen patients who were initially ineligible for UAS underwent multilevel surgery, including uvulopalatopharyngoplasty, distraction osteogenesis maxillary expansion, or maxillomandibular advancement. Mean age was 62.4 ± 9 years and BMI of 29.1 ± 4 kg/m2 with 5 female patients. The cohort of 17 patients who met criteria for UAS from the start had a mean age of 62.9 ± 14 years and mean BMI of 26.7 ± 4 kg/m2 with 2 female patients. Mean AHI reduction for the multilevel group was 37.6 ± 21.2 events per hour (P < .001). Mean AHI reduction for the UAS-only group was 31.5 ± 13 events per hour (P < .001). When adjusted for age, BMI, and sex, the multilevel group had a more significant reduction (18 AHI events) compared to the isolated group (P < .001). CONCLUSIONS For patients who are ineligible for UAS due to severity of OSA or CCC of the velum, multilevel surgery including maxillomandibular advancement followed by UAS confers effective post-treatment results, which was superior to the UAS-only group.
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Affiliation(s)
- Corissa P Chang
- Resident, Department of Oral and Maxillofacial Surgery, Hospital of University of Pennsylvania, Philadelphia, PA; Visiting Research Scholar, Division of Sleep Surgery, Department of Otolaryngology- Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Sasikarn Poomkonsarn
- Visiting Research Scholar, Division of Sleep Surgery, Department of Otolaryngology- Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA; Clinical Instructor, Department of Otolaryngology, Center of Excellence in Otolaryngology Head and Neck Surgery, Rajavithi Hospital, Bangkok, Thailand
| | - Helen Giannakopoulos
- Associate Professor, Department of Oral and Maxillofacial Surgery, Hospital of University of Pennsylvania, Philadelphia, PA
| | - Yifei Ma
- Statistician, Department of Otolaryngology- Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Robert Riley
- Clinical Professor, Department of Otolaryngology- Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Stanley Yung Liu
- Chief, Department of Plastic Surgery, Maxillofacial Surgery, Stanford Health Care, Stanford, CA; Associate Professor, Department of Otolaryngology- Head and Neck Surgery, and by Courtesy, Division of Plastic & Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA.
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Maresch KJ. Perioperative and Perianesthesia Considerations for Hypoglossal Nerve Stimulator Implantation in Obstructive Sleep Apnea Patients. J Perianesth Nurs 2022; 37:760-765.e1. [PMID: 35618616 DOI: 10.1016/j.jopan.2022.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 02/06/2022] [Accepted: 02/11/2022] [Indexed: 10/18/2022]
Abstract
Hypoglossal nerve stimulation (Inspire Medical Systems, Maple Grove, Minnesota) is an innovative treatment option for eligible patients with moderate to severe obstructive sleep apnea (OSA). Since U.S. Food and Drug Administration approval in 2014, over 18,000 patients have been implanted. The device includes an implanted pacemaker-sized pulse generator, one sensing lead, and one stimulation lead. During sleep, inspirations and expirations are detected by the sensing lead. At end expiration, the stimulation lead triggers the hypoglossal nerve to contract and stiffen the tongue thus preventing airway obstruction and improving OSA. Perioperative and perianesthesia nurses have an important role in caring for these patients during all aspects of the surgical insertion process: evaluation for eligibility, device implantation, and future visits to the perioperative area for related and unrelated procedures. This article reviews anatomic and physiologic factors contributing to airway collapse in OSA, function of the hypoglossal nerve stimulation device, the evaluation, implantation, and activation process, and considerations for patient care in the perioperative and perianesthesia periods. Precautions needed for other therapies, including Magnetic Resonance Imaging, diathermy, and radiation are also discussed.
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Affiliation(s)
- Karen J Maresch
- Staff CRNA, University of Pittsburgh Medical Center, Pittsburgh, PA.
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Zibly Z, Averbuch S, Deogaonker M. Emerging Technologies and Indications of Neuromodulation and Increasing Role of Non Invasive Neuromodulation. Neurol India 2020; 68:S316-S321. [PMID: 33318368 DOI: 10.4103/0028-3886.302453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Altering the enormous complex connectivity and output of the central nervous system is one of the most fascinating development in medical technologies. It harbors the ability to treat and modulate different neurological disorders and diseases such as Parkinson's disease, Alzheimer's disease and even help with drug delivery to treat unreachable areas of brain via opening of the blood brain barrier. Evolution of neuromodulation techniques has been significant in last few years. They have become less invasive and more focused. Newer neuromodulation techniques consist of invasive, minimally invasive and non-invasive technologies. The decision to use one of these technologies depends on the indication and the targeted area within the central or peripheral nervous system. In the last decade technological advances and the urge to minimize the surgical and the long term complications of hardware implantation, have pushed the neurosurgical community to increase the use of non-invasive neuromodulation technics. In this article, we will discuss the different emerging technologies in neuromodulation and the increasing role of non-invasive neuromodulation.
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Affiliation(s)
- Zion Zibly
- Department of Neurosurgery, Functional Neurosurgery Unit, The Focused Ultrasound Institute and Sackler School of Medicine, Tel Aviv University, Israel
| | - Shay Averbuch
- Sackler School of Medicine, Tel Aviv University, Israel
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Chang CP, Dierks E, Cheng A, Ma Y, Liu SY. Does the Lack of Gender-Specific Apnea-Hypopnea Index Cutoff for Obstructive Sleep Apnea Impact Surgical Selection? J Oral Maxillofac Surg 2020; 79:666-671. [PMID: 33271184 DOI: 10.1016/j.joms.2020.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 11/01/2020] [Accepted: 11/02/2020] [Indexed: 12/13/2022]
Abstract
PURPOSE The apnea-hypopnea index (AHI) is the parameter on which the severity of obstructive sleep apnea (OSA) is based and is also the determinant for both clinicians and third-party payers for surgical procedures. The purpose of this retrospective cross-sectional chart review is to examine differences in symptoms and AHI between men and women with OSA and whether this may impact timing and selection of surgical care. METHODS Retrospective cross-sectional study of patients aged 18 years and older who presented at a single center for surgical evaluation of OSA from January 2017 to 2020. AHI, oxygen desaturation index, respiratory disturbance index, and lowest oxygen saturation were obtained from polysomnography. The predictor variable was gender, and the outcome variable was AHI. Unadjusted and multivariate adjusted linear regression models were used to compare differences in AHI between gender, controlling for age, body mass index (BMI), Epworth sleepiness scale, and fatigue severity scale. Poisson regression analysis with robust error was used to assess the relative risks of antidepressant and anxiolytic medication use between genders. RESULTS A total of 408 consecutive new patients seen for surgical evaluation to treat OSA (248 men and 160 women) were included. Median patient age was 40 years for men and 41 years for women. Median AHI for men was 22.1 events per hour and 13.7 for women (P < .001). When adjusted for age and BMI, men have 33.2% higher AHI than women, with age contributing to 2% and BMI contributing to 6% of the difference. When controlling for age, BMI, Epworth sleepiness scale, and fatigue severity scale, women have a 2.2 increased relative risk of taking anxiolytic or antidepressant medications. CONCLUSIONS Women with OSA seeking surgery in a dedicated sleep practice have 33% lower AHI than men when controlling for age, BMI, and symptoms. Based on our findings, non-gender-specific AHI may handicap the surgeon from offering the full range of available procedures to women with OSA.
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Affiliation(s)
- Corissa P Chang
- Visiting Research Scholar, Division of Sleep Surgery, Department of Otolaryngology- Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Eric Dierks
- Senior Consultant, Head and Neck Institute, Affiliate Professor, Oregon and Health Sciences University, Department of Oral and Maxillofacial Surgery, Portland, OR
| | - Amanda Cheng
- Chief Orthodontist, US Sleep Apnea, San Francisco, CA
| | - Yifei Ma
- Statistician, Department of Otolaryngology- Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Stanley Yung Liu
- Assistant Professor, Department of Otolaryngology, Stanford Health Care, Stanford, CA; and by Courtesy, Division of Plastic Surgery, Director of Sleep Surgery Fellowship, Stanford University School of Medicine and Chief, Maxillofacial Surgery, Stanford Health Care, Stanford, CA.
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Yu MS, Ibrahim B, Riley RW, Liu SYC. Maxillomandibular Advancement and Upper Airway Stimulation: Extrapharyngeal Surgery for Obstructive Sleep Apnea. Clin Exp Otorhinolaryngol 2020; 13:225-233. [PMID: 32683836 PMCID: PMC7435433 DOI: 10.21053/ceo.2020.00360] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 04/16/2020] [Indexed: 12/14/2022] Open
Abstract
There are many ways to categorize surgery for obstructive sleep apnea (OSA), one of which is to distinguish between intrapharyngeal and extrapharyngeal procedures. While the general otolaryngologist treating OSA is familiar with intrapharyngeal procedures, such as uvulopalatopharyngoplasty and tongue base reduction, extrapharyngeal sleep operations such as maxillomandibular advancement (MMA) and upper airway stimulation (UAS) have evolved rapidly in the recent decade and deserve a dedicated review. MMA and UAS have both shown predictable high success rates with low morbidity. Each approach has unique strengths and limitations, and for the most complex of OSA patients, the two in combination complement each other. Extrapharyngeal airway operations are critical for achieving favorable outcomes for sleep surgeons.
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Affiliation(s)
- Myeong Sang Yu
- Division of Sleep Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford Hospital and Clinics, Stanford, CA, USA.,Department of Otorhinolaryngology-Head and Neck Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Badr Ibrahim
- Division of Sleep Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford Hospital and Clinics, Stanford, CA, USA
| | - Robert Wayne Riley
- Division of Sleep Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford Hospital and Clinics, Stanford, CA, USA
| | - Stanley Yung-Chuan Liu
- Division of Sleep Surgery, Department of Otolaryngology-Head and Neck Surgery, Stanford Hospital and Clinics, Stanford, CA, USA
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Hong SO, Poomkonsarn S, Millesi G, Liu SYC. Upper airway stimulation as an alternative to maxillomandibular advancement for obstructive sleep apnoea in a patient with dentofacial deformity: case report with literature review. Int J Oral Maxillofac Surg 2019; 49:908-913. [PMID: 31870520 DOI: 10.1016/j.ijom.2019.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 05/21/2019] [Accepted: 08/16/2019] [Indexed: 12/17/2022]
Abstract
Obstructive sleep apnoea (OSA) is characterized by repeated upper airway collapse leading to oxygen desaturation resulting in cardiovascular and neurocognitive sequelae. Upper airway surgeries such as palatopharyngoplasty, tongue base surgery, and maxillomandibular advancement can improve patient tolerance of continuous positive airway pressure, quality of life, and the severity of OSA. Upper airway stimulation (UAS) of the hypoglossal nerve is a contemporary US Food and Drug Administration-approved treatment modality for OSA with a fundamentally different mechanism. We report the case of a 65-year-old male with a high body mass index, hypertension, diabetes, dentofacial deformity, and severe OSA. He presented with a respiratory distress index (RDI) of 89.1 events per hour, apnoea-hypopnoea index (AHI) of 82.7 events per hour, and minimum oxygen saturation of 75%. He chose to undergo UAS. Initially, complete concentric collapse of the velum was found during drug-induced sedation endoscopy, which was converted by palatopharyngoplasty to meet inclusion criteria for UAS. The patient achieved surgical cure with postoperative RDI and AHI of 2 events per hour with minimum oxygen saturation of 83%, and resolution of daytime somnolence. UAS is an effective surgical option to broaden the surgeon's ability to treat OSA, especially if facial skeletal surgery is contraindicated or declined by the patient with dentofacial deformity.
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Affiliation(s)
- S O Hong
- Department of Oral and Maxillofacial Surgery (Dentistry), International St. Mary's Hospital, Catholic Kwandong University, Incheon, South Korea
| | - S Poomkonsarn
- Department of Otolaryngology, Stanford University School of Medicine, Stanford, California, USA; Center of Excellence in Otolaryngology Head and Neck Surgery, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
| | - G Millesi
- Department of Craniomaxillofacial and Oral Surgery, University Hospital, Medical University of Vienna, Vienna, Austria
| | - S Y C Liu
- Department of Otolaryngology, Stanford University School of Medicine, Stanford, California, USA.
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Faizal WM, Ghazali NNN, Badruddin IA, Zainon MZ, Yazid AA, Ali MAB, Khor CY, Ibrahim NB, Razi RM. A review of fluid-structure interaction simulation for patients with sleep related breathing disorders with obstructive sleep. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2019; 180:105036. [PMID: 31430594 DOI: 10.1016/j.cmpb.2019.105036] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 08/02/2019] [Accepted: 08/12/2019] [Indexed: 05/05/2023]
Abstract
Obstructive sleep apnea is one of the most common breathing disorders. Undiagnosed sleep apnea is a hidden health crisis to the patient and it could raise the risk of heart diseases, high blood pressure, depression and diabetes. The throat muscle (i.e., tongue and soft palate) relax narrows the airway and causes the blockage of the airway in breathing. To understand this phenomenon computational fluid dynamics method has emerged as a handy tool to conduct the modeling and analysis of airflow characteristics. The comprehensive fluid-structure interaction method provides the realistic visualization of the airflow and interaction with the throat muscle. Thus, this paper reviews the scientific work related to the fluid-structure interaction (FSI) for the evaluation of obstructive sleep apnea, using computational techniques. In total 102 articles were analyzed, each article was evaluated based on the elements related with fluid-structure interaction of sleep apnea via computational techniques. In this review, the significance of FSI for the evaluation of obstructive sleep apnea has been critically examined. Then the flow properties, boundary conditions and validation of the model are given due consideration to present a broad perspective of CFD being applied to study sleep apnea. Finally, the challenges of FSI simulation methods are also highlighted in this article.
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Affiliation(s)
- W M Faizal
- Department of Mechanical Engineering Technology, Faculty of Engineering Technology, University Malaysia Perlis,02100 Padang Besar, Perlis, Malaysia; Department of Mechanical Engineering, Faculty of Engineering, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - N N N Ghazali
- Department of Mechanical Engineering, Faculty of Engineering, University of Malaya, 50603 Kuala Lumpur, Malaysia.
| | - Irfan Anjum Badruddin
- Dept. of Mechanical Engineering, College of Engineering, King Khalid University, PO Box 394, Abha 61421. Kingdom of Saudi Arabia.
| | - M Z Zainon
- Department of Mechanical Engineering, Faculty of Engineering, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Aznijar Ahmad Yazid
- Department of Mechanical Engineering, Faculty of Engineering, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Mohamad Azlin Bin Ali
- Department of Mechanical Engineering, Faculty of Engineering, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - C Y Khor
- Department of Mechanical Engineering Technology, Faculty of Engineering Technology, University Malaysia Perlis,02100 Padang Besar, Perlis, Malaysia
| | - Norliza Binti Ibrahim
- Department of Oral & Maxillofacial Clinical Science, Faculty of Dentistry, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Roziana M Razi
- Department of Paediatric Dentistry and Orthodontics, Faculty of Dentistry, University of Malaya, 50603, Kuala Lumpur, Malaysia
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