Uvulopalatopharyngoplasty in the Management of Obstructive Sleep Apnea: The Mayo Clinic Experience

OBJECTIVE: To assess the role of uvulopalatopharyngoplasty (UPPP) in the treatment of obstructive sleep apnea (OSA) using polysomnography (PSG) data within 6 months before and after surgery.PATIENTS AND METHODS: We analyzed PSG and body mass index (BMI) data from patients with OSA who were 18 years or older and who underwent UPPP between January 1, 1988, and August 31, 2006.RESULTS: Sixty-three patients (51 men [81.0%]; mean ± SD age, 42.1±13.9 years; mean ± SD BMI, 34.9±7.2) underwent PSG a mean ± SD of 50±47 days before and 88.5±34.0 days after UPPP. Surgical cure was defined as a postoperative apnea-hypopnea index (AHI) of 5 or less. Fifteen patients (24%) achieved a surgical cure. Twenty-one patients (33%) had a postoperative AHI of 10 or less, whereas 32 (51%) achieved a 50% or greater reduction in AHI and/or an AHI of 20 or less. No significant changes were noted in BMI before and 6 months after UPPP. Patients who attained an AHI of 5 or less were younger (mean ± SD age, 35.9±13.1 vs 44±13.7 years; P=.05), had lower BMIs (mean ± SD, 30.8±6.5 vs 34.6±6.6; P=.05), and had less severe OSA (mean ± SD AHI, 38.1±33.6 vs 69.6±32.8; P=.004). Of the 48 patients (76%) with a post-UPPP AHI greater than 5, 35 (56%) received continuous positive airway pressure, with a mean reduction in pressure of 1.4 cm H₂O (95% confidence interval, -0.4 to -2.4 cm H₂O).CONCLUSION: Independent of changes in BMI, in our retrospective analysis, UPPP achieved an AHI of 5 or less in 24% and an AHI of 10 or less in 33% of patients with OSA who underwent PSG 6 months before and after surgery. In those with residual OSA who received continuous positive airway pressure, the required pressure setting decreased by 1.4 cm H₂O.AHI = apnea-hypopnea index; BMI = body mass index; CPAP = continuous positive airway pressure; OSA = obstructive sleep apnea; PSG = polysomnography; UPPP = uvulopalatopharyngoplastyObstructive sleep apnea (OSA) is highly prevalent, affecting 4% of men and 2% of women who meet a disease-defining threshold of at least 5 episodes of apnea or hypopnea per hour of sleep (apnea-hypopnea index [AHI] ≥5) and excessive daytime sleepiness.¹ Continuous positive airway pressure (CPAP), a technique that pneumatically supports the upper airway, is a therapeutic mainstay for OSA. It has been shown to reduce the AHI, improve sleepiness and quality of life, and reduce cardiovascular risk.^2,3 Despite demonstrable benefits and technological equipment advances, compliance with CPAP therapy varies, with 29% to 83% of patients using CPAP for less than 4 hours a night in various studies.⁴ Accordingly, physicians may recommend other options for their patients with OSA, including risk factor modification such as weight loss, oral appliances that advance the mandible or tongue during sleep,⁵ or a variety of surgical procedures to bypass or expand the upper airway.⁶The most common surgical procedure performed for OSA is uvulopalatopharyngoplasty (UPPP).^7,8 Introduced by Fujita et al⁹ in 1981, UPPP involves tonsillectomy (if not previously performed), trimming and reorientation of the posterior and anterior tonsillar pillars, and excision of the uvula and posterior palate. Often, UPPP is combined with other nasopharyngeal or oropharyngeal procedures. The reported success of UPPP as a treatment of OSA is between 16% and 83%, depending on the definition of a positive outcome.^7,10 Some authors have defined surgical success or cure after UPPP as a 50% reduction in the AHI, whereas others combine this criterion with an absolute AHI of 20 or less.^11-14 Unfortunately, use of these criteria means that successfully treated patients may still have mild to moderate residual OSA. Increasing evidence shows that, when treating OSA, reducing the AHI to less than 5 is necessary to improve health care-related outcome measures, such as hypertension.¹⁵ Accordingly, there have been calls for caution about UPPP as first-line therapy for OSA and for all future studies of UPPP to base surgical success on AHI outcomes of 5 or less or 10 or less, targets typically expected from CPAP therapy.^7,16 Therefore, to better define response to UPPP, we reviewed the UPPP experience at Mayo Clinic''s site in Rochester, MN, using these more stringent and contemporary criteria.     

Reversal of Sleep-Disordered Breathing with Opioid Withdrawal

Obstructive sleep apnea, central sleep apnea, sleep related hypoventilation, Biot's or ataxic breathing, and cluster breathing are some of the commonly described sleep disorders in patients who are on long-term opioids. Continuous positive airway pressure that is commonly used to treat obstructive sleep apnea may not be effective in treating sleep-disordered breathing in long-term opioid users, and an adaptive servoventilator (ASV) may be needed. We present a 30-year-old woman with excessive daytime sleepiness and sleep-disordered breathing for the past 4 years. Medical history was complicated by chronic osteomyelitis, periorbital abscess, and chronic facial pain requiring methadone for pain control for the last 4 years. In this case, ASV, though effective, was not tolerable due to chronic facial pain, and successful withdrawal of methadone at our pain rehabilitation center resolved the sleep-disordered breathing and improved daytime sleepiness. This is to our knowledge the first case report of resolution of sleep-disordered breathing and improvement in daytime sleepiness after withdrawal of long-term opioid use.     

Mosquito Larvicidal Activity of Mangrove Plant Extracts and Synergistic Activity of Rhizophora apiculata with Pyrethrum against Culex quinquefasciatus

Plant samples were collected from 15 mangrove species, Acanthus ilicifolius, Aegiceras corniculatum, Avicennia marina. A. officinalis, Bruguiera cylindrica, Ceriops decandra, Excoecaria agallocha, Rhizophora apiculata, R. Lamarckii, R. mucronata, Salicornia brachiata, Sesuvium portulacastrum, Sonneratia apetala, Suaeda maritima, S. monoica and Xylocarpus granatum. The 22 samples were extracted in acetone and petroleum ether separately, and the extracts were tested for their activity against the larvae of mosquito, Culex quinquefasciatus. Petroleum ether extract of R. apiculata was found most effective with LC 50 of 25.7 mg/l. The extract was studied further with pyrethrum for its synergistic larvicidal activity. The extract exhibited synergism and the synergistic factor was 0.81 at 5 mg/l.     

Vertical atlantoaxial dislocation

An unusual case of vertical atlantoaxial dislocation without medulla oblongata or spinal cord injury is reported. The pathogenic process suggested occipito-axial dislocation. The case was treated surgically with excellent results on mobility and pain. Received: 19 December 1997 Revised: 23 October 1998 Accepted: 11 January 1999     

Vascular changes, cardiovascular disease and obstructive sleep apnea

Vascular changes related to obstructive sleep apnea (OSA) can lead to chronic cardiovascular consequences such as hypertension. The cardiovascular consequences are owing to nocturnal perturbations related to intrathoracic pressure changes, intermittent hypoxia, sympathetic neural activation, endothelial dysfunction, oxidative stress and systemic inflammation. Intermittent hypoxia due to sleep-related events in OSA activates the renin-angiotensin system and increases the levels of endothelin-1. Intermittent hypoxia also results in oxidative stress, as evidenced by elevated levels of xanthine oxidoreductase, lipid peroxidation and the presence of reactive oxygen species. There is also evidence for a decrease in antioxidant capacity. Patients with OSA may have endothelial dysfunction that resolves with continuous positive airway pressure. OSA is a state of inflammation as evidenced by elevated levels of C-reactive protein, IL-6, NF-κB, TNF-α, ICAM-1, VCAM-1 and E-selectin. This may suggest that OSA is a predisposing factor for atherogenesis. This article will discuss the role of nocturnal perturbations consequent to OSA resulting in endothelial dysfunction, oxidative stress, and inflammation and how they may subsequently play a causative role in cardiovascular disorders.     

Epigallocatechin gallate attenuates fibroblast proliferation and excessive collagen production by effectively intervening TGF‐β1 signalling

Pulmonary fibrosis (PF) poses a huge burden to the patients and society due to lack of an effective treatment drug. Activation of fibrocyte, fibroblast and myofibroblasts are important steps in the development of PF. Targeting this common pathway with natural chemicals may lead to the development of new drug regimens for PF treatment. In this study, PF was induced in male Wistar rats by intratracheal administration of Bleomycin (BLM). Epigallocatechin gallate (EGCG) was administered to one of the groups of rats to test its efficacy against the development of PF. Bleomycin‐induction resulted in significant elevation of matrix metalloproteinase (MMP)‐2 and ‐9 expression, increased RNA and protein expression of transforming growth factor (TGF)‐β1, Smads and alpha‐smooth muscle actin (α‐SMA). EGCG treatment normalized the BLM induced aberrations in these rats. The protective role of EGCG was also validated in vitro using the WI‐38 fibroblast cell line. TGF‐β1 incubated cells exhibited increased fibroblast proliferation and hydroxyproline levels with a concomitant decrease in the expression of MMPs 2 and 9. An increase in protein expression levels of p‐Smad, α‐SMA and type I collagen (COL1A) was also exhibited by fibroblasts upon TGF‐β1 incubation. Simultaneous treatment of EGCG to WI‐38 cells significantly decreased these protein expressions alongside normalizing the MMPs expression. The study revealed that EGCG inhibited fibroblast activation and collagen accumulation by inhibiting TGF‐β1 signalling and thus can be considered as an effective drug against PF.     

Obstructive sleep apnea in the perioperative setting: complications and management strategies

Obstructive sleep apnea (OSA) is frequently encountered in an undiagnosed, untreated state in perioperative patients. It increases the risk of respiratory, cardiac, and infectious complications following surgical procedures. Patients with OSA may require additional monitoring, unplanned escalations in care, and prolonged hospitalization. It is important to identify patients at risk for OSA during the preoperative assessment so that appropriate anesthesia, postsurgical monitoring, and pain control can be planned. Herein, we discuss data regarding perioperative outcomes in patients with OSA, methods to quickly identify patients at high risk for OSA, and implementation of clinical safeguards to minimize OSA-associated complications. An algorithm is provided to guide the perioperative management of patients with OSA.     

"Wing flaps": perforator-based pedicled paraumbilical flaps for skin defects in hand and forearm

BACKGROUND: Single large-area or 2 small- to moderate-sized raw areas in the hand and forearm are difficult to cover with conventional groin or superficial inferior epigastric artery (SIEA) flaps. Though abdomen is a favorable donor site for a pedicled distant flap for soft tissue coverage of the hand and forearm, pedicle flaps based on paraumbilical perforators are not commonly used. METHODS: We herein describe a method of soft tissue coverage using 2 flaps based on 1 paraumbilical perforator in certain difficult clinical situations, unsuitable to be covered with groin or SIEA flaps. By virtue of having a very narrow common pedicle for 2 substantially large flaps close to the chosen paraumbilical perforator, the configuration of it prompted us to call these twin flaps "wing flaps," or a winged version of paraumbilical pedicle flaps. The wing flap described was used to cover twin raw areas (in 6 cases) and a large area (in 1 case) in the hand and forearm. RESULTS: All 7 flaps went on to heal very well and served the purpose. The only complication observed was a minor thumb web contracture in one case, which improved with physiotherapy. CONCLUSION: The winged version of pedicled paraumbilical perforator flaps should find a place in the surgical armamentarium for soft tissue coverage in the hand and forearm in difficult situations. The advantages and simplicity of these flaps have been described, based on our experience in a small series of 7 cases.