Objective and subjective long term outcome of maxillomandibular advancement in obstructive sleep apnea.

STUDY OBJECTIVES: To evaluate the objective and subjective long-term outcome of maxillomandibular advancement (MMA) in Far-East Asian patients with moderate to severe obstructive sleep apnea (OSA). METHODS: This is a long-term follow-up study to evaluate the treatment outcome of MMA in OSA patients by objective polysomnography (PSG) and subjective questionnaires (Pittsburgh Sleep Quality Index-PSQI, Insomnia Severity Index-ISI, Beck Anxiety Inventory-BAI, Beck Depression Inventory-BDI, Epworth Sleepiness scale-ESS, and Short Form-36 Quality of Life-SF-36). Evaluation was done before surgery and we followed these patients one and two years after surgery. We also assessed the neurocognitive function by Continuous performance test (CPT) and Wisconsin Card Sorting Test (WCST) before and after MMA. RESULTS: A total of 82 patients with OSA (female = 19) were enrolled and 53 participants (75.7% men, age 35.66 ± 11.66 years [mean ± SD], BMI = 24.80 ± 3.29) completed the two-year follow-up. The apnea-hypopnea index (AHI) decreased from a mean of 34.78 ± 26.01 to 3.61 ± 2.79 and 7.43 ± 6.70 events/hour (p = 0.007) at the first and second year evaluation. There was significant improvement in PSG (especially respiratory profile), questionnaires (PSQI and ISI total score), and neurocognitive testing (attention and executive function) after MMA. Meanwhile, no major complication such as avascular necrosis of bonny segments, facial nerve injury, blindness or compromise of airway was found after surgery. CONCLUSIONS: MMA is a clinically effective treatment for patients with moderate-to-severe OSA as demonstrated by significant long-term decrease in AHI and improvement in neurocognitive testing.

Clinical practice guideline: tonsillectomy in children.

OBJECTIVE: Tonsillectomy is one of the most common surgical procedures in the United States, with more than 530,000 procedures performed annually in children younger than 15 years. Tonsillectomy is defined as a surgical procedure performed with or without adenoidectomy that completely removes the tonsil including its capsule by dissecting the peritonsillar space between the tonsil capsule and the muscular wall. Depending on the context in which it is used, it may indicate tonsillectomy with adenoidectomy, especially in relation to sleep-disordered breathing. This guideline provides evidence-based recommendations on the preoperative, intraoperative, and postoperative care and management of children 1 to 18 years old under consideration for tonsillectomy. In addition, this guideline is intended for all clinicians in any setting who interact with children 1 to 18 years of age who may be candidates for tonsillectomy. PURPOSE: The primary purpose of this guideline is to provide clinicians with evidence-based guidance in identifying children who are the best candidates for tonsillectomy. Secondary objectives are to optimize the perioperative management of children undergoing tonsillectomy, emphasize the need for evaluation and intervention in special populations, improve counseling and education of families of children who are considering tonsillectomy for their child, highlight the management options for patients with modifying factors, and reduce inappropriate or unnecessary variations in care. RESULTS: The panel made a strong recommendation that clinicians should administer a single, intraoperative dose of intravenous dexamethasone to children undergoing tonsillectomy. The panel made a strong recommendation against clinicians routinely administering or prescribing perioperative antibiotics to children undergoing tonsillectomy. The panel made recommendations for (1) watchful waiting for recurrent throat infection if there have been fewer than 7 episodes in the past year or fewer than 5 episodes per year in the past 2 years or fewer than 3 episodes per year in the past 3 years; (2) assessing the child with recurrent throat infection who does not meet criteria in statement 2 for modifying factors that may nonetheless favor tonsillectomy, which may include but are not limited to multiple antibiotic allergy/intolerance, periodic fever, aphthous stomatitis, pharyngitis and adenitis, or history of peritonsillar abscess; (3) asking caregivers of children with sleep-disordered breathing and tonsil hypertrophy about comorbid conditions that might improve after tonsillectomy, including growth retardation, poor school performance, enuresis, and behavioral problems; (4) counseling caregivers about tonsillectomy as a means to improve health in children with abnormal polysomnography who also have tonsil hypertrophy and sleep-disordered breathing; (5) counseling caregivers that sleep-disordered breathing may persist or recur after tonsillectomy and may require further management; (6) advocating for pain management after tonsillectomy and educating caregivers about the importance of managing and reassessing pain; and (7) clinicians who perform tonsillectomy should determine their rate of primary and secondary posttonsillectomy hemorrhage at least annually. The panel offered options to recommend tonsillectomy for recurrent throat infection with a frequency of at least 7 episodes in the past year or at least 5 episodes per year for 2 years or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and 1 or more of the following: temperature >38.3°C, cervical adenopathy, tonsillar exudate, or positive test for group A ß-hemolytic streptococcus.

Maxillomandibular advancement for obstructive sleep apnea.

Although nasal continuous positive airway pressure therapy is considered the first-line treatment of obstructive sleep apnea, surgery has been shown to be a valid option for patients who are intolerant to positive pressure therapy. In the past 20 years, maxillomandibular advancement has been widely accepted as the most effective surgical therapy for obstructive sleep apnea syndrome. Maxillomandibular advancement has been shown to enlarge the pharyngeal and hypopharyngeal airway by physically expanding the facial skeletal framework. It has also been shown that the forward movement of the maxillomandibular complex increases tissue tension. This decreases the collapsibility of the velopharyngeal and suprahyoid musculature and improves lateral pharyngeal wall collapse, all of which have been shown to be significant components contributing to the upper airway obstruction in obstructive sleep apnea. The outcome of maxillomandibular advancement has been extensively reported, with success rates of 57% to 100%. A recent meta-analysis of 627 patients from 22 studies showed an overall success rate of 86%. The long-term follow-up of 56 patients for 43.7 months from 3 studies showed a surgical success rate of 89%. These data are similar to my experience with an 89% success rate in more than 600 maxillomandibular advancement procedures performed.

Sleep apnea surgery: putting it all together.

Since the first description of uvulopalatopharyngoplasty (UPPP) in 1972, the surgical management of obstructive sleep apnea syndrome (OSA) has become increasingly popular. This popularity is caused by several reasons. The psychomotor sequelae of OSA, such as excessive daytime sleepiness, daytime fatigue, and poor sleep quality caused by sleep fragmentation, have major deleterious impact on patients' well being, which behooves them to seek treatment. The risk of hypertension, heart attack, and stroke also prompts patients to seek treatment. Further, despite the potential success of nasal continuous positive airway pressure (CPAP), patients' compliance represents a clear problem, thus causing patients to seek treatment alternatives, namely surgery. All surgeons treating patients who have OSA must realize that the management of OSA crosses specialty lines and no single specialty can adequately take care of patients alone.

Surgical treatment of obstructive sleep apnea: upper airway and maxillomandibular surgery.

Upper airway surgery is an important treatment option for patients with obstructive sleep apnea (OSA), particularly for those who have failed or cannot tolerate positive airway pressure therapy. Surgery aims to reduce anatomical upper airway obstruction in the nose, oropharynx, and hypopharynx. Procedures addressing nasal obstruction include septoplasty, turbinectomy, and radiofrequency ablation (RF) of the turbinates. Surgical procedures to reduce soft palate redundancy include uvulopalatopharyngoplasty, uvulopalatal flap, laser-assisted uvulopalatoplasty, and RF of the soft palate with adenotonsillectomy. More significant, however, particularly in cases of severe OSA, is hypopharyngeal or retrolingual obstruction related to an enlarged tongue, or more commonly due to maxillomandibular deficiency. Surgeries in these cases are aimed at reducing the bulk of the tongue base or providing more space for the tongue in the oropharynx so as to limit posterior collapse during sleep. These procedures include genioglossal advancement, hyoid suspension, distraction osteogenesis, tongue RF, lingualplasty, and maxillomandibular advancement. Successful surgery depends on proper patient selection, proper procedure selection, and experience of the surgeon. Most surgeries are done in combination and in a multistep manner, with maxillomandibular advancement typically being reserved for refractory or severe OSA, or for those with obvious and significant maxillomandibular deficiency. Although not without risks and not as predictable as positive airway pressure therapy, surgery remains an important therapeutic consideration in all patients with OSA. Current research aims to optimize the success of these procedures by identifying proper candidates for surgery, as well as to develop new invasive procedures for OSA treatment.

Hypopharyngeal airway surgery.

Obstructive sleep apnea (OSA) is the result of upper airway obstruction during sleep. Hypopharyngeal airway obstruction can be caused by the prominence or relaxation of the base of the tongue, lateral pharyngeal wall, and occasionally, the aryepiglottic folds or epiglottis. Although nasal continuous positive airway pressure (CPAP) is considered as the first treatment for obstructive sleep apnea, surgery has been shown to be a viable option for patients who are intolerant of positive pressure therapy. This article presents the current state of hypopharyngeal surgery for sleep apnea. Preoperative airway evaluation with fiberoptic nasopharyngoscopy, the use of lateral cephalometric radiograph, and the formulation of a surgical plan with selection of procedures to address hypopharyngeal obstruction are discussed.

Surgical therapy for obstructive sleep apnea syndrome.

Despite advances in positive pressure therapy for obstructive sleep apnea, compliance continues to be a problem for many patients. Sleep apnea surgery is a viable option for patients who are intolerant of positive pressure therapy. This review presents the current state of the art in sleep apnea surgery, including airway evaluation with fiberoptic nasopharyngoscopy and lateral cephalometric radiography, formulation of a surgical plan with selection of procedures to address specific sites of obstruction, as well as discussion of published surgical outcomes.

Surgical therapy for adult obstructive sleep apnea.

Despite advances in positive pressure therapy for obstructive sleep apnea, compliance continues to be a problem for many patients. Sleep apnea surgery is a viable option for patients who are intolerant of positive pressure therapy. This review will present the current state of art in sleep apnea surgery, including airway evaluation with fiberoptic nasopharyngoscopy and lateral cephalometric radiograph, formulation of a surgical plan through a selection of procedures to address specific sites of obstruction, as well as discussion of published surgical outcomes.

Adult chronic sleepwalking and its treatment based on polysomnography.

Adult sleepwalking affects 2.5% of the general population and may lead to serious injuries. Fifty young adults with chronic sleepwalking were studied prospectively. Clinical evaluation, questionnaires from patients and bed partners, and polysomnography were obtained on all subjects in comparison with 50 age-matched controls. Subjects were examined for the presence of psychiatric anxiety, depression and any other associated sleep disorder. Isolated sleepwalking or sleepwalking with psychiatric disorders was treated with medication. All other patients with other sleep disorders were treated only for their associated problem. Prospective follow-up lasted 12 months after establishment of the most appropriate treatment. Patients with only sleepwalking, treated with benzodiazepines, dropped out of follow-up testing and reported persistence of sleepwalking, as did patients with psychiatric-related treatment. Chronic sleepwalkers frequently presented with sleep-disordered breathing (SDB). All these patients were treated only for their SDB, using nasal continuous positive airway pressure (CPAP). All nasal CPAP-compliant patients had control of sleepwalking at all stages of follow-up. Non-compliant nasal CPAP patients had persistence of sleepwalking. They were offered surgical treatment for SDB. Those successfully treated with surgery also had complete resolution of sleepwalking. Successful treatment of SDB, which is frequently associated with chronic sleepwalking, controlled the syndrome in young adults.

Three-dimensional computed tomography and polysomnography findings after extended uvulopalatal flap surgery for obstructive sleep apnea.

OBJECTIVES: Using both sleep physiological parameters and image data to evaluate the efficacy of extended uvulopalatal flap (EUPF) surgery in the treatment of obstructive sleep apnea (OSA). MATERIAL AND METHODS: Fifty patients with OSA underwent EUPF that consisted of bilateral tonsillectomy, dissection and removal of the submucosal adipose tissue of the soft palate and supratonsillar areas, and imbrications and repositioning of the denuded uvulopalatal flap. Polysomnography (PSG) and 3-dimensional computed tomography (3-D CT) data were obtained at baseline and 6 months postoperatively. Good response to surgery was defined as a reduction of the respiratory disturbance index (RDI) to less than 20 events/h and a greater than 50% reduction of the baseline RDI. RESULTS: Forty-two patients (84%) achieved good results. The RDI and minimal O2 saturation improved significantly (P<.0001) after EUPF. The postoperative 3-D CT evaluation showed a significant increase in the retropalatal space (P<.0001). The preoperative lateral diameter of retropalatal space was predictive of the change of RDI (R2=0.15, P=.05). The effect of increased retropalatal space (r=0.59, P=.0415) was significant in patients with baseline RDI ranged from 31 to 60 events/h. CONCLUSIONS: With special emphasis on the removal of palatal fat, EUPF appeared to be effective in the reduction of sleep apnea in selected patients. 3-D CT proved that this technique was effective in widening the upper airway by relieving the retropalatal obstruction.

Maxillomandibular expansion for the treatment of sleep-disordered breathing: preliminary result.

OBJECTIVE: To assess the outcomes of maxillomandibular expansion (MME) by distraction osteogenesis (DO) for the treatment of sleep-disordered breathing (SDB). METHODS: This was a prospective study of six consecutive patients with SDB. All of the patients have maxillary and mandibular constriction and were treated with MME. Variables examined include age, sex, body mass index (BMI), polysomnographic results (PSG), Epworth Sleepiness Scale (ESS), and the extent of the widening of the maxilla and mandible. RESULTS: All six patients (4 males) completed MME for the treatment of SDB. The mean age was 22.2 +/- 11.4 years. The mean maxillary expansion was 10.3 +/- 3.0 mm, and the mean mandibular expansion was 9.5 +/- 2.9 mm. ESS improved from 10.2 +/- 1.9 to 5 +/- 2.9. The mean apnea/ hypopnea index (AHI) improved from 13.2 +/- 15.6 to 4.5 +/- 5.8 events per hour, and the mean lowest oxygen saturation (LSAT) improved from 88.2 +/- 2.9% to 91.3 +/- 3.3%. The mean esophageal pressure improved from -20 +/- 11.3 cm H2O to -8 +/- 3.6 cm H2O. No complications were encountered, and the follow-up period was 18.1 +/- 9.8 months. CONCLUSION: : The result suggests that MME improves SDB in patients with maxillary and mandibular constriction and can be a valid treatment.

Practice parameters for the dopaminergic treatment of restless legs syndrome and periodic limb movement disorder.

Dopaminergic agents, particularly dopamine agonists, have been used with increasing frequency in the treatment of restless legs syndrome and periodic limb movement disorder. These evidence-based practice parameters are complementary to the Practice Parameters for the Treatment of Restless Legs Syndrome and Periodic Limb Movement Disorder, published in 1999. These practice parameters were developed by the Standards of Practice Committee and reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine. Recommendations are based on the accompanying comprehensive review of the medical literature regarding the dopaminergic treatment of restless legs syndrome (RLS) and periodic limb movement disorder (PLMD), which was developed by a task force commissioned by the American Academy of Sleep Medicine. The following recommendations serve as a guide to the appropriate use of dopaminergic agents in the treatment of RLS and PLMD. Levodopa with decarboxylase inhibitor, and the dopaminergic agonists pergolide, pramipexole, and ropinirole are effective in the treatment of RLS and PLMD. Other dopamine agonists (talipexole, cabergoline, piribidel, and alpha-dihydroergocryptine) and the dopaminergic agents amantadine and selegiline may be effective in the treatment of RLS and PLMD, but the level of effectiveness of these medications is not currently established. Lastly, no specific recommendations can be made regarding dopaminergic treatment of children or pregnant women with RLS or PLMD.

Sleep disordered breathing: surgical outcomes in prepubertal children.

OBJECTIVE: To evaluate the treatment outcomes of sleep disordered breathing (SDB) in prepubertal children 3 months following surgical intervention. STUDY DESIGN: Retrospective investigation of 400 consecutively seen children with SDB who were referred to otolaryngologists for treatment. METHOD: After masking the identities and conditions of the children, the following were tabulated: clinical symptoms, results of clinical evaluation and polysomnography at entry, the treatment chosen by the otolaryngologists, and clinical and polysomnographic results 3 months after surgery. RESULTS: Treatment ranged from nasal steroids to various surgical procedures. Adenotonsillectomy was performed in only 251 of 400 cases (68%). Four cases included adenotonsillectomy in conjunction with pharyngoplasty (closure of the tonsillar wound by suturing the anterior and posterior pillar to tighten the airway). Persistent SDB was seen in 58 of 400 children (14.5%), and an additional 8 had persistent snoring. Best results were with adenotonsillectomy. CONCLUSION: SDB involves obstruction of the upper airway, which may be partially due to craniofacial structure involvement. The goal of surgical treatment should be aimed at enlarging the airway, and not be solely focused on treating inflammation or infection of the lymphoid tissues. This goal may not be met in some patients, thus potentially contributing to residual problems seen after surgery. The possibility of further treatment, including collaboration with orthodontists to improve the craniofacial risk factors, should be considered in children with residual problems.

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.

An adjunctive method of radiofrequency volumetric tissue reduction of the tongue for OSAS.

OBJECTIVES: Temperature-controlled radiofrequency volumetric reduction (TCRF), a minimally invasive procedure, has been used to treat tongue base obstruction in Obstructive Sleep Apnea Syndrome (OSAS). An adjunctive method was objectively evaluated. METHOD: A prospective, nonrandomized clinical study was undertaken on 20 consecutive OSAS patients with isolated tongue base obstruction. Under local anesthesia, multiple lesions of the ventral tongue (genioglossus insertion) and dorsal tongue were given at each treatment session. A visual analog scale was used to assess changes in speech and swallowing. Polysomnography and Epworth Sleepiness Scale (ESS) were used to assess outcome. Patients were maintained on nasal continuous positive airway pressure after each treatment. RESULTS: Patients received a mean 4.6 +/- 0.6 treatments for a mean total of 7915 +/- 1152 joules. There was no significant change in speech or swallowing at 3 months after completion of treatment. Patients reported a significant decrease in sleepiness with a mean change in ESS from 12.4 +/- 2.9 to 7.3 +/- 3.0 (P < 0.001). Mean apnea/hypopnea index decreased from 35.1 +/- 18.1 to 15.1 +/- 17.4 (P < 0.001). Transient mild to moderate pain and swelling occurred after each treatment. There were no significant complications (ulceration, paresthesia, infection). CONCLUSION: TCRF can successfully treat the OSAS patient with tongue base obstruction. Combined treatment of the ventral (genioglossus insertion) and dorsal tongue appears safe and may improve outcome with less total energy when compared with traditional dorsal-only applications.

Anterior cervical spine fusion and sleep disordered breathing.

The authors reviewed 12 patients who developed obstructive sleep apnea (OSA) syndrome in association with anterior cervical spine fusion. Four subsequent patients were studied prospectively before C2 to C4 anterior fusion and documented to have OSA by questionnaire, visual analogue scales, polysomnography, and multiple sleep latency tests. The authors found that placement of the anterior cervical plates reduced the size of the upper airway. Symptoms and objective findings were controlled with nasal continuous positive airway pressure.