Multilevel temperature-controlled radiofrequency for obstructive sleep apnea: extended follow-up.

OBJECTIVE: To determine long-term effectiveness of multilevel (tongue and palate) temperature-controlled radiofrequency tissue ablation (TCRFTA) for patients with obstructive sleep apnea syndrome (OSAS). STUDY DESIGN AND SETTING: Prospective, 2-institution case series. Twenty-nine subjects with mild to moderate OSAS and who were at least 1 year from completion of multilevel TCRFTA were included, representing a subset of subjects who were enrolled in a previously published controlled trial. Exclusion criteria for this extended follow-up study included any additional treatment for OSAS after completion of TCRFTA. RESULTS: Median follow-up was 23 months. Daytime sleepiness and OSAS-related quality of life were significantly improved at extended follow-up (both P < 0.001). Median reaction time testing and apnea-hypopnea index (AHI) were also significantly improved at long-term follow-up (P = 0.03 and 0.01). Body mass index was unchanged (P = 0.94). CONCLUSIONS: Multilevel TCRFTA treatment of mild to moderate OSAS resulted in prolonged improvement in daytime somnolence, OSAS-related quality of life, psychomotor vigilance, and AHI in this group of subjects at extended follow-up.     

Sleep parameters after surgery for obstructive sleep apnea

Obstructive sleep apnea (OSA) is a disorder that is frequently treated surgically. Few reports in the literature give objective reports of the effect of such treatment on polysomnographic parameters before and after treatment, although symptomatic improvement is common. This article reviews total sleep time (TST) spent in apnea, number of apneic episodes per hour or sleep apnea index (SAI), and oxygen desaturations in such patients treated with tracheostomy, uvulopalatopharyngoplasty (UPP), and combinations of these. Although improvement is noted in these parameters after UPP, this is not as impressive as some reports in the literature indicate. Our suggested indications for this type of surgery are discussed.     

One-year results: palatal implants for the treatment of obstructive sleep apnea.

OBJECTIVE: To evaluate long-term effectiveness of palatal implants for treatment of mild to moderate obstructive sleep apnea (OSA). STUDY DESIGN: A prospective study of 26 referred patients with a pretreatment apnea-hypopnea index (AHI) of 10 to 30 and a body mass index of < or =30, representing an extended follow-up of a subset of 41 patients enrolled in previous short-term trials. RESULTS: Twenty-one of 26 patients (80.8%) experienced a decrease in AHI. Fifteen of 26 patients (57.7%) had a follow-up AHI <10 at 1 year, whereas 13 patients (50%) had a 50% or greater reduction to an AHI <10 at 1 year. Mean AHI was reduced from 16.5 +/- 4.5 at baseline to 12.5 +/- 10.5 at 3 months (P < 0.014) and to 12.3 +/- 12.7 at 1 year (P < 0.019). CONCLUSIONS: Patients initially responding to palatal implants with improved AHI maintained improvement through long-term follow-up at 1 year.     

The efficacy of anatomically based multilevel surgery for obstructive sleep apnea.

OBJECTIVE: Most reports in the literature focus on the efficacy of a single procedure for obstructive sleep apnea (OSA). We review the overall efficacy of a surgical methodology based on localizing the level of anatomic obstruction for each patient and surgical correction of the nasal, oropharyngeal, or hypopharyngeal obstruction.Study design and setting Retrospective review of cases performed by a single practitioner using a systematic approach to surgery for OSA with preoperative and postoperative sleep studies. RESULTS: Forty-two patients with a respiratory disturbance index (RDI) greater than 15 were included in the study. Surgery involved at least 2 levels of obstruction usually performed in 2 stages. All patients reported symptomatic improvement. Overall, 83.3% (35 of 42) of patients were cured according to the accepted RDI criteria of more than 50% reduction and final RDI of less than 20. All 21 patients with mild OSA (RDI, <29), 73% of patients with moderate OSA (RDI, 30 to 49), and 50% of patients with severe OSA (RDI, >50) were cured. CONCLUSION: The use of an anatomically based methodology in approaching patients with OSA seems to offer a higher efficacy than a single procedure as reported in the literature.     

Obstructive sleep apnea surgery: patient perspective and polysomnographic results.

OBJECTIVE: The goal of this study was to assess the outcomes of obstructive sleep apnea (OSA) surgery based on the patient perspective and polysomnographic data. STUDY DESIGN: Fifty-six patients with severe OSA completed the 2-phase reconstructive protocol. A minimum of 6 months after the phase II surgery and after the postoperative polysomnography, questionnaires with visual analog scales (VAS 0-10) were mailed to the patients to assess their perceptions of treatment results. RESULTS: Forty-two (75%) questionnaires were returned. The mean patient age was 46.3 years. The mean respiratory disturbance index improved from 58.7 to 10.0. The mean lowest oxygen saturation improved from 76.3 to 87.3%. All 42 patients reported improved sleep (VAS 8.7). Although 10 patients reported changes in speech, the changes were insignificant, with 9 of the patients scoring 0 on the VAS (VAS 0.08 +/-0.3). Five patients reported changes in swallowing, and their VAS scores were 0.5, 0.9, 1.0, 2.7, and 6.9 (mean VAS 2.4+/-2.7). Forty patients (95%) were satisfied with their results and would undergo the reconstruction again. CONCLUSION: Surgical airway reconstruction for severe OSA is a highly effective treatment option base on the objective as well as the subjective assessment.     

Treatment options for obstructive sleep apnea

Opinion statement  Sleep apnea is a major public health problem that afflicts 9% of women and 24% of men 30 to 60 years of age. It is highly treatable, but when untreated, it has been associated with (but not necessarily linked to) increased probability of cerebral and coronary vascular disease, congestive heart failure, metabolic dysfunction, cognitive dysfunction, excessive daytime sleepiness, motor vehicle accidents, reduced productivity, and decreased quality of life. The gold standard for treatment in adults is positive airway pressure (PAP) therapy: continuous PAP (CPAP), bilevel PAP, autotitrating CPAP, or autotitrating bilevel PAP. Measures to increase compliance with PAP therapy include medical or surgical treatment of any underlying nasal obstruction, setting appropriate pressure level and airflow, mask selection and fitting, heated humidification, desensitization for claustrophobia, patient and partner education, regular follow-up with monitoring of compliance software, and attendance of support groups (eg, AWAKE). Adjunctive treatment modalities include lifestyle or behavioral measures and pharmacologic therapy. Patients with significant upper airway obstruction who are unwilling or unable to tolerate PAP therapy may benefit from surgery. Multilevel surgery of the upper airway addresses obstruction of the nose, oropharynx, and hypopharynx. A systematic approach may combine surgery of the nose, pharynx, and hypopharynx in phase 1, whereas skeletal midface advancement or tracheotomy constitutes phase 2. Clinical outcomes are reassessed through attended diagnostic polysomnogram performed 3 to 6 months after surgery. Oral appliances can be used for patients with symptomatic mild or moderate sleep apnea who prefer them to PAP therapy or for whom PAP therapy has failed or cannot be tolerated. Oral appliances also may be used for patients with severe obstructive sleep apnea who are unable or unwilling to undertake PAP therapy or surgery. For children, the main treatment modality is tonsillectomy and adenoidectomy, with or without turbinate surgery. Children with craniofacial abnormalities resulting in maxillary or mandibular insufficiency may benefit from palatal expansion or maxillary/mandibular surgery. PAP therapy may be used for children who are not surgical candidates or if surgery fails.     

Postoperative risk following uvulopalatopharyngoplasty for obstructive sleep apnea.

A study was conducted to assess oxygenation and respiratory changes on the first and second postoperative nights after uvulopalatopharyngoplasty (UPPP) for obstructive sleep apnea (OSA). Twelve patients were postoperatively evaluated with 8-hour nocturnal polysomnography on four occasions: (1) PREOP--night before UPPP, (2) POPN1--first postoperative night, (3) POPN2--second postoperative night, and (4) 3MOS--3-month follow-up study. Results demonstrate that apnea index (AI) and respiratory disturbance index (RDI) were significantly improved at 3MOS from PREOP levels: AI (p less than 0.01) and RDI (p less than 0.05). There were no statistical differences from PREOP to POPN1 or POPN2 for AI, RDI, lowest oxyhemoglobin saturation (LSAT), or number of desaturations (#DESAT). One of twelve patients dropped LSAT greater than 10% from PREOP to POPN1 or POPN2 (82% PREOP to 71% POPN2). Patients were grouped by PREOP LSAT greater than or equal to 80% or less than 80%, and the postoperative change in LSAT was evaluated by comparing PREOP to a value averaging POPN1 and POPN2. Patients with LSAT greater than or equal to 80% decreased by 2.6%; patients with LSAT less than 80% improved by 6.2%. This change in LSAT between groups was statistically different (p = 0.02). These data suggest that in the majority of patients, preoperative indices remain unchanged for at least 2 days after surgery, even for patients who demonstrated improvement at 3 months. However, worsening does occur in some patients. On the basis of the results of this study and clinical experience with the postoperative course, a selective management protocol is outlined.     

Adenotonsillectomy for obstructive sleep apnea in obese children.

OBJECTIVE: To study changes in sleep behavior and quality of life in obese children after adenotonsillectomy for obstructive sleep apnea.Study design and setting Prospective study at the University of New Mexico Children's Hospital. METHODS: Children who met inclusion criteria and had a respiratory distress index (RDI) greater than 5 were enrolled in the study and underwent adenotonsillectomy. All children underwent preoperative and postoperative full-night polysomnography. Age- and gender-specific percentile BMI was recorded at the time of polysomnography. Caregivers were asked to complete an OSA-18 quality of life survey prior to polysomnography and a second survey within 6 months of surgery. Scores from preoperative and postoperative polysomnography and OSA-18 surveys were compared using the paired Student's t test. RESULTS: The study population included 30 children. Twenty-six children (86%) were male. The mean age of the children at the time of inclusion in the study was 9.3 years; range, 3.0 to 17.2. The mean preoperative BMI was 28.6 (range, 19.2 to 47.1) and the mean postoperative BMI was 27.9 (range, 17.8 to 27.9). A 2-tailed paired t test showed that this difference is not statistically significant (P = 0.06). The mean preoperative RDI was 30.0 and the mean postoperative RDI was 11.6 (P < 0.001). The preoperative mean total OSA-18 score was 78.2 and the postoperative mean total score was 39.8 (P < 0.001). CONCLUSION: Obese children with OSA who undergo adenotonsillectomy show a marked improvement in RDI and in quality of life with no change in BMI. However, in the majority of children, OSA does not resolve.     

Same-stage nasal and palatopharyngeal surgery for obstructive sleep apnea: is it safe?

OBJECTIVE: The study goal was to determine the safety of performing same-stage nasal and palatopharyngeal surgery for the treatment of obstructive sleep apnea syndrome (OSAS). STUDY DESIGN AND SETTING: We conducted a retrospective review of 91 consecutive patients who underwent surgery for OSAS at tertiary care facilities. METHODS: Patients were divided into 2 groups: group 1 had same-stage nasal and palatopharyngeal surgery (n = 63), whereas group 2 had palatopharyngeal surgery at a stage separate from the nasal surgery (n = 28). Patient demographics, severity of OSAS, type of surgery, perioperative care, and postoperative complications were reviewed. RESULTS: There were 55 men and 8 women in group 1, with an average age of 48 years. Group 2 consisted of 20 men and 8 women, with an average age of 45 years. The mean respiratory disturbance index was 36.5 and 33.5 for group 1 and 2, respectively. The mean lowest arterial Oxygen saturation for group 1 was 82%, whereas that of group 2 was 81%. Patients in both groups were observed in a hospital setting for a minimum of 1 day. They were admitted to a room close to the nurse's station, with continuous pulse oximeter monitoring. There were 3 complications reported for group 1: pneumonia (1 patient, postoperative day 4), tonsil bleed (1 patient, postoperative day 6), and septal hematoma (1 patient). One patient in group 2 had a tonsil bleed (postoperative day 8). There were no incidents of airway compromise or cardiopulmonary events in the immediate postoperative period. CONCLUSION: Same-stage nasal and palatopharyngeal surgery for OSAS is safe. Patients could be monitored with continuous pulse oximetry and managed outside of an intensive care unit setting in the immediate postoperative period.     

Maxillofacial surgery and obstructive sleep apnea: a review of 80 patients

To determine the effectiveness of the surgical treatment of obstructive sleep apnea, we retrospectively evaluated 80 patients. One group consisted of 55 patients who had undergone a limited osteotomy of the anterior mandible: inferior sagittal osteotomy with hyoid myotomy and suspension. Important criteria for the selection of these patients were normal pulmonary function, normal mandibular skeletal development, and the absence of morbid obesity. Polysomnography revealed that 37 patients (67%) had responded to the surgical treatment and 18 patients (33%) had not. The second group of 25 patients, selected for morbid obesity, severe mandibular deficiency, and failure of other surgical procedures, had undergone maxillomandibular osteotomy with hyoid advancement. All patients in the second group showed good results, as determined by polysomnography.     

The impact of pediatric obstructive sleep apnea on ambulatory surgery

The purpose of this paper is to review pediatric obstructive sleep apnea syndrome (OSAS) with an emphasis on ambulatory adenotonsillectomy. Difficulties in establishing a diagnosis by clinical criteria alone are discussed. Diagnostic tests to establish a diagnosis of OSAS are discussed. The child with severe obstructive sleep apnea is at increased risk for post-adenotonsillectomy respiratory morbidity. The perioperative management with a focus on the ambulatory candidate is discussed.

The child with OSAS presents a challenge to ambulatory surgery because of the high prevalence of OSAS, difficulty in establishing a diagnosis of OSAS and the increased risk of respiratory morbidity.     

Objective evidence that bariatric surgery improves obesity-related obstructive sleep apnea

BACKGROUND: Obstructive sleep apnea (OSA) is associated with obesity. Our aim in this study is to report objective improvement of obesity-related OSA and sleep quality after bariatric surgery. METHODS: Prospective bariatric patients were referred for polysomnography if they scored >or=6 on the Epworth Sleepiness Scale. The severity of OSA was categorized by the respiratory disturbance index (RDI) as follows: absent, 0 to 5; mild, 6 to 20; moderate, 21 to 40; and severe, <40. Patients were referred for repeat polysomnography 6 to 12 months after bariatric surgery or when weight loss exceeded 75 lbs. Means were compared using paired t tests. Chi-square tests and linear regression models were used to assess associations between clinical parameters and RDI; P<.05 was considered statistically significant. RESULTS: Of 349 patients referred for polysomnography, 289 patients had severe (33%), moderate (18%), and mild (32%) OSA; 17% had no OSA. At a median of 11 months (6 to 42 months) after bariatric surgery, mean body mass index (BMI) was 38 +/- 1 kg/m2 (P<.01 vs 56 +/- 1 kg/m2 preoperatively) and the mean RDI decreased to 15 +/- 2 (P<.01 vs 51 +/- 4 preoperatively) in 101 patients who underwent postoperative polysomnography. In addition, minimum oxygen saturation, sleep efficiency, and rapid eye movement latency improved, and the requirement for continuous positive airway pressure was reduced (P相似文献   

Palatal and tongue base surgery for surgical treatment of obstructive sleep apnea: a prospective study.

OBJECTIVE: To assess the effect of concurrent uvulopalatopharyngoplasty (UPPP) and hypopharyngeal procedures in obstructive sleep apnea (OSA) patients with diffuse airway narrowing. STUDY DESIGN AND SETTING: Forty-eight patients were treated surgically by a single surgeon in private practice over 2 years. Symptoms, Epworth score, and polysomnographic outcome were assessed preoperatively and postoperatively. The Friedman staging system was applied. UPPP with genioglossus advancement, hyoid suspension, or radiofrequency treatment was carried out. RESULTS: In 37 patients with complete data, the average apnea-hypopnea index (AHI) was reduced from 46.5 +/- 24.8 to 14.9 +/- 16.8. The Epworth score was reduced from 12.1 +/- 4.9 to 6.7 +/- 3.7. Most patients reported improved sleep quality, alertness, memory, concentration, and mood. CONCLUSION: Successful outcome, defined by symptom and AHI reduction, was achieved with multilevel surgery for most patients with advanced Friedman stages 2 and 3. SIGNIFICANCE: Multilevel surgery seems effective in treating severe OSA patients with diffuse airway narrowing. EBM rating: C-4.     

The effect of hyoid suspension in a multilevel surgery concept for obstructive sleep apnea.

OBJECTIVE: This study investigated the outcome of the hyoid suspension as a part of a multilevel surgery protocol. STUDY DESIGN AND SETTING: Eighty-three patients with obstructive sleep apnea (OSA) underwent a multilevel surgical treatment because of continuous positive-airway pressure intolerance, 67 with the hyoid suspension and 16 without the hyoid suspension. All patients underwent a pre- and postoperative polysomnography in the sleep laboratory. RESULTS: The mean preoperative apnea hypopnea index (AHI) was 36.4+/-21.2 and 19.4+/-19.7 postoperatively for all patients (P<0.0001). Further statistically significant changes were found for the arousal index, the oxygen saturation, and the daytime sleepiness. No statistically significant change was found for body mass index. In the group of patients treated without the hyoid suspension, the AHI did not decrease statistically significant. After surgery, 59.7% of the subjects with the hyoid suspension were regarded as cured. CONCLUSION: Multilevel surgery including the hyoid suspension is an effective treatment in subgroup of OSA patients. EBM rating: C-4.     

Pathophysiology of obstructive sleep apnea

This article explores the physiologic basis and symptoms of obstructive sleep apnea--a general term encompassing central sleep apnea and obstructive sleep apnea. The former is relatively uncommon while the latter is much more common. Episodic collapse and blockage of the upper airway occur during sleep despite continuous respiratory effort. Three types of sleep obstructive breathing--apnea, hypopnea, and airway resistance--are associated with respiratory-related arousals from sleep.     

Proteinuria in obstructive sleep apnea

BACKGROUND: Previous studies have reported an association between obstructive sleep apnea (OSA) and proteinuria, but are limited in their ability to assess proteinuria accurately, to adjust for confounders such as obesity, or to exclude confidently underlying renal disease in patients with OSA and nephrotic-range proteinuria. METHODS: The spot urine protein/creatinine ratio was measured in a prospective consecutive series of 148 patients referred for polysomnography who were not diabetic and had not been treated previously for OSA. The urine protein/creatinine ratio was compared across four levels of OSA severity, based on the frequency of apneas and hypopneas per hour: <5 (absent), 5 to 14.9 (mild), 15 to 29.9 (moderate), and > or =30 (severe). RESULTS: The median level of urine protein/creatinine ratio in all categories of OSA was <0.2 (range 0.03 to 0.69; median 0.06 in patients with normal apnea hypopnea index, 0.06, 0.07, 0.07 in patients with mild, moderate, and severe OSA, respectively). Eight subjects had a urine protein/creatinine ratio greater than 0.2. Univariate analysis showed a significant association between urine protein/creatinine ratio and older age (P < 0.0001), hypertension (P < 0.0001), coronary artery disease (P = 0.003), and arousal index (P = 0.003). Body mass index (P = 0.16), estimated creatinine clearance (P = 0.17), and apnea hypopnea index (P = 0.13) were not associated with the urine protein/creatinine ratio. In multiple regression analysis, only age and hypertension were independent positive predictors of the urine protein/creatinine ratio (P < 0.0001, R2 = 0.17). CONCLUSION: Clinically significant proteinuria is uncommon in sleep apnea. Nephrotic range proteinuria should not be ascribed to sleep apnea and deserves a thorough renal evaluation.