Management of Persistent, Post-adenotonsillectomy Obstructive Sleep Apnea in Children: An Official American Thoracic Society Clinical Practice Guideline.

Background: Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder. Although adenotonsillectomy is first-line management for pediatric OSA, up to 40% of children may have persistent OSA. This document provides an evidence-based clinical practice guideline on the management of children with persistent OSA. The target audience is clinicians, including physicians, dentists, and allied health professionals, caring for children with OSA. Methods: A multidisciplinary international panel of experts was convened to determine key unanswered questions regarding the management of persistent pediatric OSA. We conducted a systematic review of the relevant literature. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to rate the quality of evidence and the strength of the clinical recommendations. The panel members considered the strength of each recommendation and evaluated the benefits and risks of applying the intervention. In formulating the recommendations, the panel considered patient and caregiver values, the cost of care, and feasibility. Results: Recommendations were developed for six management options for persistent OSA. Conclusions: The panel developed recommendations for the management of persistent pediatric OSA based on limited evidence and expert opinion. Important areas for future research were identified for each recommendation.

Social Media Use by Residents and Faculty in Otolaryngology Training Programs.

OBJECTIVES: Despite the growth of social media in healthcare, the appropriateness of online friendships between otolaryngological residents and attendings is poorly defined in the current literature. This issue is of growing importance, particularly as residency programs increasingly utilize social media as a means of connecting with and evaluating applicants due to limited in-person experiences during the COVID-19 pandemic. Our objective was to better understand the prevalence of and concerns surrounding social media use between residents and faculty. METHODS: This study sent out 2 surveys in 2017 to all United States Otolaryngology residency program directors to disperse to their residents and attendings, respectively. RESULTS: We received a response from 72 residents and 98 attendings. Our findings show that social media is commonly used by both residents and attendings, and most residents have at least 1 online friendship with an attending. Resident and attending opinions diverge on topics such as appropriateness of use, privacy settings, and professionalism. CONCLUSIONS: We call on residency programs to delineate a transparent social media policy so applicant expectations on social media are clear.

The new face of war: Craniofacial injuries from Operation Inherent Resolve.

BACKGROUND: During the last 20 years of conflict in the Middle East, improvements in body armor and the use of improvised explosive devices have resulted in an increased incidence of complex craniofacial trauma (CFT). Currently, CFT comprises up to 40% of all casualties. We present new data from the recent conflict in Iraq and Syria during Operation Inherent Resolve. METHODS: Data were collected for patients treated at role 1, role 2, and role 3 facilities in Iraq and Syria over a 1-year period. During this time, a specialized head & neck surgical augmentation team was deployed and colocated with the central role 3 facility. Data included for this cross-sectional study are as follows: injury type and mechanism, triage category, initial managing facility and subsequent levels of care, and procedures performed. RESULTS: Ninety-six patients sustained CFT over the study period. The most common injuries were soft tissue (57%), followed by cranial (44%) and orbital/facial (31%). Associated truncal and/or extremity injuries were seen in 46 patients (48%). There were marked differences in incidence and pattern of injuries between mechanisms (all p < 0.05). While improvised explosive devices had the highest rate of cranial and truncal injuries, gunshot wounds and blunt mechanisms had higher incidences of orbital/facial and neck injuries. Overall, 45% required operative interventions including complex facial reconstruction, craniotomy, and open globe repair. Mortality was 6% with 83% due to associated severe brain injury. Most patients were local nationals (70%) who required discharge or transfer to the local health care system. CONCLUSION: Complex craniofacial trauma is increasingly seen by deployed surgeons, regardless of subspecialty training or location. Deployment of a centrally located head and neck team greatly enhances the capabilities for forward deployed management of CFT, with excellent outcomes for both US and local national patients. LEVEL OF EVIDENCE: Therapeutic/care management; Level V.

Dynamic sleep MRI in obstructive sleep apnea: a systematic review and meta-analysis.

PURPOSE: The objective of this study is to systematically review the international literature for dynamic sleep magnetic resonance imaging (MRI) as a diagnostic tool in obstructive sleep apnea (OSA), to perform meta-analysis on the quantitative data from the review, and to discuss its implications in future research and potential clinical applications. STUDY DESIGN: A comprehensive review of the literature was performed, followed by a detailed analysis of the relevant data that has been published on the topic. METHODS: Clinical key, Uptodate, Ovid, Ebscohost, Pubmed/MEDLINE, Scopus, Dynamed, Web of Science and The Cochrane Library were systematically searched. Once the search was completed, dynamic sleep MRI data were analyzed. RESULTS: Nineteen articles reported on 410 OSA patients and 79 controls that underwent dynamic sleep MRI and were included in this review. For meta-analysis of dynamic sleep MRI data, eight articles presented relevant data on 160 OSA patients. Obstruction was reported as follows: retropalatal (RP) 98%, retroglossal (RG) 41% and hypopharyngeal (HP) in 5%. Lateral pharyngeal wall (LPW) collapse was found in 35/73 (48%) patients. The combinations of RP + RG were observed in 24% and RP + RG + LPW in 16%. If sedation was used, 98% of study participants fell asleep compared to 66% of unsedated participants. CONCLUSIONS: Dynamic sleep MRI has demonstrated that nearly all patients have retropalatal obstruction, retroglossal obstruction is common and hypopharyngeal obstruction is rare. Nearly all patients (98%) who are sedated are able to fall asleep during the MRI. There is significant heterogeneity in the literature and standardization is needed.

Implementing a Protocol to Reduce Opioid Prescriptions in Military Otolaryngology: A Quality Improvement Initiative.

INTRODUCTION: To compare pain medication refill rates for adult septoplasty and rhinoplasty patients before and after initiating a multimodal analgesic protocol for reducing opioid prescriptions (PROP). MATERIALS AND METHODS: Data from 58 adult patients were retrieved by retrospective chart review (19 septoplasties and 10 rhinoplasties before initiating PROP in September 2018 and 21 septoplasties and 8 rhinoplasties after PROP). We selected consecutive septoplasties and rhinoplasties, at which time a new discharge order set was implemented. The new order set consisted of 10 oxycodone tabs (5 mg), 100 acetaminophen tabs (325 mg), and 28 celecoxib tabs (200 mg). The primary outcome variable was the number of initial opioid prescriptions and refills filled by any provider. RESULTS: Among the septoplasties, there was a 46% decrease in total morphine milligram equivalent (MME) prescribed, from a mean of 202.0 mg in the non-PROP group (95% CI, 235.4, 174.6) to 108.6 mg in the PROP group (95% CI, 135.8, 81.4), with no difference in refill rates. Among the rhinoplasties, there was a 51% decrease in total MME prescribed, from a mean of 258.8 mg in the non-PROP group (95% CI, 333.4, 184.1) to 126.6 mg in the PROP group (95% CI, 168.1, 85.0) with no difference in refill rates. CONCLUSIONS: The outcomes after PROP implementation for septoplasty and rhinoplasty at our institution suggest that opioid prescription rates can be significantly decreased to manage postoperative pain, with no difference in opioid refill rates. The results also warrant further investigation into patient pain, satisfaction, provider efficiency, and healthcare costs.

Myofunctional therapy for OSA: a meta-analysis.

INTRODUCTION: Myofunctional therapy (MT) improves obstructive sleep apnea (OSA) in patients. AREAS COVERED: We systematically reviewed publications to evaluate MT as a treatment for OSA. We identified relevant articles and performed a meta-analysis on apnea-hypopnea index (AHI) scores, lowest oxygen saturation (LSAT), and Epworth Sleepiness Scale (ESS). Search databases were retained as primary data sources with the search performed through 18 June 2021. EXPERT OPINION: Fifteen studies with 237 patients provided OSA outcomes before and after MT, which were analyzed for this meta-analysis. The mean AHI scores decreased from 28.0 ± 16.2/h to 18.6 ± 13.1/h. The AHI standard mean difference (SMD) is -1.34 (large effect) [95% CI -0.84, -1.85], (P < 0.00001). LSAT (197 patients) improved from 83.18 ± 6.10% to 85.13 ± 7.01%. The LSAT SMD is 0.44 [95% CI 0.75, 0.12], (P < 0.007). Sleepiness measured via ESS (156 patients) demonstrated a decrease from 12.71 ± 5.73 to 8.78 ± 5.80. The ESS SMD is -1.0 [95% CI -0.50, -1.50], (P < 0.0001).

Diagnostic Testing for COVID-19: Systematic Review of Meta-Analyses and Evidence-Based Algorithms.

BACKGROUND: Coronavirus Disease-19 (COVID-19), a disease caused by infection with the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), is a global pandemic. Diagnosis is critical and diagnostic techniques include reverse transcriptase polymerase chain reaction (RT-PCR), serologic antibody testing, and chest computed tomography (CT). Despite rigorous meta-analyses looking into these techniques, there is no summary and additionally no algorithm to help guide diagnostic testing. Our objective is to perform a systematic review of the literature and to provide evidence-based algorithms for diagnosing or ruling out COVID-19. METHODS: Data were gathered using PubMed and Ovid research databases using a predefined medical subject heading (MeSH) based search, and sources that were included in the study had their references reviewed to screen for more sources for this study. Sources were collected up to 23 August 2020. Two researchers searched through the databases for articles and data/articles meeting inclusion criteria were extracted. RESULTS: 395 articles were identified, and 10 studies were included. Meta-analyses of diagnostic tests were included in our systematic review. An overview was then provided for each diagnostic test. Sensitivities and specificities for RT-PCR, serologic antibody tests and chest CT were collected, and the data was stratified by categorical variables. Two evidence-based algorithms were developed for symptomatic and asymptomatic patients in the hospitalized and ambulatory settings. CONCLUSIONS: This article provides a summary of the up-to-date efficacy of the most utilized diagnostic tests currently available for COVID-19. Additionally, this article provides evidence-based COVID-19 diagnostic algorithms for symptomatic and asymptomatic patients in the hospitalized and ambulatory settings.

The Value of Oxygen Desaturation Index for Diagnosing Obstructive Sleep Apnea: A Systematic Review.

OBJECTIVES: Intermittent hypoxemia is a risk factor for developing complications in obstructive sleep apnea (OSA) patients. The objective of this systematic review was to identify articles evaluating the accuracy of the oxygen desaturation index (ODI) as compared with the apnea-hypopnea index (AHI) and then provide possible values to use as a cutoff for diagnosing adult OSA. STUDY DESIGN: Systematic Review of Literature. METHODS: PubMed, the Cochrane Library, and SCOPUS databases were searched through November 2019. RESULTS: Eight studies (1,924 patients) met criteria (age range: 28-70.9 years, body mass index range: 21.9-37 kg/m2 , and AHI range: 0.5-62 events/hour). Five studies compared ODI and AHI simultaneously, and three had a week to months between assessments. Sensitivities ranged from 32% to 98.5%, whereas specificities ranged from 47.7% to 98%. Significant heterogeneity was present; however, for studies reporting data for a 4% ODI ≥ 15 events/hour, the specificity for diagnosing OSA ranged from 75% to 98%, and only one study reported the positive predictive value, which was 97%. Direct ODI and AHI comparisons were not made because of different hypopnea scoring, different oxygen desaturation categories, and different criteria for grading OSA severity. CONCLUSION: Significant heterogeneity exists in studies comparing ODI and AHI. Based on currently published studies, consideration should be given for diagnosing adult OSA with a 4% ODI of ≥ 15 events/hour and for recommending further evaluation for diagnosing OSA with a 4% ODI ≥ 10 events/hour. Screening with oximetry may be indicated for the detection of OSA in select patients. Further study is needed before a definitive recommendation can be made. Laryngoscope, 131:440-447, 2021.

Effect of myofunctional therapy on children with obstructive sleep apnea: a meta-analysis.

OBJECTIVE: To systematically review the current literature for articles describing the effect of myofunctional therapy on pediatric obstructive sleep apnea (OSA) and to perform a meta-analysis on the sleep study data. METHODS: Three authors (A.B., K.K. and M.C.) independently searched from inception through April 20, 2020 in PubMed/MEDLINE, Scopus, Embase, Google Scholar and The Cochrane Library. Mean difference (MD), standard deviations and 95% confidence intervals were combined in the meta-analysis for apnea-hypopnea index (AHI), mean oxygen saturations, and lowest oxygen saturations (nadir O2). RESULTS: 10 studies with 241 patients met study criteria and were further analyzed. The AHI reduced from 4.32 (5.2) to 2.48 (4.0) events/hr, a 43% reduction. Random effects modeling demonstrated a mean difference in AHI of -1.54 (95% CI -2.24,-0.85)/hr, z-score is 4.36 (p < 0.0001). Mean oxygen saturation increased by 0.37 (95% CI 0.06,0.69) percent, z-score is 2.32 (p = 0.02). There was no significant increase in nadir O2. CONCLUSIONS: Despite heterogeneity in exercises, myofunctional therapy decreased AHI by 43% in children, and increased mean oxygen saturations in children with mild to moderate OSA and can serve as an adjunct OSA treatment.

Impact of Alcohol Consumption on Snoring and Sleep Apnea: A Systematic Review and Meta-analysis.

OBJECTIVE: To systematically review the international literature for studies evaluating the effect of alcohol consumption on the occurrence and severity of snoring and obstructive sleep apnea and to use the available data to perform a meta-analysis. DATA SOURCES: MEDLINE, Embase, The Cochrane Library, CINAHL/EBASCO, and Scopus. REVIEW METHODS: The protocol was registered in PROSPERO in March 2018. Following PRISMA guidelines, 2 independent researchers conducted a search from their inception through July 2018. Polysomnography (PSG) data were collected for sleep stages, apnea-hypopnea index (AHI), respiratory disturbance index, and/or lowest oxygen saturation (LSAT). Data concerning the frequency and severity of snoring intensity and sleep architecture were also collected. Only studies with PSG data were evaluated, with exclusion of studies with home sleep testing data. A multivariate regression and pooled analysis with forest plot was performed. RESULTS: A total of 1266 manuscripts were screened, and 13 manuscripts with 279 patients met inclusion criteria. Pooled analysis of AHI for control versus alcohol consumption revealed a mean difference (MD) of 3.98 events per hour (95% CI, 3.27 to 4.68; P < .001). Pooled analysis of LSAT for control versus alcohol consumption revealed an MD of -2.72% (95% CI, -3.69 to -1.76; Z score, 5.53; P < .00001). CONCLUSION: Alcohol consumption is associated with worsening severity of snoring, altered sleep architecture, AHI, as well as lowest oxygen saturation among patients susceptible to snoring and obstructive sleep apnea.

The Impact of Playing a Musical Instrument on Obstructive Sleep Apnea: A Systematic Review.

STUDY OBJECTIVES: To conduct a systematic review of the medical literature evaluating the effects of playing a musical instrument on obstructive sleep apnea (OSA). DATA SOURCES: Scopus, CINAHL, PubMed, and OVID. REVIEW METHODS: Searches were performed through October 22, 2019. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement was followed. RESULTS: After thorough investigation amidst specific exclusion criteria, four studies were included in the systematic review: one randomized controlled trial and three cross-sectional studies. Polysomnography was used to assess apnea-hypopnea index (AHI) related to obstructive sleep apnea (OSA) in the randomized controlled trial, while the Berlin questionnaire was used to assess high- and low risk OSA in the cross-sectional studies. Various instrument types were mentioned in these studies, largely focusing on wind instruments and subgroups within the wind instrument family. CONCLUSION: Current literature, although sparse, suggests that playing certain types of wind instruments are associated with either improving patients' AHI or reducing the risk of developing OSA. Future studies with larger sample sizes utilizing validated diagnostic tools to measure the presence and severity of OSA are necessary to determine the true impact of such interventions. Although more research is needed, sustainable and minimally invasive interventions such as playing a specific type of musical instrument could serve as an accessible, inexpensive, and effective adjunctive treatment for OSA.

Nasal cannula technique for ventilating during the administration of general anesthesia in neonates and pediatric patients.

Objective: Minor surgeries on the oral cavity, e.g., frenulectomies, are often performed under general mask anesthesia. The objective is to present the nasal cannula technique for ventilating step-by-step method for ventilating during general anesthesia for minor surgeries in neonates and pediatric patients. Technique: The nasal cannula technique for ventilating has been used in over 20 pediatric cases (neonates and toddlers), without the need to re-mask during the procedure and without complications or oxygen desaturations. After induction of general mask anesthesia, propofol with or without adjunctive ketamine is administered. The anesthesia mask is exchanged with a nasal cannula, using the largest sized prongs that accommodate the nares, and the nasal cannula is connected to the anesthesia circuit. This permits administration of inspired fractions of oxygen. Conclusion: The nasal cannula technique for ventilating provides a safe method for delivering general anesthesia and ventilating during minor surgeries for neonates and pediatric patients.

Lingual frenuloplasty with myofunctional therapy: Exploring safety and efficacy in 348 cases.

BACKGROUND: Ankyloglossia is a condition of altered tongue mobility due to the presence of restrictive tissue between the undersurface of the tongue and the floor of mouth. Potential implications of restricted tongue mobility (such as mouth breathing, snoring, dental clenching, and myofascial tension) remain underappreciated due to limited peer-reviewed evidence. Here, we explore the safety and efficacy of lingual frenuloplasty and myofunctional therapy for the treatment of these conditions in a large and diverse cohort of patients with restricted tongue mobility. METHODS: Four hundred twenty consecutive patients (ages 29 months to 79 years) treated with myofunctional therapy and lingual frenuloplasty for indications of mouth breathing, snoring, dental clenching, and/or myofascial tension were surveyed. All procedures were performed by a single surgeon using a scissors and suture technique. Safety and efficacy was assessed >2 months postoperatively by means of patient-reported outcome measures. RESULTS: In all, 348 surveys (83% response rate) were completed showing 91% satisfaction rate and 87% rate of improvement in quality of life through amelioration of mouth breathing (78.4%), snoring (72.9%), clenching (91.0%), and/or myofascial tension (77.5%). Minor complications occurred in <5% of cases including complaints of prolonged pain or bleeding, temporary numbness of the tongue-tip, salivary gland issues, minor wound infection or inflammation, and need for revision to excise scar tissue. There were no major complications. CONCLUSION: Lingual frenuloplasty with myofunctional therapy is safe and potentially effective for the treatment of mouth breathing, snoring, clenching, and myofascial tension in appropriately selected patient candidates. Further studies with objective measures are merited. LEVEL OF EVIDENCE: 3.

Nocturnal dialysis improves sleep apnea more than daytime dialysis: a meta-analysis of crossover studies.

PURPOSE: To systematically review the literature for articles evaluating differences in polysomnography (PSG) data when patients are on primarily daytime hemodialysis (conventional hemodialysis or continuous ambulatory peritoneal dialysis) versus nocturnal hemodialysis (nocturnal hemodialysis or nocturnal peritoneal dialysis). Then to perform a meta-analysis on the available PSG data, specifically evaluating differences in apnea hypopnea index (AHI) and mean saturation of oxygen (SpO2) between these two groups. METHODS: Two authors systematically searched MEDLINE/Pubmed, Scopus, EMBASE, CINAHL, and Cochrane. Searches were performed through December 6, 2018. RESULTS: A total of four adult crossover studies (91 patients, age 50.4 ± 12.4, BMI 25.1 ± 5.3) reported PSG data. The daytime hemodialysis (DHD) and nocturnal hemodialysis (NHD) AHI decreased from 24.6 ± 18.2 to 12.6 ± 11.8 (events/hour) with a mean difference of -11.9 [95% CI -13.47, -10.37], Z score of 15.07 (P < 0.00001). The standardized mean difference was -1.35 [95% CI -2.70, 0.01]. Two studies reported mean SpO2 changes during PSG. The DHD and NHD SpO2 increased from 92.7 ± 2.4 to 94.7 ± 2.2 with a mean difference of 2.26 [95% CI -0.18, 4.71], Z score 1.82 (P = 0.07). CONCLUSION: In the current literature, nocturnal hemodialysis improves AHI more than daytime hemodialysis. A trend towards improvement in mean SpO2 with nocturnal dialysis was noted, but did not reach statistical significance. Consideration can be given for transitioning patients who have end stage renal disease and sleep apnea from daytime to nocturnal hemodialysis as an adjunct to other treatment modalities.

Genial tubercle position and genioglossus advancement in obstructive sleep apnea (OSA) treatment: a systematic review.

BACKGROUND: To systematically review the literature for methods to localize the genial tubercle as a means for performing an advancement of the genioglossus muscle. METHODS: PubMed, Google Scholar, CRISP, EMBASE, CINAHL, and Scopus were searched from inception through June 16, 2015. RESULTS: One hundred fifty-two articles were screened, and the full text versions of 12 articles were reviewed in their entirety and 7 publications reporting their methodology for localizing the genial tubercle. Based upon these measurements and the results published from radiographic imaging and cadaveric dissections of all the papers included in this study, we identified the genial tubercle as being positioned within the mandible at a point 10 mm from the incisor apex and 10 mm from the lower mandibular border. CONCLUSION: Based upon the results of this review, the genial tubercles were positioned within the mandible at a point 10 mm from the incisor apex and 10 mm from the lower mandible border. It may serve as an additional reference for localizing the genial tubercle and the attachment of the genioglossus muscle to the mandible, although the preoperative radiological evaluation and the palpation of the GT are recommended to accurately isolate.

Laser-assisted uvulopalatoplasty (LAUP) complications and side effects: a systematic review.

Objective: Laser-assisted uvulopalatoplasty (LAUP) has been used as a treatment option for snoring and obstructive sleep apnea for almost three decades. It has been previously reported that some patient's sleep-disordered breathing worsened following surgery. The aim of this paper is to further elucidate the specific complications of LAUP. Data sources: A systematic search of the electronic databases MEDLINE/PubMed, Google Scholar, and Embase. Review methods: The PRISMA statement was followed. Databases were searched from inception through September 2, 2018. The following search was applied to MEDLINE/PubMed ((laser AND uvul*) OR (LAUP) OR (LAVP) OR (laser AND (apnea OR apnoea OR sleep))). Results: Forty-two studies with a mean follow-up of 16.1 months reported complications on 3,093 total patients who underwent LAUP. The percentages and associated complications of LAUP are as follows: bleeding (2.6%), candidiasis (0.3%), dryness (7.2%), dysgeusia (0.3%), dysosmia (0.2%), globus sensation (8.2%), surgical site infection (1.3%), velopharyngeal (VP) insufficiency (3.9%), and VP stenosis (1.6%). The mean duration of patient-reported pain in studies that reported pain was 11.65 days. Only globus and VP insufficiency had a significant incidence compared with either the general population or the post-oropharyngeal surgery population with relative risks of 1.48 and 2.25, respectively. Overall, there were approximately 26 complications per 100 patients who underwent LAUP. Conclusion: LAUP is associated with a statistically significant rate of VP insufficiency and globus sensation; however, studies lack details of surgical approaches, suggesting that in a population identified as good candidates, a tissue-sparing approach may result in fewer complications.

Unilateral vs Bilateral Supraglottoplasty: A Meta-analysis of Rates of Return to Surgery and Supraglottic Stenosis.

OBJECTIVE: To perform a systematic review with meta-analysis of data to determine the rates of repeat surgery and supraglottic stenosis in unilateral versus bilateral supraglottoplasty for laryngomalacia. DATA SOURCES: PubMed/Medline, Cochrane Central, Scopus, Google Scholar, Web of Science, and Embase. REVIEW METHODS: Databases were searched through January 30, 2018. Studies with unilateral or bilateral supraglottoplasty techniques for laryngomalacia were included. The need for repeat (revision or completion) surgery and rates of supraglottic stenosis were primary outcomes. Data were substratified and a meta-analysis performed. RESULTS: A total of 251 articles were reviewed, and 20 articles met inclusion criteria (1186 patients: 663 bilateral, 523 unilateral). Regarding the need to return to surgery, the rate of revision for bilateral surgery was 4.1%, compared to the revision and combined revision/completion rates for unilateral surgery which respectively were 1.1% (odds ratio [OR] 0.27; 95% CI 0.11-0.67; P = .002) and 18.0% (OR 5.16; 95% CI 3.31-8.06; P < .0001). The unilateral versus bilateral supraglottic stenosis rates were 0% versus 1.2% (P = .011). CONCLUSION: Unilateral supraglottoplasty has a significantly higher rate of repeat surgery, mainly attributed to contralateral surgery, when compared with bilateral supraglottoplasty. There is a small but statistically significant risk of supraglottic stenosis in bilateral procedures. The benefit of a unilateral procedure should be weighed against the cost of subjecting patients to a 4-fold increased risk of repeat surgery.

Changing practice: Trends in skeletal surgery for obstructive sleep apnea.

OBJECTIVES/HYPOTHESIS: The objective of this study was to systematically review the English literature for articles that have described skeletal surgeries in the treatment of obstructive sleep apnea in both adults and children. From these articles trends and patterns in the treatment of OSA with skeletal procedures are described. STUDY DESIGN: Three databases including MEDLINE, Google Scholar and the Cochrane Library were searched through May 1, 2018. METHODS: The systematic and independent literature reviews were performed and the determination of included studies was made by consensus. Relevant studies were examined based on six categories of skeletal surgery: 1) Hyoid Advancement 2) Genioplasty/Genioglossus Advancement 3) Maxillary Expansion 4) Maxillomandibular Advancement 5) Mandibular Distraction and 6) Maxillomandibular Expansion. RESULTS: 1875 studies were analyzed for inclusion of which 414 were ultimately included in our analysis. A steady increase in the publication of articles pertaining to maxillary expansion and maxillomandibular advancement was identified. Research interest in hyoid advancement and genioplasty/genioglossus advancement has declined in the past decade. CONCLUSIONS: Changing trends in skeletal surgery for OSA offer exciting and efficacious therapeutic surgical modalities. MMA is the most widely studied and efficacious multi-level surgery for OSA today. Newer modalities such as adult maxillary expansion offer encouraging early results with minimal complication rates, and further study should be directed in this area.