Minimally invasive, single-stage, multilevel surgery for obstructive sleep apnoea: A systematic review and meta-analysis.

OBJECTIVES: Minimally invasive, single-staged multilevel surgery (MISS MLS) could be an optimal treatment for selected patients with obstructive sleep apnea (OSA). We aim to systematically review the efficacy of MISS MLS for patients with OSA, as well as the clinical outcomes and possible complications in OSA patients before and after MISS MLS. DESIGN AND SETTING: Systematic review and meta-analysis. Six databases were searched, and the PRISMA guideline was followed. PARTICIPANTS: Patients with OSA receiving MISS MLS. MAIN OUTCOME MEASURES: The random-effects model was adopted for the statistical synthesis. The percentage and 95% confidence interval (CI) were adopted as the effect measurements of MISS MLS for OSA. Subgroup analyses and sensitivity analyses were also performed to identify the heterogeneity among the studies. RESULTS: There were initially 154 articles for identification. Eventually, six studies with a total of 848 OSA patients completely met the inclusion criteria and were further enrolled for analysis. The pooled analysis showed statistically significant lower AHI (apnea/hypopnea index, /hr.; mean difference: -8.931, 95% CI: -11.591 to -6.271, I2 = 87.4%), ESS (mean difference: -2.947, 95% CI: -4.465 to -1.429, I2 = 94.9%), and snoring severity with 0-10 visual analog scale after surgery (mean difference: -4.966, 95% CI: -5.804 to -4.128, I2 = 96.4%). The success rate was 46% in mild/moderate OSA; however, 18% in severe OSA. There were no major complications occurred. CONCLUSIONS: The acceptable surgical outcomes, esp. in mild/moderate OSA, and rare complications are the major advantages of MISS MLS. The evidence of this study could aid the decision making in selecting suitable treatment programs for OSA patients.

Inflammatory biomarkers of neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios in 563 severe OSA patients before and after surgery.

BACKGROUND: Evidence has proved that high neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were risk factors for cardiovascular comorbidities. The alterations of NLR and PLR following obstructive sleep apnea (OSA) treatment were under studied and thus should be investigated. This study aimed to evaluate the changes of inflammatory biomarkers including NLR and PLR in severe OSA patients after surgical interventions of the upper airway, and their relationships with improvements in polysomnographic (PSG) parameters. METHODS: This retrospective cohort study included 563 consecutive severe OSA patients at a tertiary academic medical center who received OSA surgery, as well as underwent pre- and post-operative polysomnographic (PSG) examinations and blood tests. The changes of major PSG estimates, NLR, and PLR before and at least 3 months after OSA surgery were analyzed using paired t-tests with subgroup analyses. Pearson's correlations were performed to discover which PSG parameter contributed to the improvement of the values. RESULTS: After OSA surgery, the major PSG estimates, NLR and PLR dropped significantly in the overall population. In those with a higher preoperative NLR (pre-operative NLR≧3) and PLR (pre-operative PLR≧150), the mean (SD) difference of NLR (- 0.8 [1.6], 95% CI - 1.5 to - 0.2) and PLR (- 41.6 [40], 95% CI - 52.8 to - 30.5) were even more substantial. The changes of the "apnea, longest (r = 0.298, P = .037)" and "hypopnea, longest (r = 0.321, P = .026)" were found significantly related to the improvement of PLR. CONCLUSION: NLR and PLR did significantly drop in severe OSA patients following OSA surgery, and this could be related to the alterations of sleep indices. The findings could possess clinical importance for severe OSA patients after OSA surgeries in reducing possible OSA-associated cardiovascular comorbidities.

Homocysteine Levels in Severe OSA Patients Before and After TORS-OSA Surgery.

OBJECTIVE: The increased risk of cardiovascular diseases owing to a high level of serum homocysteine has been widely reported. Literature has demonstrated that patients with obstructive sleep apnea/hypopnea syndrome (OSA) had a higher homocysteine level than control group. This study aimed to investigate the alteration of serum homocysteine levels in severe OSA patients receiving transoral robotic surgery (TORS). STUDY DESIGN: Retrospective chart review. SETTING: Tertiary academic medical center. METHODS: Data of polysomnography (PSG) and serum homocysteine levels before and at least 3 months after the surgery were collected and analyzed via paired t tests. A subgroup analysis based on the preoperative homocysteine level (≥15 mcmol/L, as hyperhomocysteinemia group) was conducted to compare the intergroup differences of homocysteine decrease. Pearson's correlation was used to survey the relationships between the changes of major PSG parameters and the levels of homocysteine decrease at baseline and after TORS-OSA surgery. RESULTS: Two hundred sixty-one patients with severe OSA were enrolled. There were significant improvements in major PSG parameters after TORS-OSA surgery. Homocysteine levels significantly decreased from 12.1 ± 3.9 to 11.4 ± 3.7 mcmol/L (difference = -0.7 ± 2.8 mcmol/L, p = .001) postoperatively, which was shown in the hyperhomocysteinemia group (difference = -2.9 ± 4.7 mcmol/L, p = .007) to a greater extent. Pearson's correlation revealed that ΔODI (oxygen desaturation index/h) was the predominant estimate with a positive association with Δhomocysteine (r = 0.525, p = .012). CONCLUSION: TORS-OSA surgery could decrease homocysteine levels in OSA patients. The effects were more relevant in severe OSA patients with abnormal preoperative homocysteine levels.

Decreased Peripapillary and Macular Vascular Densities in Patients with Moderate/Severe Obstructive Sleep Apnea/Hypopnea Syndrome.

Purpose: To compare peripapillary and macular vascular densities (PVDs and MVDs) between patients with obstructive sleep apnea/hypopnea syndrome (OSA) and control subjects with symptoms of sleep-related breathing disorders only by swept-source optical coherence tomography angiography (OCTA). Participants and Methods: In this prospective study, 192 participants underwent a full-night polysomnography to determine OSA severity and subsequently received OCTA measurements as well as AngioTool software analysis. Results: A total of 146 patients with OSA (51 mild, 43 moderate, 52 severe) and 24 control subjects (apnea/hypopnea index, AHI <5) were enrolled. PVDs and MVDs in the superficial and choroidal layers were significantly different among the four groups. When participants with simple snoring/mild OSA (AHI <15) were grouped together and compared with moderate/severe OSA (AHI ≥15), PVDs were significantly lower for the latter group in the superficial layer (p = 0.0003), deep layer (p = 0.004), and choroidal layer (p = 0.003). MVDs were also lower for the moderate/severe OSA group in the superficial (p = 0.012) and choroidal layer (p = 0.004). Negative correlations were identified between AHI and PVDs in the superficial layer (ρ = -0.257, p = 0.0007), deep layer (ρ = -0.197, p = 0.0102) and choroidal layer (ρ = -0.220, p = 0.0039) and between AHI and MVDs in the superficial layer (ρ = -0.199, p = 0.0094) and choroid layer (ρ = -0.186, p = 0.0152). Conclusion: PVDs and MVDs were significantly lower in patients with moderate/severe OSA as compared to subjects with simple snoring/mild OSA. Furthermore, decreased PVDs and MVDs significantly correlated with OSA severity.

Alterations of Ocular Surface and Tear Film in Patients with Obstructive Sleep Apnea/Hypopnea Syndrome.

Purpose: Obstructive sleep apnea/hypopnea syndrome (OSA) results in repeated oxygen desaturation, repeated arousals, and episodic nocturnal activation of sympathetic nervous system during sleep. Untreated OSA is strongly associated with an increase of cardio- and cerebrovascular disorders, as well as the damages of ophthalmological microstructures. However, previous literature only simply studied the association between the ophthalmic disorders and OSA. In the present study, we first investigated the alterations of ocular surface and tear film non-invasively with the innovated corneal topographer in untreated OSA patients and normal control subjects. Furthermore, we analyzed in depth whether the correlations between OSA severity and ocular surface exams exist. Participants and Methods: Participants underwent a full-night polysomnography to determine OSA occurrence and severity. All participants subsequently received Ocular Surface Disease Index questionnaire and comprehensive ocular exams, including floppy eyelid syndrome (FES) assessment, oculus scan for tear meniscus height, non-invasive keratograph tear film breakup time (NIKBUT), and ocular surface redness, endothelial cell density, and corneal fluorescein staining. Results: One hundred eighty-one participants were prospectively enrolled in the study. FES was found in 11.5% of the normal control group and 60.0% of the severe OSA group (p=0.0005). There were significant differences in the first-NIKBUT (F-NIKBUT) (p < 0.0001), average-NIKBUT (A-NIKBUT) (p = 0.0007), and redness scores over the nasal bulbar (p = 0.032), temporal bulbar (p < 0.0001), nasal limbal (p = 0.014), and temporal limbal (p < 0.0001) areas among the four groups. F-NIKBUT and A-NIKBUT were significantly shorter in the moderate/severe OSA group (apnea/hypopnea index (AHI) ≥15) than in the normal/mild OSA group (AHI <15) (both p < 0.0001). The redness scores over the temporal bulbar (p < 0.0001) and temporal limbal (p < 0.0001) areas were also significantly different in these two OSA groups. Moreover, F-NIKBUT and A-NIKBUT negatively correlated with AHI. Nasal bulbar redness, temporal bulbar redness, nasal limbal redness, and temporal limbal redness positively correlated with AHI. Conclusion: OSA patients had higher occurrence of FES. The NIKBUT was significantly shorter, and the temporal conjunctival redness scores over bulbar and limbal areas were higher in the moderate/severe OSA group than in the normal/mild OSA group. NIKBUT and conjunctival hyperemia significantly correlated with the severity of untreated OSA.

Clinical Predictors of OSA Treatment Success Following Implantation of a Hypoglossal Nerve Stimulation Device.

OBJECTIVE: To identify prognostic indicators associated with successful hypoglossal nerve stimulation (HGNS) therapy to treat obstructive sleep apnea (OSA), focusing on patients' physiologic response to awake tongue protrusion. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary care center. METHODS: We included consecutive patients with moderate-severe OSA who underwent HGNS implantation from December 2017 to December 2019. Data abstracted include standard demographics, body mass index (BMI), pre- and postoperative apnea-hypopnea index (AHI), and Friedman tongue position (FTP). Additionally, change in hypopharyngeal cross-sectional area on awake tongue protrusion was abstracted. Patients protruded their tongues, and the physician visualized change. Positive change in hypopharyngeal cross-sectional area was documented as +1 and a negative change as -1. Chi-square tests for independence and logistic regression analysis were performed to determine indicators of successful surgery. RESULTS: Thirty-nine patients were included in this study. Mean ± SD AHI decreased significantly from 43.1 ± 17.36 to 9.18 ± 8.18. Surgical success was achieved in 79.5% of patients. Variables analyzed included BMI >32, preoperative AHI, FTP, and change in hypopharyngeal cross-sectional area on awake tongue protrusion (positive, 65.8%; negative, 34.2%). Positive predictors of success were positive change in hypopharyngeal cross-sectional area (P = .0133), severe OSA (P = .0290), and FTP IIb (P < .0001). Negative predictors were BMI >32 (P = .041) and negative change in hypopharyngeal cross-sectional area (P = .02). CONCLUSION: Positive change in hypopharyngeal cross-sectional area on awake tongue protrusion and severe baseline AHI were positive predictors of successful HGNS therapy. Negative change in hypopharyngeal cross-sectional area on awake tongue protrusion and BMI >32 were negative predictors.

Effects of TORS-OSA Surgery on Lower Urinary Tract Symptoms, Overactive Bladder Symptoms, and Nocturia in Male Patients with Obstructive Sleep Apnea/Hypopnea Syndrome.

Objective: To determine the presence of lower urinary tract symptoms (LUTS), and overactive bladder (OAB) symptoms in men with obstructive sleep apnea/hypopnea syndrome (OSA) and the effects of transoral robotic surgery (TORS) for the treatment of OSA on these conditions. Materials and Methods: One hundred twenty-three patients with a diagnosis of OSA were prospectively enrolled. The evaluations of LUTS and OAB symptoms were based on self-administered questionnaires containing international prostate symptom score (IPSS) and OAB symptom score (OABSS), respectively. Men with an OABSS urgency score of ≥2 and sum score of ≥3 were considered to have OAB. The therapeutic outcomes were assessed at baseline, and 12 weeks after TORS-OSA Surgery. Results: There were significant differences in IPSS, and OABSS according to OSA severity. After TORS-OSA surgery, significant improvements on OSA severity, daytime quality of life (QoL) and nighttime sleep quality were observed. TORS-OSA surgery was also associated with a statistically significant improvement of LUTS, LUTS QoL score, and OAB symptoms (IPSS 22.1% decrease; IPSS QoL score 21.1% decrease; OABSS17.4% decrease) at post-operative 3 months' follow-up. The presence of OAB, and severe nocturia was significantly reduced from 22.8% to 11.4% (p=0.001), 5.7% to 0.8% (p=0.031) after TORS-OSA surgery. There were no patients who had acute airway compromise or massive bleeding peri- or post-operatively. Conclusion: TORS upper airway surgery could improve LUTS and OAB symptoms on male patients with OSA in addition to improvement of major parameters of sleep study and sleep-related QoL.

Systematic review and updated meta-analysis of multi-level surgery for patients with OSA.

OBJECTIVES: To perform an updated systematic review for determining the surgical success rate of multilevel upper airway surgery for patients with obstructive sleep apnea/hypopnea syndrome (OSA). METHODS: A systematic review was performed to identify English-language studies that evaluated the treatment of adult OSA patients with multilevel OSA surgery up to January, 2018. We used polysomnography as a metric of treatment success. Articles were only included if the surgery intervention involved at least two of the frequently involved anatomic sites: nose, oropharynx and hypopharynx. Eighty-seven studies fit the inclusion criteria and a meta-analysis was performed to determine the overall success. RESULTS: The meta-analysis included 3931 subjects with a mean age of 46.1 years. The originally reported success rate in the included literature was 59.9%. A meta-analysis was performed to redefine the success rate to be consistent with the commonly agreed upon criteria - namely "a reduction in apnea/hypopnea index (AHI, /hr.) of 50% or more and an AHI of less than 20". The recalculated success rate was 60.2%. Standard meta-analytic techniques for combining p-values between studies after weighting for sample size found significant improvements in AHI, apnea index, % of rapid eye movement sleep, lowest saturation of oxygen (%), and Epworth Sleepiness Scale. CONCLUSION: This study shows the significant improvement of treatment outcomes with multilevel surgery for OSA patients.

OSA Treatment on Cardio- and Cerebrovascular Comorbidities: A Long-term Nationwide Cohort Study.

OBJECTIVE: To compare the cardio- and cerebrovascular outcomes and survival rates of surgical and nonsurgical interventions for patients with obstructive sleep apnea (OSA) based on a national population-based database. STUDY DESIGN: Retrospective cohort study. SETTING: Taiwan National Health Insurance Research Database. METHODS: We analyzed all cases of OSA among adults (age >20 years and confirmed with ICD-9-CM) from January 2001 to December 2013. We compared the patients with OSA who received upper airway surgery with age-, sex-, and comorbidity index-matched controls with continuous positive airway pressure (CPAP) treatment. The risk of myocardial infarction (MI) or stroke after treatment of OSA-related surgery versus CPAP was investigated. RESULTS: During follow-up, 112 and 92 incident cases of MI occurred in the OSA surgery and CPAP treatment groups, respectively (rates of 327 and 298 per 100,000 person-years). Furthermore, 50 and 39 cases were newly diagnosed with stroke in the OSA surgery and CPAP treatment groups (rates of 144 and 125 per 100,000 person-years). Cox proportional hazard regressions showed that the OSA treatment groups (OSA surgery vs CPAP) were not significantly related to MI (hazard ratio, 1.03 [95% CI, 0.781-1.359]; P = .833) and stroke (hazard ratio, 1.12 [95% CI, 0.736-1.706]; P = .596) at follow-up, after adjustment for sex, age at index date, days from diagnosis to treatment, and comorbidities. CONCLUSION: Our study demonstrated that there was no difference of cardio- and cerebrovascular results between CPAP and surgery for patients with OSA in a 13-year follow-up. LEVEL OF EVIDENCE: 3.

Computer-Assisted Quantitative Analysis of Drug-Induced Sleep Endoscopy for Obstructive Sleep Apnea/Hypopnea Syndrome.

OBJECTIVES: To use computer-assisted quantitative measurements of upper airway changes during drug-induced sleep endoscopy (DISE) and to correlate these parameters with disease severities and physiologic changes in patients with obstructive sleep apnea/hypopnea syndrome (OSA). DESIGN: A retrospective study. SETTING: Tertiary academic medical center. PATIENTS AND METHODS: A total of 170 patients who failed continuous positive airway pressure therapy and then underwent upper airway surgery were enrolled. All patients received polysomnography and DISE preoperatively. We used ImageJ 1.48v to obtain maximal and minimal measurements, including cross-sectional areas and anterior-posterior and lateral diameters at 4 anatomic levels (retropalatal, oropharyngeal, retroglossal, and retroepiglottic) under DISE, and then computed the percentage changes. We analyzed the clinical values of DISE changes by computer-assisted analysis in patients with OSA and any correlations between these changes and polysomnography parameters. RESULTS: The percentage changes of upper airway showed significant collapses at all 4 anatomic levels (all P < .0001). We also found that the changes at retropalatal levels were significantly greater and that retroglossal levels were significantly smaller, while the changes of anterior-posterior diameters at retroglossal levels showed a significant positive association with apnea-hypopnea index and desaturation index. However, there were no statistically significant correlations between upper airway changes and obesity. CONCLUSION: Computer-assisted quantitative analysis could evaluate upper airway changes of OSA in an objective way and may help identify the sites of obstruction during DISE more accurately. Upper airway showed multilevel collapse with independent significant changes in patients with OSA, with the retropalatal and retroglossal levels playing important roles in particular.

Alternations of Blood Pressure Before and After OSA Surgery.

OBJECTIVE: To investigate the changes of blood pressure (BP) on patients with obstructive sleep apnea/hypopnea syndrome (OSA) before and after upper airway surgery. DESIGN: Case series with chart review. SETTING: Tertiary academic medical center. SUBJECTS AND METHODS: Patients with OSA who underwent upper airway surgery were enrolled. We retrospectively investigated the nighttime and daytime BP before and at least 3 months after OSA surgery. Paired t test was used to compare the changes of BP before and after surgery. Generalized estimating equation was used to examine the prognostic significance of the variables in predicting the changes of postoperative BP. RESULTS: In total, 176 patients with OSA (149 men, 27 women; mean age, 42.9 years; mean apnea/hypopnea index, 43.1/h) were enrolled in this study. The overall nighttime and daytime BP decreased significantly before and after OSA surgery (daytime systolic BP was reduced from 137.3 ± 14.0 mm Hg to 132.7 ± 17.0 mm Hg, P < .01; nighttime systolic BP was reduced from 138.7 ± 16.0 mm Hg to 133.7 ± 15.3 mm Hg, P < .01; daytime diastolic BP was reduced from 87.7 ± 14.7 mm Hg to 84.9 ± 10.6 mm Hg, P = .01; nighttime diastolic BP was reduced from 85.4 ± 12.9 mm Hg to 83.1 ± 11.1 mm Hg, P = .02). The changes of nighttime systolic and diastolic BP were significantly associated with the improvement of percentage of O2 saturation <90% during polysomnography. CONCLUSION: Surgical modifications of the upper airways for patients with OSA could benefit blood pressure.

Effects of CPAP for patients with OSA on visual sensitivity and retinal thickness.

OBJECTIVE: Obstructive sleep apnea/hypopnea syndrome (OSA) could compromise oxygenation of the optic nerve and cause glaucomatous optic neuropathy; there has been no study to investigate the microstructure changes of the optic nerve and retina in OSA patients before and after continuous positive airway pressure (CPAP) therapy. In this study, we assess whether treatment with CPAP might improve visual sensitivity and retinal thickness in patients with OSA. METHODS: Patients with OSA were prospectively recruited and referred for ophthalmologic evaluation at baseline and three months after CPAP treatment. Each patient underwent an ophthalmological exam, standard automated perimetry (SAP), and optical coherence tomography (OCT) exam. Peripapillary retinal nerve fiber layer (RNFL) and macular layer (ML) thickness parameters were measured. The SAP, RNFL, and ML thickness parameters before and after treatment were compared. RESULTS: A total of 32 OSA patients were consecutively enrolled. At baseline, the mean deviation (MD) of SAP was -2.15 ± 1.90 dB (dB). After CPAP treatment, the MD was -1.38 ± 1.37 dB (p = 0.017). Regarding the OCT parameters, the inferior quadrant and nasal-inferior sector of RNFL thickness significantly improved after treatment (p = 0.025 and 0.004, respectively). The ML thickness in the superior-inner sector, inferior-outer sector, nasal-outer sector, superior hemisphere, and inferior hemisphere were also significantly improved after treatment. Improvement of ML thickness in the superior-inner sector positively correlated with the apnea/hypopnea index (r = 0.405, p = 0.022) and desaturation index (r = 0.473, p = 0.006) on pre-treatment polysomnography. CONCLUSION: The treatment of CPAP could improve visual sensitivity and increase retinal thickness in patients with OSA.

Alternations of Circadian Clock Genes Expression and Oscillation in Obstructive Sleep Apnea.

Circadian misalignment plays an important role in disease processes and can affect disease severity, treatment outcomes, and even survivorship. In this study, we aim to investigate whether expression and daily oscillation patterns of core circadian clock genes were disturbed in patients with obstructive sleep apnea/hypopnea (OSA) syndrome. We performed real-time quantitative reverse transcriptase-polymerase chain reactions to examine the expression of the nine core circadian clock genes in leukocytes of peripheral blood collected at 12 AM, 6 AM, 12 PM, and 6 PM from 133 patients with OSA and 11 normal controls. Daily expression patterns of the nine circadian clock genes were observed in normal controls, but three of these genes (BMAL1, CLOCK, CRY2) were disrupted in patients with OSA. The expressions of eight circadian clock genes (except PER1) at midnight were significantly downregulated in patients with severe OSA. Binary logistic regression analysis selected CRY1 and PER3 as independent factors for severe OSA and showed that the combined expressions of CRY1 and PER3 enhanced the capability of predicting severe OSA (Odds ratio, 5.800; 95% CI, 1.978 to 17.004; p = 0.001). Our results show that combined expressions of CRY1 and PER3 at midnight could be a potential predictor for severe OSA.

Effects of OSA Surgery on Ophthalmological Microstructures.

OBJECTIVE: Obstructive sleep apnea/hypopnea syndrome (OSA) could compromise oxygenation of the optic nerve and cause glaucomatous optic neuropathy; however, there were no studies to investigate the changes of visual function and retinal microstructures in OSA patients after upper airway surgery. We aim to assess the changes in the visual sensitivity and retinal fiber layer thickness in OSA patients before and after surgery. METHODS: This prospective single-blind study enrolled patients with OSA from a tertiary academic medical center who had unsuccessful conservative therapy and then underwent surgery. The patients were referred for comprehensive ophthalmologic evaluation at baseline and 6 months after OSA surgery. The polysomnographic findings were collected pre- and postoperatively. Visual sensitivities on standard automated perimetry (SAP) were assessed. Peripapillary retinal nerve fiber layer (RNFL) thickness and macular layer (ML) thickness parameters were measured by spectral-domain optical coherence tomography (OCT). RESULTS: A total of 108 OSA patients were enrolled. Six months after surgery, the major parameters of polysomnography (PSG), mean deviation, and pattern standard deviation of SAP significantly improved in these OSA patients. Regarding the OCT parameters, thickness of ML in the nasal-outer, superior-inner, temporal-inner, inferior-inner, nasal-inner sectors, and total ML thickness significantly increased 6 months after upper airway surgery in the severe OSA group (apnea/hypopnea index ⩾30 per hour). CONCLUSION: The visual sensitivities on SAP, ML thickness on OCT, and oxygenation status on PSG significantly improved 6 months after upper airway surgery in patients with severe OSA. Upper airway surgery may ameliorate the microstructures of the retina in patients with severe OSA.

Clinical Prediction Model for Obstructive Sleep Apnea among Adult Patients with Habitual Snoring.

OBJECTIVE: To identify standard clinical parameters that may predict the presence and severity of obstructive sleep apnea/hypopnea syndrome (OSA). DESIGN: Case series with chart review. SETTING: Tertiary academic medical center. SUBJECTS AND METHODS: A total of 325 adult patients (274 men and 51 women; mean age, 44.2 years) with habitual snoring completed comprehensive polysomnography and anthropometric measurements, including modified Mallampati grade (also known as updated Friedman's tongue position [uFTP]), tonsil size grading, uvular length, neck circumference, waist circumference, hip circumference, and body mass index (BMI). RESULTS: When the aforementioned physical parameters were correlated singly with the apnea/hypopnea index (AHI), we found that sex, uFTP, tonsil size grading, neck circumference, waist circumference, hip circumference, thyroid-mental distance, and BMI grade were reliable predictors of OSA. When all important factors were considered in a multiple stepwise regression analysis, an estimated AHI can be formulated by factoring sex, uFTP, tonsil size grading, and BMI grade as follows: -43.0 + 14.1 × sex + 12.8 × uFTP + 5.0 × tonsil size + 8.9 × BMI grade. Severity of OSA can be predicted with a receiver operating characteristic curve. Predictors of OSA can be further obtained by the "OSA score." CONCLUSION: This study has distinguished the correlations between sex, uFTP, tonsil size, and BMI grade and the presence and severity of OSA. An OSA score might be beneficial in identifying patients who should have a full sleep evaluation.

Effects of Upper Airway Surgery on Daytime Sleepiness in Nonobese Patients with Obstructive Sleep Apnea/Hypopnea Syndrome.

INTRODUCTION:: The aim of this study was to evaluate the effects of upper airway surgery on daytime sleepiness in nonobese patients with obstructive sleep apnea/hypopnea syndrome (OSA). METHODS:: This retrospective study included 121 consecutive adult nonobese patients with OSA from a tertiary academic medical center. Patients with OSA who refused continuous positive airway pressure therapy, or in whom it was unsuccessful, and then underwent OSA surgery were enrolled. Evaluations of excessive daytime sleepiness using the Epworth Sleepiness Scale (ESS) and major parameters of objective full-night polysomnography were collected preoperatively and at least 3 months postoperatively. Statistical analysis was performed using the Wilcoxon signed rank test and Wilcoxon rank sum test. RESULTS:: When pre- and postoperative ESS and polysomnographic parameters were compared in all patients, ESS scores, apnea/hypopnea index, and snoring index showed statistically significant improvements ( P = .007, P < .001, and P < .001, respectively). When patients were classified into mild, moderate, and severe OSA groups, snoring index had statistically significant improvements in all 3 groups, and apnea/hypopnea index had statistically significant decreases in the moderate and severe OSA groups. Although reductions in ESS scores were found in all 3 groups, the most statistically significant improvement was noted only in the severe OSA group. CONCLUSIONS:: OSA surgery can improve daytime sleepiness in nonobese patients with OSA, especially for patients with severe OSA. This study elucidates the effects of OSA surgery on daytime sleepiness by excluding the major confounding factor of obesity. This study adds to the literature on the effects of upper airway surgery for nonobese patients with OSA on daytime quality of life.

Clinical Predictors of Pediatric Obstructive Sleep Apnea Syndrome.

OBJECTIVE: To develop an adequate model using reliable clinical and physical factors to predict pediatric obstructive sleep apnea/hypopnea syndrome (OSAS). METHODS: Complete anthropometric measurements including BMI z score, tonsil size grading, and updated Friedman tongue position (uFTP) were evaluated. Subjective assessments of clinical symptoms/signs, including snoring visual analog scale (VAS), nasal obstruction, and mouth breathing, were recorded. RESULTS: Eighty-eight children (57 boys and 31 girls, mean age = 9.0 years) were confirmed to have OSAS by comprehensive polysomnography (PSG). When the aforementioned variables were analyzed individually, the results indicated that snoring VAS, nasal obstruction, mouth breathing, and BMI z score were reliable predictors of apnea/hypopnea index (AHI/h) values (correlation coefficient r = 0.386, P < .001; r = 0.416, P < .001; r = 0.255, P = .02; and r = 0.243, P = .02, respectively). When all significant factors were included in the stepwise multiple linear regression analysis, the final predictive model is: Pediatric AHI = 0.108 + 0.103 snoring VAS + 0.894 nasal obstruction + 0.207 BMI z score ( F = 4.06, P = .01). CONCLUSION: The proposed noninvasive, simple, inexpensive, and easy to perform screening tool could be used to predict pediatric OSAS. An abnormal calculated AHI may prompt clinical physicians to conduct further PSG diagnostics and treatment.

Parathyroidectomy for the treatment of hyperparathyroidism: Thirty-day morbidity and mortality.

OBJECTIVES/HYPOTHESIS: Evaluate morbidity and mortality rates for patients with different levels of hyperparathyroidism (HPT) undergoing parathyroidectomy (PTX), specifically comparing primary hyperparathyroidism to secondary and tertiary hyperparathyroidism. Assess predictive factors of increased morbidity and mortality. STUDY DESIGN: Retrospective national database review. METHODS: Patients undergoing PTX, defined by Current Procedural Terminology codes 60500, 60502, 60505, for the treatment of HPT, were identified in the American College of Surgeons National Surgical Quality Improvement Program database between 2006 and 2014. Incidence of morbidity and mortality was calculated for primary, secondary, and tertiary HPT. A t test, analysis of variance, and χ2 analyses were used to assess preoperative characteristics among the three groups. RESULTS: A total of 21,267 patients were included in the analysis. There was an overall 7.2% morbidity and mortality rate, including 45 (0.21%) deaths, a 1.8% readmission rate, and a 1.9% reoperation rate, but morbidity and mortality rates were widely divergent when comparing primary to secondary and tertiary HPT. PTX resulted in a 4.9% morbidity and mortality rate for primary HPT (n = 14,500), 26.8% morbidity and mortality rate for secondary HPT (n = 1661), and 21.8% morbidity and mortality rate for tertiary HPT (n = 588). The primary reason for readmission was hypocalcemia (18.3%). Hematoma (7.2%) and postoperative hemorrhage (3.3%) were the two most common causes of reoperation. Elevated preoperative serum creatinine, alkaline phosphatase, and hypertension resulted in a higher rate of complications after PTX (P < .0001). CONCLUSIONS: Although surgery for primary HPT is an extremely common and safe procedure with minimal morbidity and mortality rates, PTX for secondary and tertiary HPT has significantly higher rates of morbidity and mortality, requiring special attention in the postoperative period. Predictive factors of poor outcomes include hypertension, elevated creatinine, and elevated alkaline phosphatase. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:528-533, 2018.

Hearing Outcomes after Ossicular Reconstruction with Removal of the Malleus.

Objectives (1) Evaluate hearing outcomes of patients after planned malleus removal during ossicular chain reconstruction. (2) Analyze hearing results for titanium (Ti) and hydroxyapatite (HA) total ossicular prostheses (TOPs) and partial ossicular prostheses (POPs). (3) Compare Ti and HA partial prostheses. Study Design Retrospective case series with chart review. Setting Tertiary health care organization. Subjects and Methods A chart review was conducted of 139 consecutive patients who presented with chronic otitis media with perforation (with or without cholesteatoma) and were treated with initial-stage tympanoplasty (with or without mastoidectomy) and managed with TOP (n = 22) or POP (n = 117) between July 2010 and July 2015. The malleus was completely removed in all cases. Hearing was assessed via bone and air conduction pretone averages (0.5, 1, 2 kHz) pre- and postoperatively. Air-bone gap (ABG) and change in ABG (ΔABG) were analyzed. Pre- and postoperative values were compared. Results The overall mean ABG decreased from 29.4 ± 12.3 dB to 18.2 ± 11.4 dB postoperatively ( P < .001) with a mean ΔABG of 14.5 dB (95% CI, 12.793-16.203). Overall success was achieved by 69.1%. The POP group achieved higher success (70.9%) than the TOP group (59.1%; P = .0001). Mean ABG decreased significantly within surgical groups (TOP and POP) and prosthesis material groups (Ti and HA; all P < .001). Ti had statistically higher success than HA in both techniques: POP ( P = .0478) and TOP ( P = .0251). There was a 98% graft take rate. Conclusion Planned malleus removal during ossicular chain reconstruction, regardless of disease extent, allows for simpler reconstruction and comparable favorable results to preservation of the malleus and should be considered during surgical planning.

Effects of Minimally Invasive Surgery for Patients With OSA on Quality of Life.

OBJECTIVE: To retrospectively study the effects of minimally invasive single-stage multilevel surgery (MISS MLS) for treating patients with obstructive sleep apnea/hypopnea syndrome (OSA) on quality of life (QOL). METHODS: All OSA patients with multilevel obstruction who failed or refused continuous positive airway pressure (CPAP) treatment and then underwent Pillar implants and temperature-controlled radiofrequency of the base of tongue (RFBOT) were enrolled. The subjective symptoms and QOL (SF-36 Taiwan Standard Version 1.0) parameters were collected preoperatively and a minimum of 3 months postoperatively. Postoperative morbidity and complications were also recorded. RESULTS: Thirty-seven patients (30 men, 7 women; mean age = 46.8 years; mean BMI = 23.9 kg/m2) were enrolled. The mean Epworth Sleepiness Scale changed from 12 ± 4.3 to 10.6 ± 4.3 ( P = .004, Wilcoxon signed-rank test). The mean snoring visual analog scale reduced from 9.5 ± 1.3 to 4.0 ± 2.0 ( P < .0001). The mean score of SF-36 increased from 65.5 ± 19.6 to 75.2 ± 16.7 ( P = .001). The SF-36 subscales showed statistically significant changes, especially in bodily pain, role-emotional, and general health. CONCLUSION: The study demonstrated that MISS MLS was effective on QOL in selected patients for treating OSA patients who are unresponsive to conservative OSA therapy.