Correction Of Obstructive Sleep Apnea Research Articles

Ризик розвитку синдрому обструктивного апное сну у хворих на цукровий діабет 2-го типу

Актуальність. Поширеність синдрому обструктивного апное сну (СОАС) у осіб із цукровим діабетом (ЦД) 2-го типу становить від 18 до 36 %. Мета дослідження: вивчити частоту СОАС і особливості його перебігу у хворих на ЦД 2-го типу. Матеріали та методи. Обстежено 300 пацієнтів (середній вік 59,40 ± 6,66 року) з ЦД 2-го типу (150 жінок і 150 чоловіків). Результати. За результатами анкетування відзначено, що хропіння уві сні зустрічалося у 45,4 % чоловіків і 75,7 % жінок з ЦД 2-го типу. 87 % пацієнтів пред’являли скарги на слабкість упродовж дня. У 25,7 % жінок і 10,6 % чоловіків виявлені періодичні зупинки дихання уві сні. Підвищення артеріального тиску, переважно в уранішні години, спостерігалося у пацієнтів з ЦД 2-го типу серед жінок частіше (96,9 %), ніж у чоловіків (65,1 %). Високий ризик розвитку СОАС мали 37,5 % чоловіків і 40,9 % жінок з ЦД 2-го типу. Висновки. СОАС має негативний вплив на якість життя хворих на ЦД 2-го типу, а також знижує показники загального здоров’я і фізіологічного сну, що позначається на фізичному і психологічному стані пацієнтів. Пацієнти з надмірною масою тіла більше зазнають ризику розвитку СОАС. Отримані результати дозволяють рекомендувати подальше дослі­дження хворих з полісомнографом для постановки діагнозу СОАС і його лікування.

Maxillary expansion for treatment of obstructive sleep apnea

Patients having obstructive sleep apnea frequently present malocclusion such as maxillary constriction, posterior crossbite, and long face. Maxillary expansion has been addressed to correct the malocclusion and to improve obstructive sleep apnea. In growing patients, rapid palatal expander (RPE) can separate the midpalatal suture and expand the maxilla, which results in increase of volume in the nasal cavity and nasopharynx as well as increase of the cross-sectional area. In non-growing patients, miniscrew-assisted rapid palatal expander canbe used for the same effect. Maxillary expansion can be used for correction of obstructive sleep apnea in caseof maxillary constriction.

Counterclockwise Rotational Orthognathic Surgery for the Obstructive Sleep Apnea in Class II Dentofacial Deformity: Polysomnography and 3D Computed Tomographic Analysis.

Traditionally, maxillomandibular advancement is an orthognathic surgical procedure that has been used to manage obstructive sleep apnea in patients not able or willing to maintain adherence to continuous positive airway pressure therapy or for patient who are not able to adhere to treatment. However, maxillomandibular advancement often leads to unsatisfactory cosmetic results.This prospective study investigated functional and esthetic outcomes using polysomnography and 3-dimensional computed tomography, after counterclockwise rotational orthognathic surgery. We enrolled 17 patients with obstructive sleep apnea, who underwent orthognathic surgery at single institution between March 2013 and December 2018.After 12 months, the patients' mean self-rated score for facial appearance, using a 10-step visual analog scale, was 7.36. The preoperative apnea-hypopnea index and respiratory disturbance index were 34.70 and 37.45, respectively; postoperative indices were 11.60 and to 12.69, respectively (P = 0.003, 0.003). The mean posterior pharyngeal airway space increased from 5357.88 mm3 preoperatively to 8481.94 mm3 after 6 postoperative months.Counterclockwise rotational orthognathic surgery for the correction of obstructive sleep apnea turned out to be the ideal solution not only in the correction of the sleep apnea, but also in the facial esthetics.

Effect of Nocturnal Hypoxia on Nocturia in Patients With Obstructive Sleep Apnea.

PurposeTo identify the association between nocturia and obstructive sleep apnea (OSA), we compared results of polysomnography (PSG) with the presence or absence of nocturia in patients with suspected OSA.MethodsPatients underwent PSG for suspected OSA. The International Prostate Symptom Score and quality of life (IPSS/QoL) questionnaire was evaluated to assess voiding symptoms that may affect sleep quality. The results of PSG were compared between patient groups with or without nocturia.ResultsIn logistic regression analysis, age (odds ratio [OR], 1.052; P=0.004), diabetes mellitus (OR, 6.675; P<0.001), mean O2 saturation (OR, 0.650; P=0.017), oxygen desaturation index (ODI) 3 (OR, 1.193; P=0.010), and ODI4 (OR, 1.136; P=0.014) affected nocturia independently among the OSA-suspected patients.ConclusionsHypoxia caused by OSA affects the incidence of nocturia. Less desaturated OSA patients with nocturia may require more urological evaluation and treatment for nocturia even after the correction of OSA.

High-flow nasal cannula for children not compliant with continuous positive airway pressure

ObjectivesContinuous positive airway pressure (CPAP) is an effective treatment of severe obstructive sleep apnea (OSA) but poor compliance is a major limitation. High-flow nasal cannula (HFNC) has been used as an alternative but data about efficacy and objective long-term compliance are scarce; this study aims to address this lack of data. Patients/methodsAll consecutive patients, aged 0–18 years, treated with CPAP for a severe OSA defined as an apnea–hypopnea index (AHI) > 10 events/h, and not compliant with home CPAP therapy, defined by a CPAP use of <2 h/night, after at least four weeks from CPAP initiation were considered eligible for the study. HFNC was started during an outpatient visit. Study outcomes were the objective compliance (number of hours use/night) after one month and the improvement of OSA on a respiratory polygraphy (RP) with HFNC. ResultsEight patients (two boys, mean age 8.9 ± 6.2 years, mean AHI 33 ± 22 events/h) were included in the study: Down syndrome (N = 6), Pierre Robin syndrome (N = 1), Pfeiffer syndrome (N = 1). After one month, five (62%) patients slept with HFNC more than 4 h/night (mean compliance 7 h 10 min ± 0 h 36 min/night). HFNC corrected OSA in the five compliant patients (mean AHI 2 ± 2 events/h with HFNC). HFNC was not accepted by the three oldest patients with Down syndrome. ConclusionA good compliance as well as a correction of OSA may be obtained with HFNC in selected children with OSA not compliant to CPAP. HFNC may be used as a rescue therapy for children not compliant with CPAP.

Outpatient initiation of long-term continuous positive airway pressure in children.

Current guidelines recommend initiating continuous positive airway pressure (CPAP) in children during an overnight in-hospital titration study. Due to a shortage of hospital beds and economic constraints, we started a program for outpatient initiation of CPAP in selected children with obstructive sleep apnea (OSA). Objective CPAP compliance and efficacy were evaluated in consecutive children enrolled in an outpatient CPAP program when they fulfilled the following criteria: persistent OSA, age >6 months, stable condition, family living in the Parisian area and agreeing with a regular follow-up. Thirty-one children, median (range) age 8.9 years (0.8-17.5), were included in the program. The most common diagnosis were Down syndrome (n = 7), achondroplasia (n = 3), and obesity (n = 3). Median baseline obstructive apnea-hypopnea index (OAHI) was 12.5 events/h (5-100). Median duration of follow-up was 12.3 months (2.2-25.2). Four subjects (three adolescents with Down syndrome) were not compliant at 2-month follow-up with a compliance <4 h/night. In the other 27 subjects, median compliance was 08:21 h:min/night (05:45-12:20), with a median number of night use per month of 25 (18-30). CPAP efficacy at the end of follow-up was excellent in the compliant subjects with a median AHI of two events/h (0-4) and normal gas exchange with CPAP therapy. Three subjects were successfully weaned from CPAP treatment during the study period. Initiating CPAP in an outpatient setting in children is feasible and effective in selected subjects. A high rate of compliance can be achieved as well as a correction of OSA.

Correction of hypercapnia improves cognitive efficiency and attention in a brain-injured patient

Correction of obstructive sleep apnea (OSAS) by non-invasive continuous pressure ventilation (CPAP) allows an improvement of attentional and executive functions, especially post-stroke. On the other hand, in chronic obstructive pulmonary disease, correction of hypercapnia by bilevel positive airway pressure ventilation (BiPAP) improves cognitive impairment. We present a case of a brain-injured patient who remains hypercapnic despite an effective CPAP for the correction of an OSAS. We present a 36-year-old patient with visuo-spatial disorders, dysexecutive syndrome, cerebellar syndrome, swallowing disorders after a rupture of a right vertebral artery aneurysm 2 years before. Oral feeding by adapted texture (mixed), tracheotomy, CPAP for OSAS for several months were needed. We performed cognitive assessments (MoCA: Montreal Cognitive Assessment and BAWL: Attentional Battery William Lennox), pre- (T1) and post- (T2) correction of hypercapnia by night BiPAP, 2 months later. After correction of hypercapnia (T1 PaCO 2 = 7.36 kPa or 55 mmHg then T2 PaCO 2 = 5.86 kPa or 44 mmHg), improvement of: Global cognitive efficiency (MoCA score: + 4/30); Attention (MoCA attention items: +2/6); Simple reaction times (BAWL: –32 ms, from percentile 5 at T1 to percentile 15 at T2); Memory encoding (MoCA 5 words test: + 2/5 points and no false memories anymore). In addition, dysphagia improves by mealtime reduction (50 min versus 1h40) and laryngeal penetration decrease, which allows a withdrawal of the tracheotomy. In this case, the improvement of global cognitive capacities, attention and cognitive processing speed seems to result from the decrease of capnia. The persistence of sequelae of the intracranial aneurysm rupture (specially visuo-spatial and cerebellar) suggests that improvements on cognitive functions stem from the correction of hypercapnia. This case suggests the importance of a normalization of capnia in brain-injured patients with ventilatory disorders to improve the cognitive (global and attentional) capacities and autonomy in daily life (feeding and tracheotomy withdrawal). Larger studies are needed to confirm this.

Change in Posterior Pharyngeal Space After Counterclockwise Rotational Orthognathic Surgery for Class II Dentofacial Deformity Diagnosed With Obstructive Sleep Apnea Based on Cephalometric Analysis.

Although maxillomandibular advancement (MMA) is an orthognathic surgical procedure used to manage obstructive sleep apnea (OSA) in individuals who are noncompliant with continuous positive airway pressure therapy, simple MMA encounters problems in terms of aesthetic outcomes in Asian populations with preexisting dentoalveolar protrusion. Our current prospective investigation describes changes in posterior pharyngeal space and aesthetic outcomes after counterclockwise rotational orthognathic surgery, which is known to be quite difficult in terms of the maintenance of the skeletal stability in skeletal class II patients with OSA. This prospective study investigated the surgical outcome of patients who suffered from OSA following counterclockwise rotational orthognathic surgery. The patients were skeletal class II patients who underwent orthognathic surgery between March 2013 and December 2014. Cephalometric posterior airway analysis and a questionnaire for facial perception were used to assess pharyngeal airway and patient perception of facial appearance. A total of 14 patients were included. Satisfactory results were achieved without complications in all OSA patients. The airway parameters for anteroposterior length significantly increased. Thirteen patients answered a questionnaire on their facial appearance, and the visual analog scale averaged 7.31 points, indicating a favorable facial appearance. Counterclockwise rotational orthognathic surgery without maxilla advancement for the correction of OSA can effectively increase the posterior pharyngeal space, with favorable aesthetic results. With thoughtful application, this novel approach may be an alternative to standard approaches for the correction of OSA using orthognathic surgery.

Nocturia Improvement With Surgical Correction of Sleep Apnea.

PurposeTo evaluate changes in nocturia after surgical correction of obstructive sleep apnea (OSA).MethodsA total of 66 patients were included in the present study. All had been diagnosed with OSA syndrome by polysomnography and underwent uvulopalatopharyngoplasty (UPPP). Preoperative and postoperative lower urinary tract symptoms (LUTS), quality of life (QoL), and nocturia episodes were evaluated using the International Prostate Symptom Score (IPSS) and overactive bladder symptom score (OABSS) questionnaires. Three months postoperatively, telephone interviews were performed to determine the success of surgery, current LUTS, and nocturia episodes. Patients were divided into surgical success and failure groups. Surgical success was defined as snoring decrease more than 50% based on the patient’s subjective judgment.ResultsThe response rate was 56% and success rate was 73%. In all patients, nocturia episodes significantly decreased from 1.7±1.1 to 0.8±1.2 (P=0.002). Mean IPSS score, OABSS score, and QoL scores were also significantly improved. The success group showed a significant decrease in nocturia episodes, and total IPSS, OABSS, and QoL scores. However, the failure group did not show significant changes in all parameters.ConclusionsOSA correction improved nocturia as well as other LUTS. These improvements were not observed in the failure group. This study shows that OSA is a cause of nocturia and that other LUTS and nocturia can be improved by surgical correction of OSA.

Abstract: The Change of Posterior Pharyngeal Space after Counter Clock-wise Rotational Orthognathic Surgery Based on Cephalometry

INTRODUCTION: Maxillomandibular advancement (MMA) is an orthognathic surgical procedure that has been used to manage OSA in individuals who are noncompliant with CPAP therapy.1 MMA is a site-specific procedure, performed for the purpose of creating an enlarged posterior airway space at multiple anatomic levels, including the nasopharynx, oropharynx, and hypopharynx.2 MMA has been shown to significantly improve OSA, with reported short term success rates ranging from 75% to 100%.3–5 This prospective investigation describes the functional and aesthetic outcomes after the counter clock wise rotational orthognathic surgery in skeletal class II patients with the obstructive sleep apnea based on pre and postoperative polysomnography and cephalometry. MATERIALS AND METHODS: This retrospective study investigated the surgical outcome of 12 patients who suffered from obstructive sleep apnea following the counter clock wise rotational orthognathic surgery in terms of functional and aesthetic outcomes. The patients included in this study were skeletal class II patients who underwent orthognathic surgery between March, 2013 and December, 2014 at the Seoul Asan Medical Center, University Medical Center for tertiary care. The pharyngeal airway assessment was done through polysomnography and cephalometric posterior airway analysis using PRL–PSP, PRL–PTO and PRL–E distances. RESULTS: The follow-up period ranged from 10 to 36 months (average, 20.5 months). The average age of the patients was 28.5 years, with 9 male and 11 female patients. Compared to preoperative results (mean preop distance of PRL–PSP: 19.97, PRL–PTO: 18.68, PRL–E: 16.2), PRL–PSP, PRL–PTO and PRL–E distances were increased statistically significant in immediate postoperative cephalometry. (p<0.005) (mean immediate postop distance of PRL–PSP: 23.1, PRL–PTO: 22.9, PRL–E: 18.6). The results were maintained 6 months after the surgery(mean distant postop distance of PRL–PSP: 22.2, PRL–PTO: 22.5, PRL–E: 18.0). There was no significant change in PRL–PSP, PRL–PTO and PRL–E distances.(p>0.05). CONCLUSION: The change of the posterior pharyngeal space in counter clock-wise rotational orthognathic surgery without maxilla advancement for the correction of obstructive sleep apnea is presented. Our findings indicate that this approach can lengthen the posterior pharyngeal space effectively. With considered application, this novel approach could be an alternative to standard approaches in the correction of obstructive sleep apnea using orthognathic surgery. DISCLOSURES/FINANCIAL SUPPORT:None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. REFERENCES: 1. Fernández-Ferrer L, Montiel-Company JM, Pinho T, Almerich-Silla JM, Bellot-Arcís C. Effects of mandibular setback surgery on upper airway dimensions and their influence on obstructive sleep apnoea - a systematic review. J Craniomaxillofac Surg. 2015;43:248–53. 2. Demetriades N, Chang DJ, Laskarides C, Papageorge M. Effects of mandibular retropositioning, with or without maxillary advancement, on the oro-naso-pharyngeal airway and development of sleep-related breathing disorders. J Oral Maxillofac Surg. 2010;68:2431–6. 3. Gonçalves JR, Gomes LC, Vianna AP, Rodrigues DB, Gonçalves DA, Wolford LM. Airway space changes after maxillomandibular counterclockwise rotation and mandibular advancement with TMJ Concepts® total joint prostheses: three-dimensional assessment. Int J Oral Maxillofac Surg. 2013;42:1014–22. 4. Hatab NA, Konstantinović VS, Mudrak JK. Pharyngeal airway changes after mono- and bimaxillary surgery in skeletal class III patients: Cone-beam computed tomography evaluation. J Craniomaxillofac Surg. 2015;43:491–6. 5. Jakobsone G, Stenvik A, Espeland L. The effect of maxillary advancement and impaction on the upper airway after bimaxillary surgery to correct Class III malocclusion. Am J Orthod Dentofacial Orthop. 2011;139:e369-76.

Risk Factors for Obstructive Sleep Apnea Are Prevalent in People with Psychosis and Correlate with Impaired Social Functioning and Poor Physical Health.

Obstructive sleep apnea (OSA) in the general community is associated with obesity, smoking, alcohol, and sedative medication use and contributes to depressed mood, daytime sedation, and sudden cardiovascular deaths. Poor cardiovascular health, impaired social functioning, and negative and cognitive symptoms are also among the common clinical features of psychotic disorders. People with psychosis have higher rates of sleep disturbance; however, OSA has not been extensively investigated in this population. This study aimed to determine the prevalence of OSA and general sleep disruption symptoms in a representative Australian sample of people with psychosis. We investigated the prevalence of potential risk factors for OSA, including obesity, psychotropic medications, and substance abuse in this population. Finally, we evaluated associations between symptoms of OSA, symptoms of general sleep disruption, and various clinical features in people with psychosis. Participants took part in the Second National Australian Survey of Psychosis, a population-based survey of Australians with a psychotic disorder aged 18-64 years. Symptoms associated with OSA (snoring and breathing pauses during sleep) in the past year were assessed using questions from the University of Maryland Medical Centre Questionnaire and symptoms associated with general sleep disruption in the past week using the Assessment of Quality of Life Questionnaire. Data collected included psychiatric diagnosis and symptoms, education, employment, medications, smoking status, physical activity, drug and alcohol use, and cognitive function. Physical health measures included body mass index, waist circumference, blood pressure, fasting blood glucose, and lipids. Snoring was reported by 41.9%; 7% stating they frequently stopped breathing (pauses) during sleep. Univariate logistic regressions show OSA symptoms (pauses and snoring) were associated with older age, female gender, lower levels of social participation or employment, cardiovascular risk factors, sedentary lifestyle, and poorer quality of life, while symptoms of general sleep disruption were more likely in people with depressive symptoms. Australians with psychosis have high levels of sleep disturbance, including OSA. OSA symptoms were associated with cardiovascular disease risk factors, reduced social participation and employment, and poorer quality of life. Whether correction of OSA can improve these factors in people with psychosis remains to be determined.

Multidisciplinary Approach for Correction of Obstructive Sleep Apnea

ABSTRACTObstructive sleep apnea (OSA) is the most common type of sleep apnea and is caused by complete or partial obstructions of the upper airway. In this study we are presenting a case report of 11-year-old male patient with enlarged adenoids and tonsils, convex profile, receded chin, lower lip trap, class II skeletal and dental relationship with increased overjet. Surgical removal of enlarged adenoids was done before commencement of twinblock therapy. After this, two-step advancement with expansion in both arches utilizing twin blocks was planned. Four months into the treatment, patient reported with history of facial trauma with avulsed maxillary left central incisor. Twin block was then modified with pontic as replacement for maxillary left central incisor. Sagittal correction resulting in class I molar relationship was achieved in next 6 months. Fixed appliance therapy was followed. The design of the appliance and the results achieved after the postfunctional therapy are presented in this case report.How to cite this articleMadhaswar AB, Ravindranath VK, Daga PN. Multidisciplinary Approach for Correction of Obstructive Sleep Apnea. J Contemp Dent 2016;6(3):189-193.

Obstructive sleep apnea and cardiovascular risk in children

Obstructive sleep breathing disorders in children encompasses a wide range of pathological conditions, among which obstructive sleep apnea is the most severe disorder. The paper gives data on a relationship of the above disorder to the higher risk for childhood cardiovascular disease. It indicates the link of obstructive sleep apnea to impaired autonomic regulation, which manifests itself as hypersympaticotonia determined by cardiac rhythm characteristics, metabolic parameters, and blood pressure levels. Myocardial electrical instability is detected, which appears as increased QT interval dispersion on ECG. The observed changes raise the risk of cardiac arrhythmias. Obstructive sleep apnea in children is accompanied by increases in vascular tone and blood pressure, change in the endothelial structure, and activation of a systemic inflammatory response, which contributes to atherogenetic processes. The above disorders can be persistent if timely treatment is absent. The diagnosis and correction of obstructive sleep apnea in children are constituents in the prevention of cardiovascular disease.

Modified Interim Mandibular Advancement (MIMA) Appliance for Symptomatic Correction of Obstructive Sleep Apnea.

Obstructive Sleep Apnea (OSA) is a chronic, progressive, multifactorial, life-threatening disorder that causes significant impact on patient's life. Patients with OSA [Apnea/Hypopnea Index (AHI)>30] who cannot tolerate Continuous Positive Airway Pressure (CPAP) therapy or are not surgical candidates may benefit from oral appliances. This paper describes interim appliance devised from existing Hawley's retainer in patients with OSA. A 38-year-old man of athletic built with history of orthodontic treatment six months back due to esthetic concerns and wearing upper Hawley's retainer, reported with chief complaint of frequent nocturnal awakening along with excessive daytime somnolence. Based on diagnostic aids, he was diagnosed with Class II Division 1 malocclusion with severe mandibular retrusion. Sleep test revealed AHI score of 34, suggestive of severe OSA. With ENT and Oral surgeon concurrence, mandibular advancement of 7mm with Bilateral Sagital Split Osteotomy (BSSO) with distraction was contemplated as a viable functional and curative stable treatment plan. Because of non-adherence and non-compliance with CPAP therapy and on request of patient, an interim anterior positioning appliance was devised to facilitate comfortable sound sleep till the time surgery is impending. After three months of wearing this customized appliance, improved quality of sleep was discernible; both subjectively as reported by patient and objectively using sleep test (AHI=9.8).

HIF-Mediated Changes in Erythropoiesis and Gene Expression in Chronic Intermittent Hypoxia Due to Obstructive Sleep Apnea

1st, 2nd, and 3rdauthors deserve equal credit.Red cell mass is tightly controlled by hypoxia, a process regulated by hypoxia-inducible transcription factors (HIFs). Obstructive sleep apnea (OSA) involves chronic intermittent hypoxia during sleep and has multiple organismal detrimental effects including hypertension, diabetes, cognitive impairment, heart attacks, and thrombotic complications. Polycythemia is not recognized as a feature of OSA, but we see occasional patients with polycythemia and OSA whose hematocrits are normalized by successful therapy with continuous positive airway pressure (CPAP).We set out to analyze the effect of OSA on erythropoiesis in 18 non-smoking OSA patients without any chronic pulmonary disease and with normal hematocrits. Their blood was drawn before and after an overnight polysomnography (PSG) and, to account for possible circadian oscillation changes, at the same time of day. Patients ranged in OSA severity based on apnea-hypopnea index from mild to severe. An average of 98.5 minutes was spent with oxygen saturations of 89% or lower, with a 4% oxygen desaturation index of 22.9/hr. The average lowest oxygen saturation value was 78%, 6/18 subjects had hypertension and 4/18 diabetes. Three of these patients achieved remission of OSA over 3 months of successful therapy with CPAP, and were reanalyzed.We considered the possibility that daily rapid changes from hypoxia to normoxia can lead to overcorrection of augmented erythropoiesis by preferential destruction of erythrocytes made in hypoxia; i.e. neocytolysis. We attempted to replicate data using our neocytolysis mouse model in OSA patients wherein neocytolysis is mediated by excessive generation of ROS from increased reticulocyte mitochondrial mass due to HIF-regulated reduction of Bnip3L levels upon return to normoxia. The reticulocyte-derived ROS then destroy hypoxia-produced young RBCs having reduced catalase (CAT) downregulated by increased miR-21 (see J. Song at this ASH). We also analyzed HIFs levels by QT-PCR of selected HIF-regulated gene transcripts (GLUT1, HK1, VEGFA, and PDK1) and the principal HIF inhibitor, PHD2, in reticulocytes. HK1 transcripts were higher in OSA patients than in controls. The expression of other HIF-targeted genes in OSA patients showed the same trend with HK1 expression but did not reach statistical significance.In uncontrolled OSA (before and after overnight PSG), there were significant changes in CAT and BNIP3L transcript levels in reticulocytes compared to CPAP-corrected OSA. We found that CAT and BNIP3L transcript levels increased after CPAP treatment, indicating that in uncontrolled OSA, catalase and BNIP3L are low, causing generation of excessive ROS from mitochondria and, in keeping with this observation, we observed a significant decrease in miR21 leading to increased CAT. Compared to after correction of OSA, these BNIP3L and CAT changes would account for the absence of polycythemia during OSA. Increased mitochondrial mass generates additional ROS, thus replicating mouse neocytolysis in human OSA. Pre-OSA HIF activity is not markedly different from post-OSA HIF activity, perhaps reflecting the limitations of analyzing terminally differentiated cells. It is likely that miRNA changes in reticulocytes do not reflect acute changes that are present in erythroid progenitors with transcriptional activity. This limitation will be corrected by repeated analyses performed a few days after initiation of CPAP therapy.We also analyzed erythropoiesis and observed a decreasing trend in erythropoietin level and erythroferrone transcripts after correction of OSA, findings compatible with augmented erythropoiesis in uncontrolled OSA.Correlation of these and future data with those few OSA subjects who develop erythrocytosis is expected to uncover individual variations in hypoxic response leading to changes in HIFs response. Elucidation of erythroid, inflammatory (granulocyte analyses) and thrombotic (platelet analyses) OSA complications offers the possibility of targeted interventions by HIF inhibitors (i.e., digoxin) and/or HIF augmentation (PHD2 inhibitors). DisclosuresNo relevant conflicts of interest to declare.

Maxillary, Mandibular, and Chin Advancement: Treatment Planning Based on Airway Anatomy in Obstructive Sleep Apnea

Surgical correction of obstructive sleep apnea (OSA) syndrome involves understanding a number of parameters, of which the 3-dimensional airway anatomy is important. Visualization of the upper airway based on cone beam computed tomography scans and automated computer analysis is an aid in understanding normal and abnormal airway conditions and their response to surgery. The goal of surgical treatment of OSA syndrome is to enlarge the velo-oropharyngeal airway by anterior/lateral displacement of the soft tissues and musculature by maxillary, mandibular, and possibly, genioglossus advancement. Knowledge of the specific airway obstruction and characteristics based on 3-dimensional studies permits a directed surgical treatment plan that can successfully address the area or areas of airway obstruction. The end occlusal result can be improved when orthodontic treatment is combined with the surgical plan. The individual with OSA, though, is more complicated than the usual orthognathic patient, and both the medical condition and treatment length need to be judiciously managed when OSA and associated conditions are present. The perioperative management of the patient with OSA is more complex and the margin for error is reduced, and this needs to be taken into consideration and the care altered as indicated.

Diagnosis, Treatment Planning, and Surgical Correction of Obstructive Sleep Apnea

The aim of this report is to present the scientific rationale for considering maxillomandibular advancement as the surgical treatment of choice in selected patients with obstructive sleep apnea syndrome; review the treatment planning that will identify those patients who would benefit from this procedure; review the surgical techniques; and review the patient outcomes after maxillomandibular advancement surgery. Patients with obstructive sleep apnea syndrome who have demonstrable retropositioning of the maxilla and mandible should be informed of maxillomandibular advancement as the primary surgical treatment for obstructive sleep apnea syndrome.

Maxillomandibular Advancement Surgery for the Treatment of Moderate-Severe Obstructive Sleep Apnea: A Systematic Review

Maxillomandibular Advancement Surgery for the Treatment of Moderate-Severe Obstructive Sleep Apnea: A Systematic Review

Outcome assessment of patients undergoing maxillofacial procedures for the treatment of sleep apnea: comparison of subjective and objective results

Purpose The purpose of this study was to compare the subjective findings of the Epworth Sleepiness Scale (ESS) to the objective findings of the overnight sleep study (OSS) in 57 patients who underwent phase I and phase II surgery for the correction of obstructive sleep apnea (OSA). Patients and methods Forty-two patients in phase I category (hyoid suspension, palatal surgery, and/or genioglossus advancement) and 15 patients in phase II category (maxillomandibular advancement) were examined. All patients had an OSS and completion of an ESS preoperatively and at a minimum of 8 weeks postoperatively. The results of each test were evaluated to examine any relationship between the improvements of the findings of the OSS to the changes in the ESS. Results Using accepted criteria, phase I surgery produced an 80% success rate and phase II surgery produced a greater than 95% success rate in both the respiratory disturbance index and the ESS. Conclusions 1) Both phase I and phase II procedures are effective in treating OSA. 2) Phase II appears to be more effective in treating OSA using both objective and subjective evaluations. 3) Improvement in ESS scores and excessive daytime sleepiness seems to parallel the improvement in OSS scores in patients undergoing surgical correction of OSA.

Nasal Continuous Positive Airway Pressure Use In Children With Obstructive Sleep Apnea Younger Than 2 Years of Age

To assess the efficacy of continuous positive airway pressure (CPAP) in obstructive sleep apnea (OSA) patients who are < 2 years of age. A retrospective chart review of 18 patients from 1992 to 1999 who had OSA confirmed by polysomnography. All patients in this study also completed a separate night of CPAP polysomnography to determine the effectiveness of CPAP in the correction of OSA. Nasal CPAP compliance data were gathered via clinical follow-up examination, telephone interview, or mailed questionnaire. All patients were studied in the Sleep Disorders Center at Loma Linda University Children's Hospital in Loma Linda, CA. All patients were < 2 years old. After OSA was confirmed by the results of technician-attended nocturnal polysomnography, separate technician-attended nocturnal CPAP polysomnography was completed. On CPAP nights, CPAP pressure was titrated to ameliorate OSA and snoring. CPAP pressure was increased by 2-cm H(2)O or 1-cm H(2)O increments. Data were analyzed by dependent groups t test at p < 0.05 level of significance. CPAP statistically improved respiratory parameters significantly when compared to baseline polysomnography. The following four patient subgroups emerged from the analysis: group 1 consisted of six patients who had tracheostomies prior to the CPAP trial, with two patients using CPAP as an alternative to tracheostomy; group 2 consisted of two patients who had previous unsuccessful adenostonsillectomies and who used CPAP successfully, with both having OSA resolution over time; group 3 consisted of four patients who did not tolerate CPAP on the study night; and group 4 consisted of six patients who used CPAP nightly, had OSA resolution over time, and therefore, no longer needed CPAP therapy. Thus, 10 of 18 patients used CPAP either on an interim basis for corrective therapy or as a primary treatment modality for OSA. These data show that children < 2 years of age can tolerate and use CPAP effectively. In several cases, CPAP treatment could be discontinued as OSA resolved over time. The reasons for this are discussed in the text.