Experiencia en pacientes operados de roncopatía y apnea obstructiva del sueño / Clinical experience in patients with surgery of rhonchopathy and obstructive sleep apnea syndrome

RESUMEN Introducción: La uvulopalatofaringoplastía (UPPP) es un procedimiento ampliamente difundido en el tratamiento del ronquido y el síndrome de apnea e hipopnea obstructiva del sueño (SAHOS), ya que permite aumentar el área de sección transversal de la vía aérea superior y eliminar tejidos obstructivos. Conocer el grado de satisfacción de los pacientes con la cirugía es importante para nuestro desempeño. Objetivo: Evaluar la satisfacción de los pacientes con el procedimiento UPPP con cirugía nasal con datos subjetivos mediante la aplicación de una encuesta para ser respondida de forma anónima. Material y método: Estudio observacional, descriptivo. Se envió vía email una encuesta de 4 preguntas cerradas creada en la plataforma online MonkeySurvey a los pacientes que fueron sometidos a UPPP (faringoplastía de relocalización) con cirugía nasal entre 2015 y 2016. Resultados: 27 pacientes respondieron la encuesta. Sesenta y seis coma seis por ciento tenían ronquido primario y/o SAHOS leve, 33,3% SAHOS severo. La edad media al momento de la cirugía fue 41 años. El tiempo de seguimiento medio fue 10 meses (324 meses). Noventa y dos coma cinco por ciento de los pacientes están satisfechos con la cirugía UPPP; 81,4% refieren que recomendarían la cirugía a otra persona. Noventa y dos coma cinco por ciento refieren mejoría en los ronquidos. Noventa y cinco coma seis por ciento de los pacientes con somnolencia diurna refiere mejoría. Conclusión: La cirugía UPPP con técnica faringoplastía de relocalización combinada con cirugía nasal en pacientes con ronquido primario y SAHOS ha demostrado una alta tasa de satisfacción según la percepción de los pacientes en el seguimiento desde los 3 meses hasta los 2 años posoperatorios.

ABSTRACT Introduction: Uvulopalatopharyngoplasty (UPPP) is a widely used surgical procedure for snoring and obstructive sleep apnea syndrome (OSAS), since it allows to increase of the cross-sectional area of the upper airway and elimination of obstructive tissues. Knowing the degree of satisfaction of patients with surgery is important for our performance. Aim: To evaluate patient satisfaction with UPPP procedure (relocation pharyngoplasty) with nasal surgery with subjective data through the application of a survey to be answered anonymously. Material and method: Observational, descriptive study. A survey of 4 closed questions created in the MonkeySurvey online platform was sent to patients who underwent UPPP with nasal surgery between 2015 and 2016 via email. Results: 27 patients answered the survey. 66.6% had primary snoring and/or mild OSAS, 33.3% severe OSAS. The average age at the time of surgery was 41 years. The mean follow-up time was 10 months (3-24 months). 92.5% of patients are satisfied with UPPP surgery; 81.4% reported that they would recommend surgery to another person. 92.5% reported improvement in snoring. 95.6% of patients with daytime somnolence reported improvement. Conclusion: UPPP surgery with relocation pharyngoplasty technique combined with nasal surgery in patients with primary snoring and OSAS has shown a high satisfaction rate according to the perception of patients at follow-up from 3 months to 2 years postoperative.

Influencia del exceso de peso en el éxito de la adenoamigdalectomía en pacientes con hiperplasia adenoamigdalina sintomática / The influence of overweight in the success of adenotonsillectomy in patients with adenotonsillar symptomatic hyperplasia

Resumen Introducción: En población pediátrica con malnutrición por exceso, existe controversia respecto al rol de la hiperplasia adenoamigdalina en la etiología de los trastornos del sueño y de la efectividad de la adenoamigdalectomía sobre dicha sintomatología. Objetivo: Comparar la efectividad de la adenoamigdalectomía entre pacientes pediátricos eutróficos y con malnutrición por exceso sometidos a adenoamigdalectomía por hiperplasia adenoamigdalina, en relación a la disminución de la sintomatología. Materiales y método: Estudio retrospectivo mediante revisión de fichas clínicas entre junio de 2016 y enero de 2017 de pacientes operados de adenoamigdalectomía por hiperplasia adenoamigdalina sintomática. Se clasificaron los pacientes de acuerdo a edad y estado nutricional en 4 grupos y se evaluó la resolución de la sintomatologia mediante interrogación a padres/tutores. Resultados: Se incluyeron 98 pacientes, con una edad media de 6,3 años. 44,9% de los pacientes fueron eutróficos y 55,1% con malnutrición por exceso. El análisis estadístico entre pacientes eutróficos y aquellos con malnutrición no demostró diferencias significativas en relación a la resolución de la sintomatología. Conclusión: La adenoamigdalectomía por hiperplasia adenoamigdalina sintomática se asocia a una reducción de la frecuencia de roncopatía con pausas en pacientes pediátricos, independientemente del estado nutricional.

Abstract Introduction: In pediatric population with malnutrition by excess, the role of the adenotonsillar hyperplasia in the etiology of breathing-related sleep disorders, and the effectivity of the adenotonsillectomy for reducing symptoms remains controversial. Aim: To compare and evaluate the effectiveness of the adenotonsillectomy between eutrophic and malnutrition by excess pediatric patients submitted to adenotonsillectomy by adenotonsillar hyperplasia, regarding to symptoms resolution. Material and method: A retrospective study was performed collecting data from clinical records between June 2016 and January 2017 of patients submitted to adenotonsillectomy by symptomatic adenotonsillar hyperplasia. Patients were assigned to 4 groups according to age and nutrional status and the rate of symptoms resolution was evaluated through interrogation to parents/guardians. Results: We included 98 patients, with an average age of 6.3 years. A 44.9% of patients were eutrophic and 55.1% had malnutrition by excess. Comparing eutrophic and malnutrition by excess patients, no significant differences were observed regarding to symptoms resolution. Conclusion: The adenotonsillectomy by symptomatic adenotonsillar hyperplasia was associated to an amelioration of the rate of snoring and respiratory pauses during sleeping in pediatric patients, independently of the nutritional status.

Hyoid Bone Suspension as a Part of Multilevel Surgery for Obstructive Sleep Apnea Syndrome

Abstract Introduction Since oropharyngeal surgery alone is often insufficient to treat obstructive sleep apnea (OSA), advances have been developed in hypopharyngeal surgery. Objective To assess hyoid suspension surgery as part of amultilevel OSA surgery, also including palatal surgery. Methods The study included patients with OSA symptoms with apnea hypopnea index (AHI) > 15. They were scheduled for hyoid suspension after a nasoendoscopy during Müller maneuver and drug induced sleep endoscopy (DISE). All patients had body mass index (BMI) < 35 kg/m2. Hyoidothyroidopexy combined with tonsillectomy and palatal suspension was performed in all cases. Results The mean AHI dropped significantly (p < 0.0001) from 68.4 ± 25.3 preoperatively to 25.6 ± 9.52 postoperatively. The mean lowest oxygen (O2) saturation level increased significantly from 66.8 ± 11.3 to 83.2 ± 2.86 (p < 0.0001). In addition, the snoring score significantly decreased (p < 0.0001) from a preoperative mean of 3.4 ± 0.54 to 2 ± 0.7 at 6 months postoperatively. In regard to the Epworth sleepiness scale (ESS), it showed significant improvements (p < 0.0001) as its mean diminished from 13.8 ± 5.4 preoperatively to 5.2 ± 1.6 postoperatively. Conclusion Hyoidothyroidopexy using absorbable suture seems to produce a good outcome in treating OSA. It could be effectively and safely combined with other palatal procedures in the multilevel surgery for OSA.

Is the difference in the volume of the pharyngeal space, as measured by acoustic pharyngometry, before and after tonsillectomy proportional to the volume of the excised tonsils?

OBJECTIVE: Adenotonsillectomy is recognized as an effective therapy for snoring and sleep disorders in children. It is important to understand whether adenotonsillectomy significantly increases the volume of the pharyngeal space. The goal of this study was to evaluate the change in oropharyngeal volume after adenotonsillectomy and the correlation of this change with the objective volume of the tonsils and body mass index. METHODS: We included 27 subjects (14 males) with snoring caused by tonsil and adenoid hypertrophy. The mean age of the subjects was 7.92 (±2.52) years. Children with craniofacial malformations or neuromuscular diseases or syndromes were excluded. The parents/caregivers answered an adapted questionnaire regarding sleep-disordered breathing. All patients were subjected to weight and height measurements and body mass index was calculated. The subjects underwent pharyngometry before and after adenotonsillectomy and the volume of both excised tonsils together was measured in cm3 in the operating room. RESULTS: Pharyngometric analysis showed that the mean pharyngeal volume was 28.63 (±5.57) cm3 before surgery and 31.23 (±6.76) cm3 after surgery; the volume of the oropharynx was significantly increased post-surgery (p=0.015, Wilcoxon test). No correlation was found between the objective tonsil volume and the post-surgical volume increase (p=0.6885). There was a fair correlation between the oropharyngeal volume and body mass index (p=0.0224). CONCLUSION: Adenotonsillectomy increases the volume of the pharyngeal space, but this increase does not correlate with the objective tonsil size. Furthermore, greater BMI was associated with a smaller increase in the pharyngeal volume. Oropharyngeal structures and craniofacial morphology may also play a role in the increase in oropharyngeal volume.

Intervenção fisioterapêutica em adultos roncadores / Physiotherapeutic intervention in snoring adults

INTRODUÇÃO: O ronco é caracterizado como o som emitido pela vibração dos tecidos moles da faringe, por causa da dificuldade que o ar encontra ao passar pela via aérea superior com obstrução parcial. OBJETIVO: Analisar a eficácia da intervenção fisioterapêutica em adultos roncadores, atendidos na clínica-escola de Fisioterapia da Universidade do Sul de Santa Catarina (Unisul). MÉTODO: Trata-se de uma pesquisa explicativa, quantitativa e quase experimental. Na primeira fase, a amostra foi composta por sete indivíduos residentes da cidade de Tubarão e na segunda fase três participantes fizeram parte da intervenção fisioterapêutica. Os dados foram tratados com estatística descritiva (média e desvio-padrão), inferencial (teste de wilcoxon com p < 0,05) e correlação de Pearson. RESULTADOS:Na primeira fase, relacionando a Escala de Epworth com as variáveis analisadas, as mulheres apresentaram maior propensão ao sono, os indivíduos acima de 50 anos e com IMC > 25 apresentaram maior sonolência excessiva diurna e a qualidade de vida foi menor em indivíduos com maior pontuação na escala. Nos resultados pré e pós-intervenção fisioterapêutica, descritos na segunda fase, dois indivíduos diminuíram a pontuação na Escala de Epworth e um aumentou, houve aumento na pontuação de SF36relacionado à qualidade de vida, dois indivíduos aumentaram o IMC e um diminuiu, sendo que todos os participantes diminuíram a circunferência do pescoço e a protusão de cabeça. CONCLUSÃO: A fisioterapia pode proporcionar bons resultados no tratamento do ronco, contribuindo com a diminuição da sonolência excessiva diurna e melhora da qualidade de vida.

Surgical treatment of snoring & obstructive sleep apnoea.

Obstructive sleep apnoea (OSA) syndrome is a potentially serious disorder affecting millions of people around the world. Many of these individuals are undiagnosed while those who are diagnosed, often exhibit poor compliance with nightly use of continuous positive airway pressure (CPAP), a very effective nonsurgical treatment. Various surgical procedures have been proposed to manage and, in some cases, treat OSA. In this article we review methods used to assess the sites of obstruction and a number of surgical procedures designed to address OSA. Effective surgical management of OSA depends upon developing a complete database and determining different levels of obstruction, which may include nasal, nasopharyngeal, oropharyngeal, and hypopharyngeal/retrolingual, or a combination of these sites. A systematic approach to clinical evaluation, treatment planning and surgical management is recommended and is likely to result in more predictable outcomes. Surgical treatment may involve various procedures that are performed in different stages depending on the patient’s sites of obstruction. The most commonly performed procedures include nasal reconstruction, uvulopalatopharyngoplasty (UPPP), advancement genioplasty, mandibular osteotomy with genioglossus advancement, and hyoid myotomy and suspension. In more severe cases, maxillomandibular advancement (MMA) with advancement genioplasty may be indicated. Even after appropriate surgical treatment, some patients may demonstrate continued obstruction with associated symptoms. Published indications for surgical treatment include an elevated respiratory disturbance index (RDI) with excessive daytime somnolence (EDS), oxygen desaturations below 90 per cent, medical co-morbidities including hypertension and arrhythmias, anatomic abnormalities of the upper airway and failure of medical treatment. The success of surgery in OSA is generally measured by achieving a (RDI) of less than 5, improvement of oxygen nadir to 90 per cent or more with no desaturations below 90 per cent and quality of life improvements with elimination or significant reduction of OSA symptoms. From a practical point of view, achieving these goals may be extremely difficult without patients’ cooperation, most notably in the realm of weight loss and maintenance of a healthy lifestyle.

Tratamiento quirúrgico del ronquido y la apnea obstructiva del sueño / Snoring and sleep apnea syndrome: surgical treatment

La roncopatía y la apnea obstructiva del sueño son problemas muy comunes en la población general. Su causa es un colapso de la vía aérea superior en cualquiera de sus niveles, nasal, orofaringeo y/o hipofaringeo (base de lengua). La roncopatía es un problema fundamentalmente social. Por otro lado la apnea obstructiva del sueño constituye un problema de riesgo médico por la mayor tasa de accidentes de tráfico, accidentes cardiovasculares, etc. Si bien es cierto ambas entidades son de resolución médica mediante el uso de CPAP, se han descrito un sinnúmero de técnicas quirúrgicas desde 1981 con el fin de ayudar a aquellos pacientes que no desean o no toleran el uso de CPAP.

Snoring and Sleep Apnea Syndrom are common disorders among general population. Both entities are produced by collapse of the Upper airway usually at multiples levels, nose, oropharinx and /or hypopharinx (base of tongue). Whereas snoring is social problem, sleep apnea syndrome is a medical entity because of the higher rates of traffic accidents and cardiovascular diseases. The current mainstay for treating these disorders is the CPAP, however many surgical procedures have been described since 1981 in order to help a group of patients who cannot or will not accept CPAP as a permanent form of management.

Avaliação do impacto da adenotonsilectomia sobre a qualidade de vida em crianças com hipertrofia das tonsilas palatinas e faríngeas / Assessing the impact adenotonsilectomy has on the lives of children with hypertrophy of palatine and pharyngeal tonsils

A hipertrofia das tonsilas palatinas e faríngeas é extremamente comum na infância, sendo um dos problemas mais freqüentes do consultório do otorrinolaringologista, podendo prejudicar a qualidade de vida das crianças. OBJETIVO: Avaliar o impacto da adenotonsilectomia sobre a qualidade de vida das crianças que apresentam aumento do volume das tonsilas. MATERIAL E MÉTODOS: Estudo de coorte contemporâneo longitudinal. Foi aplicado a setenta e cinco pais ou responsáveis por crianças submetidas a adenotonsilectomia um questionário específico para a avaliação da qualidade de vida, OSD-6, antes do procedimento cirúrgico e trinta dias após. RESULTADOS: A adenotonsilectomia proporcionou significativa diminuição na pontuação obtida no questionário. DISCUSSÃO: Ronco e a obstrução nasal foram os sintomas responsáveis pelas maiores pontuações nos questionários. Existe grande preocupação dos pais com o ronco das crianças e pobre correlação estatística entre o grau de obstrução e a pior qualidade de vida. CONCLUSÃO: A adenotonsilectomia apresenta impacto relevante na qualidade de vida das crianças com hipertrofia das tonsilas.

The hypertrophy of the palatine and pharyngeal tonsils is extremely common in children, being one of the most frequent causes of visits to otolaryngologists and such problem can impair the child's quality of life. AIM: to evaluate the impact of adenotonsillectomy on the lives of children with hypertrophied tonsils. MATERIALS AND METHODS: Contemporary longitudinal cohort study. A specific questionnaire used to evaluate the quality of life - OSD-6, was given to seventy five parents or guardians of children previously submitted to adenotonsillectomy, before the surgery and thirty days afterwards. RESULTS: The adenotonsillectomy provided a significant reduction in the questionnaire score. DISCUSSION: Snoring and nasal obstruction were the symptoms with the highest scores. There is a great concern from the parents with the snoring of the children and a poor statistic correlation between the degree of obstruction degree and a worse quality of life. CONCLUSION: Adenotonsillectomy causes a relevant impact in the quality of life of children with tonsil hypertrophy.

Laser-assisted outpatient septoplasty and laser-assisted uvulopalatoplasty for nasal obstruction and snoring.

OBJECTIVE: Nasal obstruction always occurs when the nasal passages are narrowed by a hypertrophic turbinate or a deviated nasal septum. Patients with nasal obstruction often have associated snoring. Laser-assisted outpatient septoplasty (LAOS) has a specific clinical application in chronic nasal obstruction due to moderate anterior septal deviation. Significant improvement has been reported in the measures of nasal obstruction following LAOS. The purpose of the present study was to evaluate the safety and efficacy of LAOS as an adjunctive procedure for snoring resulting from nasal obstruction. MATERIAL AND METHOD: Thirty-five patients with septal deviation and bothersome snoring were enrolled. Patients underwent a polysomnography study to rule out significant obstructive sleep apnea. Ablation of the nasal septum was undertaken with a carbon dioxide laser. No nasal packing was required. LAOS procedures were performed in conjunction with other snoring procedures (laser-assisted uvulopalatoplasty or laser turbinectomy) on an outpatient basis under local anesthesia. Data on the patients were compared from the preoperative to the postoperative assessment. Statistics used were determined by the Student's paired t test. RESULTS: All patients tolerated the procedure well. The additional surgical time needed to perform this procedure averaged 10 minutes. The mean nasal obstruction scale improved from 6.2 + 3.2 to 1.6 + 0.8 (p < 0.01) and the mean total nasal resistance decreased significantly after operation. Significant improvement was observed in the snoring scale (8.8 + 2.2 vs 2.8 + 1.7, p < 0. 05). No significant complications were noted. There were 2 cases of minor bleeding, which were easily treated. Postoperative pain was rated as minimal (VAS < 4). Follow-up of 4 to 6 months showed overall improvement of nasal obstruction and snoring symptoms in more than 90% of the patients. CONCLUSION: LAOS is a simple and well-tolerated treatment for deviated nasal septum. It appears to be a safe and effective adjunct surgical procedure for snorer with nasal obstruction on an outpatient basis.

Radiofrequency palatal reduction versus LAUP as a treatment of snoring and mild obstructive sleep apnea

In this study, 30 patients complaining of snoring and mild obstructive sleep apnea were randomly distributed into two groups, 15 patients each. One group was subjected to laser assisted uvulopalatoplasty [LAUP] while the other to RF. The follow up of these patients revealed that LAUP is more effective than RF, whereas RF is more tolerable than LAUP. LAUP was proved to be an effective method in the treatment of snoring and mild obstructive sleep apnea, while RF proved to be very safe and well-tolerated but needs further study to exactly evaluate its efficacy

Tratamento cirúrgico do ronco e da Síndrome da apnéia obstrutiva do sono / Surgical treatment for snoring and obstructive sleep apnea syndrome

A causa do ronco e da Síndrome da apnéia obstrutiva do sono é a obstrução ou colapso da via aérea superior durante o sono. Apresentamos uma revisão da literatura sobre a avaliação clínica e as modalidades terapêuticas para pacientes com essas alterações

Ronco e síndrome da apnéia obstrutiva do sono / Snoring and obstructive sleep apnea syndrome

Os autores apresentam uma revisäo da literatura sobre síndrome da apnéia obstrutiva do sono e ronco, através de uma breve descriçäo de sua fisiopatologia e suas possíveis complicaçöes. Além de enfocar os principais aspectos clínicos e métodos doagnósticos, esta pesquisa tem, ainda, como objetivo estabelecer, através de evidências científicas, os principais resultados e indicaçöes do tratamento clínico e cirúrgico dessas patologias.

LAUP x UPFP - quando indicar? / LAUP x UPFP - when operate?

Após avaliação clínica pela Escala de Epworth para Sonolência e pela Polissonografia, operamos 38 pacientes portadores de ronco simples e/ou Síndrome de Apnéia Obstrutiva do Sono leve ou moderada. Em 16, utilizamos a técnica cirúrgica de Uvulopalatoplasia a Laser de CO2, em 22 a Uvulopalatrofaringoplastia com o Bisturi de Alta Freqüência. Nestes 22, em 4 associamos a cirurgia de amigdalectomia, em 8, amigdalectomia e septoplastia, e em 10 septoplastia e turbinectomia inferior parcial bilateral.