Radiofrequency ablation for the treatment of mild to moderate obstructive sleep apnea

OBJECTIVES/HYPOTHESIS: Obstructive sleep apnea syndrome is due to pharyngeal obstructions, which can take place at the level of the soft palate. Temperature-controlled radiofrequency ablation has been introduced as being capable of reducing soft tissue volume and excessive compliance. The aim of the study was to evaluate prospectively the possible efficacy of temperature-controlled radiofrequency ablation applied to the soft palate in subjects with mild to moderate obstructive sleep apnea syndrome. STUDY DESIGN: Twenty-nine patients with a respiratory disturbance index between 10 and 30 events per hour, body mass index equal to or less than 30 kg/m2, and obstruction at the level of the soft palate were included in a pilot, prospective nonrandomized study. METHODS: Snoring and daytime sleepiness were evaluated subjectively. Treatment (maximum of three sessions) was discontinued when the bed partner was satisfied with the snoring level. A full night recording was performed at least 4 months after the last treatment. RESULTS: Mean snoring level decreased significantly from 8.6 +/- 1.3 to 3.3 +/- 2.5 on a visual analogue scale (0-10). Daytime sleepiness decreased nonsignificantly. Mean respiratory disturbance index decreased significantly from 19.0 +/- 6.1 events per hour to 9.8 +/- 8.6 events per hour. Mean lowest oxygen saturation value increased nonsignificantly from 85.3% +/- 4.1% to 86.4% +/- 4.4%. Of the patients, 65.5% were cured of their disease. CONCLUSIONS: Temperature-controlled radiofrequency ablation was effective in selected patients with mild to moderate obstructive sleep apnea syndrome. A full-night polysomnography is required after completion of treatment to rule out residual disease.     

Combined radiofrequency surgery of the tongue base and soft palate in obstructive sleep apnoea

OBJECTIVE: To investigate the safety and efficacy of combined temperature-controlled radiofrequency volumetric tissue reduction of the tongue base and soft palate in obstructive sleep apnoea. MATERIAL AND METHODS: A total of 20 patients with obstructive sleep apnoea and combined palatal and retrolingual obstruction were included in a non-randomized clinical trial and 51 combined treatments were performed under local anaesthesia. Postoperative pain was assessed using visual analogue scales. Functional parameters, daytime sleepiness and quality of life were assessed using questionnaires (Epworth Sleepiness Scale, Short Form-36) before and 12 weeks after the last treatment session. Concurrently, polysomnography was performed on two consecutive nights. Results The mean postoperative pain score dropped from 5.6 at Day 1 to 0.6 at Day 7. Painkillers were taken for a mean of 3.3 days. There were no postoperative complications or changes in functional parameters. Daytime sleepiness improved significantly (p<0.05). The mean respiratory disturbance index was reduced from 25.3+/-11.4 to 16.7+/-15.3 (p<0.05). Six out of 18 (33%) patients were cured after a mean of 2.7 treatment sessions. CONCLUSION: Combined radiofrequency volumetric tissue reduction of the tongue base and soft palate is a safe and effective treatment for obstructive sleep apnoea.     

Association of systematic head and neck physical examination with severity of obstructive sleep apnea-hypopnea syndrome

OBJECTIVES/HYPOTHESIS: To identify upper airway and craniofacial abnormalities is the principal goal of clinical examination in patients with obstructive sleep apnea-hypopnea syndrome. The aim was to identify anatomical abnormalities that could be seen during a simple physical examination and determine their correlation with apnea-hypopnea index (AHI). STUDY DESIGN: Consecutive patients with obstructive sleep apnea-hypopnea syndrome who were evaluated in a public otorhinolaryngology center were studied. METHODS: Adult patients evaluated previously with polysomnography met the inclusion criteria. All subjects underwent clinical history and otolaryngological examination and filled out a sleepiness scale. Physical examination included evaluation of pharyngeal soft tissue, facial skeletal development, and anterior rhinoscopy. RESULTS: Two hundred twenty-three patients (142 men and 81 women) were included (mean age, 48 +/- 12 y; body mass index, 29 +/- 5 kg/m2; AHI, 23.8 +/- 24.8 events per hour). Patients were distributed into two groups according to the AHI: snorers (18.4%) and patients with sleep apnea (81.7%). Sleepiness and nasal obstruction were reported by approximately half of patients, but the most common complaint was snoring. There was a statistically significant correlation between AHI and body mass index (P <.000), modified Mallampati classification (P =.002), and ogivale-palate (P <.001). The retrognathia was not correlated to AHI, but the presence of this anatomical alteration was much more frequent in patients with severe apnea when compared with the snorers (P =.05). Other correlations with AHI were performed considering multiple factors divided into two groups of anatomical abnormalities: pharyngeal (three or more) and craniofacial (two or more) abnormalities. There was a statistically significant correlation between pharyngeal landmarks and AHI (correlation coefficient [r] = 0.147, P =.027), but not between craniofacial landmarks and AHI. The combination of pharyngeal anatomical abnormalities, modified Mallampati classification, and body mass index were also predictive of apnea severity. CONCLUSIONS: Systematic physical examination that was used in the present study indicated that, in combination, body mass index, modified Mallampati classification, and pharyngeal anatomical abnormalities are related to both presence and severity of obstructive sleep apnea-hypopnea syndrome. Hypertrophied tonsils were observed in only a small portion of the patients. The frequency of symptoms of nasal obstruction was high in sleep apnea patients. Further studies are needed to find the best combination of anatomical and other clinical landmarks that are related to obstructive sleep apnea.     

Modified uvulopalatopharyngoplasty: The extended uvulopalatal flap

OBJECTIVE: To investigate the surgical outcomes of a modified uvulopalatopharyngoplasty-extended uvulopalatal flap in the treatment of obstructive sleep apnea.Material and methods: Thirty-three consecutive patients with obstructive sleep apnea underwent extended uvulopalatal flap that consisted of bilateral tonsillectomy, dissection and removal of submucosal adipose tissue of the soft palate and supratonsillar area; imbrication; and reposition of the denuded uvulopalatal flap. Variables of polysomnography included the respiratory disturbance index, snoring index, and minimal oxygen saturation. Surgical success was defined as achieving the postoperative respiratory disturbance index to less than 20 events per hour and a greater than 50% reduction of the preoperative respiratory disturbance index. RESULTS: Six months after operation, 27 patients (81.8%) responded successfully. The mean respiratory disturbance index decreased from 41.6 +/- 28.2 to 12.5 +/- 18.1(P <.0001), and the mean minimal oxygen saturation and snoring index improved significantly (P <.0001). The postoperative sequelae were mild with 3% of occasional nasal regurgitation. CONCLUSIONS: The results in this series revealed that extended uvulopalatal flap improves obstructive sleep apnea with minimal adverse effect in selected patients, and this technique suggests a role of fat dissecting in the palatal surgery for obstructive sleep apnea.     

软腭、舌根舌体低温等离子消融配合咽黏膜减张缝合治疗阻塞性睡眠呼吸暂停低通气综合征

目的 探讨软腭、舌根舌体低温等离子消融配合咽黏膜减张缝合治疗中、重度阻塞性睡眠呼吸暂停低通气综合征(OSAHS)的有效性。方法 38 例中度及42例重度OSAHS患者行软腭、舌根舌体低温等离子消融,将咽腭弓折返减张半荷包式缝合于扁桃体窝内,术前及术后6个月行睡眠监测、爱泼沃斯嗜睡量表(ESS)调查及咽腔测量。结果 80例患者均在术后6个月嗜睡状况改善,咽腔前后径、左右径扩大;睡眠结构得到明显改善。结论 咽黏膜减张缝合有效避免了咽腭弓术后撕裂、咽部黏膜重新松弛塌陷;软腭、舌根舌体低温等离子消融配合是治疗OSAHS的有效方法之一。     

射频消融治疗阻塞性睡眠呼吸暂停低通气综合征的疗效与适应证选择

目的:探讨低温等离子射频消融术(RFA)在阻塞性睡眠呼吸暂停低通气综合征(OSAHS)中应用的疗效及适应证。方法:对74例OSAHS患者(轻度16例,中度23例,重度35例)分别行不同狭窄部位的射频治疗,术后早期观察术区反应,评价射频治疗对局部疼痛、讲话、吞咽的影响;术后3个月检查治疗部位的体积,测量软腭和悬雍垂长度;术后6个月复查PSG、嗜睡量表及打鼾等级评分问卷调查,并与术前比较。主要依据PSG结果评价总有效率。结果:在74例患者中,治愈率为6.76%,显效率为27.03%,有效率为22.97%,总有效率为56.76%。术后AHI和最低SaO2均较术前改善(均P<0.01)。对于所有狭窄部位均得到射频治疗的患者,其总有效率为72.92%,优于尚有狭窄部位未处理的患者(P<0.01)。射频治疗后白天嗜睡程度和鼾声评级均较术前改善(P<0.01)。手术对局部疼痛、讲话及吞咽的影响很小。术后3个月大部分射频治疗过的部位,体积(或长度)均较术前明显缩小(或缩短)。结论:RFA对局部组织的消融效果确切,只要阻塞定位准确,相应治疗OS-AHS患者近期均有一定疗效。单纯鼻甲肥大所致鼾症或轻度OSAHS,射频治疗效果最为满意,软腭肥厚悬雍垂肥大、扁桃体肥大的治疗部分有效,但程度有限。射频治疗需要与其他治疗手段结合使用,或作为其他治疗的补充手段。     

A comparison of tonsillar size and oropharyngeal dimensions in children with obstructive adenotonsillar hypertrophy

Hypertrophy of the tonsils and adenoids is the most common cause of obstructive sleep apnea in children. There is relatively little known about the occurrence of subclinical variations in the dimensions of the oropharynx which may predispose to the development of obstructive sleep apnea in children without obvious craniofacial abnormalities. Fifty-one children (3-10 years) were divided into two groups: the first group consisted of 18 patients with small tonsils and no history of snoring who underwent tonsillectomy for chronic tonsillitis. They were compared to a second group of 33 patients with large tonsils who underwent tonsillectomy and adenoidectomy for symptoms of obstructive sleep apnea. Age, height, weight, body surface area and tonsil weight were correlated to the dimensions of the oropharynx obtained by direct measurement intraoperatively including the length of the soft palate, anterior-posterior depth of the nasopharynx and the distances between the medial tonsillar surfaces, anterior tonsillar pillars and lateral pharyngeal walls at mid-tonsil level. Increased patient height, weight and surface area correlated positively to increased distance between the lateral pharyngeal walls and to the length of the soft palate in the patients with small tonsils. No such correlation existed in the patients with obstructive adenotonsillar hypertrophy. In addition, the distance between the lateral pharyngeal walls was significantly decreased in the group with large, obstructing tonsils as compared to those with small tonsils and no history of obstruction (P less than 0.01). However, the patients with small tonsils and no obstruction had significantly longer soft plates (P less than 0.01) and less depth tot eh nasopharynx (P less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

Efficacy and longterm compliance of the vest preventing the supine position in patients with obstructive sleep apnea

BACKGROUND: Treating the positional obstructive sleep apnea with a vest preventing the supine position is well known to be riskless and inexpensive. It was the aim of this study to test the efficacy and, for the first time, the longterm compliance of this treatment. METHODS: 14 patients with positional obstructive sleep apnea (age 48.2 +/- 12.1 years; body-mass-index: 28.1 +/- 4.6 kg/m2 mean, +/- SD) were investigated polysomnographically without and with a vest preventing the supine position. 13.7 +/- 15.9 months later the patients were asked about the comfort of the vest and the nocturnal using time using the Likert-scale, and data about the latest Epworth Sleepiness Scale (ESS) was collected. RESULTS: The respiratory disturbance index (RDI) was reduced statistically significant from 31.3 +/- 12.9/h to 13.8 +/- 9.0/h by wearing the vest (p < 0.001). Total sleep time at an oxygen saturation below 90% decreased from 8.2 +/- 7.1% to 3.8 +/- 4.5% (p < 0.001), the snoring time from 15.4 +/-19.6 % to 9.8 +/-13.1% (p < 0.05) of the total sleep time (TST) and the arousal index from 23.1 +/-16.0/h to 18.6 +/-11.4/h (p < 0.05). 24 +/-28.8 months later 28.6% of the patients were still using the vest. Of these patients the ESS decreased from 8.5 +/-3.2 to 6.5 +/-2.9 (p < 0.05). 72.4% of the patients refused the longterm therapy with the vest because of its low wearing comfort. CONCLUSIONS: Although the vest approved to be effective against positional obstructive sleep apnea, the longterm compliance is low because of its need getting used to.     

Microdebrider-assisted extended uvulopalatoplasty: an effective and safe technique for selected patients with obstructive sleep apnea syndrome

OBJECTIVE: To assess subjective and objective outcomes in selected patients with obstructive sleep apnea syndrome who underwent microdebrider-assisted extended uvulopalatoplasty (MEUP). DESIGN: Prospective study. SETTING: Tertiary referral center. PATIENTS: Fifty patients with obstructive sleep apnea syndrome who had substantial retropalatal obstruction and more than 10 events per hour on the respiratory disturbance index (RDI) and who underwent MEUP with 6 months of follow-up. Patients with a Friedman palate position of grade 4 and a tonsil size of grade 3 or 4 were excluded. INTERVENTION: MEUP was performed in each patient under general anesthesia. The procedure consisted of removal of the redundant mucosa, tissue above the muscular layer of the soft palate, and upper poles of the tonsils using a powered microdebrider. MAIN OUTCOME MEASURES: Postoperative pain was evaluated using a visual analog scale. Before surgery and at 6 months after surgery, subjective outcomes were assessed using the Epworth Sleepiness Scale and the snoring scale, and objective outcomes were assessed using overnight polysomnography variables (RDI, snoring index, and minimal oxygen saturation). Surgical success was defined as achieving a postoperative RDI score of fewer than 20 events per hour and a greater than 50% reduction in the preoperative RDI score. RESULTS: The mean (SD) visual analog scale scores were 3.9 (1.8) on the first postoperative day and 1.3 (0.9) on the seventh postoperative day. Compared with preoperative scores, postoperative scores statistically significantly improved on the Epworth Sleepiness Scale and on the snoring scale (P < .01 for both). The median RDI score decreased from 37.9 events per hour before surgery to 6.1 events per hour at 6 months after surgery, a statistically significant difference (P < .001). The median minimal oxygen saturation and snoring index scores also improved statistically significantly (P < .001 for both). The surgical success rate was 80% (40 of 50 patients). No postoperative bleeding or long-term velopharyngeal insufficiency was observed in any patient. CONCLUSIONS: MEUP is an effective and safe surgical procedure to improve sleep apnea and snoring in selected patients with obstructive sleep apnea syndrome. The use of the microdebrider in extended uvulopalatoplasty is addressed herein for the first time (to our knowledge).     

Minimally invasive single-stage multilevel treatment for obstructive sleep apnea/hypopnea syndrome

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.     

悬雍垂腭咽成形加舌根射频消融联合手术的临床应用

目的探讨悬雍垂腭咽成形术加舌根射频消融联合治疗重度阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apnea hypopnea syndrom e,OSAHS)的疗效。方法对46例重度有腭咽和舌根平面阻塞的OSAHS的患者分两组,第一组22例(2000年8月至2002年8月)行单纯保留悬雍垂腭咽成形术,第二组24例(2002年9月至2004年8月)行保留悬雍垂腭咽成形术加舌根射频消融术。患者进行手术前后口咽腔的测量,并行睡眠监测。结果46例OSAHS患者手术后腭舌弓间距和腭咽弓间距变宽、软腭长度缩短,差异有统计学意义(P<0.001),而咽部后气道宽度(pharyngealposterior airway w idth,PPAW)在第一组没有变化,在第二组变宽,两组比较差异有统计学意义(P<0.001)。第一组患者术前睡眠呼吸暂停低通气指数(apnea hypopnea index,AH I)平均(56.5±6.0)次/h(x-±s,以下同),最低血氧饱和度(lowest SaO2,LSaO2)为0.626±0.060,术后AH I为(23.7±2.7)次/h,LSaO2(0.797±0.053);第二组术前AH I(58.4±5.1)次/h,LSaO2为0.650±0.057,术后AH I为(15.5±3.2)次/h,LSaO2为0.864±0.064。AH I、LSaO2两组术后均明显改善,差异有统计学意义(P<0.001),按照杭州会议疗效评定标准第一组有效率为72.7%(16/22),第二组有效率为87.5%(21/24)。第一组和第二组疗效相比差异也有统计学意义(R id it分析u=2.178,P<0.05)。结论对阻塞性睡眠呼吸暂停低通气综合征的患者,明确多平面阻塞,应进行联合治疗,保留悬雍垂腭咽成形加舌根射频消融术联合治疗可达到较好的疗效。     

Temperature-controlled radiofrequency tissue volume reduction of the soft palate (somnoplasty) in the treatment of habitual snoring: results of a European multicenter trial

Temperature-controlled radiofrequency tissue volume reduction of the soft palate has been introduced as a minimally invasive, outpatient procedure for the treatment of habitual snoring and mild obstructive sleep apnea. A prospective, non-randomized multi-center European clinical study was conducted to investigate the efficacy of Somnoplasty in reducing snoring. Each patient underwent a pre- and post-treatment full-night polysomnography. TCRFe of the soft palate (1 midline lesion/session) was carried out under local anesthesia with a maximum of 3 consecutive treatment sessions. Forty-five, nonapneic snorers (RDI 5.1 +/- 4.3, BMI 26.6 +/- 3.2 kg/m2) completed the protocol. A mean of 692.3 +/- 67.7) J was delivered/treatment session. There was a significant improvement in the snoring index 7.6 (+/- 2.1 ) vs 4.1 (+/- 2.9). p < 0.001 and in the Epworth Sleepiness Score 8.5 (+/- 5.0) versus 6.0 (+/- 4.3), p = 0.001. No major adverse events were reported and postoperative pain was minimal. Overall, 45% of patients had a post-treatment snoring index < 3 (success) and 84% of the patients reported an improvement in snoring. It was concluded that Somnoplasty, following a protocol with I midline lesion of maximal 700 J/lesion for 1-3 treatment sessions, improves snoring in the majority of patients. Further studies are required to investigate whether treatment efficacy can be improved by utilizing multiple lesions/session or by increasing the amount of energy/lesion. The absence of serious adverse events and the findings of minimal postoperative pain support the use of TCRFe (Somnoplasty) as a minimally invasive surgical procedure for snoring.     

Combined radiofrequency surgery of the tongue base and soft palate in obstructive sleep apnoea

Objective To investigate the safety and efficacy of combined temperature-controlled radiofrequency volumetric tissue reduction of the tongue base and soft palate in obstructive sleep apnoea.

Material and methods A total of 20 patients with obstructive sleep apnoea and combined palatal and retrolingual obstruction were included in a non-randomized clinical trial and 51 combined treatments were performed under local anaesthesia. Postoperative pain was assessed using visual analogue scales. Functional parameters, daytime sleepiness and quality of life were assessed using questionnaires (Epworth Sleepiness Scale, Short Form-36) before and 12 weeks after the last treatment session. Concurrently, polysomnography was performed on two consecutive nights.

Results The mean postoperative pain score dropped from 5.6 at Day 1 to 0.6 at Day 7. Painkillers were taken for a mean of 3.3 days. There were no postoperative complications or changes in functional parameters. Daytime sleepiness improved significantly (p<0.05). The mean respiratory disturbance index was reduced from 25.3±11.4 to 16.7±15.3 (p<0.05). Six out of 18 (33%) patients were cured after a mean of 2.7 treatment sessions.

Conclusion Combined radiofrequency volumetric tissue reduction of the tongue base and soft palate is a safe and effective treatment for obstructive sleep apnoea.     

Outcomes of hyoid suspension for the treatment of obstructive sleep apnea

OBJECTIVE: To examine the efficacy of hyoid myotomy and suspension as a treatment of hypopharyngeal obstruction in obstructive sleep apnea. DESIGN: Prospective, observational study. SETTING: Academic medical center. PATIENTS: Twenty-nine consecutive male patients with suspected hypopharyngeal obstruction INTERVENTIONS: Patients underwent hyoid suspension. Uvulopalatopharyngoplasty with or without tonsillectomy was performed at the same time for those patients who had not undergone this procedure previously. Patients underwent clinical examination and sleep study prior to surgery and approximately 1 year postoperatively. MAIN OUTCOME MEASURES: Primary outcome was a successful surgical result, defined as apnea-hypopnea index lower than 20, 50% or greater decline in apnea-hypopnea index, and no oxygen desaturations below 85% on the postoperative sleep study. Secondary outcomes included daytime sleepiness as determined by the Epworth Sleepiness Scale and the severity of snoring. Postoperative complications were also recorded. RESULTS: Only 5 (17%) of 29 patients achieved a successful outcome. The respiratory disturbance index did not change significantly for the group as a whole, although the lowest oxygen saturation did show some improvement. CONCLUSIONS: Hyoid suspension does not provide results equivalent to those reported for genioglossus advancement or multisession tongue radiofrequency. Hyoid suspension alone is not an efficacious treatment for hypopharyngeal airway obstruction in most patients with obstructive sleep apnea.     

Mood improvement after surgery for obstructive sleep apnea

OBJECTIVE: Patients with obstructive sleep apnea (OSA) may experience unfavorable psychologic symptoms such as depression and anxiety. The aim of this study was to confirm this hypothesis and to investigate whether the psychologic symptoms among OSA patients can be relieved by surgical intervention. STUDY DESIGN: Prospective, longitudinal intervention study. METHODS: The 5-Item Mental Health scale (MH-5) was used to evaluate the postoperative changes of mood after extended uvulopalatal flap (EUPF) surgery on 84 Taiwanese patients with OSA. The preoperative and postoperative MH-5 data obtained from these patients were compared with a Taiwanese population norm. RESULTS: Before surgery, the MH-5 scores of the OSA patients were significantly worse than the Taiwanese population norm of 72.8 (P <.0001). Postoperatively, mean MH-5 scores significantly increased from 61.8 +/- 16.0 to 70.0 +/- 15.8 (P =.0006). The effect size of this score change was 0.51, indicating a moderate degree of mood improvement. However, this score was still inferior to that of the population norm (P =.0045). The mood improvement was not significantly associated with the changes in either sleep apnea events or the level of sleepiness. Neither the changes in respiratory disturbance index (P =.4382), maximum arterial oxygen saturation (P =.4866), nor the change in Epworth Sleepiness Scale scores (P =.4951) were predictive of the MH-5 score improvement (R = 0.07). CONCLUSIONS: This study demonstrated that patients with OSA had a higher level of anxiety, depression, and probable behavior or personality changes than the population norm. EUPF surgery could significantly improve the mood status among OSA patients; the effect of surgery was mild but clinically relevant. However, the extent of mood improvement experienced by OSA patients receiving operations may not simply be attributable to the changes in sleep apnea events or a reduced level of sleepiness.     

Changes in quality of life and respiratory disturbance after extended uvulopalatal flap surgery in patients with obstructive sleep apnea

OBJECTIVE: To evaluate the subjective and objective outcomes of extended uvulopalatal flap (EUPF) surgery in patients with obstructive sleep apnea. DESIGN: Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), Snore Outcomes Survey (SOS), Epworth Sleepiness Scale (ESS), and polysomnography were performed preoperatively and then 6 months postoperatively. SETTING: Tertiary care, sleep disorders referral center. PATIENTS: Fifty-five consecutive patients (52 men and 3 women; mean age, 45 years) with obstructive sleep apnea. INTERVENTION: EUPF surgery. MAIN OUTCOME MEASURES: Overnight polysomnography variables included respiratory distress index (RDI), snore index, minimum oxygen saturation, sleep stages 1 and 2, sleep stages 3 and 4, rapid eye movement, and sleep efficiency. Questionnaire variables included SF-36, SOS, and ESS scores. Success of the operation was defined as a more than 50% reduction of the RDI from the initial value and a postoperative RDI of less than 20. RESULTS: The overall success rate of the EUPF surgery was 82%; the RDI, snore index, and minimum oxygen saturation improved significantly after surgery (P<.001). Sleep architecture in overnight polysomnography remained unchanged (P=.48 and P=.74). Patients demonstrated significant improvement in both their SOS and ESS scores (P<.001) and significant increases in 7 of 8 SF-36 subscales (P<.05 for all). However, there was poor correlation between the improvement in quality of life and the reduction in sleep-related respiratory events. CONCLUSIONS: Extended uvulopalatal flap surgery can greatly reduce sleep-related adverse events and proves to be an effective therapy to enhance the quality of life of patients with obstructive sleep apnea. This study also suggests that subjective and objective outcomes are equally important when reporting the results of EUPF surgery.     

Plasma radiofrequency preceded by pressure recording enhances success for treating sleep-related breathing disorders

OBJECTIVES: Sleep-related breathing disorders (SRBD) that cannot be treated conservatively are commonly treated using uvulopalatopharyngoplasty, although success rates are generally less than 70%. The purpose of this study was to assess a plasma-mediated radiofrequency (RF)-based coblation assisted upper airway procedure (CAUP) to treat SRBD patients determined to have obstruction localized to the upper (mid)-pharyngeal region. STUDY DESIGN: Prospective case series (n = 40). METHODS: Six patients had socially bothersome snoring, and 34 patients had mild to moderate sleep apnea (apnea/hypopnea index [AHI] <20), with the primary level of obstruction (>50%) within the upper pharyngeal region as determined using whole night recordings, including airway pressure fluctuation monitoring (ApneaGraph, MRA-Medical Ltd, Gloucestershire, UK). CAUP consisted of making a lateral palatal incision, ablating three upward channels on each side of the midline (fan-shaped) into the soft palate using a plasma mediated RF-based device (ArthroCare Corporation, Austin, TX), and performing a partial uvulectomy. Clinical outcomes included the Epworth Sleepiness Scale (ESS), partner rating of snoring using a visual analogue scale (VAS), and night-time apnea and hypopnea events (AHI, hypopnea index [HI], apnea index [AI]). RESULTS: Patients were 28 to 68 (46 +/- 12) years old; 28 (70%) were male. Preoperatively, clinical assessment scores (median +/- interquartile range) were as follows: ESS (11.0 +/- 3.0), VAS (8.15 +/- 1.00), AHI (9.58 +/- 5.58), HI (9.00 +/- 5.29), AI (0.333 +/- 0.625). After CAUP, no postoperative scarring, fibrosis, or any other clinically significant side effects were observed. Postoperatively (9.1 +/- 1.5; 7-15 mo), ESS (4.0 +/- 1.0), VAS (2.70 +/- 1.38), AHI (3.75 +/- 2.92), HI (3.58 +/- 2.50), and AI (0.167 +/- 0.167) were significantly improved (P < .001). CONCLUSION: CAUP preceded by site-specific obstruction diagnosis using pressure recording is a well-tolerated outpatient treatment that is well suited for treating SRBD.     

Usefulness of uvulopalatopharyngoplasty with genioglossus and hyoid advancement in the treatment of obstructive sleep apnea

OBJECTIVE: To evaluate the usefulness of uvulopalatopharyngoplasty plus mandibular osteotomy with genioglossus and hyoid advancement in the treatment of obstructive sleep apnea syndrome (OSAS). DESIGN: Prospective study of 20 consecutive patients with OSAS. SETTING: University medical center. PATIENTS AND INTERVENTIONS: Twenty OSAS patients with multilevel upper airway obstruction who refused continuous positive airway pressure treatment. All patients were evaluated before and 6 months after surgery by clinical history, the Epworth Sleepiness Scale, physical examination, fiberoptic nasopharyngoscopy combined with the Müller maneuver, cephalometric analysis, nocturnal polysomnography, and a second-night polysomnography with upper airway pressure recording during sleep. Surgery procedures were uvulopalatopharyngoplasty plus mandibular osteotomy with genioglossus and hyoid advancement. Surgical successful outcome was defined as an apnea-hypopnea index (AHI) lower than 20 plus subjective resolution of daytime symptoms. MAIN OUTCOME MEASURE: Surgical success rate. RESULTS: Mean +/- SD AHI decreased from 60.5 +/- 16.5 to 44.6 +/- 27(P =.007), and CT90 (percentage of time with oxyhemoglobin saturation below 90%) decreased from 39.5% +/- 26% to 25.1% +/- 26.4% (P =.002). The overall surgical success rate was 35% but increased to 57% in patients with moderate OSAS (AHI, 41-60) and to 100% in mild OSAS (AHI, 21-40). In the group of severe OSAS, the success rate was 9%. Predictors of surgical outcome success were the AHI, CT90, stages 2 and 3-4 sleep percentages, and the cephalometric ANB angle (angle formed from the deepest point on the maxillary outer contour to the nasion to the deepest point on the outer mandibular contour). CONCLUSION: Patients with mild and moderate OSAS and multilevel obstruction in the upper airway may benefit from uvulopalatopharyngoplasty plus genioglossus and hyoid advancement.     

Head and neck physical examination: comparison between nonapneic and obstructive sleep apnea patients

STUDY OBJECTIVES: The purpose of this study was to apply a systematic physical examination, used to evaluate obstructive sleep apnea (OSA) patients, in nonapneic patients. DESIGN: Study was prospective. SETTING: Patients were seen in the sleep laboratory and department of otorhinolaryngology. PATIENTS OR PARTICIPANTS: Nonapneic patients (n = 100) were involved in the study. INTERVENTIONS: Physical examination to evaluate facial skeleton, pharyngeal soft tissue, rhinoscopy, and body mass index. Data were compared with a previously published study (2003) on a group of OSA patients (n = 223). MEASUREMENTS AND RESULTS: Skeletal examination detected retrognathism in 6%, class II occlusion in 12%, and high-arched hard palate in 11%. The modified Mallampati classification showed 54% in class I to II and 46% in class III to IV. Only 1% of nonapneic patients had tonsils of degree III to IV. Oropharynx evaluation showed web palate in 38%, posterior palate in 19%, thick palate in 10%, thick uvula in 10%, long uvula 15%, voluminous lateral wall in 11%, and tongue edge crenations in 28%. Anterior rhinoscopy detected significant septal deviation in 1% and turbinate hypertrophy in 31% of patients. CONCLUSIONS: The head and neck physical examination, considering both skeletal and soft tissue alterations, illustrated significant differences between nonapneic and OSA patients. Body mass index, modified Mallampati classification, tonsils hypertrophy, and high-arched hard palate previously related to the presence of sleep apnea in the literature showed different outcomes in nonapneic patients. Nonapneic patients had less alterations in nasal anatomy (severe septal deviation and enlarged turbinate). Skeletal parameters, such as retropositioned mandible and angle class II occlusion, were less frequent in nonapneic patients.     

The association of the severity of obstructive sleep apnea with plasma leptin levels

OBJECTIVE: To examine whether circulating leptin levels correlate with the severity of disease in patients with obstructive sleep apnea. DESIGN: Prospective nonrandomized study. SETTING: Referral sleep laboratory for patients with sleep-disordered breathing and biochemistry laboratory.Patients Thirty-two subjects (mean +/- SD age, 47 +/- 12 years) who were referred for suspected sleep apnea underwent an overnight sleep study and fasting morning venous blood sampling. Patients were divided into 3 groups with respect to apnea-hypopnea index: (1) severe sleep apnea (n = 8), apnea-hypopnea index greater than 20; (2) mild sleep apnea (n = 12), apnea-hypopnea index between 5 and 20; and (3) nonapneic control (n = 12), apnea-hypopnea index less than 5. RESULTS: Leptin levels (mean +/- SD) were 21.2 +/- 8.6, 16.2 +/- 5.2, and 10.6 +/- 7.5 ng/mL (P =.005) in patients with severe and mild obstructive sleep apnea and nonapneic controls, respectively. Plasma leptin levels correlated positively with the degree of sleep-disordered breathing as recorded by the apnea-hypopnea index (r = 0.54, P =.001) and percentage of sleep time spent with oxygen saturation below 90% (r = 0.39, P =.02). CONCLUSIONS: Circulating leptin concentrations in patients with obstructive sleep apnea, independent of body mass index and age, are significantly higher than levels in nonapneic controls and there is a positive relationship between leptin concentrations and the severity of sleep apnea. Hyperleptinemia may be a prognostic marker of obstructive sleep apnea syndrome.