Friedman Stage Research Articles

Sleep Quality After Modified Uvulopalatopharyngoplasty: Results From the SKUP3 Randomized Controlled Trial.

To investigate whether uvulopalatopharyngoplasty (UPPP) improves sleep quality in patients with obstructive sleep apnea (OSA) using the Functional Outcomes of Sleep Questionnaire (FOSQ) and the Karolinska Sleep Questionnaire (KSQ). Randomized controlled trial used to compare modified UPPP with controls at baseline and after 6 months. The controls received delayed surgery and a 6-month postoperative follow-up. All operated patients were offered a 24-month follow-up. At each follow-up, patients underwent polysomnography and vigilance testing and completed questionnaires. Nine scales were evaluated: five subscales and the total score in the FOSQ and three subscales in the KSQ. Sixty-five patients, mean 42.3 years (SD 11.5), Friedman stage I and II, body mass index < 36 kg/m2, and moderate-to-severe OSA, were randomized to intervention (n = 32) or control (n = 33). In the FOSQ and in the KSQ, the mean rate of missing values was 6.2% (range 0%-19%) and 20.5% (3%-38%), respectively. In 8 of 9 scales, significant differences were observed between the groups in favor of UPPP. There were significant correlations between results from the questionnaires and objective measures from polysomnography and the vigilance test. At the 6- and 24-month postoperative follow-ups, eight of nine scales were significantly improved compared with baseline. In selected patients with OSA, subjective sleep quality was significantly improved 6 months after UPPP compared with controls, with stable improvements 24 months postoperatively. The correlations between subjective and objective outcomes and the long-term stability suggest a beneficial effect from surgery, although a placebo effect cannot be excluded. NCT01659671. http://www.clinicaltrials.gov.

SKUP3 : 6 and 24 months follow-up of changes in respiration and sleepiness after modified UPPP.

Our previous randomized controlled trial of patients with obstructive sleep apnea syndrome (OSAS) showed that modified uvulopalatopharyngoplasty (UPPP), including tonsillectomy, significantly improved nocturnal respiration, daytime sleepiness, and quality of life in the intervention group compared to controls who had delayed surgery after 6 months. This is the continuous report with the 6- and 24-month postoperative results. Single-center prospective cohort study. Sixty-five patients with apnea-hypopnea index (AHI) ≥ 15, body mass index (BMI) < 36, Epworth Sleepiness Scale (ESS) ≥ 8, and Friedman stage I or II underwent UPPP after failing nonsurgical treatment. The results from polysomnography and ESS at 6 and 24 months were compared to baseline. Eight percent and 20% dropped out from the 6- and 24-month follow-ups, respectively. The AHI value decreased significantly from mean (standard deviation) 52.9 (20.5) at baseline to 23.6 (20.2) after 6 months, and to 24.1 (20.9) after 24 months (P < 0.001). Patients with tonsil size 2, and 3 to 4, had significant reductions in the AHI after both follow-ups. The median ESS score decreased significantly from 13 (range 8-21) to 6.5 (1-18) after 6 months, and to 5 (2-17) after 24 months (P < 0.001). The BMI remained unchanged. There were significant modest correlations for the reductions in AHI and ESS after 24 months. Modified UPPP was effective in improving nocturnal respiration and daytime sleepiness in OSAS patients at both 6- and 24-month follow-up. Patients with tonsil size 2, and 3 to 4, benefitted similarly from surgery with improved respiration. 2b. Laryngoscope, 128:1238-1244, 2018.

Expansion Pharyngoplasty by New Simple Suspension Sutures without Tonsillectomy.

The aim of this study was to introduce and assess a new minimally invasive expansion pharyngoplasty for obstructive sleep apnea (OSA) using bilateral new advancement sutures without tonsillectomy. Among 24 patients who had OSA with Friedman stage II or III and type I Fujita, bilateral sutures were performed to advance and stabilize palatopharyngeus and palatoglossus muscles anterolaterally. Mean apnea hypopnea index decreased significantly from 28.6 ± 4.2 preoperatively to 8.9 ± 4.9 postoperatively. The lowest oxygen saturation increased significantly from 79.25 ± 4.12 to 89.29 ± 4.12. Moreover, the visual analog score showed statistically significant reduction in the snoring intensity from a preoperative mean of 8.2 ± 1.4 to 2.1 ± 1.4 at 6 months postoperatively. Significant improvements were also documented in the Epworth Sleepiness Scale, as its mean decreased from 11.7 ± 2.9 preoperatively to 5.1 ± 2.2 postoperatively. In conclusion, the described new sutures could significantly correct OSA in patients with retropalatal obstruction and lateral pharyngeal walls collapse with easy applicability and no reported complication.

Predicting Outcomes after Uvulopalatopharyngoplasty for Adult Obstructive Sleep Apnea: A Meta-analysis.

Uvulopalatopharyngoplasty (UPPP) remains one of the most common surgical treatments for patients with obstructive sleep apnea. However, the results after UPPP are unpredictable. The purpose of this meta-analysis is to identify predictors of success after UPPP. A literature search was performed utilizing PubMed, EMBASE, SCOPUS, and the Cochrane Library. The keywords and medical subject heading terms used were uvulopalatopharyngoplasty and UPPP. Studies were included if UPPP was used as a single surgical procedure for the treatment of obstructive sleep apnea and results were presented separately as responder (surgical success) and nonresponder (surgical failure). Exclusion criteria included pediatric patients and other surgical procedures (eg, nasal and hypopharyngeal) performed at the same time as the UPPP. Age, body mass index, preoperative apnea-hypopnea index, Friedman stage, and several cephalometric variables were compared between responders and nonresponders. A total of 1257 studies were screened, with 15 studies included in this meta-analysis. Our results demonstrate that Friedman stage I is a strong predictor for success after UPPP, while Friedman stage III and low hyoid position are negative predictors. Age, body mass index, preoperative apnea-hypopnea index, and other cephalometric measurements were not significant. Friedman stage and hyoid position are important predictors for UPPP.

Anterolateral Advancement Pharyngoplasty

To investigate the efficacy of anterolateral advancement pharyngoplasty to enlarge pharyngeal airspace and to decrease palatal and lateral pharyngeal wall collapse in the treatment of obstructive sleep apnea (OSA). Prospective study. University medical hospital. Forty-one patients underwent an anterolateral advancement pharyngoplasty procedure according to the following criteria: body mass index <30 kg/m(2), Friedman stage II or III, type I Fujita, nocturnal polysomnography diagnostic of OSA, retropalatal and lateral pharyngeal collapse, and diagnosis with flexible nasoendoscopy during a Müller's maneuver based on a 5-point scale. Patients with retroglossal airway collapse were excluded from the study. The principle of this technique is to advance and fix the palatopharyngeus muscle with the superior pharyngeus constrictor muscle without transecting any of their fascicules anterolateral to the pterygomandibular raphe and anterosuperior to the levator veli palatine muscle. Pre- and postoperative polysomnography findings (mean ± SD) showed significant statistical differences: apnea hypopnea index (AHI) decreased from 42.1 ± 16.34 to 16.3 ± 10.3 (P ≤ .001); percentage of time with oxyhemoglobin saturation <90% decreased from 18.5% ± 4.2% to 10.1% ± 1.3% (P ≤ .001); and lowest oxygen saturation level increased from 79.9% ± 14.8% to 89.3% ± 11.1% (P ≤ .05). The mean time for patients to return to a normal diet was 12.2 days. There was no postoperative bleeding, velopharyngeal insufficiency, speech alternations, or taste loss. Based on a threshold of a 50% reduction in AHI and AHI <20, surgical success was 86.8%. Anterolateral advancement pharyngoplasty appears to be an effective technique with a high surgical success rate in the treatment of OSA patients with lateral pharyngeal wall collapse.

Modified Friedman stage in predicting glossopharyngeal obstruction in obstructive sleep apnea

Conclusions: Modified Friedman stage can be used to predict glossopharyngeal obstruction better than before in patients with obstructive sleep apnea (OSA).Objective: To evaluate the diagnostic value of modified Friedman stage in predicting glossopharyngeal obstruction in patients with OSA.Methods: Eighty-five OSA patients with Friedman stage III were divided into IIIa group and IIIb group based on an imaginary line drawn in the horizontal and middle position of the soft palate. Polysomnography (PSG) was performed after nasopharyngeal tube (NPT) insertion (NPT-PSG) to diagnose glossopharyngeal obstruction. Apnea-hypopnea index (AHI) determined by NPT-PSG (NPT-AHI) and glossopharyngeal obstruction result determined by NPT-PSG (NPT-PSG result) were compared between the two groups.Results: There were significant differences in NPT-AHI (p < 0.01) and NPT-PSG result (p < 0.01) between the two groups.

Efficacy of Coblation Endoscopic Lingual Lightening in Multilevel Surgery for Obstructive Sleep Apnea.

Multilevel obstruction is involved in the pathogenesis of obstructive sleep apnea (OSA). Coblation endoscopic lingual lightening (CELL) is a variation of glossectomy to reduce tongue collapse and can be considered in the surgical management of adults with OSA. To evaluate the clinical and polysomnographic outcomes of tongue base reduction using CELL in multilevel surgery for OSA. A retrospective case-control study was performed to review the medical records of adults with OSA (apnea-hypopnea index [AHI], >20) and Friedman stage III (tongue position III and tonsil size I-II) who underwent combined CELL and relocation pharyngoplasty (group 1) or relocation pharyngoplasty alone (group 2) for OSA between January 1, 2012, and December 31, 2013, at a tertiary referral sleep center. The groups were matched by age, sex, body mass index, and AHI at baseline. The dates of the analysis were May 30 to June 29, 2014. Coblation endoscopic lingual lightening. The primary outcome measure was change in AHI after surgery (after ≥6 months). Other outcomes were differences in surgical response rates, perioperative apnea index, lowest oxygen saturation, and Epworth Sleepiness Scale score. The study cohort comprised 90 participants. Their mean (SD) age was 40.7 (9.2) years, and 96% (86 of 90) were male. Group 1 patients (n = 30) underwent combined CELL and relocation pharyngoplasty, and group 2 patients (n = 60) underwent relocation pharyngoplasty only. The mean (SD) AHI decreased from 48.4 (16.9) to 16.5 (11.2) (P < .001) in group 1 and from 44.2 (19.3) to 20.1 (15.6) (P < .001) in group 2 . Percentage change in AHI was significantly different between group 1 and group 2 (mean [SD], -65.5 [20.5] vs -53.2 [30.3]) (P = .047). The surgical response rate was greater in group 1 (73% [22 of 30]) than in group 2 (50% [30 of 60]) (P = .04). Without increasing complications, combined CELL and relocation pharyngoplasty achieved greater AHI reduction and a higher surgical response rate among adults with OSA and Friedman stage III compared with relocation pharyngoplasty alone.

Addressing the Retrolingual Space in Obstructive Sleep Apnea: Outcomes Stratified by Friedman Stage in Patients Undergoing Transoral Robotic Surgery

Background/Aims: To stratify outcomes in patients with moderate to severe obstructive sleep apnea-hypopnea syndrome (OSAHS) undergoing transoral robotic surgery (TORS) ± multilevel procedures according to Friedman stage. Methods: A total of 118 patients with moderate to severe OSAHS between 2010 and 2013 were stratified preoperatively by Friedman stage. All patients had TORS-assisted lingual tonsillectomy, either stand-alone or in combination with palatal surgery. Apnea-hypopnea index (AHI) was measured preoperatively and 3 months postoperatively. Success was defined as a decrease in AHI by 50% and AHI <20. Results: The average pre- and postoperative AHI was 43.0 and 22.6, respectively, and the overall success rate was 63%. When stratifying by Friedman stage, success was seen in 75% of stage I, 70% of stage II, 66% of stage III, and 10% of stage IV patients. When stratifying by preoperative BMI, success was seen in 75% of stage II and 72% of stage III patients with BMI <30, compared to 58% of stage II and 56% of stage III patients with BMI >30. Conclusions: TORS-assisted lingual tonsillectomy ± multilevel procedures can be successful in treating patients with moderate to severe OSAHS with Friedman stage I-III anatomy. Success rates are even greater if patients are stratified according to preoperative BMI, as those with BMI <30 are more likely to achieve success even with Friedman stage II-III anatomy.

SKUP(3) RCT; continuous study: Changes in sleepiness and quality of life after modified UPPP.

Our previous study showed that modified uvulopalatopharyngoplasty (UPPP), including tonsillectomy, significantly improved nocturnal respiration in obstructive sleep apnea syndrome (OSAS) patients. This is a continuous study of changes in daytime sleepiness and quality of life. Prospective randomized controlled trial (RCT), two parallel arms. Sixty-five patients with apnea-hypopnea index ≥ 15, body mass index < 36, Epworth Sleepiness Scale (ESS) ≥ 8, Friedman stage I or II, failing nonsurgical treatment. The intervention group (n = 32) underwent surgery, and the controls (n = 33) had no treatment. At baseline and the 7-month follow-up, polysomnography, questionnaires, and vigilance tests were implemented. All patients answered the questionnaires, and 48 took the vigilance test. Epworth Sleepiness Scale decreased significantly in the intervention group, from a mean (standard deviation) of 12.5(3.2) to 6.8(3.9), but nonsignificantly in the control group, from 12.9(3.1) to 12.5(3.9), a significant group difference (P < 0.001). The physical and mental component score on the Short Form-36 questionnaire increased significantly in the intervention group, from a mean 47.8(8.3) to 51.2(8.8) and from 42.1(10.6) to 48.1(9.7), respectively, but with nonsignificant changes in the controls: 49.0(9.0) to 48.3(9.1) and 41.0(10.2) to 42.7(11.5), significant group differences (P = 0.007, P = 0.031), respectively. The sleep latency/vigilance test showed a significant mean increase in the intervention group of 7(12.4) minutes and a decrease in the controls of 2.2(10.6), a significant group difference (P = 0.011). There were significant correlations between changes in subjective outcomes and nocturnal respiration. This RCT shows that modified UPPP was effective in improving daytime sleepiness and quality of life in OSAS patients. It strengthens the body of evidence on the potential effect of surgery offered to selected patients. 1b. Laryngoscope, 126:1484-1491, 2016.

The effect of tonsillectomy alone in adult obstructive sleep apnea.

The purpose of this study was to determine the effect of tonsillectomy as a single procedure in the treatment of adult obstructive sleep apnea (OSA). Prospective multi-institutional study evaluating adults with tonsillar hypertrophy scheduled to undergo tonsillectomy as an isolated surgery. Tertiary care medical centers within the US Department of Defense. Adult subjects with tonsillar hypertrophy who were already scheduled for tonsillectomy were enrolled from October 2010 to July 2013. Subjects underwent physical examination, Epworth Sleepiness Scale, Berlin Questionnaire, and polysomnogram before surgery and after. Collected data included demographics, questionnaire scores, apnea-hypopnea index (AHI), and lowest saturation of oxygen. A total of 202 consecutive subjects undergoing tonsillectomy were enrolled. The final analysis included 19 subjects testing positive for OSA. The mean age was 27.9 years; mean body mass index, 29.6; median tonsil size, 3; and most frequent Friedman stage, 1. The AHI before surgery ranged from 5.4 to 56.4 events per hour. The mean AHI decreased from 18.0 to 3.2 events per hour after surgery, a reduction of 82%. The responder rate--with subjects achieving at least a 50% reduction of AHI to a value <15--was 94.7%. Following tonsillectomy, there were statistically significant reductions in median lowest saturation of oxygen level and Epworth Sleepiness Scale and Berlin scores. Adult tonsillectomy alone has beneficial effect in OSA management, particularly in young overweight men with large tonsils, moderate OSA, and low Friedman stage.

Change of Obstruction Site by Modified Jaw Thrust Maneuver in Obstructive Sleep Apnea Patients

Background and Objective We evaluated possibility of modified jaw thrust maneuver with drug induced sleep endoscopy (DISE), as an indicator of mandibular advancement treatment such as mandibular advance device, geniohyoid advancement and other treatment modalities. Methods Sixty seven Korean male, obstructive sleep apnea patient, confirmed by full night polysomnography were enrolled. We performed DISE and analyzed obstruction sites before and after modified jaw thrust maneuver. Degree of improvement in obstruction more than one grade of obstruction, was defined as “responder by modified jaw thrust maneuver”. Non-responder was defined as the airway does not open by the modified jaw thrust maneuver. Association was analyzed among the patient’s characteristics [body mass index (BMI), Friedman stage, and respiratory disturbance index (RDI)] and the results. Results In retropalatal level obstruction, responder by modified jaw thrust maneuver was most commonly observed at antero-posterior (AP) obstruction (70.31%) while it was least observed at combined obstruction (66.67%). In retroglossal level obstruction, responder by modified jaw thrust maneuver was most commonly observed at AP obstruction (77.50%), while lateral obstruction was least observed (68.75%). Between group comparisons including, group of responder and group of non-responder of combined obstruction of retropalatal level and lateral obstruction of retroglossal level, revealed that there were no statistically significant differences in BMI, Friedman stage, and RDI (p < 0.05). Conclusions Airway obstruction did not extend to the same pattern by modified jaw thrust maneuver. Modified jaw thrust maneuver under DISE is a useful diagnostic tool and predictor of therapeutic effects of mandibular advancement treatment. Key words: Sleep apnea, Obstructive, Diagnosis, Mandibular advancement

Expansion Sphincter Pharyngoplasty for Obstructive Sleep Apnea: Outcome Evaluated by Pre‐ and Postoperative Polysomnography

Objectives: (1) Determine the effectiveness of expansion sphincter pharyngoplasty (ESP) in the treatment of moderate and severe obstructive sleep apnea (OSA). (2) Be able to analyze the effects of the ESP on the sleep stages of patients with moderate and severe OSA. (3) Confirm changes in oxygen saturation after surgery. Methods: A retrospective review of a prospective data set of 20 patients with moderate and severe OSA who underwent ESP. Patients studied were adults with small tonsils, body mass index less than 30 kg/m2, Friedman stage II or III, and type I Fujita. Charts between 2010 to 2014 were reviewed, and preoperative and postoperative polysomnographic values were analyzed. Results: Eighteen patients (90%) undergoing ESP showed some improvement. The surgery was effective in the treatment of severe and moderate obstructive sleep apnea syndrome (OSAS; P &lt; .001). Patients with severe OSAS had better results with ESP than patients with moderate OSAS ( P &lt; .001). After surgery there were significant changes in sleep stages ( P &lt; .05). Minimum oxygen saturation improved in the moderate and severe OSAS groups. Conclusions: ESP is a valid therapeutic option for the treatment of OSA, and showed better results in severe cases rather than moderate ones. There are variations in the sleep stages that must be considered after this surgery. The surgical technique can bring benefits in oxygen saturation in patients with OSAS.

Surgical Evaluation in Obstructive Sleep Apnea: Climbing the Steep Part of the Learning Curve.

Many physiologic factors contribute to obstructive sleep apnea (OSA), including pharyngeal anatomy, dilator muscle activation, lung volumes, arousal threshold, and ventilatory control.1 Although it may be possible to examine the relative importance of these factors in researchsettings, there are no clinically available tests that can be used to treat patientsaccordingly (forexample,usingasedativehypnoticagent for those patientswith a low arousal threshold). Surgery is an anatomical treatment, and Woodson2 summarizes the evidence regarding identificationof thepatternofobstructionand surgical treatment of OSA. The first relevant issue is how to predict outcomes of palate surgerywith tonsillectomy.Higher-level evidence fromcohort studies indicates that Friedman stage shows the clearest association with outcomes after uvulopalatopharyngoplasty (UPPP). There are conflicting studies about the relative value of endoscopy and theMuellermaneuver duringwakefulness, but Iwanaga et al3 and Hessel and Vries4 showed that druginduced sleep endoscopy (DISE) is also associated with UPPP outcomes. Comparison of findings from evaluation methods has not been undertaken as extensively for alternative palate procedures. This is important because some of these procedures (expansion sphincter pharyngoplasty, lateral pharyngoplasty) have demonstrated better outcomes than UPPP in randomizedtrials andbecauseonly 10%ofOSAcasesareFriedman stage 1. The second key issue is how to select alternative or adjunctive treatments and whether the findings predict outcomes.Mostof the literature regardingevaluationmethodshas focused on findings that are associated with worse outcomes, identifying mandible position (eg, SNB [sellanasion-B point] angle on the lateral cephalogram) and body mass index as factors associated with outcomes for all hypopharyngeal or retroglossal procedures.DISEmay identify specific structures (VOTE classification) that contribute specifically to obstruction, but no studies have prospectively used DISE to select procedures. However, there are cohort studies showing that specificDISE findings are associatedwithworse outcomes after surgery,5,6 mandibular repositioning appliance use, or hypoglossal nerve stimulation. In my own practice, I use Friedman stage to select patients for isolated palate surgery and complement this with awake endoscopy for a more detailed evaluation of the pharynx. Insteadof usingDISE as a routine separate evaluation for all patients, as is done in some European centers, I prefer to use it as a stand-alone evaluation in approximately 20%ofpatients where I believe that it can change recommendations, such as those with previous surgery or an especially unclear pattern of obstruction. In some cases, I will perform DISE at the timeof a procedure to guide the selectionof a specific palate surgery technique or the extent of tongue base tissue resection, but this is based on personal experience rather than anything approaching a randomized trial. Woodson2 correctly describes that the surgical evaluation of OSA surgery remains in its infancy. Current techniques that evaluate physical anatomymaybe combinedwith physiologic measures suchaspharyngeal critical closingpressure.Asnovel technologies and techniques for treatment become available, so too will major advances in sleep surgery with larger, controlled, and prospective studies of evaluation methods. Both areashaveprovenessential inourquest toselectproceduresand enable targeted, effective, and predictable outcomes.

SKUP3 randomised controlled trial: polysomnographic results after uvulopalatopharyngoplasty in selected patients with obstructive sleep apnoea

ObjectiveTo assess the 6-month efficacy of uvulopalatopharyngoplasty (UPPP) compared with expectancy in selected patients with obstructive sleep apnoea syndrome (OSAS).DesignA prospective single-centre randomised controlled trial with two parallel arms stratified...

Associated predictors of therapeutic response to uvulopharyngopalatoplasty for severe obstructive sleep apnea hypopnea syndrome

The aim of this study was to determine the associated factors affecting the outcome of uvulopharyngopalatoplasty (UPPP) in patients with severe obstructive sleep apnea hypopnea syndrome (OSAHS), and to investigate whether cephalometric measurements were predictive of the therapeutic response to UPPP in patients with severe OSAHS. We retrospectively studied 51 consecutive patients who underwent revised UPPP with uvula preservation (H-UPPP), or Z-palatopharyngoplasty (ZPPP) for severe OSAHS [apnea-hypopnea index (AHI) >30]. All patients were evaluated using physical examination, Epworth Sleepiness Scale (ESS), cephalometry, and nocturnal polysomnography (PSG) before surgery and at 6-12 months after surgery. Based on the success criteria defined as an AHI of <20 and a decrease >50 %, the overall success rate was 45.1 %. The preoperative distance from the posterior border of the uvula to the middle pharyngeal wall (U-MPW) was significantly longer in the responder group than in the nonresponder group, when considering the whole group or the H-UPPP group alone. Among all study subjects, U-MPW and change in body mass index (△BMI) were the significant predictors of surgical success. U-MPW was the key predictor for H-UPPP surgical success, whereas mandibular plane angle (MPA) and Friedman stage were the key predictors for ZPPP surgical success. In conclusion, U-MPW was a significant predictor of UPPP surgical success. Patients with U-MPW >10 mm who are unwilling to receive nasal continuous positive airway pressure (CPAP) therapy might be suitable candidates for UPPP surgery.

Impact of obesity on uvulopalatopharyngoplasty success in patients with severe obstructive sleep apnea: a retrospective single-center study in Taiwan

Conclusion: Our findings suggest that, in Asian patients with severe obstructive sleep apnea (OSA), obesity is a better predictor of uvulopalatopharyngoplasty (UPPP) failure than Friedman stage III. Objectives: This study evaluated UPPP success rates in obese and non-obese Asian patients treated for severe OSA. Methods: Records of patients who underwent UPPP for treatment of OSA were retrospectively reviewed. Preoperative and postoperative apnea/hypopnea index (AHI) and Epworth Sleepiness Scale (ESS) score, and Friedman stage were compared in non-obese (body mass index (BMI) <27 kg/m2) and obese (BMI ≥27 kg/m2) patients. Treatment success was defined as >50% reduction in preoperative AHI or postoperative AHI of <20 events/h. Results: Treatment success was significantly lower (p < 0.0001) in the obese group (24.6%) compared with the non-obese group (62.5%). After adjusting for gender, age, BMI, Friedman stage, and preoperative AHI and ESS score, obesity was a significant independent negative predictor of treatment success (adjusted OR = 0.297, 95% CI = 0.114–0.773, p = 0.013).

Clinical Predictors for Successful Uvulopalatopharyngoplasty in the Management of Obstructive Sleep Apnea

Objective. To assess the clinical parameters for successful uvulopalatopharyngoplasty in the management of obstructive sleep apnoea syndrome documented with pre- and postoperative polysomnography. Materials and Methods. A study group of 50 patients diagnosed as having OSA by full night polysomnography were assessed clinically and staged on basis of Friedman staging system. BMI and neck circumference were considered, and videoendoscopy with Muller's maneuver was done in all to document the site of obstruction. The study group divided into surgical and nonsurgical ones. Twenty-two patients out of fifty were then selected for uvulopalatopharyngoplasty. The selection of surgical group was done primarily on basis of clinical parameters like neck circumference, Friedman stage of the patient and site, and/or level of obstruction of patient. Postoperative polysomnography was done six months after surgery to document the change in AHI score. Result. The study group consists of fifty patients with mean age of 44.4 ± 9.3 years. UPPP was done in twenty-two, and the result of the surgery as defined by 50% reduction in preoperative AHI with postoperative AHI < 20/h was seen to be 95.2%. Postoperative change in AHI done after 6-month interval was seen to be statistically significant with P value < 0.001. Conclusion. UPPP is ideal option for management of obstructive sleep apnoea syndrome in properly selected patients on the basis of Friedman stage and site of obstruction detected by videoendoscopy with Muller's maneuver.

Treatment of Obstructive Sleep Apnea-Hypopnea Syndrome With Combined Uvulopalatopharyngoplasty and Midline Glossectomy: Outcomes From a 5-Year Study

The aim of this retrospective long-term follow-up study was to assess 5-year outcomes after combined uvulopalatopharyngoplasty (UPPP) and midline glossectomy surgery for the treatment of obstructive sleep apnea-hypopnea syndrome (OSAHS). A total of 34 subjects with OSAHS with combinatory obstructions of posterior soft palate and posterior tongue area who underwent combined midline glossectomy and UPPP were successfully followed for 5 years to examine the therapeutic effect of treatment. All subjects were of Friedman stage II or III and had major stenoses at the base of the tongue. The apnea-hypopnea index (AHI), and mean lowest S(pO(2)) were measured preoperatively and postoperatively to assess therapeutic efficacy. The mean preoperative AHI was 56.0 ± 8.4 episodes/h, while the mean lowest S(pO(2)) was 62.1 ± 10.6%. AHI and mean lowest S(pO(2)) were significantly increased and decreased, respectively, from preoperative levels at each follow-up point after surgery, up to 5 years (P < .05). The average widened pharyngeal space after surgery was 42 mm(2). At 6 months, surgery was classified as being curative in 27/34 (79.41%) of subjects, and markedly effective or effective in the remaining subjects. At 5 years, surgery was classified as being curative in 7/34 (20.59%) subjects, markedly effective or effective in 25/34 (73.53%) subjects, and not effective in 2/34 (5.88%) subjects. Five years after surgery the average body mass index for the subjects who were not cured was slightly higher than those who were cured, but the difference was not statistically significant (31.3 ± 3.7 kg/m(2) vs 29.7 ± 3.6 kg/m(2), P = .29). Subjects who were cured had lower supine AHI values than those who were not cured (2-year postoperative AHI 36.8 ± 9.2 episodes/h vs 43.8 ± 6.9 episodes/h, P = .03, 5-year post-operation AHI 32.1 ± 7.6 episodes/h vs 41.7 ± 8.2 episodes/h, P = .006). These findings suggest that combined midline glossectomy and UPPP can be an effective treatment for subjects with Friedman stage II or III OSAHS and substantial stenosis around the base of the tongue.

Lateral oropharyngeal wall and supraglottic airway collapse associated with failure in sleep apnea surgery

To identify patterns of airway collapse during preoperative drug-induced sleep endoscopy (DISE) as predictors of surgical failure following multilevel airway surgery for patients with obstructive sleep apnea-hypopnea syndrome (OSAHS). Retrospective clinical chart review. Medical records of patients who underwent site-specific surgical modification of the upper airway for treatment of OSHAS were reviewed. Patients were included in this study if they had a preoperative airway evaluation with DISE as well as preoperative and postoperative polysomnography. Airway obstruction on DISE was described according to airway level, severity, and axis of collapse. Severe airway obstruction was defined as >75% collapse on endoscopy. Surgical success was described as a postoperative apnea-hypopnea index (AHI) of <20 and a >50% decrease in preoperative AHI. A total of 34 patients were included in this study. The overall surgical success rate was 56%. Surgical success (n = 19) and surgical failure (n = 15) patients were similar with regard to age, gender, body mass index, preoperative AHI, Friedman stage, adenotonsillar grades, and surgical management. DISE findings in the surgical failure group demonstrated greater incidence of severe lateral oropharyngeal wall collapse (73.3% vs. 36.8%, P = .037) and severe supraglottic collapse (93.3% vs. 63.2%, P = .046) as compared to the surgical success group. The presence of severe lateral pharyngeal wall and/or supraglottic collapse on preoperative DISE is associated with OSAHS surgical failure. The identification of this failure-prone collapse pattern may be useful in preoperative patient counseling as well as in directing an individualized and customized approach to the treatment of OSHAS.

Acute supraglottitis in adults: What's the optimal airway intervention?

To validate the Friedman stage and define the proper timing for airway intervention in adult cases of acute supraglottitis, we evaluated the clinical courses and management of adult patients. 202 adult patients with acute supraglottitis were included in this study. The diagnosis of supraglottitis was established by flexible nasolaryngoscopic examination. Friedman stages were classified in each patient. In this study, the first three days of serial nasolaryngoscopic findings for each patient were evaluated. All patients were treated successfully with only conservative methods. There were no significant differences between patients with Friedman stages I or II/III. Among the patients that had serial nasolaryngoscopic findings, only one patient presented with progressive swelling of the epiglottis, and there were no cases of persistent swelling. The airway intervention threshold should be raised from Friedman stages II-III. And, airway intervention should not be needed if patients are tolerant of their respiratory discomfort.