Identification of Obstructive Sleep Apnea in Patients Who Snore

As the field of sleep medicine has evolved, the clinical implications of obstructive sleep apnea (OSA) in snoring patients have become well accepted. Recent advances in surgical therapy for snoring allow otolaryngologists to offer simple outpatient treatment to patients with this problem. However, because the incidence of OSA in snorers seeking medical attention is unknown, the appropriate pretreatment evaluation of these patients is a subject of continued debate. Ninety-four snoring patients were recruited for a study to determine the incidence of OSA in this highly selected population. Subjects answered an extensive sleep questionnaire to determine factors that might suggest a diagnosis of OSA. Level III ambulatory sleep studies were performed on each participant. The incidence of OSA in this group was 72% (42% severe and 30% mild to moderate). Twenty of the subjects with OSA also underwent formal level I sleep studies, and the diagnosis of OSA was confirmed in each instance. Although there was a relationship between body mass index and OSA and certain questions correlated with OSA, the sensitivity and specificity of these data alone or in combination were too low to recommend their use in lieu of a formal sleep study. Given the remarkably high incidence of OSA in this group, which may reflect that seen by otolaryngologists who treat snoring, a sleep study should be performed to diagnose OSA and institute therapy for this condition. Level III ambulatory monitoring devices may be the most cos-teffective alternative for evaluating this high-risk population.     

Oropharyngeal Scintigraphy: A Computerized Analysis of Swallowing in Patients With Obstructive Sleep Apnea

This study examines the oropharyngeal-upper esophageal scintigraphic transit in patients with obstructive sleep apnea (OSA) syndrome, as well as the effect of uvulopalatopharyngoplasty (UPPP) on this transit. Scintigraphy is a safe, noninvasive test that is suitable as a screening test for oropharyngoesophageal motor disorders. A qualitative and quantitative evaluation of the swallowed radionuclide bolus was performed in 47 patients by means of a Cine Mode visual inspection and by computerized analysis. Three groups of patients were studied and compared: group 1, 10 healthy patients; group 2, 18 OSA patients before UPPP; and group 3, 19 OSA patients 6 months up to 2 years after UPPP. Oropharyngoesophageal scintigraphy was normal in 90% of group 1 patients (9/10) as well as in group 3, where 95% of patients (18/19) had a normal transit unlinked to the degree of improvement in the respiratory disturbance index. The radionuclide transit was abnormal in 79% OSA patients(15/18) in group 2. Statistically significant differences of mean transit abnormalities between the three groups were found ( P = 0.0001). Moreover, mean transit abnormalities in the OSA patients before UPPP were statistically significantly lower than in the group of patients after UPPP(56.2% vs 87.4, P ≤ 0.05).     

Cosmetic Enhancement Associated With Surgery for Obstructive Sleep Apnea

Objective: To document the capacity of surgery for obstructive sleep apnea (OSA) to incorporate techniques that incidentally improve the cosmetic features of the patients. Study Design: Retrospective analysis of surgical outcomes at an academic practice. Methods: Moderate to severe OSA usually requires multilevel pharyngeal surgery, including tongue base surgery. The surgical procedures, including hyoid myotomy and mandibular osteotomy with tongue advancement, afford the opportunity to address cosmetic deficits, such as microgenia and excessive submental skin and fat. Outcomes achieved using these procedures over a 4-year period were analyzed. Results: Of 428 consecutive patients presenting for evaluation of sleep-related breathing disorders, 212 were deemed surgical candidates. Ninety-seven of these had office-based procedures for snoring, upper airway resistance syndrome, or mild OSA. The remaining 115 had formal surgical procedures done, and 68 of these had multilevel pharyngeal surgery. Of these, 12 had defined cosmetic deficiencies that were addressed at the time of the sleep apnea surgery. There were 7 men and 5 women, with a mean age of 48.2 years. The group was moderately obese (mean BMI = 31.8) and had moderate to severe OSA (mean RDI = 37.0, mean LSAT = 78%). Cosmetic deficits identified included turkey gobbler deformity (n = 8), microgenia (n = 6), excessive submental fat (n = 2), and nasal deformity (n = 1); several patients had more than one addressable problem. All patients achieved an improved postoperative appearance. Representative photographs are presented. Conclusions: A surgical approach to the management of sleep apnea affords an opportunity to also address cosmetic deficiencies, including excessive submental skin and fat, microgenia, and nasal deformities.     

Identifying Obstructive Sleep Apnea in Patients Presenting for Laser-Assisted Uvulopalatoplasty

The authors report on a series of 850 patients with snoring who were evaluated for laser-assisted uvulopalatoplasty (LAUP). Stepwise multivariate linear regression was employed to correlate patient symptoms and characteristics to the respiratory disturbance index (RDI). Body mass index, falling asleep while driving, snoring every night, and stopping breathing during sleep were found to correlate strongly with an increasing RDI (variance of 25%). Logistic multivariate linear regression analysis was used to predict the outcome of apnea (RDI>10). This model selected all of the above variables, as well as age, male sex, and the total number of symptoms, as being strong predictors of apnea. A receiver operating characteristic curve was used to describe the ability of this model to predict apnea. The authors conclude that otolaryngologists play an important role in the evaluation of OSAS, especially when a snoring patient may undergo LAUP, and they present an algorithm for the evaluation of such a patient. The authors believe that the clinical assesment, including a thorough history and a complete physical examination, remains extremely important in this evaluation. At present, the authors strongly recommend referral for a PSG if there is any suspicion of OSAS.     

Screening for Obstructive Sleep Apnea in Patients Presenting for Snoring Surgery

Excessive mortality is associated with obstructive sleep apnea (OSA). Therefore it is important to diagnose OSA in patients presenting for snoring surgery. A prospective study was performed to develop screening models to detect OSA compared with universal polysomnography for sensitivity and cost. Multivariate analysis of 150 consecutive patients was based on clinical data, questionnaire data, and polysomnography. Two screening models obtained 100% sensitivity and reduced the need for polysomnograms. Cost savings of screening based on clinical data was projected to be $35 to $80 per patient using reported prevalence rates of OSA among snorers. A screening model for OSA using clinical data alone is more cost-effective than one that combines these data with pulse oximetry data, but savings over universal polysomnography were modest.     

The Impact of National Health Insurance Coverage on Compliance With Positive Airway Pressure Therapy in Patients With Obstructive Sleep Apnea

Objectives. Compliance with positive airway pressure (PAP) in patients with obstructive sleep apnea (OSA) directly affects its treatment efficacy. Since July 2018, polysomnography and PAP therapy have been covered by the National Health Insurance (NHI), which has reduced the price barrier and promoted PAP therapy in Korea. This study aimed to compare changes in PAP compliance before and after NHI implementation.Methods. This study is a retrospective analysis in a tertiary hospital setting in Korea. From 2011 to 2019, patients with OSA (apnea-hypopnea index ≥5) treated using a PAP device for ≥1 month were included. They were classified as belonging to the pre-insurance (PI) group (having started PAP before July 2018) or the NHI group (having received a PAP reimbursement by the NHI service). We collected and analyzed medical records and PAP use information for between-group comparisons of compliance. We defined compliance as the percentage of usage days, the percentage of days with usage for ≥4 night hours, and average daily usage hours.Results. We included 146 and 100 patients in the PI and NHI groups, respectively. Automatic PAP mode and NHI were independent predictors of compliance B at the 3- and 9-month follow-up points. The NHI group showed significantly higher compliance A at 3, but not 9 months. For compliance B, the NHI group showed significantly higher compliance than the PI group at 1 month and 3 months, but not at 9 months. Compared with the PI group, the NHI group showed significantly higher compliance C only at 3 months.Conclusion. The NHI has positively affected PAP therapy in patients with OSA. Insurance policy may affect compliance within the first 3 months of PAP therapy.     

Laser-Assisted Uvulopalatoplasty for Obstructive Sleep Apnea

Laser-assisted uvulopalatoplasty (LAUP) can reduce snoring by sequentially removing excessive vibratory tissue of the velopharynx. The procedure can be performed under local anesthesia in an office setting. Since the appearance of the soft palate is similar after both LAUP and uvulopalatopharyngoplasty, LAUP may also be efficacious in the management of obstructive sleep apnea syndrome (OSAS). LAUP was performed in 34 consecutive prospectively evaluated patients with OSAS. Of the 34 patients, 28 (82%) were male; the mean age was 53 years, and the mean body mass index was 31.1. In the study population of 13 patients who completed preoperative and postoperative sleep studies, the apnea index decreased from 19.4 to 4.2 (P=.006), the respiratory disturbance index (RDI) decreased from 31.2 to 15.7 (P=.092), and mean lowest oxyhemoglobin saturation increased from 82.3% to 85.0% (P=.581). The RDI fell to 10 or lower in 38.5.% of patients and was reduced by at least 50% in 53.8% of the study group. Snoring was significantly reduced in 92.3% of patients (P<.001). These early results suggest that LAUP may be efficacious in the management of OSAS.