Multilevel Surgery For Obstructive Sleep Apnea Research Articles

Therapeutic Effect of Multilevel Surgery on Laryngopharyngeal Reflux in Obstructive Sleep Apnea Patients: Impact on the Reflux Symptom Index and Reflux Finding Score.

Our previous study found that multilevel obstructive sleep apnea (OSA) surgery mitigated laryngopharyngeal reflux (LPR) symptoms in terms of the reflux symptom index (RSI), but no studies have investigated the impact of OSA surgery on laryngoscopic parameters. The aim of this study was to examine the clinical outcome of LPR improvement following OSA surgery, with a focus on both the RSI and the reflux finding score (RFS). Prospectively collected data from 28 patients who underwent multilevel OSA surgery from 2017 to 2021 were retrospectively analyzed. Patients were asked to complete the RSI questionnaire and underwent a laryngoscopic examination to evaluate the RFS before and after surgery. Age, height, weight, body mass index (BMI), and polysomnography data before and after surgery were also reviewed. After surgery, the total RSI and RFS decreased significantly from 11.96±8.40 to 7.68±6.82 (P=0.003) and from 6.57±3.49 to 3.21±1.87 (P<0.001). The positive rates of RSI and RFS decreased from 28.6% to 17.9% and 32.1% to 0%, respectively. Significant improvements were found in the RSI subdomains of throat clearing, throat mucus, breathing difficulty, troublesome cough, and heartburn sensation, while all RFS subdomains except granuloma improved significantly. In subgroup analyses, no significant differences were found between subgroups based on age, OSA severity, or BMI. OSA surgery has the potential to alleviate both LPR symptoms and laryngoscopic. Additional research integrating more objective techniques and novel treatment strategies is required to better comprehend the clinical impact of OSA surgery on LPR.

Quality of Life and Excessive Daytime Sleepiness in Adults with Obstructive Sleep Apnea Who Are Treated with Multilevel Surgery or Adherent to Continuous Positive Airway Pressure.

Obstructive Sleep Apnea (OSA) syndrome is a respiratory sleep disorder characterized by a reduction (hypopnea) in or a complete cessation (apnea) of airflow in the upper airways at night, in the presence of breathing effort. The gold standard treatment for OSA is ventilation through continuous positive airway pressure (CPAP), although this often shows poor patient compliance. In recent years, transoral robotic surgery (TORS) has been proposed as a valid surgical treatment for patients suffering from OSA in a multilevel surgical setting. The aim of this study is to analyze the effects on QoL and daytime sleepiness of multilevel surgery for OSA (barbed pharyngoplasty + transoral robotic surgery). Furthermore, we compared the impact on QoL and daytime sleepiness of two different treatments for patients with moderate to severe OSA, such as CPAP and TORS. Sixty-seven OSA patients who underwent multilevel robotic surgery and sixty-seven OSA patients treated with CPAP were enrolled, defined as Group 1 and Group 2, respectively. The Glasgow Benefit Inventory (GBI) questionnaire was administrated to evaluate the changes in the QoL. Respiratory outcomes were evaluated and compared. Group 1 showed a GBI total average value of +30.4, whereas Group 2, a value of +33.2 (p = 0.4). General benefit score showed no difference between groups (p = 0.1). Better values of social status benefit (p = 0.0006) emerged in the CPAP Group, whereas greater physical status benefit (p = 0.04) was shown in the TORS Group. Delta-AHI (−23.7 ± 14.3 vs. −31.7 ± 15.6; p = 0.001) and Delta-ODI (−24.5 ± 9.5 vs. −29.4 ± 10.5; p = 0.001) showed better values in the CPAP group. Therapeutic success rate of the Multilevel TORS Group was 73.1% and 91% in the CPAP group (p = 0.01), respectively. Multilevel TORS and CPAP have a positive effect on the quality of life of OSA patients. Greater social support has been reported in the CPAP group and better physical health status in the TORS group. No statistical difference emerged in the reduction in daytime sleepiness between both groups.

Expansion Hyoidthyroidpexy: Combined Hyoid Surgery Techniques for Obstructive Sleep Apnea: All in One.

We provide expansion hyoidthyroidpexy as a novel surgical procedure for obstructive sleep apnea (OSA) that could combine different techniques of hyoid bone surgery in 1 procedure. This case series included patients with OSA who had an apnea-hypopnea index (AHI) >15 and showed predominant lateral wall hypopharyngeal collapse. In 21 patients, the procedure was performed smoothly without technical difficulties or operative adverse events, resulting in lateral expansion of each horn of the hyoid bone by ≥1 cm without early or late complications. At 6 months postoperatively, both AHI and the mean lowest oxygen saturation level were significantly improved ( P < .0001). The new expansion hyoidthyroidpexy technique is a reliable, easy, and effective procedure with good surgical outcomes in patients with OSA. It is feasible to be employed in the protocol of multilevel surgery for OSA.

Drug-Induced Sleep Computed Tomography-Directed Upper Airway Surgery for Obstructive Sleep Apnea: A Pilot Study.

A surgical response to upper airway (UA) surgery for obstructive sleep apnea (OSA) depends on adequate correction of collapsible sites in the UA. This pilot study aimed to examine the surgical response to UA surgery directed by drug-induced sleep computed tomography (DI-SCT) for OSA. Prospective case series. Tertiary referral center. This study recruited 29 OSA patients (median age, 41 years; median body mass index, 26.9 kg/m2) who underwent single-stage DI-SCT-directed UA surgery between October 2012 and September 2014. DI-SCT was performed with propofol for light sedation with a bispectral monitor before and after UA surgery. Nonresponders were defined as those with a reduction in apnea-hypopnea index <50% after 6 months following UA surgery. DI-SCT showed that 28 (97%) patients had collapses at multiple sites, all of whom underwent multilevel UA surgery accordingly. The apnea-hypopnea index decreased from 53.6 to 26.8 ( P < .001). There were 18 (62%) nonresponders and 11 (38%) responders. Multiple-site collapses could not predict surgical response ( P > .99). The nonresponders had significant improvements in velopharyngeal, oropharyngeal lateral wall, and tongue collapses (all P < .05), whereas the responders had significant improvements in velopharyngeal and oropharyngeal lateral wall collapses (both P ≤ .05). Despite multilevel OSA surgery, residual UA obstruction in nonresponders likely occurs due to multiple mechanisms. DI-SCT may help to elucidate the reasons for a nonresponse.

Hyoid Bone Suspension as a Part of Multilevel Surgery for Obstructive Sleep Apnea Syndrome.

Introduction Since oropharyngeal surgery alone is often insufficient to treat obstructive sleep apnea (OSA), advances have been developed in hypopharyngeal surgery. Objective To assess hyoid suspension surgery as part of a multilevel OSA surgery, also including palatal surgery. Methods The study included patients with OSA symptoms with apnea hypopnea index (AHI) > 15. They were scheduled for hyoid suspension after a nasoendoscopy during Müller maneuver and drug induced sleep endoscopy (DISE). All patients had body mass index (BMI) < 35 kg/m2. Hyoidothyroidopexy combined with tonsillectomy and palatal suspension was performed in all cases. Results The mean AHI dropped significantly ( p < 0.0001) from 68.4 ± 25.3 preoperatively to 25.6 ± 9.52 postoperatively. The mean lowest oxygen (O 2 ) saturation level increased significantly from 66.8 ± 11.3 to 83.2 ± 2.86 ( p < 0.0001). In addition, the snoring score significantly decreased ( p < 0.0001) from a preoperative mean of 3.4 ± 0.54 to 2 ± 0.7 at 6 months postoperatively. In regard to the Epworth sleepiness scale (ESS), it showed significant improvements ( p < 0.0001) as its mean diminished from 13.8 ± 5.4 preoperatively to 5.2 ± 1.6 postoperatively. Conclusion Hyoidothyroidopexy using absorbable suture seems to produce a good outcome in treating OSA. It could be effectively and safely combined with other palatal procedures in the multilevel surgery for OSA.

Transoral Robotic Surgery for Obstructive Sleep Apnea

The purpose of this review is to describe the role of transoral robotic surgery (TORS) in the surgical management of obstructive sleep apnea (OSA). Numerous studies have examined the best techniques and efficacy of TORS for OSA as a component of multi-level surgery for OSA. The role of transoral robotic surgery (TORS) for obstructive sleep apnea (OSA) emerged in 2008 as a novel approach for the treatment of retroglossal and supraglottic obstruction. This technique provides an alternative surgical approach for patients with obstruction in these areas. Success rates with TORS are modestly improved over alternative approaches to the tongue base and offer an added advantage of addressing neighboring regions of the airway including access to the supraglottis.

Changes in the Reflux Symptom Index After Multilevel Surgery for Obstructive Sleep Apnea.

Objectives This study evaluated whether the symptoms of laryngopharyngeal reflux (LPR) change after multilevel surgery for obstructive sleep apnea (OSA).Methods Patients who underwent multilevel surgery for OSA between April 2009 and September 2014 were enrolled in this study. All patients underwent preoperative polysomnography prior to surgery and were asked to complete the reflux symptom index (RSI) questionnaire before and after surgery.Results Of 73 enrolled patients, 24 (33%) reported an RSI score >13 and were thus classified as having reflux. The mean RSI score before surgery was 11.48±7.95; this number decreased to 4.95±6.19 after surgery (P<0.001). The rate of positive RSI responses was 33% before surgery and 9% after surgery. Each variable that comprised the RSI improved significantly after surgery, except for difficulty with swallowing. Regarding the degree of RSI improvement after surgery, there were no significant differences between subgroups according to sex, age, body mass index, OSA severity, or surgical outcome.Conclusion LPR symptoms are prevalent in OSA patients. Treatment for OSA using multilevel surgery potentially reduces the symptoms of LPR.

Targeted Multilevel Surgical Management of Obstructive Sleep Apnea: A Case Series of 44 Patients

Objectives: (1) Assess the effectiveness of multilevel surgery in the treatment of obstructive sleep apnea (OSA). (2) Analyze outcomes based on reduction of apnea hypopnea index (AHI) and positive airway treatment pressures. Methods: Case-series review in a tertiary referral center. A total of 44 patients underwent multilevel OSA surgery between November 2009 and September 2013. Depending on the preoperative examination and OSA severity based on sleep study, patients underwent multilevel surgery including nasal, oropharyngeal, transoral robotic, tongue base, hyoid, and/or orthognathic surgery. Follow-up sleep studies at 4 months were obtained and compared with preoperative data. Results: Overall AHI was significantly reduced from a mean of 44.5 to 19.9 ( P = .0008), 78.9 to 35.8 ( P = .0001) in the severe OSA group, 21.4 to 7.0 ( P = .0001) in the moderate group, and 8.7 to 4.5 ( P = .0004) in the mild group. AHI reduced from mean of 98.1 to 31.7 ( P = .0013) in those who underwent orthognathic surgery and 36.1 to 18.1 ( P = .011) in those who had soft tissue procedures without orthognathic surgery. Overall continuous positive airway pressure (CPAP) improved from mean of 10.9 to 4.7 cmH20 ( P = .0001). Body mass index was significantly higher in the severe OSA group than the mild and moderate groups. No significant difference was noted in neck circumference between the 3 groups. Conclusions: Targeted multilevel OSA surgery in this cohort was successful in an overall reduction of AHI and CPAP pressures. The maximum improvement in AHI was seen in patients with moderate OSA and in those who had an orthognathic procedure.

Safety of Multilevel Surgery in Obstructive Sleep Apnea&lt;subtitle&gt;A Review of 487 Cases&lt;/subtitle&gt;&lt;alt-title&gt;Safety of Multilevel Surgery in OSA&lt;/alt-title&gt;

To review the safety of multilevel surgery in patients with obstructive sleep apnea (OSA). Retrospective review. A total of 487 consecutive patients with OSA and 1698 surgical procedures from January 2007 to May 2010. Multilevel OSA surgery comprising nasal surgery (endoscopic sinus surgery, septoplasty, and inferior turbinate reduction), palate surgery (traditional uvulopalatopharyngoplasty, expansion sphincter pharyngoplasty and anterior palatoplasty), and tongue surgery (hyoid suspension, radiofrequency tongue base, and tongue suspension suture). Surgical complications. The overall complication rate was 7.1%, with 1 patient having an upper airway obstruction. Complications were as follows: (1) 6 patients had postoperative oxygen desaturation within 3 hours after extubation (these patients had severe OSA [apnea-hypopnea index > 60 and lowest oxygen saturation level <80%]), (2) 15 patients had persistent hypertension (these patients had a history of hypertension), (3) 15 patients had secondary hemorrhage (7-12 days postoperatively), (4) there were 2 cases of negative pressure pulmonary edema, (5) 9 patients had tongue edema (following tongue surgery), and (6) 1 patient had upper airway obstruction requiring reintubation. Patients who had undergone tongue surgery were admitted routinely to the high-dependency unit (step-down care from the intensive care unit) overnight. Routine postoperative admission to the intensive care unit for all patients with OSA is unnecessary. These patients should be closely monitored in the postanesthesia care unit area after surgery, and based on the outcome of this period, they can be observed overnight in either the high-dependency unit or the general ward.

OSA Surgery: Reviewing the Reviews and Their Implications

Program Description: The American Academy of Sleep Medicine and Agency for Healthcare Research and Quality have recently published controversial systematic reviews of the obstructive sleep apnea (OSA) surgery literature. These are now being used by third-party payors to reconsider coverage policies, including those for soft palate procedures such as uvulopalatopharyngoplasty. The purpose of this miniseminar is to present these reviews and the debates they raise, examine the available higher level studies, and present a framework for evaluating OSA surgery outcomes. AASM and AHRQ reviews. Systematic reviews can synthesize are powerful but challenging tools that can help guide clinical decisions. Any review has general as well as specific strengths and weaknesses, whether related to methods that require oversimplification of each study’s findings, selection of outcome measures to compare results across studies, or the scope of the review that leaves certain studies excluded. This segment will examine the reviews’ methods and findings, highlighting their importance as well as gaps, particularly those regarding multilevel OSA surgery and the evaluation of sleep study outcomes alone. As for most surgical fields, the bulk of the OSA surgery literature consists of case series studies, with all of their inherent limitations. However, there are a number of higher level OSA surgery studies, including randomized trials and cohort studies. The program will review these higher level studies and provide grades for the available evidence concerning OSA surgical interventions. As for every surgical intervention, outcomes after OSA surgery vary widely, not only among various procedures but also for individual patients. There is a tendency to criticize or discard procedures that do not achieve ideal outcomes universally. The alternative is to pursue a nuanced evaluation of whether those patients who appear to respond to surgery achieve meaningful clinical improvements and also to match procedures and patients in order to increase the proportion of treated patients who do respond to surgery. This portion of the miniseminar will review evidence showing that there is a subgroup of patients who obtain meaningful clinical improvements after surgery, strategies to match procedures and patients, and a framework for presenting and reading results of sleep surgery trials that is based on this variation in outcomes. Educational Objectives: 1) Learn the findings of recent OSA surgery reviews, along with their strengths and weaknesses. 2) Understand the findings of higher-level studies in the field. 3) Appreciate the variation in outcomes across procedures and patients, along with the implications.

Outcomes of Hyoid Myotomy and Suspension Using a Mandibular Screw Suspension System

To review the outcomes of hyoid myotomy and suspension with a mandibular screw anchoring device. Case series with chart review. Academic and private sleep surgery clinics. The study is a consecutive case series of patients undergoing hyoid myotomy and suspension using a mandibular screw suspension device as part of multilevel treatment of obstructive sleep apnea (OSA). Outcomes of interest included complication rates, change in daytime sleepiness scores, and change in apnea-hypopnea index (AHI). Ten women and 23 men with a mean age of 54 years (range, 33-73 years) underwent hyoid myotomy and suspension using a mandibular screw suspension device. Four (12%) patients experienced minor complications, including neck seroma (3 patients) and tongue edema (1 patient). Epworth Sleepiness Scale scores fell from a preoperative median of 12 to a postoperative median of 6 (P = .002). Ten patients (30%) refused the postoperative sleep study. In the 23 patients who underwent postoperative sleep studies, AHI scores decreased from a preoperative mean ± SD of 40.9 ± 25.1 to 18.6 ± 21.2 postoperatively (P = .001). Ten patients (30%) achieved a postoperative AHI below 10. The Repose system was initially applied using a standard hyoid dissection but was later modified using a minimally invasive small incision (<2 cm) approach that demonstrated significantly fewer complications (P = .04). Hyoid myotomy and suspension with a mandibular screw anchor is an effective method with which to address hypopharyngeal collapse in multilevel surgery for OSA. The procedure can be performed with a small-incision, minimally invasive approach with minimal complications and patient morbidity.