Approaches For Obstructive Sleep Apnea Research Articles

Cardiovascular disease and sleep apnea in patients with type 2 diabetes mellitus

The article provides information on concomitant conditions of type 2 diabetes mellitus such as cardiovascular diseases, sleep apnea syndrome. Questions about the types of sleep breathing disorders and factors predisposing to this condition are discussed. Data on the prevalence of sleep apnea in the world are demonstrated. The main approaches to the diagnosis of this condition are shown. Differences in therapy approaches for obstructive sleep apnea and central sleep apnea have been demonstrated. The issues of the relationship between obstructive sleep apnea, type 2 diabetes mellitus and cardiovascular diseases are considered. The data of clinical studies evaluating the relationship of sleep apnea and cardiovascular diseases are presented. Their mutually aggravating influence is shown. Information is provided on the effect of sleep apnea on the main clinical outcomes according to clinical research data. The relationship between sleep apnea and heart failure is discussed. The main issues of the inflammatory profile of sleep apnea are discussed, which are closely related to cardiovascular diseases and type 2 diabetes and include: macrophage recruitment and inflammatory biomarkers such as C-reactive protein, chemokines and cytokines such as interleukin 6, tumor necrosis factor α, nuclear kappa factor B, as well as adhesion molecules such as selectins, intracellular adhesion molecule-1 (ICAM-1) and intracellular vascular adhesion molecule (VCAM-1), imbalance between prooxidant and antioxidant factors. These factors contribute to the development of microvascular and macrovascular complications in type 2 diabetes mellitus. Special attention is paid in the publication to the discussion of the main factors predisposing to the development of sleep apnea in heart failure in patients with type 2 diabetes mellitus. The data on the main diagnostic tests for patients with heart failure and type 2 diabetes are presented. Information is provided on the use of drugs from the group of sodiumglucose cotransporter type 2 inhibitors in patients with type 2 diabetes and sleep apnea syndrome. Reasonable recommendations on the use of these drugs are presented, taking into account the modern strategy for the treatment of type 2 diabetes.

Anthropometric screening approach for obstructive sleep apnea in Japanese men: development and validation of the ABC scale

BackgroundThe existing screening tools for the detection of moderate and severe obstructive sleep apnea (OSA) are tailored to Western individuals. The aim of this study was to formulate and validate a simple anthropometric tool for OSA screening in a Japanese male population by incorporating objective indicators obtained during routine medical checkups.MethodsIn total, 443 Japanese men, who were suspected of having OSA and visited our sleep disorder clinic from 2009 to 2012, were retrospectively divided into two groups (development group [DG], n = 206; validation group [VG], n = 237). In the DG, OSA was defined as an apnea–hypopnea index of ≥ 15 events/h. Data regarding clinical and anthropometric variables (age, body mass index [BMI], neck circumference [NC], waist circumference [WC]) were obtained. For parameters that were associated with OSA on simple logistic regression analysis, cutoff values were calculated with receiver operating characteristic curves to create a new screening tool. The utility of the tool was evaluated in the VG and compared to that of the modified Berlin questionnaire (mBQ) for OSA.ResultsAge (odds ratio [OR] = 1.033, p = 0.002), BMI (OR = 1.231, p < 0.001), NC (OR = 1.327, p < 0.001), and WC (OR = 1.083, p < 0.001) were significant risk factors for OSA in the DG. Cutoff values for the prediction of OSA were age: ≥ 46.5 years, BMI: ≥ 25.45 kg/m2, NC: ≥ 38.35 cm, and WC: ≥ 90.75 cm. Our screening tool, incorporating age, BMI, and WC, yielded 70.1% sensitivity (mBQ: 85.4%) and 66.0% specificity (mBQ: 35.0%) in the VG.ConclusionsOSA screening in Japanese men has been conducted only in limited settings such as sleep clinics. The study findings support the implementation of screening in medical checkups using objective indices to enable early detection and treatment of OSA.

Determinants of apnea-hypopnea index variability during home sleep testing

BackgroundA single-night attended in-laboratory polysomnography or home sleep testing are common approaches for obstructive sleep apnea (OSA) diagnosis. However, internight variability in apnea-hypopnea index value is common, and may result in misclassification of OSA severity and inapropriate treatment decisions. ObjectiveTo investigate factors determining short-term apnea-hypopnea index variability using multi-night automated home sleep testing, and to determine how this variability impacts clinical decisions. Patients/methodsAdults with suspected OSA who successfully performed three home sleep tests using measurements of mandibular jaw movements (Sunrise, Namur, Belgium) combined with automated machine learning analysis were enrolled. Data analysis included principal component analysis, generalized estimating equation regression and qualitative agreement analysis. Results160 individuals who performed three sleep tests over a mean of 8.78 ± 8.48 days were included. The apnea-hypopnea index varied by −0.88 events/h (5th-95th percentile range: −14.33 to 9.72 events/h). Based on a single-night recording, rates of overtreatment and undertreatment would have been of 13.5% and 6.0%, respectively. Regression analysis adjusted for age, sex, body mass index, total sleep time, and time between home sleep tests showed that time spent in deep non-rapid eye movement sleep and with head in supine position were independent significant predictors of the apnea-hypopnea index variability. ConclusionsAt the individual level, short-term internight variability in the apnea-hypopnea index was significantly associated with time spent in deep non-rapid eye movement sleep and head in supine position. Clinical decisions based on a single-night testing may lead to errors in OSA severity classification and incorrect therapeutic decisions.

A Debate on Surgical and Nonsurgical Approaches for Obstructive Sleep Apnea: A Comprehensive Review.

Regular and unobstructed breathing during the night is the prerequisite for an undisturbed and restful sleep. The most prevalent nocturnal breathing disturbance with morbid consequences is obstructive sleep apnea syndrome. The prevalence of obstructive sleep apnea (OSA) is increasing, and a significant number of patients with OSA are undiagnosed. On the other hand, the "obesity epidemic" is a growing concern globally. A sleep test is required to diagnose sleep apnea and to individualize therapy. A multidisciplinary approach is the key to success. This narrative review presents a debate on whether surgery is a friend or a foe in the treatment of sleep apnea. Depending on the type and severity of the apnea, the causal factor, and the presence of obesity and hypercapnia as well as the associated pathologies, the optimal therapeutic method is determined for each individual case. The article concludes that each case is unique, and there is no ideal method. Positive pressure ventilation, although a therapeutic gold standard, has its disadvantages extensively discussed in this paper. Nevertheless, it is necessary prior to any surgical intervention, either for the curative treatment of the causal factor of apnea or for elective surgery for another condition. The anesthetic risks associated with the presence of apnea and obesity should not be neglected and should form the basis for decision making regarding surgical interventions for the treatment of sleep apnea.

Metabolomic approach for obstructive sleep apnea in adults: a systematic review.

Obstructive Sleep Apnea (OSA) corresponds to episodes of complete or partial upper airway obstruction during sleep. The gold standard for diagnosing OSA is polysomnography; however, metabolomics is an innovative and highly sensitive method that seeks to identify and quantify small molecules in biological systems. Identify the metabolites most frequently associated with obstructive sleep apnea in adults. The search for articles was conducted between October 2020 and August 2021, in electronic databases, such as MEDLINE/PubMed, Scielo, Embase, and Cochrane, through the combination of descriptors: obstructive sleep apnea, metabolomic, adult. This systematic review included all cross-sectional studies published, including human patients aged 18years or older, of both genders who underwent type I or II polysomnography and metabolomics study. The search strategy selected 3697 surveys, and 4 of them were selected to be a part of this systematic review. Based on the analyzed surveys, it was found that all of them were able to diagnose OSA, reaching a sensitivity of 75-97%, and specificity that ranged from 72 to 100%; besides differentiating patients with OSA (severe, moderate, and mild) from simple snorers with a mean sensitivity of 77.2% and specificity of 66.25%. These findings suggest that, in addition to being used as a screening and diagnostic strategy for OSA, metabolomics has the potential to be used for severity stratification and to monitor the disease's progression.

Restorative Exercise Models in Dysphagia and Obstructive Sleep Apnea: A Review

<h3>Objective(s)</h3> Restorative dysphagia exercise approaches hold merit in research and practice within speech-language pathology given strong evidence for targeted interventions leading to improved deglutition. Restorative exercise approaches for obstructive sleep apnea (OSA) share common anatophysiologic bases with dysphagia; however, have received limited scientific attention to establish their utility as non-invasive treatment alternatives for OSA. Researchers' primary aim was to provide a summary of the current state-of-science on the biomechanics of OSA with a summary of therapeutic targets relative to muscle physiology. A secondary aim was assessing the physiologic adaptations following restorative dysphagia exercise relative to exercise models for treatment of OSA for comparative analysis. Clinical research and scope-of-practice implications of exercise benefits reflected in similar biomechanical profiles and muscular adaptations in OSA and dysphagia are discussed. <h3>Data Sources</h3> Literature was identified using hand-searched and database-driven methods from PubMed, Google Scholar, and Medline. <h3>Study Selection</h3> (1) systematic reviews/meta-analysis; (2) author(s) quantified measures of article strengths/weaknesses; (3) published after 2011; (4) available in English. <h3>Data Extraction</h3> Authors independently assessed articles for eligibility and evidence strength using The Scottish Intercollegiate Guidelines Network (SIGN) tool. Average SIGN ratings across intervention categories were obtained. <h3>Data Synthesis</h3> Study results were categorized and assessed for strength of evidence with SIGN and conclusions on therapeutic targets and the physiologic adaptations relative to specific targets. A majority of studies were systematic reviews and meta-analyses. Researchers identified sources of variation and consistency in outcome measures across studies, leading to a quantitative and qualitative synthesis of findings within dysphagia and OSA outcome measures. <h3>Conclusions</h3> Preliminary findings point to potential adjuvant treatment avenues in some patients with OSA and potential co-recruitment of OSA-related muscles during restorative dysphagia exercises. Findings point to common therapeutic targets and anatophysiologic goals within dysphagia and OSA exercise interventions. <h3>Author(s) Disclosures</h3> Nicholas Stocker is first author, Laura L.O. Froeschke is second author, Raymond Kraus is third author.

Expert consensus for the use of home sleep apnea test in the diagnosis of obstructive sleep apnea in adults

With the advancement of home sleep apnea test (HSAT) technology and the increase of encouraging evidence of home-based management approach for obstructive sleep apnea (OSA), HSAT devices using different types of biosignal acquisition technology are more and more widely used for the diagnosis of OSA in adults. HSAT for the diagnosis of OSA should be performed in combination with a comprehensive clinical and sleep evaluation. HSAT can be used as a diagnostic tool for uncomplicated OSA with a high pretest probability of moderate to severe OSA. A negative HSAT result cannot exclude the diagnosis of OSA for subjects with high clinical suspicion. Polysomnography (PSG) is preferred for the diagnosis of OSA in patients with significant comorbid medical conditions. The clinical application of HSAT in the diagnosis of complicated OSA needs to refer to the severity of clinical condition, comorbid disease, personal preference, local medical insurance policy and the accessibility of medical resources. HSAT may be indicated for the diagnosis of OSA in patients for whom attended PSG is not possible by virtue of immobility, safety, or critical illness. HSAT can be used for the screening of OSA in subjects with cardiocerebrovascular diseases. Follow-up HSAT or PSG is recommended to evaluate therapeutic response with non-positive airway pressure (PAP) interventions. Follow-up HSAT or PSG can be used for reassessment for patients with clinically significant weight fluctuation, persistent or recurrent symptoms under good PAP adherence, emergence or changes in cardiovascular diseases. Due to limitations of current automatic scoring algorithms that restrict the diagnostic accuracy, it is mandatory to review the raw data of type 3 devices. The selection of HSAT equipment, interpretation of monitoring results and the development of management plan should be under the guidance of physicians with sleep medicine training. Consumer-grade technologies are not appropriate for the clinical diagnosis of OSA due to lack of validation.

Dose-response relationship between weight loss and improvements in obstructive sleep apnea severity after a diet/lifestyle interventions: secondary analyses of the "MIMOSA" randomized clinical trial.

Lifestyle-induced weight loss is a complementary therapeutic approach for obstructive sleep apnea (OSA). We aimed at identifying the dose-response relationship between weight loss and OSA severity improvement. This is a secondary analysis of a 6-month clinical trial in 180 adult, overweight/obese moderate-to-severe OSA patients. Participants were randomized to a standard care, a Mediterranean diet, or a Mediterranean lifestyle arm. All patients were prescribed with continuous positive airway pressure (CPAP), while intervention arms additionally participated in a weight-loss dietary/lifestyle intervention. Based on percent change in weight at 6 months, participants were categorized into a weight-stable/gain (WS/GG) group or 3 weight-loss groups (WLG): < 5%WLG, 5%-10%WLG, and ≥ 10%WLG. Polysomnographic data and OSA symptoms were evaluated preintervention and postintervention. Respiratory events and oximetry indices improved only in patients who lost weight and improvements were proportional to the degree of weight loss. Median percent change in apnea-hypopnea index (AHI) was -11.7%, - 37.9%, and - 49.3% in the < 5%WLG, 5%-10%WLG, and ≥ 10%WLG, respectively (P < .001). Compared to the WS/GG, the age-, sex-, baseline-, and CPAP use-adjusted relative risk (95% confidence interval) of severe OSA (AHI ≥ 30 events/h) was 0.45 (0.23-0.87) in the 5%-10%WLG and 0.32 (0.17-0.64) in the ≥ 10%WLG; the risk was also lower in the ≥ 10%WLG vs the < 5%WLG (0.42 [0.22-0.82]). Insomnia and daytime sleepiness also improved more in participants exhibiting ≥ 5% weight loss. Even a < 5% weight loss can reduce respiratory events, but a ≥ 5% and ideally ≥ 10% weight loss is necessary for reducing the prevalence of severe OSA. Registry: ClinicalTrials.gov; Name: Mediterranean Diet/Lifestyle Intervention in Obstructive Sleep Apnea; URL: https://clinicaltrials.gov/ct2/show/NCT02515357; Identifier: NCT02515357. Georgoulis M, Yiannakouris N, Kechribari I, etal. Dose-response relationship between weight loss and improvements in obstructive sleep apnea severity after a diet/lifestyle intervention: secondary analyses of the "MIMOSA" randomized clinical trial. J Clin Sleep Med. 2022;18(5):1251-1261.

An automatic screening approach for obstructive sleep apnea from photoplethysmograph using machine learning techniques

Obstructive sleep apnea (OSA), a very common sleep disorder remains as an underdiagnosed root cause for several cardiovascular and cerebrovascular diseases. In this paper, we propose an efficient and accurate system that utilizes a single sensor for effective screening of OSA using machine learning algorithms. The automatic screening system involves a photoplethysmogram (PPG) signal, a novel algorithm to detect and remove the corrupted part of the signal, a feature extraction module to extract several features from the PPG waveform and a classifier module which helps in screening for OSA. The elemental idea behind this work is that there is a characteristic relationship between the shape of the PPG waveform and the oxygen desaturation in the apnea patients. The method as described was tested on 285 subjects, inclusive of both normal and apnea patients, and the results were obtained after 10-fold-cross validation of the different machine learning techniques viz., univariate regression, multivariate regression, support vector machine and random forest. The best results in screening OSA were obtained from random forest algorithm with the highest performance (Acc:98.0%, Sen:98.6%, Spec:99.3%) for all the combined features. The proposed work is an effective system for automatic screening of OSA from a single PPG sensor, thereby reducing the need for a very expensive and overnight polysomnography sleep study.

More Than the Sum of the Respiratory Events: Personalized Medicine Approaches for Obstructive Sleep Apnea.

Traditionally, the presence and severity of obstructive sleep apnea (OSA) have been defined by the apnea-hypopnea index (AHI). Continuous positive airway pressure is generally first-line therapy despite low adherence, because it reliably reduces the AHI when used, and the response to other therapies is variable. However, there is growing appreciation that the underlying etiology (i.e., endotype) and clinical manifestation (i.e., phenotype) of OSA in an individual are not well described by the AHI. We define and review the important progress made in understanding and measuring physiological mechanisms (or endotypes) that help define subtypes of OSA and identify the potential use of genetics to further refine disease classification. This more detailed understanding of OSA pathogenesis should influence clinical treatment decisions as well as help inform research priorities and clinical study design. In short, treatments could be individualized on the basis of the underlying cause of OSA; patients could better understand which symptoms and outcomes will respond to OSA treatment and by how much; and researchers could select populations most likely to benefit from specific treatment approaches for OSA.

Dental Approach for Obstructive Sleep Apnea by Using Oral Appliance in Tokushima University Hospital: New Challenge of Clinical Treatment

Obstructive sleep apnea (OSA) is characterized by intermittent upper airway obstruction during sleep. It causes sleep fragmentation from brief arousal and affects social life by excessive daytime sleepiness. Moreover, OSA is considered a risk factor for cardiovascular complications and type 2 diabetes as associated features. The gold standard treatment for OSA is continuous positive airway pressure during sleep. However, if this treatment is frustrating to the patient or the apnea and hypopnea index is low or mild, alternative treatments for OSA must be found. One possible treatment is an oral appliance (OA) to improve the upper airway configuration. Dental clinicians have attempted to improve this respiratory condition caused by OSA by using OA, and at Tokushima University Hospital, OA therapy has been in use since 1993. Nishigawa et al. introduced a method to fabricate an OA and to investigate the effects of this therapy. In the present article, the method of OA fabrication was modified, and its effects were evaluated. Dental clinicians should have some knowledge about the mechanics of sleep and the management of sleep conditions so that they can cooperate closely with medical physicians. Thus, collaboration between the medical and dental fields can help patients attain healthy sleep.

An Automatic Screening Approach for Obstructive Sleep Apnea Diagnosis Based on Single-Lead Electrocardiogram

Traditional approaches for obstructive sleep apnea (OSA) diagnosis are apt to using multiple channels of physiological signals to detect apnea events by dividing the signals into equal-length segments, which may lead to incorrect apnea event detection and weaken the performance of OSA diagnosis. This paper proposes an automatic-segmentation-based screening approach with the single channel of Electrocardiogram (ECG) signal for OSA subject diagnosis, and the main work of the proposed approach lies in three aspects: (i) an automatic signal segmentation algorithm is adopted for signal segmentation instead of the equal-length segmentation rule; (ii) a local median filter is improved for reduction of the unexpected RR intervals before signal segmentation; (iii) the designed OSA severity index and additional admission information of OSA suspects are plugged into support vector machine (SVM) for OSA subject diagnosis. A real clinical example from PhysioNet database is provided to validate the proposed approach and an average accuracy of 97.41% for subject diagnosis is obtained which demonstrates the effectiveness for OSA diagnosis.

Obstructive Sleep Apnea: Incidence and Impact on Hypertension?

There are a number of recent studies evaluating sleep disordered breathing and its treatment in the context of blood pressure control. In addition, total sleep time and subjective sleep complaints may also be related to hypertension; these will be reviewed. Recent findings in original articles document that sleep disordered breathing and decreased total sleep time, if chronic, may contribute to an increased risk for development of hypertension. Treatment of sleep apnea with either continuous positive airway pressure (CPAP) or oral devices are reasonable treatment approaches for obstructive sleep apnea (OSA), but the data on the effect on blood pressure remain unclear. In summary, treatment of sleep disordered breathing may help reduce blood pressure or decrease development of incident hypertension.

Response to Testosterone and Sympathetic Nerve Activity During Pregnancy

HomeHypertensionVol. 61, No. 5Response to Testosterone and Sympathetic Nerve Activity During Pregnancy Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBResponse to Testosterone and Sympathetic Nerve Activity During Pregnancy Vijayakumar Chinnathambi, Meena Balakrishnan, Jayanth Ramadoss, Chandrasekhar Yallampalli and Kunju Sathishkumar Vijayakumar ChinnathambiVijayakumar Chinnathambi Division of Reproductive EndocrinologyDepartment of Obstetrics and GynecologyUniversity of Texas Medical BranchGalveston, TX Search for more papers by this author , Meena BalakrishnanMeena Balakrishnan Division of Reproductive EndocrinologyDepartment of Obstetrics and GynecologyUniversity of Texas Medical BranchGalveston, TX Search for more papers by this author , Jayanth RamadossJayanth Ramadoss Division of Reproductive EndocrinologyDepartment of Obstetrics and GynecologyUniversity of Texas Medical BranchGalveston, TX Search for more papers by this author , Chandrasekhar YallampalliChandrasekhar Yallampalli Division of Reproductive EndocrinologyDepartment of Obstetrics and GynecologyUniversity of Texas Medical BranchGalveston, TX Search for more papers by this author and Kunju SathishkumarKunju Sathishkumar Division of Reproductive EndocrinologyDepartment of Obstetrics and GynecologyUniversity of Texas Medical BranchGalveston, TX Search for more papers by this author Originally published25 Mar 2013https://doi.org/10.1161/HYPERTENSIONAHA.113.01216Hypertension. 2013;61:e45Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2013: Previous Version 1 We are strongly encouraged by the enthusiasm expressed by Dr Carter1 regarding our recent article.2 Dr Carter commented that we used a well-controlled experimental model and that it is a novel study that provides critical mechanistic insight and a potential therapeutic target for gestational hypertension, and he emphasized that there is a need for clinical translation of this important work. Further, Dr Carter appreciated the clinical significance of our study and extended its possible implications toward pregnancy-associated obstructive sleep apnea. We thank Dr Carter for his positive comments and his suggestions on the need for simultaneous assessment of sympathetic neural and endothelial function.Our study demonstrated that elevated maternal testosterone levels cause blunting of endothelial NO-mediated vasodilation and concomitant increases in systemic mean arterial pressure. Dr Carter raises the possibility that testosterone during pregnancy may exacerbate muscle sympathetic nerve activity, which may contribute to blunting of NO-mediated vasodilation and increases in mean arterial pressure. It is likely that a significant interaction exists between testosterone and muscle sympathetic nerve activity in endothelial function. Previous studies show that acute increases in sympathetic activity lead to decreased endothelial function.3 Men tend to have higher sympathetic outflow than women,4 who are shown to have higher endothelial NO production, suggesting sex steroids contribute to sympathetic activity regulation. As mentioned by Dr Carter,1 women with polycystic ovarian syndrome or preeclampsia, known to be associated with decreased endothelial function, have severely increased sympathetic outflow. The increased sympathetic nerve activity in polycystic ovarian syndrome patients was shown to be attributable to the excessive testosterone levels.5Although our studies show that direct exposure of endothelial cells to testosterone in culture leads to decreases in the endothelial NO synthase activity state with decreased nitrate/nitrite production, additional detrimental effects on endothelial cells mediated through enhanced muscle sympathetic nerve activity cannot be discounted. Clearly, as suggested by Dr Carter, additional studies are warranted to confirm whether elevated testosterone exaggerates muscle sympathetic nerve activity and whether it may contribute to endothelial dysfunction and increased arterial blood pressure.Similarly, as suggested by Dr Carter, it is plausible that testosterone may be a contributing factor for the development of obstructive sleep apnea in preeclamptic patients. It was an interesting suggestion by Dr Carter to determine whether nonpharmaceutical approaches for obstructive sleep apnea (ie, continuous positive airway pressure) help prevent endothelial and cardiovascular dysfunction associated with elevated testosterone. We thank Dr Carter for his critical suggestions and agree that simultaneous assessment of sympathetic neural and endothelial function is needed and is important for clinical translation of this work.Vijayakumar ChinnathambiMeena BalakrishnanJayanth RamadossChandrasekhar YallampalliKunju SathishkumarDivision of Reproductive EndocrinologyDepartment of Obstetrics and GynecologyUniversity of Texas Medical BranchGalveston, TXSources of FundingFinancial support from the National Institutes of Health through grants HD069750, HL58144, AA19446, and HL102866 is greatly appreciated.DisclosuresNone.

Anatomic changes after hyoid suspension for sleep apnea: A MRI study

Objectives: Hyoid suspension is frequently used in surgical approaches for obstructive sleep apnea, usually combined with genioglossus or maxillomandibular advancement. An enlargement of the retrolingual space is thought to be the underlying mechanism for treatment efficacy. A systematic evaluation of the effects on upper airway anatomy has not yet been performed. Methods: Ten patients with obstructive sleep apnea were included in this prospective trial. All subjects underwent an isolated hyoid suspension using 4 sutures for permanent fixation of the hyoid bone to the thyroid cartilage and a dissection of the stylohyoid ligaments. Subjects underwent an evaluation of their upper airway soft tissue following a standardized MRI protocol before as well as 1 and 6–10 weeks after surgery. Results: So far, 5 patients completed the protocol. Relevant changes in upper airway soft tissue anatomy (eg, retrolingual space, posterior airway spaces [PAS]) could not be detected. For retrolingual space preoperative volume was 7.9 ± 1.7 ccm compared to 7.4 ± 1.0 ccm postoperatively. Changes for PAS were as follows: nasal plane 1.7 ± 0.3 cm to 1.7 ± 0.3 cm; occlusal plane 0.6 ± 0.6 cm to 0.5 ± 0.3 cm and mandibular plane 1.0 ± 0.4 cm to 1.0 ± 0.2 cm. Conclusions: In contrast to the assumption that hyoid suspension enlarges the upper airway, no changes in soft tissue parameters could be detected. The beneficial effects demonstrated for hyoid suspension seem to be linked to functional effects and/or a stabilization of soft tissue due to the fixation of the hyoid bone preventing upper airway collapse rather than to simple changes in airway diameters.

Discussion

Advancement of the lower border of the anterior mandible for the treatment of obstructive sleep apnea syndrome (OSAS) was first described in 1984. 1 Riley R Guilleminault C Powell N et al. Mandibular osteotomy and hyoid bone advancement for obstructive sleep apnea: A case report. Sleep. 1984; 7: 79 Crossref PubMed Scopus (120) Google Scholar The initial rationale for this surgical approach was based on the findings that patients with OSAS have decreased posterior airway space (PAS) and increased distance between the mandible and the hyoid. The initial version of the procedure was just a high sliding genioplasty to advance the genioglossus, geniohyoid, and the anterior belly of the digastric muscles. With increasing understanding that the genioglossus muscle plays an important role in nocturnal airway obstruction, 2 Remmers JE Degroot WJ Sauerland EK et al. Pathogensis of upper airway occlusion during sleep. J Appl Physiol. 1978; 44: 931 PubMed Google Scholar , 3 Mezzanotte WS Tangel DJ White DP Waking genioglossal electromyogram in sleep apnea patients versus normal controls (a neuromuscular compensatory mechanism). J Clin Invest. 1992; 89: 1571 Crossref PubMed Scopus (589) Google Scholar an extension superiorly to fully incorporate the genioglossus muscle was developed. Although Prinsell, 4 Prinsell JR Maxillomandibular advancement surgery in a site-specific treatment approach for obstructive sleep apnea in 50 consecutive patients. Chest. 1999; 116: 1519 Crossref PubMed Scopus (212) Google Scholar as well as Hendler et al recently described the “modified mortise genioplasty,” a similar osteotomy design has been previously published. 5 Powell NB Riley RW Obstructive sleep apnea. Orthognathic surgery perspectives, past, present and future. Oral Maxillofac Clin North Am. 1990; 2: 843 Google Scholar , 6 Powell NB Riley RW Guilleminault C The hypopharynx: Upper airway reconstruction in obstructive sleep apnea syndrome. in: Snoring and Obstructive Sleep Apnea (ed 2). Raven Press, New York, NY1994: 193-209 Google Scholar , 7 Riley RW Powell NB Guilleminault C Inferior sagittal osteotomy of the mandible with hyoid myotomy-suspension: A new procedure for obstructive sleep apnea. Otolaryngol Head Neck Surg. 1986; 94: 589 PubMed Google Scholar

Maxillomandibular Advancement (MMA) in a Site-Specific Treatment Approach for Obstructive Sleep Apnea: A Surgical Algorithm

Maxillomandibular Advancement (MMA) in a Site-Specific Treatment Approach for Obstructive Sleep Apnea: A Surgical Algorithm

Maxillomandibular Advancement Surgery in a Site-Specific Treatment Approach for Obstructive Sleep Apnea in 50 Consecutive Patients

To report the efficacy of maxillomandibular advancement (MMA) surgery, with a description of several innovations, as a site-specific treatment of obstructive sleep apnea syndrome (OSAS) in selected cases with disproportionate velo-orohypopharyngeal anatomy. Clinical series of 50 consecutive cases. Surgery was performed in a hospital operating room, and perioperative management was provided in an intensive care environment. Except for polysomnography (PSG), which was performed and interpreted by independent sleep facilities/physicians, all pre- and postoperative evaluations were accomplished in a solo office private practice setting. Patients were referred for MMA evaluation when applicable conservative therapies such as nasal continuous positive airway pressure (nCPAP) were not tolerated, refused, or unsuccessful. Case selection was based primarily on the sites of disproportionate upper airway anatomy. MMA consisted of a Lefort I osteotomy, bilateral sagittal split ramus osteotomies, and a new modified procedure called an anterior inferior mandibular osteotomy with indirect hyoid suspension. Some patients also received concomitant adjunctive nonpharyngeal procedures. Obtained at a mean of 5.2 months postoperatively, revealed significant improvement in all cases. Mean BPs (n = 50) were lowered, subjective symptoms were ameliorated, and mean body mass index (n = 50) was reduced. Cephalometric analysis (n = 50), with several new modifications including standardization for phases of respiration, quantified structural changes in soft-tissue and bony landmarks. Postoperative PSG results (n = 50) showed dramatic improvement over preoperative data (n = 50), with therapeutic values similar to nCPAP (n = 42). Mean values improved from preoperative to postoperative vs nCPAP for apnea index (34.5 to 1.0 vs 2.0, respectively), apnea-hypopnea index (59.2 to 4.7 vs 5.4, respectively), lowest arterial oxyhemoglobin desaturations (72.7% to 88.6% vs 88.6%, respectively), and number of desaturations < 90% (118.8 to 6.6 vs 2.4, respectively). The success rate was 100%. MMA is highly successful and safe and may be a definitive primary single-staged surgical treatment of selected OSAS cases with diffusely complex or multiple sites of disproportionate velo-orohypopharyngeal anatomy.

Sectioning the Hyoid Bone as a Therapeutic Approach for Obstructive Sleep Apnea

After research studies, including systematic lateral x-rays, of normal controls and obstructive sleep apnea syndrome (OSAS) patients, we decided to perform a medial resection of the hyoid bone in OSAS patients. The procedure is similar to that performed for ductus thyreoglossus. To date, three patients have undergone the operation under anesthesia. The two cases have been followed for several months (the third underwent surgery only recently) and have improved, indicating that this procedure can be beneficial for OSAS.