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Kattimani V, Panneerselvam E, Tiwari R, Panga GSK, Sreeram RR. An Overview of Systematic Reviews on the Surgical Management of Obstructive Sleep Apnoea. J Maxillofac Oral Surg 2023; 22:781-793. [PMID: 38105854 PMCID: PMC10719205 DOI: 10.1007/s12663-023-02051-x] [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: 08/24/2023] [Accepted: 10/21/2023] [Indexed: 12/19/2023] Open
Abstract
Background Obstructive Sleep Apnoea (OSA) is a common sleep disorder marked by partial or total obstruction of the upper airway while a person is asleep leading to breathing difficulty, reduced oxygenation and frequent awakenings. This condition affects the general health significantly compromising quality of life. The objective of this overview is to thoroughly assess the systematic reviews on current surgical therapies for the management of OSA in terms of patient outcomes. Methods A thorough literature search was performed from inception till 31st December 2022 using PubMed, and Cochrane databases. Studies evaluating the effectiveness and safety of different surgical techniques for the management of OSA were considered. The quality of articles was assessed using AMSTAR (A MeaSurement Tool to Assess systematic Reviews) and Glenny et al. checklist. Results Out of eighteen studies, only seven studies met the inclusion and exclusion criteria. Results showed that the majority of studies were in the pediatric age group except one systematic review which assessed the adult age group. Conclusion None of the published articles had compared all surgical procedures based on the standard evaluating procedure nor followed all reporting guidelines in the primary studies. For better implementation, further multi center studies are warranted with unique reporting criteria and guidelines about pre- as well as post-operative phases. Future research should concentrate on contrasting strategies, combination therapies, and evaluating long-term effects. Supplementary Information The online version contains supplementary material available at 10.1007/s12663-023-02051-x.
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Affiliation(s)
- Vivekanand Kattimani
- SIBAR Institute of Dental Sciences, Takkellapadu, Guntur, Andhra Pradesh 522509 India
| | | | - Rahul Tiwari
- Narsinhbhai Patel Dental College and Hospital, Sankalchand Patel University, Visnagar, Gujarat India
| | | | - Roopa Rani Sreeram
- SIBAR Institute of Dental Sciences, Takkellapadu, Guntur, Andhra Pradesh 522509 India
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2
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Chang JL, Goldberg AN, Alt JA, Alzoubaidi M, Ashbrook L, Auckley D, Ayappa I, Bakhtiar H, Barrera JE, Bartley BL, Billings ME, Boon MS, Bosschieter P, Braverman I, Brodie K, Cabrera-Muffly C, Caesar R, Cahali MB, Cai Y, Cao M, Capasso R, Caples SM, Chahine LM, Chang CP, Chang KW, Chaudhary N, Cheong CSJ, Chowdhuri S, Cistulli PA, Claman D, Collen J, Coughlin KC, Creamer J, Davis EM, Dupuy-McCauley KL, Durr ML, Dutt M, Ali ME, Elkassabany NM, Epstein LJ, Fiala JA, Freedman N, Gill K, Boyd Gillespie M, Golisch L, Gooneratne N, Gottlieb DJ, Green KK, Gulati A, Gurubhagavatula I, Hayward N, Hoff PT, Hoffmann OM, Holfinger SJ, Hsia J, Huntley C, Huoh KC, Huyett P, Inala S, Ishman SL, Jella TK, Jobanputra AM, Johnson AP, Junna MR, Kado JT, Kaffenberger TM, Kapur VK, Kezirian EJ, Khan M, Kirsch DB, Kominsky A, Kryger M, Krystal AD, Kushida CA, Kuzniar TJ, Lam DJ, Lettieri CJ, Lim DC, Lin HC, Liu SY, MacKay SG, Magalang UJ, Malhotra A, Mansukhani MP, Maurer JT, May AM, Mitchell RB, Mokhlesi B, Mullins AE, Nada EM, Naik S, Nokes B, Olson MD, Pack AI, Pang EB, Pang KP, Patil SP, Van de Perck E, Piccirillo JF, Pien GW, Piper AJ, Plawecki A, Quigg M, Ravesloot MJ, Redline S, Rotenberg BW, Ryden A, Sarmiento KF, Sbeih F, Schell AE, Schmickl CN, Schotland HM, Schwab RJ, Seo J, Shah N, Shelgikar AV, Shochat I, Soose RJ, Steele TO, Stephens E, Stepnowsky C, Strohl KP, Sutherland K, Suurna MV, Thaler E, Thapa S, Vanderveken OM, de Vries N, Weaver EM, Weir ID, Wolfe LF, Tucker Woodson B, Won CH, Xu J, Yalamanchi P, Yaremchuk K, Yeghiazarians Y, Yu JL, Zeidler M, Rosen IM. International Consensus Statement on Obstructive Sleep Apnea. Int Forum Allergy Rhinol 2023; 13:1061-1482. [PMID: 36068685 PMCID: PMC10359192 DOI: 10.1002/alr.23079] [Citation(s) in RCA: 46] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Jolie L. Chang
- University of California, San Francisco, California, USA
| | | | | | | | - Liza Ashbrook
- University of California, San Francisco, California, USA
| | | | - Indu Ayappa
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | - Maurits S. Boon
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Pien Bosschieter
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | - Itzhak Braverman
- Hillel Yaffe Medical Center, Hadera Technion, Faculty of Medicine, Hadera, Israel
| | - Kara Brodie
- University of California, San Francisco, California, USA
| | | | - Ray Caesar
- Stone Oak Orthodontics, San Antonio, Texas, USA
| | | | - Yi Cai
- University of California, San Francisco, California, USA
| | | | | | | | | | | | | | | | | | - Susmita Chowdhuri
- Wayne State University and John D. Dingell VA Medical Center, Detroit, Michigan, USA
| | - Peter A. Cistulli
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - David Claman
- University of California, San Francisco, California, USA
| | - Jacob Collen
- Uniformed Services University, Bethesda, Maryland, USA
| | | | | | - Eric M. Davis
- University of Virginia, Charlottesville, Virginia, USA
| | | | | | - Mohan Dutt
- University of Michigan, Ann Arbor, Michigan, USA
| | - Mazen El Ali
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | - Kirat Gill
- Stanford University, Palo Alto, California, USA
| | | | - Lea Golisch
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | | | | | - Arushi Gulati
- University of California, San Francisco, California, USA
| | | | | | - Paul T. Hoff
- University of Michigan, Ann Arbor, Michigan, USA
| | - Oliver M.G. Hoffmann
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | - Jennifer Hsia
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Colin Huntley
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | | | - Sanjana Inala
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | | | | | | | | | | | - Meena Khan
- Ohio State University, Columbus, Ohio, USA
| | | | - Alan Kominsky
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | - Meir Kryger
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Derek J. Lam
- Oregon Health and Science University, Portland, Oregon, USA
| | | | | | | | | | | | | | - Atul Malhotra
- University of California, San Diego, California, USA
| | | | - Joachim T. Maurer
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Anna M. May
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Ron B. Mitchell
- University of Texas, Southwestern and Children’s Medical Center Dallas, Texas, USA
| | | | | | | | | | - Brandon Nokes
- University of California, San Diego, California, USA
| | | | - Allan I. Pack
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | | | | | | | | - Mark Quigg
- University of Virginia, Charlottesville, Virginia, USA
| | | | - Susan Redline
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Armand Ryden
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | | | - Firas Sbeih
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | | | | | | | | | - Jiyeon Seo
- University of California, Los Angeles, California, USA
| | - Neomi Shah
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | - Ryan J. Soose
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Erika Stephens
- University of California, San Francisco, California, USA
| | | | | | | | | | - Erica Thaler
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sritika Thapa
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Nico de Vries
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | | | - Ian D. Weir
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Josie Xu
- University of Toronto, Ontario, Canada
| | | | | | | | | | | | - Ilene M. Rosen
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Transoral Tongue Suspension for Obstructive Sleep Apnea-A Preliminary Study. J Clin Med 2022; 11:jcm11174960. [PMID: 36078891 PMCID: PMC9456292 DOI: 10.3390/jcm11174960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/10/2022] [Accepted: 08/20/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives: To evaluate the safety and efficacy of a novel technique for transoral tongue suspension (TOTS) in obstructive sleep apnea (OSA) patients. Material and Methods: The retrospective study enrolled 24 consecutive OSA patients (21 males; average age, 43 years; average apnea−hypopnea index (AHI), 42.2 event/h; average body mass index (BMI), 25.7 kg/m2) with tongue obstruction confirmed by drug-induced sleep endoscopy. All patients received TOTS as the main procedure in conjunction with uvulopalatopharyngoplasty (UPPP). Key procedures of TOTS included a transoral sublabial approach, drilling two holes on the mandible, passing the polypropylene through the hole to the tongue base using a suture passer and returning the polypropylene through loop traction, and tying the polypropylene to the mandible. Lingual tonsil ablation (n = 8) was also implemented in hypertrophic lingual tonsils (grades III and IV). Results: The operation time for TOTS was around 30 min. No wound bleeding or airway compromise occurred throughout the postoperative period. Minor complications were temporary and included swelling of the tongue, numbness of the lower incisor, and sublabial wound dehiscence (n = 2). The quality of life improved significantly in the patients’ subjective daytime sleepiness according to the Epworth Sleepiness Scale (11.4 ± 3.2 vs. 5.7 ± 1.6, p < 0.001). The objective parameters of OSA also improved significantly in the apnea/hypopnea index (42.2 ± 21.8 vs. 19.5 ± 16.2, p < 0.001), minimal oxygen saturation (77.1 ± 12.2 vs. 81.7 ± 8.1, p = 0.026), and snoring index (207 ± 141 vs. 101 ± 91, p = 0.03). Conclusions: The demonstrated TOTS showed its advantage in low morbidity with a scarless exterior and easy performance with free availability in treating adult OSA patients with tongue obstruction. TOTS combined with UPPP significantly improved AHI and daytime sleepiness. TOTS can be implemented with lingual tonsillectomy to achieve both stabilization of the tongue and widening of hypopharyngeal airway.
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Systematic review and updated meta-analysis of multi-level surgery for patients with OSA. Auris Nasus Larynx 2021; 49:421-430. [PMID: 34736806 DOI: 10.1016/j.anl.2021.10.001] [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] [Received: 08/08/2021] [Revised: 09/01/2021] [Accepted: 10/13/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To perform an updated systematic review for determining the surgical success rate of multilevel upper airway surgery for patients with obstructive sleep apnea/hypopnea syndrome (OSA). METHODS A systematic review was performed to identify English-language studies that evaluated the treatment of adult OSA patients with multilevel OSA surgery up to January, 2018. We used polysomnography as a metric of treatment success. Articles were only included if the surgery intervention involved at least two of the frequently involved anatomic sites: nose, oropharynx and hypopharynx. Eighty-seven studies fit the inclusion criteria and a meta-analysis was performed to determine the overall success. RESULTS The meta-analysis included 3931 subjects with a mean age of 46.1 years. The originally reported success rate in the included literature was 59.9%. A meta-analysis was performed to redefine the success rate to be consistent with the commonly agreed upon criteria - namely "a reduction in apnea/hypopnea index (AHI, /hr.) of 50% or more and an AHI of less than 20". The recalculated success rate was 60.2%. Standard meta-analytic techniques for combining p-values between studies after weighting for sample size found significant improvements in AHI, apnea index, % of rapid eye movement sleep, lowest saturation of oxygen (%), and Epworth Sleepiness Scale. CONCLUSION This study shows the significant improvement of treatment outcomes with multilevel surgery for OSA patients.
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5
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Baptista PM, Garaycochea O, O’Connor C, Plaza G. Tongue Surgery That Works in OSA. CURRENT OTORHINOLARYNGOLOGY REPORTS 2021. [DOI: 10.1007/s40136-021-00357-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Zhou N, Ho JPTF, Huang Z, Spijker R, de Vries N, Aarab G, Lobbezoo F, Ravesloot MJL, de Lange J. Maxillomandibular advancement versus multilevel surgery for treatment of obstructive sleep apnea: A systematic review and meta-analysis. Sleep Med Rev 2021; 57:101471. [PMID: 33831676 DOI: 10.1016/j.smrv.2021.101471] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 02/03/2021] [Accepted: 02/18/2021] [Indexed: 12/12/2022]
Abstract
Multilevel surgery (MLS) and maxillomandibular advancement surgery (MMA) are two established options in surgical management of obstructive sleep apnea (OSA), which target different levels of airway obstruction. The objective of this review was to comparatively evaluate the clinical efficacy and safety of MMA and MLS in the treatment of OSA. MEDLINE and Embase databases were searched for studies on MMA and/or MLS in OSA patients. Twenty MMA studies and 39 MLS studies were identified. OSA patients who underwent MMA showed significant improvements in AHI, LSAT, ODI, and ESS by -46.2/h, 13.5%, -30.3/h, and -8.5, respectively. The pooled rates of surgical success and cure for MMA were 85.0% and 46.3%, respectively. Patients who underwent MLS showed significant improvements in AHI, LSAT, ODI, and ESS by -24.7/h, 8.7%, -19.1/h, and -5.8, respectively. The pooled surgical success and cure rates for MLS were 65.1% and 28.1%, respectively. The rates of major complication of MMA and MLS were 3.2% and 1.1%, respectively, and the rate of minor complication of MMA was higher than that of MLS. We conclude that both MMA and MLS are effective treatment options for OSA. Compared to MLS, MMA may be more effective in improving OSA. However, the complication rate of MMA is higher.
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Affiliation(s)
- Ning Zhou
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC Location AMC and Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam, Amsterdam, the Netherlands; Department of Orofacial Pain and Dysfunction, Academic Center for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
| | - Jean-Pierre T F Ho
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC Location AMC and Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam, Amsterdam, the Netherlands
| | - Zhengfei Huang
- Department of Orofacial Pain and Dysfunction, Academic Center for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Department of Clinical Neurophysiology, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, the Netherlands
| | - René Spijker
- Medical Library, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Cochrane Netherlands, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Nico de Vries
- Department of Orofacial Pain and Dysfunction, Academic Center for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands; Department of Otorhinolaryngology - Head and Neck Surgery, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, the Netherlands; Department of Otorhinolaryngology - Head and Neck Surgery, Antwerp University Hospital (UZA), Antwerp, Belgium
| | - Ghizlane Aarab
- Department of Orofacial Pain and Dysfunction, Academic Center for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Frank Lobbezoo
- Department of Orofacial Pain and Dysfunction, Academic Center for Dentistry Amsterdam (ACTA), University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Madeline J L Ravesloot
- Department of Otorhinolaryngology - Head and Neck Surgery, Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, the Netherlands
| | - Jan de Lange
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC Location AMC and Academic Centre for Dentistry Amsterdam (ACTA), University of Amsterdam, Amsterdam, the Netherlands
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Jain N, Rodin J, Boon MS, Huntley CT. A systematic approach to the evaluation and management of obstructive sleep apnea: The Jefferson Protocol. Am J Otolaryngol 2021; 42:102866. [PMID: 33418179 DOI: 10.1016/j.amjoto.2020.102866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 12/22/2020] [Indexed: 12/20/2022]
Abstract
Obstructive sleep apnea (OSA) has become increasingly prevalent in the United States. While continuous positive airway pressure (CPAP) therapy remains the gold standard for treatment, surgical intervention can enhance compliance and improve outcomes for those intolerant of CPAP. Since the majority of OSA patients have multilevel obstruction, it is critical that otolaryngologists understand each patient's pattern and anatomic level of obstruction before solidifying a treatment plan. This publication serves as a comprehensive review of evaluation, characterization, and management of OSA. Further, the authors outline their departmental algorithm for identifying ideal surgical candidates and tailoring corresponding surgical interventions.
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8
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Abstract
Obstructive sleep apnea (OSA) is a multisystem breathing disorder associated with increased morbidity and mortality. Clinical and operative assessment tools improve surgical approaches to treat airway obstruction. The primary sites of anatomic obstruction are at the levels of the nasal, palatal, and hypopharyngeal airway. The literature suggests a relationship between reduced neuromuscular tone and the age-related increase in OSA prevalence for normal-weight adults. Pharyngeal soft tissue collapse due to reduced airway pressure is defined as the critical closing pressure. Respiratory biochemistry homeostasis is an additional factor in maintaining airway patency.
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Affiliation(s)
- Kevin Coughlin
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, 910 Madison Avenue, Suite 410, Memphis, TN 38163, USA
| | - George M Davies
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, 855 Monroe Avenue, Suite 327, Memphis, TN 38163, USA.
| | - Marion Boyd Gillespie
- Department of Otolaryngology-Head and Neck Surgery, University of Tennessee Health Science Center, 910 Madison Avenue, Suite 408, Memphis, TN 38163, USA
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9
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Baptista PM, Costantino A, Moffa A, Rinaldi V, Casale M. Hypoglossal Nerve Stimulation in the Treatment of Obstructive Sleep Apnea: Patient Selection and New Perspectives. Nat Sci Sleep 2020; 12:151-159. [PMID: 32104122 PMCID: PMC7026121 DOI: 10.2147/nss.s221542] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 02/01/2020] [Indexed: 12/22/2022] Open
Abstract
Hypoglossal nerve stimulation (HNS) is an increasingly widespread OSA treatment. It is a non-anatomical modifying surgery able to achieve an adequate objective and subjective result with a reasonable complication rate. HNS exploits the neurostimulation to reduce upper airway collapsibility providing a multilevel upper airway improvement within a single procedure. Proper patient selection has a fundamental role in determining an adequate long-term clinical outcome. All patient candidates for HNS undergo a standard comprehensive sleep medicine assessment and upper airway surgical examination. Several features should be assessed preoperatively in order to predict patients' response to HNS treatment. In particular, the assessment of OSA severity, BMI > 32 Kg/m2, collapse pattern during drug-induced sleep endoscopy (DISE), and many other parameters, is central for a good patient selection and customization of OSA treatment. HNS is indeed one of the most promising tools in the widespread context of personalized sleep medicine. HNS is an adjustable medical device that could be titrated in order to improve HNS effectiveness, maintaining patient comfort. Moreover, HNS provides the opportunity for patients to play an active role in their own care, with a potential improvement in therapy adherence and efficacy. This review summarizes the current evidence in patient selection for HNS, highlighting the reasons behind the optimistic future of this OSA treatment in the context of personalized medicine.
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Affiliation(s)
- Peter M Baptista
- Department of ORL, Clínica Universidad de Navarra, Pamplona, Spain
| | - Andrea Costantino
- Otorhinolaryngology Unit, Humanitas Clinical and Research Center-IRCCS, Milan, Italy
| | - Antonio Moffa
- Department of Otolaryngology, Integrated Therapies in Otolaryngology, University Campus Bio-Medico, Rome, Italy.,Department of Otolaryngology, University of Foggia, Foggia, Italy
| | - Vittorio Rinaldi
- Department of Otolaryngology, Integrated Therapies in Otolaryngology, University Campus Bio-Medico, Rome, Italy
| | - Manuele Casale
- Department of Otolaryngology, Integrated Therapies in Otolaryngology, University Campus Bio-Medico, Rome, Italy
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Cambi J, Chiri ZM, De Santis S, Franci E, Frusoni F, Ciabatti PG, Boccuzzi S. Outcomes in single‐stage multilevel surgery for obstructive sleep apnea: Transoral robotic surgery, expansion sphincter pharyngoplasty and septoplasty. Int J Med Robot 2019; 15:e2034. [DOI: 10.1002/rcs.2034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 08/19/2019] [Accepted: 08/28/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Jacopo Cambi
- Department of ENTOspedale della Misericordia Grosseto Italy
| | - Zaira M. Chiri
- Department of ENTOspedale della Misericordia Grosseto Italy
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11
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Mulholland GB, Jeffery CC, Ziai H, Hans V, Seikaly H, Pang KP, Rotenberg BW. Multilevel Palate and Tongue Base Surgical Treatment of Obstructive Sleep Apnea: A Systematic Review and Meta‐analysis. Laryngoscope 2019; 129:1712-1721. [DOI: 10.1002/lary.27597] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 09/11/2018] [Accepted: 09/14/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Graeme B. Mulholland
- Department of Surgery, Division of Otolaryngology–Head and Neck SurgeryUniversity of Alberta Edmonton Alberta Canada
| | - Caroline C. Jeffery
- Department of Surgery, Division of Otolaryngology–Head and Neck SurgeryUniversity of Alberta Edmonton Alberta Canada
| | - Hedyeh Ziai
- Faculty of MedicineUniversity of Ottawa Ottawa Ontario Canada
| | - Varinder Hans
- Department of Surgery, Division of Otolaryngology–Head and Neck SurgeryUniversity of Alberta Edmonton Alberta Canada
| | - Hadi Seikaly
- Department of Surgery, Division of Otolaryngology–Head and Neck SurgeryUniversity of Alberta Edmonton Alberta Canada
| | | | - Brian W. Rotenberg
- Department of Otolaryngology–Head and Neck SurgeryWestern University London Ontario Canada
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12
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Huntley C, Steffen A, Doghramji K, Hofauer B, Heiser C, Boon M. Upper Airway Stimulation in Patients With Obstructive Sleep Apnea and an Elevated Body Mass Index: A Multi-institutional Review. Laryngoscope 2018; 128:2425-2428. [DOI: 10.1002/lary.27426] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 05/22/2018] [Accepted: 06/14/2018] [Indexed: 02/02/2023]
Affiliation(s)
- Colin Huntley
- Department of Otolaryngology-Head and Neck Surgery; Thomas Jefferson University; Philadelphia Pennsylvania U.S.A
| | - Armin Steffen
- Department of Otolaryngology-Head and Neck Surgery; University of Lubeck; Lubeck Germany
| | - Karl Doghramji
- Jefferson Sleep Disorders Center; Thomas Jefferson University; Philadelphia Pennsylvania U.S.A
| | - Benedikt Hofauer
- Department of Otolaryngology-Head and Neck Surgery; Technical University of Munich; Munich Germany
| | - Clemens Heiser
- Department of Otolaryngology-Head and Neck Surgery; Technical University of Munich; Munich Germany
| | - Maurits Boon
- Department of Otolaryngology-Head and Neck Surgery; Thomas Jefferson University; Philadelphia Pennsylvania U.S.A
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13
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The effect of tongue base suspension with uvulopalato-pharyngoplasty on sleep quality in obstructive sleep apnea. Sci Rep 2018; 8:8788. [PMID: 29884835 PMCID: PMC5993727 DOI: 10.1038/s41598-018-27094-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 05/25/2018] [Indexed: 01/22/2023] Open
Abstract
The objective was to investigate whether tongue base suspension with uvulopalatopharyngoplasty (UPPP) is beneficial on polysomnography analysis for sleep quality in patients with obstructive sleep apnea (OSA) anatomically classified as Fujita type III (small tonsils and a bulky tongue base). In the retrospective study, the charts of 36 patients with OSA that underwent tongue base suspension with UPPP from 2012 through 2015 were reviewed. The surgical outcome measured according to Sher’s classification (AHI reduction > 50% and AHI < 20 per hour as success group, otherwise as failure group). The pre- and post-operative sleep quality parameters were evaluated, and the total sleep time changes were evaluated based on electroencephalography study, slow wave sleep, sleep efficiency, rapid eye movement sleep percentile, and Epworth sleep scale scores. Respiratory, the outcomes of polysomnography analysis were then compared between the successful surgery and surgical failure groups during a 1-year follow up. Total arousals and reduced respiratory arousal indices, along with unchanged periodic leg movement and spontaneous electroencephalography arousal indices, were observed in the successful surgery group but not in the surgical failure group. There were 66% resulted in surgical success by this surgery, and 34% as in failure group according to Sher’s criteria. Patient sleep quality was further improved by reducing the respiratory arousal index and increasing the rapid eye movement sleep percentile during the 1-year follow up.
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Combined Surgical Approach for Obstructive Sleep Apnea Patient. Case Rep Otolaryngol 2018; 2018:4798024. [PMID: 29796330 PMCID: PMC5896225 DOI: 10.1155/2018/4798024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 01/02/2018] [Indexed: 11/17/2022] Open
Abstract
Obstructive sleep apnea (OSA) is a disease that is associated with high morbidity and mortality and can significantly impact the quality of life in a patient. OSA is strongly associated with obesity, and literature showed that weight loss will lead to improvement in OSA. The gold standard treatment for OSA is continuous positive airway pressure (CPAP). However, other methods of treatment are available. One of these methods is multilevel sleep surgery (MLS). Literature showed that bariatric surgery can also improve OSA. A common question is which surgical procedure of these two should be performed first. We present a 5-year follow-up of a patient who underwent simultaneously bariatric surgery and MLS. His apnea-hypopnea index (AHI) decreased from 53 episodes per hour to 5.2 per hour within the first 18 months, which was measured via a level 3 polysomnography. Five years after the surgery, a repeat level 3 polysomnography showed an AHI of 6.8 episodes per hour, and the patient is asymptomatic. The patient maintained his weight and did not use CPAP after the combined surgery during the five-year period.
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Hwang CS, Kim JW, Park SC, Chung HJ, Kim CH, Yoon JH, Cho HJ. Predictors of success in combination of tongue base resection and lateral pharyngoplasty for obstructive sleep apnea. Eur Arch Otorhinolaryngol 2017; 274:2197-2203. [DOI: 10.1007/s00405-017-4467-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 01/13/2017] [Indexed: 10/20/2022]
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Lee WH, Hong SN, Kim HJ, Rhee CS, Lee CH, Yoon IY, Kim JW. A Comparison of Different Success Definitions in Non-Continuous Positive Airway Pressure Treatment for Obstructive Sleep Apnea Using Cardiopulmonary Coupling. J Clin Sleep Med 2017; 12:35-41. [PMID: 26235153 DOI: 10.5664/jcsm.5388] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 07/07/2015] [Indexed: 01/28/2023]
Abstract
STUDY OBJECTIVES The definition and the criteria for the successful treatment of obstructive sleep apnea vary, depending on the study. This study aimed to compare different success criteria of non-continuous positive airway pressure (non-CPAP) treatment for obstructive sleep apnea in terms of sleep quality by using cardiopulmonary coupling. METHODS We included 98 patients who had been treated with sleep surgery or with a mandibular advancement device at our sleep clinic from January 2011 to March 2013. The success and failure groups were divided by 6 criteria that have been used in the literature. The validity of each of the 6 criteria was evaluated by cardiopulmonary coupling-based sleep quality. RESULTS The parameters of cardiopulmonary coupling indicated that sleep quality improved with non-CPAP treatment: low-frequency coupling decreased from 57.4% ± 17.7% to 46.9% ± 16.5%, whereas high-frequency coupling increased from 30.2% ± 17.1% to 37.4% ± 16.7%. In multiple regression analysis, only the criterion of a reduction in the apnea-hypopnea index greater than 50% was significantly associated with sleep quality improvement (p = 0.016; 95% confidence interval, 1.008-1.076 in the high-frequency coupling increment; p = 0.001; 95% confidence interval, 1.025-1.099 in the low-frequency coupling decrement). CONCLUSIONS Cardiopulmonary coupling analysis showed that a reduction in the apnea-hypopnea index of more than 50% might be the optimal criterion to determine the success or failure of non-CPAP treatment in terms of sleep quality.
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Affiliation(s)
- Woo Hyun Lee
- Department of Otolaryngology, National Police Hospital, Seoul, Korea
| | - Seung-No Hong
- Department of Otorhinolaryngology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hong Joong Kim
- Department of Otorhinolaryngology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Chae-Seo Rhee
- Department of Otorhinolaryngology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Chul Hee Lee
- Department of Otorhinolaryngology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - In-Young Yoon
- Department of Psychiatry, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeong-Whun Kim
- Department of Otorhinolaryngology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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Vicente E, Marin JM, Carrizo SJ, Osuna CS, González R, Marin-Oto M, Forner M, Vicente P, Cubero P, Gil AV, Soler X. Upper airway and systemic inflammation in obstructive sleep apnoea. Eur Respir J 2016; 48:1108-1117. [PMID: 27587551 DOI: 10.1183/13993003.00234-2016] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 06/11/2016] [Indexed: 12/14/2022]
Abstract
Obstructive sleep apnoea (OSA) is associated with pharyngeal inflammation, but the coexistence of systemic inflammation is controversial. This study investigated whether local and systemic inflammatory biomarkers are related in patients with OSA. An uncontrolled extension to the study assessed the response to effective treatment.We recruited 89 patients with OSA (apnoea/hypopnoea index (AHI) ≥5 events·h-1), 28 snorers and 26 healthy controls. Pharyngeal lavage (PHAL) and plasma samples were collected at baseline and after a 1-year follow-up. Inflammatory cells were evaluated by flow cytometry; interleukin (IL)-6, IL-8 and tumour necrosis factor-α were evaluated by immunoassay.In PHAL, CD4+ T-cells, IL-6 and IL-8 were higher in OSA patients than in snorers or healthy controls (p<0.05). The AHI correlated with CD4+, IL-6 and IL-8 in PHAL (all p-values <0.05). There were no differences in the inflammatory biomarkers in plasma between the study groups and no relationship between plasma and PHAL biomarkers. Biomarkers decreased significantly in PHAL but not in plasma after 1 year of therapy with continuous positive airway pressure or surgery.In patients with OSA, increased levels of inflammatory biomarkers were found in PHAL, which were reduced with effective treatment. No simultaneous increase in plasma inflammatory biomarkers was found.
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Affiliation(s)
- Eugenio Vicente
- Otorhinolaryngology Dept, Hospital Miguel Servet, Zaragoza, Spain CIBER Enfermedades Respiratorias, Madrid, Spain Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain Both authors contributed equally
| | - Jose M Marin
- CIBER Enfermedades Respiratorias, Madrid, Spain Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain Respiratory Dept, Hospital Miguel Servet, Zaragoza, Spain Both authors contributed equally
| | - Santiago J Carrizo
- CIBER Enfermedades Respiratorias, Madrid, Spain Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain Respiratory Dept, Hospital Miguel Servet, Zaragoza, Spain
| | - Carlos S Osuna
- Haematology Dept, Hospital Miguel Servet, Zaragoza, Spain
| | | | - Marta Marin-Oto
- Translational Research Unit, Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain
| | - Marta Forner
- CIBER Enfermedades Respiratorias, Madrid, Spain Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain Translational Research Unit, Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain
| | - Paul Vicente
- Translational Research Unit, Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain
| | - Pablo Cubero
- Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain Translational Research Unit, Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain
| | - Ana V Gil
- Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain Translational Research Unit, Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain
| | - Xavier Soler
- Pulmonary, Critical Care and Sleep Division, UCSD, San Diego, USA
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Ong AA, Murphey AW, Nguyen SA, Soose RJ, Woodson BT, Vanderveken OM, de Vries N, Gillespie MB. Efficacy of Upper Airway Stimulation on Collapse Patterns Observed during Drug-Induced Sedation Endoscopy. Otolaryngol Head Neck Surg 2016; 154:970-7. [PMID: 26980916 DOI: 10.1177/0194599816636835] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 02/11/2016] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To describe upper airway collapse patterns observed on drug-induced sedation endoscopy (DISE) during screening for a clinical trial and to evaluate the impact of collapse patterns found on preoperative DISE on response rates to upper airway stimulation (UAS) therapy. STUDY DESIGN Retrospective review of an ongoing prospective multi-institutional cohort study. SETTING Twenty-two participating institutions of the STAR trial. SUBJECTS AND METHOD In total, 222 subjects were screened with DISE to determine eligibility for an implantable UAS device. Supine laryngoscopy was performed during moderate sedation (propofol and/or midazolam). Airway collapse pattern and severity were graded at 4 levels, including velum, oropharynx, tongue base, and epiglottis (VOTE classification). Patients with complete concentric collapse (CCC) at the velum were excluded from implantation. RESULTS The CCC at the velum was observed in 52 (23%) of screened subjects, and these subjects were subsequently excluded from implantation. Of the 170 subjects without CCC at the velum, 126 (77%) underwent implantation: 121 (96%) had multilevel collapse and 5 (4%) had single-level collapse. When comparing preimplantation DISE findings, UAS responders at 12 months had lower baseline VOTE scores compared with therapy nonresponders. CONCLUSION Drug-induced sedation endoscopy is an efficient and safe method for determining UAS eligibility and has the potential to identify UAS nonresponders. Most patients had multilevel airway collapse, illustrating the limitations of single-level upper airway surgery in treating obstructive sleep apnea. Upper airway stimulation is effective therapy for most patients with multilevel airway collapse; however, patients with complete anterior-posterior or lateral soft palate and/or epiglottic collapse may be at increased risk of therapy failure.
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Affiliation(s)
- Adrian A Ong
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Alexander W Murphey
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Shaun A Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ryan J Soose
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - B Tucker Woodson
- Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Olivier M Vanderveken
- Department of Otorhinolaryngology-Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium Faculty of Medicine and Health Sciences, University of Antwerp, Belgium
| | - Nico de Vries
- Faculty of Medicine and Health Sciences, University of Antwerp, Belgium Department of Otorhinolaryngology-Head and Neck Surgery, Saint Lucas Andreas Hospital, Amsterdam, the Netherlands
| | - M Boyd Gillespie
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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The Role of Soft-Tissue Surgery of the Tongue in Obstructive Sleep Apnea. CURRENT OTORHINOLARYNGOLOGY REPORTS 2016. [DOI: 10.1007/s40136-016-0109-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Long-term results of one staged multilevel surgery with tongue suspension surgery or one level palatal surgery for treatment of moderate and severe obstructive sleep apnea. Eur Arch Otorhinolaryngol 2016; 273:1227-34. [DOI: 10.1007/s00405-015-3813-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 10/22/2015] [Indexed: 11/24/2022]
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Bostanci A, Turhan M. A systematic review of tongue base suspension techniques as an isolated procedure or combined with uvulopalatopharyngoplasty in obstructive sleep apnea. Eur Arch Otorhinolaryngol 2015; 273:2895-901. [DOI: 10.1007/s00405-015-3814-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 10/22/2015] [Indexed: 11/29/2022]
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The relationship between the duration of obstructive respiratory events and outcomes of multilevel upper airway surgery in patients with obstructive sleep apnea. Eur Arch Otorhinolaryngol 2015; 273:2651-7. [DOI: 10.1007/s00405-015-3781-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Accepted: 09/08/2015] [Indexed: 10/23/2022]
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Tan KB, Toh ST, Guilleminault C, Holty JEC. A Cost-Effectiveness Analysis of Surgery for Middle-Aged Men with Severe Obstructive Sleep Apnea Intolerant of CPAP. J Clin Sleep Med 2015; 11:525-35. [PMID: 25700871 PMCID: PMC4410926 DOI: 10.5664/jcsm.4696] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 12/09/2014] [Indexed: 12/11/2022]
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) is associated with increased cardiovascular morbidity and mortality. Conventional OSA therapy necessitates indefinite continuous positive airway pressure (CPAP). Although CPAP is an effective treatment modality, up to 50% of OSA patients are intolerant of CPAP. We explore whether surgical modalities developed for those intolerant of CPAP are cost-effective. METHODS We construct a lifetime semi-Markov model of OSA that accounts for observed increased risks of stroke, cardiovascular disease, and motor vehicle collisions for a 50-year-old male with untreated severe OSA. Using this model, we compare the cost-effectiveness of (1) no treatment, (2) CPAP only, and (3) CPAP followed by surgery (either palatopharyngeal reconstructive surgery [PPRS] or multilevel surgery [MLS]) for those intolerant to CPAP. RESULTS Compared with the CPAP only strategy, CPAP followed by PPRS (CPAP-PPRS) adds 0.265 quality adjusted life years (QALYs) for an increase of $2,767 (discounted 2010 dollars) and is highly cost effective with an incremental cost-effectiveness ratio (ICER) of $10,421/QALY for a 50-year-old male with severe OSA. Compared to a CPAP-PPRS strategy, the CPAP-MLS strategy adds 0.07 QALYs at an increase of $6,213 for an ICER of $84,199/QALY. The CPAP-PPRS strategy appears cost-effective over a wide range of parameter estimates. CONCLUSIONS Palatopharyngeal reconstructive surgery appears cost-effective in middle-aged men with severe OSA intolerant of CPAP. Further research is warranted to better define surgical candidacy as well as short-term and long-term surgical outcomes. COMMENTARY A commentary on this article appears in this issue on page 509.
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Affiliation(s)
- Kelvin B. Tan
- Stanford University, Management Science and Engineering Department, Stanford, CA
- Center for Primary Care and Outcomes Research, Stanford University, Stanford, CA
| | | | | | - Jon-Erik C. Holty
- Center for Primary Care and Outcomes Research, Stanford University, Stanford, CA
- Pulmonary, Critical Care and Sleep Section, VA Palo Alto Healthcare System, Palo Alto, CA
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Lin HS, Rowley JA, Folbe AJ, Yoo GH, Badr MS, Chen W. Transoral robotic surgery for treatment of obstructive sleep apnea: factors predicting surgical response. Laryngoscope 2014; 125:1013-20. [PMID: 25346038 DOI: 10.1002/lary.24970] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 08/04/2014] [Accepted: 09/17/2014] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS We reviewed our experience with the use of transoral robotic surgery (TORS) for base of tongue (BOT) reduction either alone or as part of multilevel strategy in the treatment of obstructive sleep apnea/hypopnea syndrome (OSAHS) in order to identify clinical characteristics that may be associated with surgical response. STUDY DESIGN Case series. METHODS Between June 2010 and May 2014, BOT reduction via TORS ± partial epiglottectomy ± uvulopalatopharyngoplasty were performed on 72 patients with OSAHS. Thirty-nine patients (15 females and 24 males) with complete preoperative and postoperative clinical information including polysomnograms were included in this study. RESULTS Mean apnea-hypopnea index (AHI) was 43.9 ± 32.3 preoperatively and 21.9 ± 23.5 postoperatively and reflected a statistically significant (P < 0.001) AHI reduction of 50.9% ± 38.1%. Statistical significant reduction in daytime somnolence, as measured by Epworth Sleepiness Scale (15.6 ± 5.4 preoperatively vs. 5.7 ± 4.3 postoperatively; P < 0.001), was also achieved. No statistical significant difference was found between preoperative and postoperative body mass index (BMI) (32.9 ± 7.0 vs. 32.4 ± 7.3; P = 0.270). Surgical response, as defined by > 50% reduction in AHI and final AHI < 15 with resolution of daytime somnolence, was achieved in 21 patients (53.8%). Clinical characteristics found to be significantly different between the responders and nonresponders were BMI, AHI, and lateral velopharyngeal collapse. Patients with BMI < 30, AHI < 60, or absence of lateral velopharyngeal collapse have excellent surgical response rate of 88.2%, 67.9%, or 66.7%, respectively. CONCLUSIONS We identified three clinical characteristics associated with increased surgical response rate. This finding may be useful for patient selection and counseling prior to surgery.
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Affiliation(s)
- Ho-Sheng Lin
- Department of Otolaryngology-Head & Neck Surgery, Wayne State University and Karmanos Cancer Institute, Detroit, Michigan, U.S.A; Department of Surgery, Wayne State University, Detroit, Michigan, U.S.A
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Predicting the outcome of modified tongue base suspension combined with uvulopalatopharyngoplasty. Eur Arch Otorhinolaryngol 2014; 272:3411-6. [DOI: 10.1007/s00405-014-3311-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 09/23/2014] [Indexed: 11/26/2022]
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Berg EE, Bunge F, Delgaudio JM. Multilevel treatment of moderate and severe obstructive sleep apnea with bone-anchored pharyngeal suspension sutures. EAR, NOSE & THROAT JOURNAL 2014; 92:E1. [PMID: 23975494 DOI: 10.1177/014556131309200817] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Success rates for the surgical treatment of obstructive sleep apnea (OSA) vary, with phase I surgical success ranging from 40 to 75%. Pharyngeal suspension suture procedures are minimally invasive techniques with a reported efficacy of 20 to 78%. We conducted a study to evaluate the effectiveness of pharyngeal suspension suture procedures in conjunction with uvulopalatopharyngoplasty (UPPP) as a multilevel treatment for OSA. We retrospectively reviewed the charts of 30 adults-22 men and 8 women, with a mean age of 49 years and a mean BMI of 30.6-who were treated at a tertiary care academic medical center and a private otolaryngology practice. All patients had moderate or severe OSA, and all had failed continuous positive airway pressure therapy. Of this group, 20 patients underwent tongue base and hyoid suspension (TBHS) and 10 underwent tongue base suspension (TBS) alone; 23 patients had undergone concurrent or previous UPPP, 13 in the TBHS group and all 10 in the TBS group. Polysomnography was performed an average of 3.9 months postoperatively. Surgical success was defined as a reduction in respiratory distress index (RDI) of more than 50% and a postoperative RDI of 20 or less. The overall surgical success rate was 63% (19/30). In the surgical success group, the mean RDI fell from 44.6 to 9.4 (p < 0.0001); in the surgical failure group, the mean RDI rose from 41.3 to 48.9 (p = 0.58). There were 6 complications: 3 seromas, 2 suture breaks, and 1 dislodged screw. We conclude that pharyngeal suspension suture procedures as part of the multilevel treatment of moderate and severe OSA yields better outcomes than conventional surgical treatments with the added benefit of being minimally invasive.
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Affiliation(s)
- Eric E Berg
- Department of Otolaryngology-Head and Neck Surgery, UT Southwestern Medical Center, 5323 Henry Hines Blvd., Dallas, TX 75390, USA.
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Chen JC, Hwang JH. Sleep apnea increased incidence of primary central nervous system cancers: a nationwide cohort study. Sleep Med 2014; 15:749-54. [PMID: 24891080 DOI: 10.1016/j.sleep.2013.11.782] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Revised: 11/02/2013] [Accepted: 11/06/2013] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Obstructive sleep apnea (OSA) was associated with increased incidence of all cancers. We aimed to determine the risk for primary central nervous system (CNS) cancers in patients with sleep apnea syndrome. METHODS A total of 23,055 incident cases of newly diagnosed sleep apnea syndrome (sleep apnea group) were identified between 2000 and 2003 in the medical claims database of Taiwan's National Health Institute (NHI) program and were matched by age and gender to patients without OSA (comparison group) in the same period. The occurrence of primary malignant CNS cancers was measured 2 years after the index date over a 10-year period. RESULTS The incidence density of primary CNS cancers (per 10,000 individual-years) was 2.14 and 1.28, respectively, for the OSA and comparison groups. The overall risk for developing primary CNS cancers was significantly higher in the OSA group (adjusted hazard ratio [HR], 1.54; P=0.046) after adjusting for age, gender, and obesity, among other variables. Subgroup analysis revealed a significantly higher risk for primary brain cancers but not primary spinal cord cancers in the OSA subgroup (adjusted HR, 1.71; P=0.027). The analysis also revealed a significantly higher risk for primary CNS cancers in the insomnia with OSA subgroup (adjusted HR, 2.20; P=0.001) and in the OSA without surgical treatment subgroup (adjusted HR, 1.831; P=0.003). CONCLUSIONS OSA, especially with insomnia, may increase the risk for primary CNS cancer development, though surgical treatment may reduce this risk in participants with OSA.
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Affiliation(s)
- Jin-Cherng Chen
- Department of Neurosurgery, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Juen-Haur Hwang
- School of Medicine, Tzu Chi University, Hualien, Taiwan; Department of Otolaryngology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan; Department of Sleep Center, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan.
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Fernández-Julián E, García-Pérez MÁ, García-Callejo J, Ferrer F, Martí F, Marco J. Surgical planning after sleep versus awake techniques in patients with obstructive sleep apnea. Laryngoscope 2014; 124:1970-4. [DOI: 10.1002/lary.24577] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Revised: 12/09/2013] [Accepted: 12/30/2013] [Indexed: 11/07/2022]
Affiliation(s)
| | - Miguel Ángel García-Pérez
- Institute of Health Research INCLIVA and Department of Genetics; University of Valencia; Valencia Spain
| | | | - Felipe Ferrer
- Otorhinolaryngology Department; University of Valencia; Valencia Spain
| | - Francisco Martí
- Department of Anesthesiology; Hospital Clínico Universitario; University of Valencia; Valencia Spain
| | - Jaime Marco
- Otorhinolaryngology Department; University of Valencia; Valencia Spain
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Li S, Shi H. Lingual artery CTA-guided midline partial glossectomy for treatment of obstructive sleep apnea hypopnea syndrome. Acta Otolaryngol 2013; 133:749-54. [PMID: 23448355 DOI: 10.3109/00016489.2013.765968] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONCLUSION Midline partial glossectomy guided by lingual artery computed tomographic angiography (CTA) demonstrated a satisfactory safety profile and therapeutic effect for patients with obstructive sleep apnea hypopnea syndrome (OSAHS) due to tongue hypertrophy. OBJECTIVE To evaluate the efficacy and safety profile of midline partial glossectomy guided by lingual artery CTA for the treatment of OSAHS due to tongue hypertrophy. METHODS Sixty-seven OSAHS patients with a narrowed airway at the hypopharyngeal region due to tongue hypertrophy underwent uvulopalatopharyngoplasty (UPPP) in combination with midline partial glossectomy. The operation zone was determined according to the anatomic measurement obtained from lingual artery CTA and the resected region was much larger than with conventional midline partial glossectomy. Postoperative complications were closely monitored and sleep condition was followed up for more than 6 months and re-evaluated by polysomnography (PSG). RESULTS All the operations proceeded uneventfully without any complications, demonstrating a satisfactory safety profile. After a follow-up period of more than 6 months, of the 67 patients undergoing the procedure, 24 were cured and 34 exhibited markedly improved sleep, whereas 9 showed little or no improvement, giving an effectiveness rate of 86.6% for the operation.
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Affiliation(s)
- Shuhua Li
- Department of Otolaryngology-Head and Neck Surgery, General Hospital of Shenyang Military Area Command, Shenyang, China.
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Handler E, Hamans E, Goldberg AN, Mickelson S. Tongue suspension: an evidence-based review and comparison to hypopharyngeal surgery for OSA. Laryngoscope 2013; 124:329-36. [PMID: 23729234 DOI: 10.1002/lary.24187] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 03/27/2013] [Accepted: 04/15/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS Our first objective was to perform a systematic review of suture-based tongue suspension procedures as a stand-alone therapy for hypopharyngeal obstruction in obstructive sleep apnea (OSA). A second objective compared outcomes of tongue suspension as part of a multilevel approach to OSA surgery to genioglossus advancement (GA) with uvulopalatopharyngoplasty (UPPP), and to genioglossus advancement with hyoid suspension (GAHM) with UPPP. STUDY DESIGN Systematic review. METHODS The PubMed database was queried for English-language studies published after 1997 to create four cohorts: tongue suspension alone, tongue suspension with UPPP, GA + UPPP, and GAHM with UPPP. Chi-squared test was used to compare outcomes between cohorts. RESULTS Twenty-seven studies were included, broken down into cohorts based on our selection criteria. Six studies qualified for the tongue suspension-alone group with a surgical success rate of 36.6%. Eight studies qualified for our cohort of tongue suspension with UPPP with a surgical success rate of 62.3%. Eighteen studies qualified for our remaining two cohorts: GA + UPPP, and GAHM + UPPP. Their surgical success rates were both 61.1%. A chi-squared test to compare surgical outcomes showed that there was no difference between tongue suspension with UPPP, GA + UPPP, and GAHM + UPPP. CONCLUSION Tongue suspension is effective and safe as part of a multilevel surgical approach for patients with OSA. As a stand-alone procedure, its success rate is 36.6%, comparable to UPPP procedures for OSA success rates across the board. Tongue suspension should be considered in patients with OSA who demonstrate tongue base obstruction.
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Affiliation(s)
- Ethan Handler
- Department of Head and Neck Surgery, Kaiser Permanente, Oakland, California, U.S.A
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Li S, Wu D, Shi H. Treatment of obstructive sleep apnea hypopnea syndrome caused by glossoptosis with tongue-base suspension. Eur Arch Otorhinolaryngol 2013; 270:2915-20. [DOI: 10.1007/s00405-013-2536-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 04/25/2013] [Indexed: 12/01/2022]
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Hartzell LD, Guillory RM, Munson PD, Dunham AK, Bower CM, Richter GT. Tongue base suspension in children with cerebral palsy and obstructive sleep apnea. Int J Pediatr Otorhinolaryngol 2013; 77:534-7. [PMID: 23357781 DOI: 10.1016/j.ijporl.2013.01.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 12/30/2012] [Accepted: 01/01/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Children with cerebral palsy (CP) are commonly affected by obstructive sleep apnea (OSA). This study examines the efficacy of combined surgical techniques for OSA including tongue base suspension (TBS), using perioperative polysomnograms (PSG) in pediatric patients with CP. STUDY DESIGN Case series with outcome analysis. SETTING University based tertiary care children's hospital. METHODS A 7-year retrospective chart review of children with CP who underwent surgical management for OSA. Surgical procedures, postoperative complications, and perioperative PSG data were examined. Only patients with both preoperative and postoperative PSG results were included in the study. Based upon procedures performed patients fell into 2 equal groups for analysis. RESULTS Fourteen children were identified. Seven patients (mean age = 6.0 years) underwent combined adenotonsillectomy (T&A), uvulopalatopharyngoplasty (UPPP), and tongue base suspension (TBS). Another 7 patients (mean age = 6.3 years) underwent T&A and UPPP alone. Those who received TBS had a mean preoperative AHI of 27.2 compared to 6.8 in the group that did not have TBS. The AHI decreased by a mean of 16.5 in the TBS group and 5.0 in the non-TBS group. The mean oxygen saturation nadir improved in both the TBS (74.0-84.0) and non-TBS (64.8-84.6) groups. The arousal index also improved in the TBS (33.1-20.7) and non-TBS (11.0-5.8) groups. No surgical complications occurred. CONCLUSION This study suggests that concomitant surgical approaches for OSA in children with CP are effective. Moderate to severe OSA in this population may safely benefit from the added technique of tongue base suspension.
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Affiliation(s)
- Larry David Hartzell
- University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Department of Otolaryngology-Head and Neck Surgery, Little Rock, AR 72202, United States.
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Shie DY, Tsou YA, Tai CJ, Tsai MH. Impact of obesity on uvulopalatopharyngoplasty success in patients with severe obstructive sleep apnea: a retrospective single-center study in Taiwan. Acta Otolaryngol 2013; 133:261-9. [PMID: 23294274 DOI: 10.3109/00016489.2012.741328] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONCLUSION Our findings suggest that, in Asian patients with severe obstructive sleep apnea (OSA), obesity is a better predictor of uvulopalatopharyngoplasty (UPPP) failure than Friedman stage III. OBJECTIVES This study evaluated UPPP success rates in obese and non-obese Asian patients treated for severe OSA. METHODS Records of patients who underwent UPPP for treatment of OSA were retrospectively reviewed. Preoperative and postoperative apnea/hypopnea index (AHI) and Epworth Sleepiness Scale (ESS) score, and Friedman stage were compared in non-obese (body mass index (BMI) <27 kg/m(2)) and obese (BMI ≥27 kg/m(2)) patients. Treatment success was defined as >50% reduction in preoperative AHI or postoperative AHI of <20 events/h. RESULTS Treatment success was significantly lower (p < 0.0001) in the obese group (24.6%) compared with the non-obese group (62.5%). After adjusting for gender, age, BMI, Friedman stage, and preoperative AHI and ESS score, obesity was a significant independent negative predictor of treatment success (adjusted OR = 0.297, 95% CI = 0.114-0.773, p = 0.013).
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Affiliation(s)
- Dung-Yun Shie
- Department of Otolaryngology, China Medical University Hospital, Taichung, Taiwan, ROC
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Lee YC, Eun YG, Shin SY, Kim SW. Results of Tailor-Made Multilevel Surgery in Patients with Obstructive Sleep Apnea. SLEEP MEDICINE RESEARCH 2012. [DOI: 10.17241/smr.2012.3.2.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Prinsell JR. Primary and secondary telegnathic maxillomandibular advancement, with or without adjunctive procedures, for obstructive sleep apnea in adults: a literature review and treatment recommendations. J Oral Maxillofac Surg 2011; 70:1659-77. [PMID: 21855196 DOI: 10.1016/j.joms.2011.03.064] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Revised: 03/04/2011] [Accepted: 03/28/2011] [Indexed: 10/17/2022]
Abstract
PURPOSE To further define the role, surgical principles, and therapeutic efficacy of primary and secondary maxillomandibular advancement (MMA), with and without intrapharyngeal or extrapharyngeal adjunctive procedures, for obstructive sleep apnea in adults. MATERIALS AND METHODS A review of the literature, using mean percent reduction in apnea hypopnea index as the primary outcome measure of therapeutic efficacy for standardized comparison. Other occasionally reported MMA outcome parameters were sleep staging variables, lowest oxyhemoglobin saturation levels, Epworth scores, blood pressure changes, lateral cephalometric data, and complications. RESULTS Mean percent reduction in apnea hypopnea index was 92.1% for primary MMA with extrapharyngeal procedures, 88.4% for primary MMA, 86.6% for secondary MMA, 79.4% for primary MMA with intrapharyngeal procedures, 53.0% for non-MMA multilevel surgery, 31.3% for uvulopalatopharyngoplasty, and 89.8% for nasal continuous positive airway pressure. Treatment recommendations for telegnathic MMA included surgical goals and guidelines, indications and staging protocols, surgical principles and techniques, and postoperative airway management. CONCLUSIONS Primary and secondary MMA are highly therapeutic, and extrapharyngeal are more therapeutic than intrapharyngeal procedures when performed concomitantly with primary MMA. However, long-term success of obstructive sleep apnea treatment should be measured by a yet undefined comprehensive algorithm of standardized multiple weighted outcome parameters.
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Woodson BT, Steward DL, Mickelson S, Huntley T, Goldberg A. Multicenter study of a novel adjustable tongue-advancement device for obstructive sleep apnea. Otolaryngol Head Neck Surg 2010; 143:585-90. [DOI: 10.1016/j.otohns.2010.06.902] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2009] [Revised: 04/16/2010] [Accepted: 06/10/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE: The safety and clinical effect of a new surgical device for tongue suspension for obstructive sleep apnea (OSA) was assessed. STUDY DESIGN: Multicenter phase 2 prospective case series. SETTING: Multicenter academic and private. SUBJECTS AND METHODS: Surgically naïve patients with moderate-to-severe OSA and tongue base obstruction (body mass index < 32, apnea/hypopnea index [AHI] 15–60) underwent surgical insertion of a midline tissue anchor into the posterior tongue and connected to an adjustable mandibular bone anchor with a flexible tether. Outcomes included changes in AHI, sleepiness (Epworth Sleepiness Scale), sleep-related quality-of-life (Functional Outcomes of Sleep Questionnaire), snoring, swallowing, speech, and pain (0–10 visual analog scale). RESULTS: After the implant, 42 patients (mean age 50 years, body mass index 28) noted improvement at six months for AHI (mean [SD]: 35.5 [20.4] to 27.3 [18.8]), Epworth Sleepiness Scale (11.5 [3.9] to 7.8 [4.7]), and Functional Outcomes of Sleep Questionnaire (15.5 [2.6] to 17.5 [2.6], all P < 0.01). Snoring VAS scores improved (7.3 [2.1] to 4.7 [2.9], P < 0.01). Postimplant pain scores were mild to moderate (4.4) at day one and resolved by day five. Post-titration pain scores were mild (< 2). Device-related adverse events included wound infection (7%) and edema or seroma (5%), which resolved. However, in 31 percent of patients, asymptomatic tissue anchor barb fractures were observed radiographically. CONCLUSION: The tissue anchor failure rate of the tested device precludes its clinical use; however, the study results support that a titratable, tongue-suspension device with low direct surgical morbidity in patients with moderate-to-severe sleep apnea significantly improves multiple measures of sleep apnea. Further investigation is warranted.
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Affiliation(s)
- B. Tucker Woodson
- Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, WI
| | - David L. Steward
- Department of Otolaryngology, University of Cincinnati Academic Health Center, Cincinnati, OH
| | | | - Tod Huntley
- Head & Neck Surgery Associates Inc., Carmel, IN
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Caples SM, Rowley JA, Prinsell JR, Pallanch JF, Elamin MB, Katz SG, Harwick JD. Surgical modifications of the upper airway for obstructive sleep apnea in adults: a systematic review and meta-analysis. Sleep 2010; 33:1396-407. [PMID: 21061863 PMCID: PMC2941427 DOI: 10.1093/sleep/33.10.1396] [Citation(s) in RCA: 308] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A substantial portion of patients with obstructive sleep apnea (OSA) seek alternatives to positive airway pressure (PAP), the usual first-line treatment for the disorder. One option is upper airway surgery. As an adjunct to the American Academy of Sleep Medicine (AASM) Standards of Practice paper, we conducted a systematic review and meta-analysis of literature reporting outcomes following various upper airway surgeries for the treatment of OSA in adults, including maxillomandibular advancement (MMA), pharyngeal surgeries such as uvulopharyngopalatoplasty (UPPP), laser assisted uvulopalatoplasty (LAUP), and radiofrequency ablation (RFA), as well as multi-level and multi-phased procedures. We found that the published literature is comprised primarily of case series, with few controlled trials and varying approaches to pre-operative evaluation and post-operative follow-up. We include surgical morbidity and adverse events where reported but these were not systematically analyzed. Utilizing the ratio of means method, we used the change in the apnea-hypopnea index (AHI) as the primary measure of efficacy. Substantial and consistent reductions in the AHI were observed following MMA; adverse events were uncommonly reported. Outcomes following pharyngeal surgeries were less consistent; adverse events were reported more commonly. Papers describing positive outcomes associated with newer pharyngeal techniques and multi-level procedures performed in small samples of patients appear promising. Further research is needed to better clarify patient selection, as well as efficacy and safety of upper airway surgery in those with OSA.
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Affiliation(s)
- Sean M Caples
- Center for Sleep Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester MN, USA
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Blumen M, Crampette L, Fischler M, Galet de Santerre O, Jaber S, Larzul JJ, Meyer B, Monteyrol PJ, Payen JF, Pételle B, Rugina M, Chabolle F. Traitement chirurgical du SAHOS. Rev Mal Respir 2010; 27 Suppl 3:S157-65. [DOI: 10.1016/s0761-8425(10)70021-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Endoscopic evaluation of the upper airway in patients with sleep disordered breathing (SDB) using rigid and flexible endoscopes is a typical investigation in otorhinolaryngology. Visualizing the anatomic structure as well as the dynamic mechanism of snoring and pharyngeal obstruction during wakefulness, natural sleep, and under sedation are of special interest. The results obtained have increased our understanding of SDB with obstruction of the upper airway. Videoendoscopy under sedation (ViSe) has become increasingly established as a tool to identify the therapeutic concept in cases of CPAP failure, leading to changes compared to the concept derived from basic awake endoscopy. The success of mandibular advancement devices can be adequately predicted. However, it remains unclear to what extent the success rate of surgery can be improved by ViSe. Further research into these approaches is needed in order to become valuable tools in the diagnostic work-up of patients with sleep apnea.
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Affiliation(s)
- J T Maurer
- Schlafmedizinisches Zentrum,Universitäts-Hals-Nasen-Ohren-Klinik Mannheim, Medizinische Fakultät Mannheim der Ruprecht-Karls-Universität Heidelberg, 68135, Mannheim, Deutschland.
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Randerath WJ. Alternatives to positive airway pressure for obstructive sleep apnea syndrome. Expert Rev Respir Med 2010; 3:255-63. [PMID: 20477320 DOI: 10.1586/ers.09.12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Owing to the prevalence, the considerable risk of accidents and cardiovascular consequences, optimal treatment of obstructive sleep apnea syndrome is of crucial importance. However, many patients look for alternative conservative or surgical therapies to continuous positive airway pressure to avoid discomfort and local side-effects owing to the mask. Scientific data are lacking for most of the alternative methods. However, it has been proven that intra-oral appliances can reduce mild-to-moderate respiratory disturbances; the maxillo-mandibular osteotomy is efficient in the short- and long-term but is preferred in special situations such as craniofacial dysmorphias. Weight reduction and body positioning cannot be recommended as a single treatment for obstructive sleep apnea syndrome. Resections of muscular tissue within the soft palate have to be strictly avoided. Efficacy of gentle soft palate procedures is difficult to predict and often decreases in the years following this treatment. Multilevel surgery concepts are of increasing interest, although more data from prospective, controlled studies are needed.
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Affiliation(s)
- Winfried J Randerath
- Professor of Medicine, Institute of Pneumology at the University Witten/Herdecke, Clinic for Pneumology & Allergology, Center of Sleep Medicine & Respiratory Care, Bethanien Hospital, Aufderhöherstrasse 169-175, 42699 Solingen, Germany.
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Abstract
The current guideline discusses conservative and surgical therapy of obstructive sleep apnea (OSA) in adults from the perspective of the ear, nose and throat specialist. The revised guideline was commissioned by the German Society of Ear-Nose-Throat, Head-Neck Surgery (DG HNO KHC) and compiled by the DG HNO KHC's Working Group on Sleep Medicine. The guideline was based on a formal consensus procedure according to the guidelines set out by the German Association of Scientific Medical Societies (AWMF) in the form of a"S2e guideline". Research of the literature available on the subject up to and including December 2008 forms the basis for the recommendations. Evaluation of the publications found was made according to the recommendations of the Oxford Centre for Evidence-Based Medicine (OCEBM). This yielded a recommendation grade, whereby grade A represents highly evidence-based studies and grade D those with a low evidence base.
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Fibbi A, Ameli F, Brocchetti F, Mignosi S, Cabano ME, Semino L. Tongue base suspension and radiofrequency volume reduction: a comparison between 2 techniques for the treatment of sleep-disordered breathing. Am J Otolaryngol 2009; 30:401-6. [PMID: 19880029 DOI: 10.1016/j.amjoto.2008.08.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2008] [Accepted: 08/03/2008] [Indexed: 11/26/2022]
Abstract
PURPOSE Lingual suspension (LS) and tongue base radio frequency volume reduction (RFVR) have been proposed as means of correcting the obstruction caused by the collapse or hypertrophy of the tongue base in patients having sleep-disordered breathing (SDB). The aim of this study was to evaluate and compare long-term results (6 months and 2 years) in a population of 24 patients having mild obstructive sleep apnea syndrome (OSAS), of whom 12 were treated with LS and 12 with RFVR. MATERIALS AND METHODS The study included 24 patients having mild OSAS (apnea-hypopnea index between 10 and 20). All patients were assessed by means of the Epworth Sleepiness Scale, collection of anthropomorphic data, fiber-optic evaluation with Muller's maneuver, cephalometric assessment, and polysomnography. Lingual suspension was performed under general anesthesia with cervical cutaneous access. Radio frequency volume reduction was performed under local anesthesia with an Ellman Surgitron Dual RF unit (Ellman International, Inc., New York, NY), using a resterilizable bipolar terminal prototype. The same ear, nose, and throat examinations and polysomnography were carried out 6 months and 2 years after the surgical procedure. RESULTS The results were evaluated according to the criteria by Sher (Sleep. 1996,19:156-177); after 6 months, the success percentage was 67% in patients treated with LS and 75% in those with RFVR. These percentages dropped to 42% in the first group and 33% in the second group after 24 months. CONCLUSIONS Lingual suspension and RFVR are simple procedures that can be quickly performed and are well tolerated by patients. However, their effectiveness drops after 2 years. Our experience has therefore led us to conclude that the minimally invasive treatment for tongue base surgery can guarantee long-term results only in 42% and 33% of patients, respectively. Moreover, RFVR is preferable because it is simpler to perform and less invasive than LS, and it can be repeated over time.
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Fernández-Julián E, Muñoz N, Achiques MT, García-Pérez MA, Orts M, Marco J. Randomized study comparing two tongue base surgeries for moderate to severe obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg 2009; 140:917-23. [DOI: 10.1016/j.otohns.2009.02.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2008] [Revised: 01/07/2009] [Accepted: 02/04/2009] [Indexed: 11/28/2022]
Abstract
Objective: To compare the effectiveness and morbidity of the tongue base radiofrequency and tongue base suspension techniques combined with uvulopalatopharyngoplasty for moderate to severe obstructive sleep apnea. Study Design and Setting: Prospective and randomized surgical trial at a university hospital. Methods: In total, 57 patients received either tongue base radiofrequency reduction (n = 29) or tongue base suspension (n = 28). Apnea-hypopnea index, lowest oxygen saturation (polysomnography), Epworth score, and side effects were assessed. Success was defined as a ≥50 percent reduction and final apneahypopnea index < 15/h, and an Epworth score < 11. Results: The success rates of the two procedures were 57.1 percent and 51.7 percent, respectively ( P = 0.79), but only 12.5 percent and 10 percent, respectively ( P = 0.87), in obese patients. Body mass index ( P = 0.0002) was the main predictor of success in a logistic regression analysis. Tongue base suspension demonstrated higher morbidity ( P < 0.05). Conclusions: The effectiveness of tongue base suspension was similar to that of tongue base radiofrequency reduction, although with significantly higher morbidity, for moderate to severe obstructive sleep apnea. The effectiveness of both techniques was lower in obese patients. Significance: Neither technique should be used in obese patients who have moderate to severe obstructive sleep apnea.
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Affiliation(s)
- Enrique Fernández-Julián
- Otorhinolaryngology Department, Hospital Clínico Universitario, University of Valencia, Valencia, Spain
| | - Noelia Muñoz
- Otorhinolaryngology Department, Hospital Clínico Universitario, University of Valencia, Valencia, Spain
| | - Maria Teresa Achiques
- Otorhinolaryngology Department, Hospital Clínico Universitario, University of Valencia, Valencia, Spain
| | - Miguel A. García-Pérez
- Research Foundation, Hospital Clínico Universitario, University of Valencia, Valencia, Spain
| | - Miguel Orts
- Otorhinolaryngology Department, Hospital Clínico Universitario, University of Valencia, Valencia, Spain
| | - Jaime Marco
- Otorhinolaryngology Department, Hospital Clínico Universitario, University of Valencia, Valencia, Spain
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Abstract
During the past two decades, different methods of upper airway evaluation for patients with obstructive sleep apnea (OSA) have been investigated. Although clinical assessment is the basis of any diagnostic workflow in OSA, the Mueller maneuver is apparently of no importance. Imaging techniques have increased our knowledge of the pathophysiology of OSA. Cephalometry is done only if maxillomandibular advancement is planned; dynamic investigations such as computed tomography and magnetic resonance imaging are able to picture the pharyngeal collapse and have the capacity to simulate the effect of interventions on OSA severity. So far, video endoscopy under sedation can only predict the success of oral appliances. Multichannel pressure recordings depict the distribution of obstructive events in the upper or lower pharyngeal segment during the entire night. The impact of sophisticated upper airway evaluation remains limited compared with standard clinical assessment. Further research is needed to develop valuable tools for the diagnostic workup of patients with OSA.
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The efficacy of multilevel surgery of the upper airway in adults with obstructive sleep apnea/hypopnea syndrome. Laryngoscope 2008; 118:902-8. [PMID: 18300704 DOI: 10.1097/mlg.0b013e31816422ea] [Citation(s) in RCA: 182] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Many patients with obstructive sleep apnea/hypopnea syndrome (OSAHS) are incapable of using continuous positive airway pressure. These patients therefore turn to surgical options as a salvage treatment. Early studies and reviews focused on the efficacy of uvulopalatopharyngoplasty, a single-level procedure for the treatment of OSAHS. Since OSAHS is usually caused by multilevel obstructions, the true focus on efficacy should be on multilevel surgical intervention. The purpose of this paper is to provide an overview of the literature on multilevel surgery for OSAHS patients. STUDY DESIGN Systematic review of the literature and meta-analysis focusing on subjective and objective outcomes of patients with OSAHS treated with multilevel surgery of the upper airway. METHODS We searched PubMed, the Cochrane database, and MEDLINE bibliographic databases up to March 31, 2007, for studies dealing with multilevel surgical modification of the upper airway for the treatment of OSAHS. Additional studies were identified from their reference lists. Articles were included only if the surgical intervention involved at least two of the frequently involved anatomic sites: nose, oropharynx, and hypopharynx. RESULTS After applying specific inclusion criteria, 49 multilevel surgery articles (58 groups) were identified. There were 1,978 patients included in the study. The mean minimal follow-up time was 7.3 months (range, 1 to 100 months). A meta-analysis was performed to redefine the success rate to be consistent with the commonly agreed upon criteria, namely "a reduction in the apnea/ hypopnea index (AHI) of 50% or more and an AHI of less than 20." "Success" implies an improved condition and is not meant to imply cure. The recalculated success rate was 66.4%. The overall complication rate was 14.6%. The evidence-base medicine (EBM) level of these 49 studies revealed that only one study was EBM level 1, two papers were EBM level 3, and the other 46 papers were ranked as level 4 evidence. CONCLUSIONS Multilevel surgery for OSAHS is obviously associated with improved outcomes, although this benefit is supported largely by level 4 evidence. Future research should focus on prospective and controlled studies.
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Friedman M, Lin HC, Gurpinar B, Joseph NJ. Minimally invasive single-stage multilevel treatment for obstructive sleep apnea/hypopnea syndrome. Laryngoscope 2007; 117:1859-63. [PMID: 17713449 DOI: 10.1097/mlg.0b013e3180f62b4d] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To assess subjective and objective improvement after single-stage multilevel minimally invasive treatment for obstructive sleep apnea/hypopnea syndrome (OSAHS). STUDY DESIGN A retrospective review of a prospective dataset of patients treated in a tertiary care referral center. METHODS Charts of 145 patients with mild/moderate OSAHS treated with a single-stage multilevel minimally invasive technique were reviewed to abstract pre- and posttreatment symptoms and polysomnographic data. One hundred twenty-two patients had minimum follow-up of 6 (range, 6-23) months and complete data available for analysis. All patients studied had three-level treatment that included nasal surgery, palatal stiffening by Pillar implant technique, and radiofrequency volume reduction of the tongue base. Primary outcomes included change from baseline in apnea/hypopnea index (AHI). Secondary outcomes included change in Epworth Sleepiness Scale (ESS) and bed-partner assessed snoring visual analogue scale (VAS, 0-10), pain levels, narcotic use, and complications. RESULTS Mean AHI decreased from 23.2 +/- 7.6 preoperatively to 14.5 +/- 10.2 postoperatively (P < .0001). Classical "cure" was achieved in 54 (47.5%) patients. Mean ESS decreased from 9.7 +/- 3.9 preoperatively to 6.9 +/- 3.3 postoperatively (P < .0001). Mean snoring VAS decreased from 9.4 +/- 0.9 preoperatively to 3.2 +/- 2.4 postoperatively (P <. 0001). CONCLUSION Polysomnographic respiratory parameters, ESS, and snoring VAS significantly improved in patients with mild/moderate OSAHS treated with single-stage multilevel minimally invasive surgery. Multilevel minimally invasive single-stage surgery is a valid option for selected patients with mild/moderate OSAHS with the understanding that they may require secondary treatment.
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Affiliation(s)
- Michael Friedman
- Department of Otolaryngology and Bronchoesophagology, Rush University Medical Center, Chicago, Illinois, USA.
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Abstract
Obstructive sleep apnea (OSA) is the result of upper airway obstruction during sleep. Hypopharyngeal airway obstruction can be caused by the prominence or relaxation of the base of the tongue, lateral pharyngeal wall, and occasionally, the aryepiglottic folds or epiglottis. Although nasal continuous positive airway pressure (CPAP) is considered as the first treatment for obstructive sleep apnea, surgery has been shown to be a viable option for patients who are intolerant of positive pressure therapy. This article presents the current state of hypopharyngeal surgery for sleep apnea. Preoperative airway evaluation with fiberoptic nasopharyngoscopy, the use of lateral cephalometric radiograph, and the formulation of a surgical plan with selection of procedures to address hypopharyngeal obstruction are discussed.
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Affiliation(s)
- Kasey K Li
- Stanford Sleep Disorders Clinic and Research Center, 401 Quarry Road, Stanford, CA 94305, USA.
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