Early polysomnographic findings and long-term subjective results in sleep apnea patients treated with laser-assisted uvulopalatoplasty

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Laser-assisted uvulopalatoplasty (LAUP) complications and side effects: a systematic review

Objective: Laser-assisted uvulopalatoplasty (LAUP) has been used as a treatment option for snoring and obstructive sleep apnea for almost three decades. It has been previously reported that some patient's sleep-disordered breathing worsened following surgery. The aim of this paper is to further elucidate the specific complications of LAUP. Data sources: A systematic search of the electronic databases MEDLINE/PubMed, Google Scholar, and Embase. Review methods: The PRISMA statement was followed. Databases were searched from inception through September 2, 2018. The following search was applied to MEDLINE/PubMed ((laser AND uvul*) OR (LAUP) OR (LAVP) OR (laser AND (apnea OR apnoea OR sleep))). Results: Forty-two studies with a mean follow-up of 16.1 months reported complications on 3,093 total patients who underwent LAUP. The percentages and associated complications of LAUP are as follows: bleeding (2.6%), candidiasis (0.3%), dryness (7.2%), dysgeusia (0.3%), dysosmia (0.2%), globus sensation (8.2%), surgical site infection (1.3%), velopharyngeal (VP) insufficiency (3.9%), and VP stenosis (1.6%). The mean duration of patient-reported pain in studies that reported pain was 11.65 days. Only globus and VP insufficiency had a significant incidence compared with either the general population or the post-oropharyngeal surgery population with relative risks of 1.48 and 2.25, respectively. Overall, there were approximately 26 complications per 100 patients who underwent LAUP. Conclusion: LAUP is associated with a statistically significant rate of VP insufficiency and globus sensation; however, studies lack details of surgical approaches, suggesting that in a population identified as good candidates, a tissue-sparing approach may result in fewer complications.

Patient Selection and Efficacy of Pillar Implant Technique for Treatment of Snoring and Obstructive Sleep Apnea/Hypopnea Syndrome

OBJECTIVE: Pillar implant (PIT) is a simple, office-based procedure with minimal morbidity that was introduced in 2003 to treat snoring and mild/moderate obstructive sleep apnea/hypopnea syndrome (OSAHS). We studied the: (1) success rate using subjective symptoms and objective polysomnographic improvement; (2) success rate based on BMI, OSAHS severity and Friedman tongue position (FTP); and (3) its value as an adjunctive or revision procedure.

STUDY DESIGN AND SETTING: Retrospective review of 125 patients who underwent the PIT for snoring and OSAHS. Patients were grouped: Group I had PIT only ( n = 29); Group II received adjunctive nasal procedures ( n = 37), Group III received adjunctive oropharyngeal procedures ( n = 55); and Group IV had failed previous UPPP ( n = 4).

RESULTS: Overall subjective and objective “cure” rates were 88.0% and 34.4%, respectively. Group IIb had the best objective cure rate of 46.7%. Neither AHI nor BMI correlated with outcome measures, whereas FTP did correlate. (FTP I and II had improved success vs FTP III and IV). Ten patients had partial extrusion of the PIT. These were removed and new PIT were carried out at a later date.

CONCLUSIONS: Based on a short-term study, the Pillar implant is an effective treatment for snoring and OSAHS in selected patients and can be combined with adjunctive procedures to treat OSAHS.

Extended follow-up of palatal implants for OSA treatment

Objective

Evaluate long-term safety and outcomes of palatal implants for patients with mild to moderate obstructive sleep apnea (OSA).

Study Design and Setting

Continuation of a prospective case series of patients with palatal implants. Polysomnography, daytime sleepiness, and snoring intensity were measured at baseline, 90 days, and extended follow-up.

Results

Twenty-two (42%) patients from the previous study were followed for a median of 435.5 days. Thirteen were classified as responders, based on their 90-day evaluation. 76.9% of initial responders maintained improvements in apnea-hypopnea index (AHI), daytime sleepiness, and snoring at extended follow-up. Nine patients were initial nonresponders for AHI and daytime sleepiness and remained unchanged at extended follow-up. However, snoring for these nine patients initially improved, and the improvement continued through extended follow-up.

Conclusion

Initial response or nonresponse to palatal implants remains stable over an extended period. The generalizability of these results is unknown because of significant loss to follow-up.

Significance

Study results report safety and beneficial long-term outcomes of palatal implants for mild to moderate OSA treatment in selected patients.

Er:Yag Laser Treatment of Simple Snorers in an Outpatient Setting

OBJECTIVE

Snoring occurs as a result of soft tissue vibration caused by a partial upper airway collapse during sleep. This study evaluated the effectiveness and potential adverse side effects associated with the use of a nonsurgical, erbium-doped yttrium aluminum garnet (Er:YAG) laser treatment for patients with snoring conditions.

MATERIALS AND METHODS

In total, 33 patients with different degrees of snoring were analyzed retrospectively. All patients received three NightLase™ Er:YAG laser treatments. Results were measured using a follow-up questionnaire and then statistically analyzed. Any effects that occurred during the first year after treatment (i.e., short-term effects) were followed up with interviews.

RESULTS

Laser treatment effectively reduced patients' snoring and achieved a 65% satisfaction rate after three treatments. The greatest improvement and satisfaction were experienced by patients aged ≥50 years. Patients reported additional benefits from this treatment including easier breathing, higher alertness, and increased focus.

CONCLUSION

Nonsurgical Er:YAG laser treatment is an effective and minimally invasive procedure to reduce patient snoring and other sleep-disordered breathing symptoms. Patients reported minimal disadvantages including minor discomfort and a low risk of side effects.

An evidence-based approach to the management of snoring in adults

BACKGROUND

Snoring is frequently encountered by the otolaryngologist. Given its significant impact on quality of life and that it is a symptom of sleep-related breathing disorders, diagnosis and treatment are of major importance. In particular, the diagnosis should aim to distinguish between simple snoring and obstructive sleep apnoea. This article aims to provide a systematic, concise and evidence-based method of managing the adult patient with snoring.

METHOD

This review was based on a literature search last undertaken on 30 June 2014. The MEDLINE, EMBASE and Cochrane databases were searched using the subject headings snoring and obstructive sleep apnoea in adults in combination with classification, diagnosis, investigations, management, treatment and surgery. Results were limited to English language articles including case series, clinical trials, randomised controlled trials, meta-analyses, systematic reviews and review articles. Relevant references from selected articles were also reviewed.

RESULTS

The majority of published literature for snoring is of level II/III evidence and that for obstructive sleep apnoea being of level I/II, with 36 relevant randomised controlled trials identified. The diagnosis of obstructive sleep apnoea involves thorough clinical assessment and typically a sleep study. Snoring may be managed with lifestyle modification, intra-oral devices or by surgical intervention, with continuous positive airway pressure being the treatment of choice for moderate-to-severe obstructive sleep apnoea.

CONCLUSIONS

A structured history of snoring and its associated symptoms, comprehensive examination including flexible laryngoscopy and sleep studies where relevant, in addition to targeted investigations, should lead to the correct diagnosis and appropriate management.

A rational approach to the management of obstructive sleep apnea syndrome

Snoring & obstructive sleep apnea syndrome (OSAS) is a globally prevalent problem which is on the rise in recent times. The treatment modalities include medical appliances and surgery. It is mandatory to have a rational approach in the management of OSAS, by meticulously analyzing both anatomical and physiological parameters causing the disorder. To define a rational approach for the management of OSAS, by devising a comprehensive protocol with assessment of anatomical level of obstruction by dynamic MRI and physiological factors by Epworth sleepiness scale (ESS) and Polysomnography. A prospective study in 110 patients was conducted over a period of 2 years, at our institute. All patients in the study group were evaluated with dynamic MRI and ESS and Polysomnography. As per the management protocols defined in the study, surgery was advocated in 46 patients (Group 1) with severe compromise in airway, while another group of 64 patients (Group 2) were provided continuous positive airway pressure support (CPAP). Successful outcomes among these 110 patients were analyzed at the end of the study period. A few patients required multimodal therapy which included surgery and CPAP support. Among 46 patients, surgical treatment proved successful in 41 patients in whom AHI reduced from 46.96 to 12.88 (improved by 62%) and ESS improved by almost ten points. Among 64 patients in CPAP group, AHI reduced from 54.2 to 11.3 (improved by 79%) and ESS improved by 11 points in all the patients, but six of them had poor compliance. Five patients among the surgical group had persistence of symptoms. Inferences derived from the above results proved the success of formulating a rational approach in the management of OSAS. Critical analysis of the anatomical and physiological factors inducing obstructive episodes and an appropriate treatment plan is vital, to produce successful outcomes in patients with OSAS. Failure of surgical procedures, are often due to improper case selection. A small group of patients may require multimodal therapy with surgery and CPAP.

[Nd:YAG laser assisted uvulopalatoplasty in the treatment of obstructive sleep apnea syndrome]

INTRODUCTION

Surgical treatment of OSAS is focused on removal of narrowing that increase airway resistance in upper respiratory tract. Nd:YAG laser beam penetrates deeper into tissue than CO2 laser followed by superior scarification ability. In this study we investigate efficacy of surgery with Nd:YAG laser assisted uvuloplasty (LAUP).

MATERIAL AND METHODS

The subject was 51 patients with OSAS treated in Department of Otolaryngology, Medical University of Gdansk during the 2004-2005 period. All patients underwent all-night PSG and the ESS (Epworth Sleepiness Scale) score was used to assess the daytime sleepiness. Surgery treatment was performed and all patients underwent LAUP and additionally lingual base laser vaporization, tonsillectomy and nasal surgery where needed. The postoperative control ENT examination including ESS and all-night PSG was performed after 6 months.

RESULTS

Success was found in 29 patients, they achieved AHI<10 and ESS<12. In another 22 patients improvement at PSG parameters and ESS score were evaluated but they were still beyond normal range. Success was obtained in 14/16 patients with preoperative AHI I degree, 10/19 AHI II, and 4/16 AHI III. Nasal surgery for enlargement of airway passage was performed more frequently (25/32) in the group with success then in the group with partial improvement (9/19). Preoperative PSG parameters were better in patients with nasal obstruction. Patients with BMI> or =30 succeeded rarely (10/22) in compare with patients with BMI<30 (success in 24/29). Preoperative PSG parameters were better in patients with BMI<30.

CONCLUSION

LAUP with Nd:YAG laser wit additional tonsillectomy, lingual base surgery and nasal surgery were needed is successful method for surgery at light and medium stage of OSAS in nonobese patients.

Combined open rhinoplasty with spreader grafts and laser-assisted uvuloplasty for sleep-disordered breathing: long-term subjective outcomes

PURPOSE

To subjectively assess the long-term outcomes of combined functional open rhinoplasty with spreader grafts and laser-assisted uvuloplasty (LAUP) for polysomnogram (PSG)-confirmed sleep-disordered breathing (SDB).

METHODS

Postoperative Epworth Sleepiness Scale (ESS) questionnaires were given to 30 patients and compared with preoperative ESS. Patients were also asked questions concerning postoperative improvement in upper airway breathing, nasal appearance, and snoring. Statistical analysis used 2-tailed parametric and nonparametric tests.

RESULTS

Thirty patients (average age 55 years) with an average (+/- standard deviation) preoperative apnea-hypopnea index (AHI) of 37 +/- 27 and mean follow-up times of 21 months were evaluated. A statistically significant 50% (P < .001) postoperative decrease in average ESS was observed. Patients with severe (AHI > 30) and very severe obstructive sleep apnea (OSA) (AHI > 60) also had statistically significant (61% and 66%, respectively, P < .001) postoperative decreases in average ESS. In all patients, subjective upper airway breathing was statistically improved (P < .008), graded as significantly in 47% and moderately in 33% of patients. According to the patient's bed partner, snoring was improved and/or decreased in 76% of patients (P = .008). All patients were satisfied with the postoperative cosmetic appearance of their nose (P < .0001). Finally, 90% of patients stated that they would have the procedure again (P = .009) and 90% stated that they would recommend the procedure to a friend or relative with the same condition (P = .009).

CONCLUSION

Subjective assessment at long-term follow-up for combined open rhinoplasty with spreader grafts and LAUP for PSG-confirmed SDB produced a statistically significant decrease in excessive daytime sleepiness, even in patients with very high AHI, with high patient satisfaction.

Laser-assisted uvulopalatoplasty and tonsillectomy for the management of obstructive sleep apnea syndrome

OBJECTIVES/HYPOTHESIS

Laser-assisted uvulopalatoplasty (LAUP) is a widely accepted procedure for the management of snoring, but its role in the treatment of obstructive sleep apnea syndrome is currently unclear. The objective of the study was to evaluate the role of LAUP in treating moderate and severe obstructive sleep apnea syndrome.

STUDY DESIGN

Retrospective review of a surgical treatment protocol for obstructive sleep apnea syndrome.

METHODS

Between October 1993 and January 1999, 80 patients with moderate or severe obstructive sleep apnea syndrome and a significant component of retropalatal obstruction were treated with surgery at the Department of Otolaryngology at Northwestern University Medical School (Chicago, IL). Surgery consisted of LAUP with tonsillectomy (if tonsils were present) with the patient under general anesthesia or LAUP alone with local anesthesia (if the tonsils were absent). No patients received traditional uvulopalatopharyngoplasty. Sixty-four of the 80 patients underwent both preoperative and postoperative polysomnograms. Surgical "response" was defined as a 50% decrease in the apnea-hypopnea index (AHI) (the total number of apneic and hypopneic events per hour of sleep); surgical "cure" was defined as a 50% decrease in AHI and a final AHI of less than 20.

RESULTS

The surgical response rate was 59% (38 of 64 patients), and the surgical cure rate was 39% (25 of 64 patients). Twelve patients (18.8%) had a higher AHI after surgery. The AHI (mean +/- SD) changed significantly from 51.4 +/- 30.9 preoperatively to 26.3 +/- 20.8 on postoperative polysomnogram (P = 7.0 x 10-9). Laser-assisted uvulopalatoplasty alone was performed in 33 patients with a response rate of 61% and a cure rate of 42%. Laser-assisted uvulopalatoplasty with tonsillectomy was performed in 31 patients with a response rate of 58% and a cure rate of 35%. The overall incidence of nasopharyngeal insufficiency was 0%.

CONCLUSION

The results of the study suggested that LAUP with adjunctive tonsillectomy is an effective treatment for patients with obstructive sleep apnea syndrome and retropalatal obstruction with a lower complication rate than standard surgical therapy (uvulopalatopharyngoplasty).

Treatment of obstructive sleep apnea, other than with continuous positive airway pressure

Treatment, other than with continuous positive airway pressure, for patients with obstructive sleep apnea remains an active area of investigation. The long-established behavior modification approaches (eg, weight loss and avoidance of alcohol and sedatives) are applicable to many patients, though unlikely to be curative. Oral appliances and surgical techniques are used, although treatment success is hindered by the site-specific nature of the therapies. These treatments are traditionally used for the patient with mild sleep apnea, but more recent studies are questioning their possible benefits in a moderate-to-severe apnea patient population. Surgical techniques range from uvulopalatopharyngoplasty and more extensive skeletal modifications (maxillomandibular advancement), to laser-assisted uvulopalatoplasty and newer minimally invasive techniques. Preoperative evaluation, patient selection, and measures of success vary somewhat between publications, making comparison of treatments and their application to the individual patient challenging.

Obstructive sleep apnea surgery: patient perspective and polysomnographic results

OBJECTIVE

The goal of this study was to assess the outcomes of obstructive sleep apnea (OSA) surgery based on the patient perspective and polysomnographic data.

STUDY DESIGN

Fifty-six patients with severe OSA completed the 2-phase reconstructive protocol. A minimum of 6 months after the phase II surgery and after the postoperative polysomnography, questionnaires with visual analog scales (VAS 0-10) were mailed to the patients to assess their perceptions of treatment results.

RESULTS

Forty-two (75%) questionnaires were returned. The mean patient age was 46.3 years. The mean respiratory disturbance index improved from 58.7 to 10.0. The mean lowest oxygen saturation improved from 76.3 to 87.3%. All 42 patients reported improved sleep (VAS 8.7). Although 10 patients reported changes in speech, the changes were insignificant, with 9 of the patients scoring 0 on the VAS (VAS 0.08 +/-0.3). Five patients reported changes in swallowing, and their VAS scores were 0.5, 0.9, 1.0, 2.7, and 6.9 (mean VAS 2.4+/-2.7). Forty patients (95%) were satisfied with their results and would undergo the reconstruction again.

CONCLUSION

Surgical airway reconstruction for severe OSA is a highly effective treatment option base on the objective as well as the subjective assessment.