The relationship between the Epworth Sleepiness Scale and polysomnographic parameters in obstructive sleep apnea patients

The aim of this study was to investigate the relationship between the subjective Epworth Sleepiness Scale (ESS) and objective polysomnographic parameters that was compared in dichotomized groups of obstructive sleep apnea (OSA) patients with and without excessive daytime sleepiness (EDS). A retrospective review of the 96 consecutive snoring patients suspected of OSA due to upper airway problems was performed. ESS score was assessed and EDS was considered present when the ESS score was >10. Polysomnography was performed for each patient. Comparisons of polysomnographic parameters between both groups of patients were performed using Mann–Whitney U-tests. The Pearson’s correlation coefficient was calculated. EDS patients showed significantly greater body mass index (BMI), AHI and ODI, higher percentage of snoring time, a longer time length of SpO₂ < 90% and lower minimum SpO₂ compared to no EDS patients. There was no statistical difference in other sleep parameters. A positive correlation between the ESS score and BMI, percentage of snoring time, minimum SpO₂ and time length of SpO₂ < 90% was identified. Despite many controversies, our conclusion is that apnea/hypoxemia has considerable coherence to account for the EDS measured by ESS in OSA patients.     

Correlation of the Epworth Sleepiness Scale with respiratory sleep parameters in patients with sleep-related breathing disorders and upper airway pathology

The aim of the study was to test whether a correlation between the Epworth Sleepiness Scale (ESS) and respiratory sleep parameters recorded by polysomnography (PSG) in patients with sleep-related breathing disorders and upper airway pathology exists. The PSG records of 130 patients (average age 52.6 ± 10.7 years) with upper airway pathology suspected of having obstructive sleep apnea (OSA) have been retrospectively evaluated. Upper airway pathology included deviation of the nasal septum, inferior nasal turbinate hypertrophy, soft palate webbing, elongated uvula, tonsillar hypertrophy, macroglossia, hypertrophy of the tongue base, unfavorable palate position relative to the tongue base. To test for a possible correlation in this patient population between ESS score and arithmetic values of AHI, SPO₂, ODI and Arousal Index, the Spearman’s correlation coefficient was calculated. No correlation between ESS and AHI, minimal SpO₂ and ODI was proven and only a weak positive correlation between Arousal Index and ESS was found in this particular patient population. We concluded that in patients with upper airway pathology, it is not possible to predict solely on the basis of the ESS score the existence of OSA or of other disturbances in Arousal Index, minimal SpO₂ and ODI. Nevertheless, historical data evaluated by questionnaires, such as the ESS provide for additional information combined with the clinical findings to select patients who are candidates for further detailed sleep studies.     

Managing obstructive sleep apnea patients with CPAP failure with a novel Lateral Pharyngoplasty as a stand-alone procedure

BackgroundObstructive sleep apnea syndrome (OSAS) is caused by a complete or partial obstruction of the upper airway. A new Cahali lateral pharyngoplasty as a stand-alone procedure for the treatment of OSA patients, whatever the level and pattern of airway obstruction in patients with CPAP failure or non-compliant patients, is it?Patients and methods40 patients with known OSAS non-compliant with CPAP or CPAP failures included. BMI, Stop-Bang score, and sleep study parameters were reported before and after the new Cahali pharyngoplasty operation. Preoperative DISE was done for all cases.ResultsThere were 28 (70%) cases with successful operation outcomes, and 12 (30%) failed cases. Postoperative Stop Bang score, AHI, snoring index were significantly reduced in comparison to preoperative data (p-value <0.001); however, minimal SpO₂ and baseline SpO₂ were significantly increased in comparison to preoperative data. There was a significant improvement in AHI postoperative. Patients collapse at the level of lateral wall hypopharynx, high tongue collapse, laryngeal collapse, tongue palate interaction, all significantly predict failure outcome of the operation (p-value = 0.022). However, the absence of laryngeal collapse (L0) had a successful prediction outcome. The high snoring index significantly predicts operation failure. However, preoperative high baseline SpO₂ predicts operation success significantly.ConclusionThe new Cahali lateral pharyngoplasty can be used as a stand-alone procedure in the absence of lateral wall collapse at the level of the hypopharynx (LH), high tongue base collapse (TH), laryngeal collapse (L1) or tongue palate interaction.     

The effect of the prone sleeping position on obstructive sleep apnoea

Conclusions: Prone positioning reveals promising results in improving the apnoea-hypopnoea index (AHI) and oxygen desaturation index (ODI) in patients with obstructive sleep apnoea (OSA). Objective: To evaluate the effect of the prone position on OSA. Methods: Thirty-two patients with mild to severe OSA were included in the study. This was a two-night study to evaluate the effect of the prone position on OSA; a first night in a normal bed with optional positioning and a second night on a mattress and pillow facilitating prone positioning. Results: A total of 27 patients, 22 males and 5 females, with a mean age of 51 years, 15 patients with positional OSA (POSA) and 12 patients with non-POSA with a total median AHI of 23 (min 5, max 93) completed the study protocol. The median AHI decreased from 23 to 7 (p < 0.001) and the median ODI from 21 to 6 (p < 0.001). The median time spent in the supine position decreased from 142 to <1 min (p < 0.0001) and the median time in the prone position increased from <1 to 330 min (p < 0.0001). In all, 17 of 27 patients (63%) were considered to be responders to prone positioning, 12 of 15 (80%) with POSA and 5 of 12 (42%) with non-POSA. Five patients did not complete the study protocol due to sleep time <4 h.     

Mattress and pillow for prone positioning for treatment of obstructive sleep apnoea

Conclusion: The new mattress and pillow for prone positioning (MPP) is efficient in reducing the apnoea-hypopnoea index (AHI) and oxygen desaturation index (ODI) in most patients with obstructive sleep apnoea (OSA), with satisfactory compliance. Objective: The aim of the present study was to evaluate the effect of the prone body and head sleep position on severity of disease in patients with OSA after 4 weeks of adaptation to a mattress and pillow facilitating prone positioning. Methods: Fourteen patients with mild to severe OSA, 11 men and 3 women with a mean AHI of 26 (min, 6; max, 53) and mean ODI of 21 (min, 6; max, 51) were evaluated. Two polysomnographic (PSG) studies were performed. The first PSG study was without any treatment and the second was after 4 weeks of adaptation to the MPP for prone positioning of the body and the head. Results: Mean AHI and ODI decreased from 26 and 21 to 8 and 7, respectively (p < 0.001) with treatment. The mean time spent in the supine position was reduced from 128 to 10 min (p = 0.02) and the prone time increased from 42 to 174 min (p = 0.02) with the MPP. The mean total sleep time was 390 min during the first PSG study night without treatment and 370 min during the second night with the MPP (p = 0.7). Ten patients (71%) reduced their AHI by at least 50% and reached a value < 10 during treatment. All patients managed to sleep on the MPP for > 4 h per night during the 4-week study.     

Short-term postoperative CPAP may improve the outcomes of velopharyngeal surgery for obstructive sleep apnea

PurposeTo evaluate the effects of short-term postoperative continuous positive airway pressure (CPAP) on the outcomes of velopharyngeal surgery for obstructive sleep apnea (OSA).Materials and methodsThis study included 119 OSA patients who underwent velopharyngeal surgery. Based on the results of postoperative pulse oximetry, the patients were divided into 3 groups: intervention, control, and observation. Patients with oxygen desaturation index (ODI) > 10 and lowest SpO₂ < 90% were randomly assigned to the CPAP intervention group and non-CPAP control. Patients with ODI ≤10 or lowest SpO₂ ≥ 90% were assigned to the non-CPAP observation group. Patients in the intervention group completed at least 3 months of CPAP treatment. Postoperative polysomnography data were compared to assess the difference of prognosis between the three groups.ResultsBaseline data showed no significant differences between the three groups except the observational group showed a significantly larger tonsil size relative to the intervention and control groups. However, there was no significant difference in terms of tonsil size between the control and intervention groups. The surgical success rate of the intervention group was 80.65%, whereas it was 55.17% in the control group, with significant difference. The success rate of the observation group was 85.71% which was significantly different from that of the control group, but not the intervention group.ConclusionShort-term postoperative CPAP treatment may improve the outcomes of velopharyngeal surgery for OSA in patients who have respiratory events related hypoxia after surgery. Further studies are necessary for the underlying mechanisms.     

Upper airway multilevel radiofrequency under local anesthesia can improve CPAP adherence for severe OSA patients

ObjectiveTo evaluate the effect of upper airway radiofrequency (RF) tissue reduction under local anesthesia (LA) in severe obstructive sleep apnea (OSA) patients using continuous positive airway pressure (CPAP) in order to improve their compliance and adherence.DesignThirty (30) patients were included in this randomized clinical trial, suffering from severe OSA seeking medical advice for better upper airway management while using CPAP. Multilevel RF tissue reduction at tongue base, soft palate and inferior nasal turbinates was done under LA in multiple sessions. The Apnea hypopnea index (AHI), arousal index, lowest SpO2, CPAP pressure, and CPAP using time were recorded pre-operatively and six months after the last RF session.ResultsPost-operatively, there were significant reduction in AHI (86.03 ± 20.5 vs. 54.65 ± 16.6 p < 0.001), arousal index (71.14 ± 17.7 vs. 35.90 ± 11.8 p < 0.001), and CPAP Pressure (17.13 ± 1.7 vs. 10.97 ± 1.5 p < 0.001). Also there was a significant increase in the lowest SpO2 (60.2 ± 0.2 vs. 75 ± 0.1 p < 0.001), and CPAP using time in hours (1.57 ± 0.56 vs. 3.75 ± 0.41 p < 0.001). Visual analogue scale (VAS) for pain was recorded showing that all patients reported throat pain mainly in the first five post-operative days which was well controlled on analgesia.Conclusion and relevanceUpper airway multilevel RF tissue reduction of tongue base, soft palate and inferior nasal turbinates under local anesthesia significantly improves the tolerance and adherence of severe OSA patients using CPAP.     

CT comparison of primary snoring and obstructive sleep apnea syndrome: role of pharyngeal narrowing ratio and soft palate-tongue contact in awake patient

Soft palate-tongue contact and automatically calculated pharyngeal narrowing ratio (PNR), defined as a ratio between the airway cross-section at the hard palate level and the narrowest cross-section from the hard palate to the epiglottis, could assist in earlier identification of potential obstructive sleep apnea syndrome (OSA) patients even on awake individuals. Parameters were studied on carotid CTA images from 67 consecutively included awake Caucasians who were later classified by second independent physician into the primary snorers (SNORE, n = 34) or obstructive sleep apnea syndrome patient (OSA, n = 33) group according to the clinical examination, laboratory testing and a full-night video polysomnography (PSG) in the sleep laboratory. Imaging and clinical data were statistically compared between groups. The odd’s ratio calculation showed a 2.95 (P = 0.0354) higher risk for OSA development in snoring person with a PNR greater than 8.6. The loose-contact subgroup among OSA patients showed significantly (P = 0.002) higher values of AHI in contrast to the in-contact subgroup. Authors didn’t have any financial relationship concerning presented study.     

Comparison of oxygen desaturation patterns in children and adults with sleep-disordered breathing

Purpose

Although the number of apnea–hypopnea episodes per hour apnea-hypopnea index (AHI) is typically used to evaluate sleep-disordered breathing (SDB) in adults, it does not provide an accurate characterization of SDB in children. We investigated differences in SDB patterns in children and adults to evaluate SDB severity in children.

Materials and methods

Fifteen adults (mean age, 45.3 ± 8.4 years) and 15 children (mean age, 6.7 ± 3.9 years) with adenotonsillar hypertrophy underwent standard polysomnography. The change of oxygen saturation (ΔSpO₂) was defined as the difference between baseline SpO₂ during stable nighttime breathing and the lowest SpO₂ accompanied by an apnea–hypopnea event. The number of apnea-hypopnea episodes was determined using two different criteria to define an episode (criterion 1: cessation of airflow for at least 10 s; criterion 2: cessation of airflow for at least two consecutive breaths).

Results

Mean ΔSpO₂ accompanied by obstructive apneas lasting ≤ 10 s was significantly greater in children than in adults, although there was no significant difference in the duration of apnea–hypopnea episodes. The slope of the regression line between ΔSpO₂ and apnea-hypopnea duration in children was greater than in adults (P < 0.005). AHI in children was higher when calculated using criterion 2 compared to criterion 1 (10.9 ± 9.4 vs. 6.5 ± 4.9/h, P = 0.003).

Conclusions

ΔSpO₂ is a good indicator of SDB severity in children, and should therefore be considered in the diagnosis and treatment of pediatric SDB along with AHI.     

Parameters affecting improvement of excessive daytime sleepiness in obstructive sleep apnea patients

ObjectivesObstructive sleep apnea (OSA) is a sleep-related breathing disorder caused by repetitive obstruction of the upper airway; this impairs gaseous exchange, resulting in hypoxia, hypercapnia, and frequent arousals. Excessive daytime sleepiness (EDS) is a common daytime symptom of OSA. EDS manifests as fatigue and impaired attention, leading to poor performance at work and falling asleep while driving, which is a major socioeconomic problem. Therefore, it is important to properly treat EDS and accurately predict the response to treatment. However, few studies have compared OSA patients showing and not showing improvement in EDS. Therefore, this study aimed to objectively analyze and compare EDS improvement and non-improvement groups.Subjects and methodsWe retrospectively reviewed the medical records of 57 OSA patients with EDS. Patients were divided into two groups according to the improvement in EDS after positive airway pressure (PAP) device treatment. We analyzed differences in clinical records including patients' age, sex, history of smoking, hypertension, diabetes, myocardial infarction, and cerebrovascular disease between the two groups. Systolic, diastolic blood pressure, blood test including blood glucose, total cholesterol, high- and low-density lipoprotein cholesterol, and triglyceride levels were also analyzed. Polysomnography (PSG) data, PAP device treatment compliance and scores of questionnaires related to various psychiatric symptoms, subjective sleep quality between the two groups were also analyzed.ResultsThere was no statistically significant difference in age, gender, or past medical history between the two groups. Systolic and diastolic blood pressure, and blood test results, were also not significantly different. Among the questionnaires related to various psychiatric symptoms, the groups showed statistically significant differences in Social Avoidance and Distress Scale (SADS) and Fear of Negative Evaluation (FNE) scores (P = 0.001 and 0.020, respectively). The group differences in the scores on the other questionnaires were not significantly different. Among the PSG items, significant group differences were observed in the percentage of stage 2 non-REM sleep (N2%, P = 0.023), apnea index (AI, P = 0.005), apnea-hypopnea index (AHI, P = 0.023), and frequency of 3 % oxygen desaturation (ODI3, P = 0.001). No obesity-related parameters showed significant group differences. The percentage of days on which a PAP device was used (out of 90 days; PAP%) and percentage of days on which a PAP device was used for >4 h (Time4%) did not differ significantly.ConclusionsThe SADS, FNE, AI, AHI, N2%, and ODI3 parameters differed significantly between the EDS improvement and non-improvement groups. These parameters may help clinicians treat and predict the prognosis of patients suffering with EDS.     

Clinical indication of nasal surgery for the CPAP intolerance in obstructive sleep apnea with nasal obstruction

ObjectiveThe role of isolated nasal surgery for obstructive sleep apnea (OSA) patients with nasal obstruction, especially for an intolerance for continuous positive airway pressure (CPAP), is unclear. The aim of this study was to assess the effects of surgery for OSA patients with symptomatic nasal obstruction and CPAP intolerance.MethodRetrospectve comparative study.1037 OSA patients with apnea-hypopnea index (AHI) ≥ 20 were enrolled. Case-control study was performed between the male apnea patients undergoing nasal surgery: surgery group (n = 43) and the pair-matched apnea patients for age, sex, body mass index, and race: control group (n = 43). The surgery group suffering from nasal obstruction could not use continuous positive airway pressure, and the CPAP group free from nasal obstruction could use it successfully.ResultsIn surgery group, surgery significantly decreased the nasal resistance and Epworth sleepiness scale scores without changing the AHI. Surgery significantly increased the nadir of oxygen saturation and shortened the apnea-hypopnea duration. Although all of the surgery group failed to use positive airway pressure preoperatively, the 40 patients of the 43 CPAP intolerance patients were able to use CPAP postoperatively. The resting three patients were cured OSA or changed the treatment to oral appliance(OA). For both groups, the cutoff nasal resistance for differentiating the failure of positive airway pressure and its success was 0.31 Pa/cm³/s.ConclusionIsolated nasal surgery is effective for an intolerance of positive airway pressure in sleep apnea with nasal obstruction presumably by decreasing nasal resistance.     

Epiglottopexy with or without aryepiglottic fold division: Comparing outcomes in the treatment of pediatric obstructive sleep apnea

ObjectiveTo determine the success of epiglottopexy with or without aryepiglottic fold division for treatment of patients with obstructive sleep apnea (OSA) with epiglottic obstruction.Study designRetrospective chart review.SettingTertiary care academic hospital.MethodsChildren with sleep study proven OSA who underwent epiglottopexy with or without aryepiglottic fold division from January 2013 to June 2017 were included. The epiglottis contributed to airway obstruction in all patients. Pre- and post-operative apnea-hypopnea index (AHI) were compared. Age, sex, body mass index (BMI) z-score and post-operative complications were also evaluated. Success was defined by post-operative AHI < 5.0 with resolution of OSA symptoms or AHI ≤ 1.0 events per hour.ResultsTwenty-eight children (age 2–17 years) underwent either epiglottopexy with division of aryepiglottic folds (N = 18) or epiglottopexy alone (N = 10). There was no difference in preoperative age, AHI, or BMI between the groups. Post-operative AHI was lower in the group undergoing epiglottopexy alone (AHI 1.50) versus with aryepiglottic fold division (AHI 3.17) (P < 0.05). No difference was found in mean AHI improvement between the two groups. For the entire cohort, success criteria were met by 53.6% of patients for AHI < 5.0 without symptoms and 25.0% of patients for AHI ≤ 1.0, with no difference in surgical success between procedures (P > 0.05).ConclusionsChildren undergoing epiglottopexy with division of aryepiglottic folds for laryngeal collapse were as likely to have improved OSA symptoms as children undergoing epiglottopexy alone.     

The effect of adenotonsillectomy on obstructive sleep apnea in children with Down syndrome*

Objective: Children with Down syndrome (DS) are liable to develop obstructive sleep apnea (OSA) due to many anatomical airway abnormalities. The tonsils and adenoid occupy part of the airway space, and their removal may be helpful in relieving airway obstruction. The aim of this study was to assess the effectiveness of adenotonsillectomy in the treatment of OSA in those children.

Methods: Fifty DS children with difficult breathing were recruited, and they were subjected to polysomnographic examination (PSG). Patients with apnea-hypopnea index (AHI)?>?1 were considered to have OSA. Adenotonsillectomy was performed for patients who had OSA and adenotonsillar hypertrophy, and after 3 months PSG was done for them with recording of the same preoperative parameters.

Results: Forty-three children demonstrated OSA on PSG, and they were included in the study. The preoperative mean AHI was 9.18 (±?6.17) that improved postoperatively to 2.72 (±?3.80) with its normalization in 72% of patients. Also, significant improvement of arousal index, minimum oxygen saturation, desaturation index, and peak end-tidal CO₂ was achieved postoperatively.

Conclusion: Adenotonsillectomy is an effective method for the treatment of OSA in children with DS. However, the condition may persist in some children who usually have airway narrowing at multiple levels.     

The role of the nose in snoring and obstructive sleep apnoea: an update

Multilevel anatomic obstruction is often present in snoring and obstructive sleep apnoea (OSA). As the nose is the first anatomical boundary of the upper airway, nasal obstruction may contribute to sleep-disordered breathing (SDB). A number of pathophysiological mechanisms can potentially explain the role of nasal pathology in SDB. These include the Starling resistor model, the unstable oral airway, the nasal ventilatory reflex and the role of nitric oxide (NO). Clinically, a number of case–control studies have shown that nasal obstruction is associated with snoring and mild SDB. However, there is not a linear correlation between the degree of nasal obstruction and the severity of SDB, while nasal obstruction is not the main contributing factor in the majority of patients with moderate to severe OSA. Randomised controlled studies have shown that in patients with allergic rhinitis or non-allergic rhinitis and sleep disturbance, nasal steroids could improve the subjective quality of sleep, and may be useful for patients with mild OSA, however, they are not by themselves an adequate treatment for most OSA patients. Similarly, nasal surgery may improve quality of life and snoring in a subgroup of patients with mild SDB and septal deviation, but it is not an effective treatment for OSA as such. On the other hand, in patients who do not tolerate continuous positive airway pressure (CPAP) well, if upper airway evaluation demonstrates an obstructive nasal passage, nasal airway surgery can improve CPAP compliance and adherence.     

Comparison of surgical outcomes of sleep surgeries preoperatively evaluated with drug-induced sleep endoscopy and Müller's maneuver

Objective The purpose of this study was to compare surgical outcomes for obstructive sleep apnea (OSA) when the procedure was based on the results of drug-induced sleep endoscopy (DISE) vs. the awake Müller's maneuver (MM).Methods Forty-seven patients with OSA who underwent sleep surgery were included. Patients were divided into 2 groups according to their preoperative upper airway evaluation method. Twenty-five patients received only MM for surgical decision making (MM group), and 22 patients received both MM and DISE (DISE group) for surgical decision making.Results The surgical success rate of the DISE group was higher than that of the MM group (59% vs. 36%), but the difference was not significant (p = 0.118). The differences between pre- and postoperative apnea-hypopnea index (AHI) values in both the MM and DISE group were highly significantly different (p < 0.001). Fifteen patients in the DISE group (68.2%) received multi-level surgery, while in the MM group only 7 patients (28%) received multi-level surgery. Patients with more severe OSA (AHI > 22 or lowest O2 saturation < 81%) had better surgical outcomes when their surgical procedures were based on the findings of DISE, rather than those of MM.Conclusion The results indicate that DISE provides no benefits with respect to surgical outcomes for patients with mild to moderate OSA; however, for patients with more severe OSA surgical procedures based on DISE result in better outcomes.     

Variables predictive of surgical outcomes after hyoid myotomy with suspension to thyroid cartilage

ObjectivesTo evaluate variables predicting improvement in obstructive sleep apnea (OSA) with hyoid suspension to thyroid cartilage 4-suture technique.MethodsSixty adult patients (age range 23–78 years) with OSA underwent hyoid suspension to thyroid cartilage with or without concurrent multi-level surgery over an eight-year period from 2011 to 2019 at a tertiary academic center. All patients had a preoperative apnea hypopnea index (AHI) ≥ 5. Changes in mean AHI, Epworth Sleepiness Scale (ESS), and lowest oxygen saturation (LSAT) were measured with paired Student t-test. Linear and logistic regression models were used to predict change in AHI and surgical success respectively with respect to body mass index (BMI), age, sex, previous sleep surgery, concurrent retrolingual surgery, concurrent palatopharyngoplasty, and preoperative AHI.ResultsThe mean AHI demonstrated a significant improvement from a preoperative AHI of 39.0 ± 25.5 to a postoperative AHI of 31.2 ± 23.4 (p = 0.005). The mean Epworth Sleepiness Score (ESS) significantly improved from 13.1 ± 6.0 to 9.2 ± 5.7 (p = 0.000012). Surgical success, defined as a 50% reduction in preoperative AHI to a postoperative AHI ≤ 20, was obtained in 18/60 (30.0%) patients. Preoperative BMI significantly correlates with variation of change in AHI in multivariable linear regression model (p = 0.003). Preoperative AHI was significant predictor of surgical success in multivariable logistic regression model.ConclusionThe magnitude of improvement in polysomnographic parameters after hyoid suspension to thyroid appears to be more significant in patients with lower BMI. Even patients with an obese BMI and severe OSA achieve significant improvement from this procedure.     

Computed tomography imaging of patients with obstructive sleep apnea

Objectives/Hypothesis: This study used computed tomography (CT) to identify anatomic features of the awake upper respiratory tract (URT) that correlate with severity of obstructive sleep apnea (OSA). Study Design: An IRB approved radiographic study of 80 patients with OSA and 56 patients from the general population. Methods: Awake, noncontrast CT was performed from the skull base to the thoracic inlet in patients with OSA. Cross‐sectional measurements of the retropalatal and retrolingual airways were made along with the size of the cervicomandibular ring and the percentage neck fat. The mandibular plane to hyoid distance, neck length, and laryngeal descent were also recorded. The posterior tongue fat content was estimated using the Hounsfield unit for radiodensity. The radiographic data were then compared with clinical information, including apnea‐hypopnea index (AHI), body mass index, and neck circumference using linear regression. Results: AHI increases with smaller retrolingual cross‐sectional airway (P = .0026) and increasing mandibular plane to hyoid distance (P = .0003) but not retropalatal airway or laryngeal descent. The posterior tongue is hypodense with higher fat content than other muscles of the head and neck. Conclusions: This study describes anatomic findings of the retrolingual airway in patients that correlate with OSA and can be measured on an upper airway CT. Patients with severe OSA (AHI ≥40) tend to have retrolingual airways less than 4% of the cross‐sectional area of the cervicomandibular ring. The retrolingual airspace is the major site of obstruction in severe OSA and should be carefully evaluated before surgical treatment is considered.     

Epiglottopexy for refractory obstructive sleep apnea in children – A single-institution experience

BackgroundRefractory obstructive sleep apnea (OSA) is a common condition in children with medical comorbidities, leading to a significant impact on quality of life. Drug-induced sleep endoscopy (DISE) has become the standard of care in identifying the levels of obstruction in children with refractory OSA. Epiglottopexy has been shown to improve OSA symptoms in adults and healthy children with epiglottic prolapse in a few studies, with minimal long-term complications. The objective of our study was to evaluate the role of epiglottopexy in children with refractory OSA.MethodsA retrospective chart review of children with refractory OSA who were found to have epiglottic prolapse on DISE, and underwent epiglottopexy between January 2018 and November 2021 at a pediatric tertiary care hospital.Results42 patients (age 8.1 ± 5.1 years) met inclusion criteria. Thirty patients (71.4 %) suffered from neurodevelopmental disease or congenital syndrome, and 14 patients (33.3 %) were gastrostomy-tube dependent. All patients had at least one prior surgical procedure to address their OSA. Thirty-six patients (85.7 %) were diagnosed with refractory OSA by polysomnography prior to surgery, with an average apnea-hypopnea index (AHI) of 12.4 ± 9.7/h. Forty patients (95.2 %) required an additional procedure in conjunction with epiglottopexy including lingual tonsillectomy (n = 27, 64.3 %), supraglottoplasty (n = 14, 33.3 %), tonsillectomy with or without revision adenoidectomy (n = 9, 21.4 %) and tongue base suspension (n = 1, 2.4 %). Twenty-one patients had repeated polysomnography; 4 patients were found to have residual severe OSA post-operatively (average AHI 17.4 ± 11.4/h), while the remaining patients demonstrated clinical improvement and a significant reduction in OSA severity, with an average AHI of 1.5 ± 2.2/h. Regression analysis identified pre-operative oxygen nadir <75 % to be associated with residual OSA postoperatively. Following surgery, 7 patients were found to have new-onset or worsening dysphagia, 6 of whom were diagnosed with complex medical comorbidities.ConclusionsEpiglottopexy, as part of multi-level airway surgery, is associated with a significant improvement in the severity of refractory OSA. Dysphagia may complicate the post-operative course, particularly in children with medical comorbidities.     

Interaction effects between characteristics of obstructive sleep apnea and obesity on dyslipidemia

ObjectivesObstructive sleep apnea (OSA) and obesity often coexist, and both can increase the risk of dyslipidemia. However, the interaction effects between the characteristics of OSA and obesity on dyslipidemia are not yet known. This study was performed to investigate this issue.MethodsBasic characteristics, polysomnography data, and biochemical markers of patients with suspected OSA seen at the First Affiliated Hospital of Nanchang University were collected. Serum lipid levels were compared after adjusting for multiple confounders. We used binary logistic regression models to assess the interaction effects of the oxygen desaturation index (ODI) and obesity, and the apnea–hypopnea index (AHI) and obesity, on dyslipidemia.ResultsA total of 343 patients were included in the study. After adjusting for multiple confounders, there were no differences in serum lipid levels between non-obese or obese patients with an AHI ≤ 30 and AHI > 30, and no interaction effect between the AHI and obesity on dyslipidemia. Obese patients, but not non-obese ones, with an ODI > 37.5 had significantly higher total cholesterol (TC) levels, and higher TC/high-density lipoprotein cholesterol (HDL-C) ratios, than patients with an ODI ≤ 37.5. In addition, a significant positive multiplicative interaction effect between obesity and the ODI was found on hyper-TC (odds ratio [OR] = 3.459; 95% confidence interval [CI] = 1.104, 10.838; p = 0.03).ConclusionA positive interaction effect was detected between obesity and intermittent hypoxia on dyslipidemia. Therefore, further attention should be paid to dyslipidemia in obese patients with intermittent hypoxia.     

Comparison of treatment outcomes between intracapsular and total tonsillectomy for pediatric obstructive sleep apnea

BackgroundIntracapsular tonsillectomy (IT) has been advocated as a treatment for pediatric obstructive sleep apnea (OSA). However, evidence in the literature utilizing polysomnography (PSG) is limited.ObjectiveTo examine the experience at a tertiary children's hospital to evaluate the effectiveness and risks of intracapsular tonsillectomy compared to total tonsillectomy (TT) for treating pediatric OSA.MethodsA retrospective study was undertaken of pediatric tonsillectomy cases performed for OSA at a tertiary children's hospital from 2005 to 2010. Patients with recurrent tonsillitis, craniofacial abnormalities, chromosomal abnormalities, neuromuscular disease, and congenital malformations were excluded. Main outcome measures were apnea-hypopnea index (AHI), minimum oxygen saturation (minO₂), and surgical complications.ResultsOf the 1583 patients reviewed in this study, there were 75 IT and 93 TT patients with pre- and post-operative PSG results. The IT patients were younger, had lower BMI, larger tonsil size, lower pre-operative (AHI) and lower post-operative AHI (p < 0.05). There was a similar percentage of patients that showed improvement in AHI and minimum oxygen saturation between the IT and TT groups. There were statistically similar average change in AHI and minimum oxygen saturation between the IT and TT groups at 5.6 ± 8.6 and 8.6 ± 12.9, respectively (p = 0.8) as well as similar improvement in minimum oxygen saturation between the two groups at 3.3% ± 4.3% and 3.0% ± 5.2%, respectively (p = 0.66). Of TT patients, 2.9% experienced post-operative bleeding with 1.6% requiring OR for control of hemorrhage. Of IT patients, 2.2% were found to have tonsillar regrowth with 2.0% returning to the OR for secondary tonsillectomy.ConclusionsIntracapsular tonsillectomy, like total tonsillectomy, is effective in improving polysomnogram results in appropriately selected children. Intracapsular tonsillectomy is a suitable option for the surgical treatment of pediatric OSA consequent to its demonstrated efficacy in relieving OSA and its favorable safety profile.