Surgery For Obstructive Sleep Apnea Research Articles

Outcomes of upper airway surgery in obstructive sleep apnea

Background and Objective: Obstructive sleep apnea (OSA) is defined as a sleep disordered breathing due to partial or complete obstruction of upper airways. This study aimed to investigate treatment outcomes and clinical complications among patients with OSA who underwent upper airway surgery in clinical settings. Materials and Methods: All patients undergone upper airway surgery for OSA were called upon to enroll in this follow-up study. Demographic characteristics, Epworth sleepiness scale (ESS), snoring, dry mouth, nocturia, improvement of high blood pressure, and complications of surgery including bleeding, infection, pain, and temporary voice change were recorded at median of 8 months after the surgery. 12 patients accepted to undergo follow-up polysomnography (PSG). Results: Among 41 participants, mean age was 44.2 ± 11.6 years, and 33 (78.6%) were male. In three patients (25%) with follow-up PSG, mean respiratory disturbance index (RDI) was decreased by 50%. The baseline and post-surgery RDI was 34.0 ± 26.2 and 24.8 ± 13.2/hours, respectively. Mean ESS pre-surgery was 9.0 ± 4.5 with a decrease of 3.9 ± 4.2 post-surgery. Most of the participants reported improved snoring. More than half of the patients reported improvement of hypertension, dry mouth, nocturia, and sleep quality. The most common reported complications were temporary changes in voice and pain. Conclusion: Surgery improved snoring, daytime sleepiness, and OSA-related problems. RDI improvement in a small subset of patients indicates importance of follow-up PSG after upper airway surgery and warrants further studies. Moreover, evaluation of the reasons of non-participation for undergoing follow-up PSG requires more investigation.

Severe obstructive sleep apnea and bariatric surgery: a case of success!

Severe obstructive sleep apnea and bariatric surgery: a case of success!

Outcomes of Drug-Induced Sleep Endoscopy-Directed Surgery for Pediatric Obstructive Sleep Apnea.

Objectives To determine the effectiveness of pediatric drug-induced sleep endoscopy (DISE)-directed surgery for children with infant obstructive sleep apnea (OSA) or OSA after adenotonsillectomy. Study Design Case series with chart review. Setting Tertiary care pediatric hospital. Subjects and Methods We included 56 children undergoing DISE from October 2013 to September 2015 who underwent subsequent surgery to address OSA. The primary outcome was successful response to DISE-directed surgery based on the postoperative obstructive Apnea-Hypopnea Index (oAHI). Wilcoxon matched-pairs signed-ranks tests were used to compare polysomnography variables before and after surgery, and regression was used to model response to surgery. Results We evaluated 56 patients with a mean age of 5.9 ± 5.5 years (range, 0.1-17.4) and mean body mass index of 21.2 ± 7.9 kg/m2 (percentile, 77 ± 30). The most commonly performed surgical procedures were adenoidectomy (48%, n = 27), supraglottoplasty (38%, n = 21), tonsillectomy (27%, n = 15), lingual tonsillectomy (13%, n = 7), nasal surgery (11%, n = 6), pharyngoplasty (7%, n = 4), and partial midline glossectomy (7%, n = 4). Mean oAHI improved from 14.9 ± 13.5 to 10.3 ± 16.2 events/hour, with 54% (30 of 56) of children with oAHI <5 and 16.1% (9 of 56) with oAHI <1. There was a significant improvement in oAHI ( P = .001) and saturation nadir ( P < .001) but not in time with end tidal carbon dioxide >50 mm Hg ( P = .14). Multivariable modeling, controlling for age, race, body mass index, sex, and baseline polysomnography variables, revealed that white race predicted success of DISE-directed surgery. Conclusion Fifty-four percent of children with infant OSA or persistent OSA after adenotonsillectomy had oAHI <5 events per hour after DISE-directed surgery. Only white race was predictive of oAHI <5 events per hour.

Modified Z-palatoplasty with one-layer closure in one-stage multilevel surgery for severe obstructive sleep apnea

ObjectiveThe meticulous two-layer closure is a step to complete the modified Z-palatoplasty, which has been reported to serve as an effective element in multilevel sleep surgery for patients with severe obstructive sleep apnea, especially with Friedman anatomical stages II and III diseases. A single layer closure—the suture closure as originally described in uvulopalatopharyngoplasty by Fujita et al., is an alternative of the two-layer closure, featured by simplicity while its efficacy has not been completely proved in patients with severe obstructive sleep apnea. MethodsBy apnea–hypopnea index (AHI), we investigated 7 patients with severe obstructive sleep apnea undergoing the modified Z-palatoplasty with one-layer closure in a multilevel surgery. ResultsThe mean apnea–hypopnea index is reduced from 52.9±17.1 (preoperative) to 18.4±9.7 events/h (postoperative) without any wound dehiscence or bleeding that results in an unplanned return to the operating room. In comparison, the percentage of reduction in mean apnea–hypopnea index is 65%. The improvement of apnea–hypopnea index is statistically significant with the p-value 0.004. ConclusionOur results support that one-layer closure remains the efficacy of modified Z-palatoplasty (with two-layer closure) in one-stage multilevel surgery for severe obstructive sleep apnea with an unfavorable anatomical stage.

Controversies in Obstructive Sleep Apnea Surgery.

Obstructive sleep apnea (OSA) is a common chronic disease characterized by repetitive pharyngeal collapse during sleep. OSA is associated with cardiovascular disease and increased mortality, among other issues. Continuous positive airway pressure (CPAP) is considered first line therapy for OSA, but is not always tolerated. Both non-surgical and surgical alternative management strategies are available for the CPAP intolerant patient. This article explores controversies surrounding airway evaluation, definition of successful treatment, and surgical management of the CPAP intolerant patient with moderate to severe OSA. Controversies specific to maxillomandibular advancement (MMA) are also discussed.

Upper airway stimulation therapy and prior airway surgery for obstructive sleep apnea.

To determine if patients with prior airway surgery for obstructive sleep apnea (OSA) had increased benefit following implantation with hypoglossal nerve stimulator. Retrospective chart review at a single institution tertiary academic care center. Following implantation with hypoglossal nerve stimulator device, the outcomes of patients who underwent prior airway surgery for OSA were compared with those who did not. Primary outcome measures included apnea-hypopnea index (AHI) and nadir oxyhemoglobin saturation (NOS) as measured by polysomnography. Secondary outcome measures included Epworth Sleepiness Scale. Forty-seven patients underwent implantation with hypoglossal nerve stimulator. Of these, 30 patients had undergone prior airway surgery for OSA, whereas 16 did not. Mean preoperative AHI and NOS were 39.3 ± 2.8 and 78% ± 1.8% for all patients, 39.4 ± 3.7 and 79% ± 14% for patients with prior airway surgery, and 39.1 ± 4.0 and 77% ± 2.6% for patients without prior surgery. Mean postoperative AHI and NOS were 3.9 ± 1.2 and 91% ± 0.4% for all patients, 4.2 ± 1.7 and 91% ± 0.5% for patients with prior surgery, and 3.4 ± 1.5 and 93% ± 0.6% for patients without prior surgery (P = 0.756 and 0.053, respectively). Overall, patients had significant improvement following implantation with hypoglossal nerve stimulator. Prior airway surgery had no statistically significant effect on postoperative AHI or NOS. 4. Laryngoscope, 128:1486-1489, 2018.

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.

Analysis of intensive care admissions among paediatric obstructive sleep apnoea referrals.

Introduction The aim of this study was to identify the proportion of children referred to a paediatric tertiary referral centre who required admission to the paediatric intensive care unit (PICU) following surgery for obstructive sleep apnoea (OSA) and to establish risk factors for these admissions. Methods Retrospective review of case notes and the operative database was performed for all children undergoing adenotonsillectomy for sleep disordered breathing and OSA symptoms in Great Ormond Street Hospital over a 10-year period. Results Overall, 1,328 children underwent adenotonsillectomy for sleep disordered breathing and OSA. The mean age was 3.1 years (standard deviation [SD]: 1.7 years). A total of 37 (2.8%) were admitted to the PICU postoperatively (mean length of PICU stay: 1.2 days, standard deviation [SD]: 0.6 days) and 282 (21.2%) required nasopharyngeal airway (nasal prong) insertion intraoperatively. The mean length of stay on the ward following surgery was 1.4 days (SD: 0.8 days). Patients with severe OSA (apnoea-hypopnoea index [AHI] >10) and ASA (American Society of Anesthesiologists) grade≥3 were more likely to require postoperative PICU admission (22/37 vs 381/1,291 [p<0.001] and 29/37 vs 660/1,291 [p=0.001] respectively). Severe OSA was also more common in children who required nasal prong insertion intraoperatively (186/282 vs 217/1,046, p<0.001). Conclusions Very few children referred to a paediatric tertiary referral centre actually require PICU admission following surgery. This may be in part due to the use of a nasopharyngeal airway in patients where postoperative obstruction is anticipated. In children with severe OSA (AHI >10) and an ASA grade of ≥3, nasopharyngeal airway insertion and potential admission to the PICU should be considered.

Subcranial and orthognathic surgery for obstructive sleep apnea in achondroplasia

PurposeObstructive sleep apnea (OSA) is a common problem in patients with achondroplasia. The purpose of this study was to assess changes in airway volumes following various degrees of facial skeletal advancement. MethodsThis was a retrospective evaluation of patients with achondroplasia who underwent facial skeletal advancement for obstructive sleep apnea. Patients were treated with either an isolated Le Fort III distraction (LF3) or Le Fort II distraction with or without subsequent Le Fort I and bilateral sagittal split osteotomies (LF2 ± LF1/BSSO). Demographic, cephalometric, volumetric, and polysomnographic variables were recorded pre- and postoperatively. ResultsSix patients with achondroplasia underwent midface advancement for treatment of OSA (2 LF2 + LF1/BSSO, 2 LF2, 2 LF3). Patients undergoing LF2 + LF1/BSSO had consistent volumetric improvements at the nasopharyngeal and oropharyngeal levels (Δ ≥ +347% and ≥+253%, respectively). Patients undergoing LF2 alone had consistent improvement in the nasopharyngeal airway alone (Δ ≥ +214%). Patients undergoing LF3 alone had consistent, but less dramatic, changes in nasopharyngeal volume (Δ ≥ +97.1%). All patients undergoing LF2 distraction (with or without LF1/BSSO) had a ≥50% reduction in the apnea–hypopnea index (AHI) postoperatively; there was no improvement in AHI with LF3 alone. ConclusionIn patients with achondroplasia-associated OSA there are variable improvements in airway volume. This preliminary report suggests that LF2 distraction, with or without subsequent LF1/BSSO, may provide consistent reductions in AHI relative to LF3 distraction.

Surgery for obstructive sleep apnoea in adults

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To review the benefits and harms of surgery for the treatment of obstructive sleep apnoea.

Predictive models of objective oropharyngeal OSA surgery outcomes: Success rate and AHI reduction ratio.

ObjectiveThe aim of this study was to develop a predictive model of objective oropharyngeal obstructive sleep apnea (OSA) surgery outcomes including success rate and apnea-hypopnea index (AHI) reduction ratio in adult OSA patients.Study designRetrospective outcome research.MethodsAll subjects with OSA who underwent oropharyngeal and/or nasal surgery and were followed for at least 3 months were enrolled in this study. Demographic, anatomical [tonsil size (TS) and palate-tongue position (PTP) grade (Gr)], and polysomnographic parameters were analyzed. The AHI reduction ratio (%) was defined as [(postoperative AHI—preoperative AHI) x 100 / postoperative AHI], and surgical success was defined as a ≥ 50% reduction in preoperative AHI with a postoperative AHI < 20.ResultsA total of 156 consecutive OSAS adult patients (mean age ± SD = 38.9 ± 9.6, M / F = 149 / 7) were included in this study. The best predictive equation by Forward Selection likelihood ratio (LR) logistic regression analysis was:ln(Px1−Px)=1.518−0.039×Age+1.392×TSGr−0.803×PTPGrThe best predictive equation according to stepwise multiple linear regression analysis was: AHIreductionratio=−39.464+(32.752×TSGr)+(2.623×AHI)−(2.542×Arousalindex)+[1.245×MinimumSaO2(%)]−[0.599×Snoring(%)] (TS/PTP Gr = 1 if TS/PTP Gr 3 or 4, TS/PTP Gr = 0 if TS/PTP Gr 1 or 2)ConclusionThe predictive models for oropharyngeal surgery described in this study may be useful for planning surgical treatments and improving objective outcomes in adult OSA patients.

Physiology-Based Modeling May Predict Surgical Treatment Outcome for Obstructive Sleep Apnea.

To test whether the integration of both anatomical and nonanatomical parameters (ventilatory control, arousal threshold, muscle responsiveness) in a physiology-based model will improve the ability to predict outcomes after upper airway surgery for obstructive sleep apnea (OSA). In 31 patients who underwent upper airway surgery for OSA, loop gain and arousal threshold were calculated from preoperative polysomnography (PSG). Three models were compared: (1) a multiple regression based on an extensive list of PSG parameters alone; (2) a multivariate regression using PSG parameters plus PSG-derived estimates of loop gain, arousal threshold, and other trait surrogates; (3) a physiological model incorporating selected variables as surrogates of anatomical and nonanatomical traits important for OSA pathogenesis. Although preoperative loop gain was positively correlated with postoperative apnea-hypopnea index (AHI) (P = .008) and arousal threshold was negatively correlated (P = .011), in both model 1 and 2, the only significant variable was preoperative AHI, which explained 42% of the variance in postoperative AHI. In contrast, the physiological model (model 3), which included AHIREM (anatomy term), fraction of events that were hypopnea (arousal term), the ratio of AHIREM and AHINREM (muscle responsiveness term), loop gain, and central/mixed apnea index (control of breathing terms), was able to explain 61% of the variance in postoperative AHI. Although loop gain and arousal threshold are associated with residual AHI after surgery, only preoperative AHI was predictive using multivariate regression modeling. Instead, incorporating selected surrogates of physiological traits on the basis of OSA pathophysiology created a model that has more association with actual residual AHI. A commentary on this article appears in this issue on page 1023. ClinicalTrials.Gov; Title: The Impact of Sleep Apnea Treatment on Physiology Traits in Chinese Patients With Obstructive Sleep Apnea; Identifier: NCT02696629; URL: https://clinicaltrials.gov/show/NCT02696629.

Lingual Tonsillectomy for Pediatric Persistent Obstructive Sleep Apnea: A Systematic Review and Meta-analysis.

Objective To determine the role of lingual tonsillectomy (LT) in pediatric patients with persistent obstructive sleep apnea (OSA) after tonsillectomy and adenoidectomy (T&A). Data Sources PubMed, OVID-MEDLINE, and Cochrane Central from 2006 to 2017. Review Methods Inclusion criteria included English-language studies containing original data on LT in pediatric patients with persistent OSA. Exclusion criteria included case reports and studies without outcome measures. Two investigators independently reviewed all manuscripts and performed quality assessment using validated tools. Meta-analysis was performed. Results Of the 866 abstracts identified, 5 studies met inclusion criteria. All studies were case series (level of evidence 4). Outcome measures included apnea-hypopnea index (AHI), minimum oxygen saturation (minSaO2), comorbidity status, and adverse events. Qualitatively, all studies demonstrated reduction in AHI and increase in minSaO2 after LT. Comorbidities may not affect the success of LT for lingual tonsil hypertrophy (LTH). LT had similar adverse event rates as T&A. Meta-analysis was performed on 4 studies. LT showed a mean change in reduction of AHI and increase of minSaO2 of -6.64 (95% CI, -8.63 to -4.65) and 4.17 (95% CI, 1.25-7.08), respectively. The overall success rate, defined as postoperative AHI <5, was 52%. Conclusion LT for LTH can be a safe and effective adjunct surgery for persistent OSA in patients after T&A. LT may reduce AHI and increase minSaO2, though complete resolution of OSA is rare. Given the limited number of patients studied, no formal recommendations can be made for the routine use of LT for LTH in persistent pediatric 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.

Hyoid myotomy and suspension without simultaneous palate or tongue base surgeryfor obstructive sleep apnea.

ObjectiveDetermine the effects of hyoid myotomy and suspension (HMS) without concurrent palatal or tongue base sleep surgery for obstructive sleep apnea (OSA).MethodPatients with OSA treated with HMS were identified using CPT code (21685) at an academic and private sleep surgery clinic. Those who underwent concurrent palatal or tongue base sleep surgery were excluded. Outcomes included simultaneous procedures, apnea-hypopnea index (AHI), lowest oxyhemoglobin saturation (LSAT), and Epworth Sleepiness Scale (ESS).ResultsNineteen patients with OSA underwent HMS without palatal or tongue base sleep surgery. The average age at surgery was (55.3 ± 13.5) years with a majority of patients being male (71%). Concurrent procedures included the following: torus mandibularis excision (n = 1), endoscopic sinus surgery (n = 4), septoplasty (n = 10), inferior turbinate reduction (n = 12), and nasal valve repair (n = 2). AHI improved significantly from (39.7 ± 21.2) events/h to (22.6 ± 22.7) events/h after HMS (P < 0.01), which represented a 43% reduction. LSAT significantly increased from (82.2% ± 9.9%) to (86.6% ± 6.2%), P < 0.01. There was no improvement in ESS after surgery (8.2 ± 4.4) to (8.3 ± 5.2), P = 0.904. A subset of patients with severe OSA (AHI > 30 events/h) had an improvement in AHI from (49.9 ± 16.6) events/h to (29.1 ± 24.9) events/h, P < 0.01.ConclusionHMS without palatal or tongue base sleep surgery improves OSA severity. It can be considered as a valid option in the treatment of OSA in appropriately-selected patients.

Barbed reposition pharyngoplasty in multilevel robotic surgery for obstructive sleep apnoea.

SUMMARYThe surgical treatment of obstructive sleep apnoea in patients who are non-compliant with continuous positive airway pressure therapy still represents a valid alternative. In recent years, the multilevel approach is becoming more diffuse in routine surgical practice, especially since the introduction of transoral robotic surgery. Barbed reposition pharyngoplasty in multilevel robotic surgery for OSA may represent a valid option to surgically approach the soft palate. Herein, we describe the technique and preliminary results of our experience.

Loop Gain Predicts the Response to Upper Airway Surgery in Patients With Obstructive Sleep Apnea.

Upper airway surgery is often recommended to treat patients with obstructive sleep apnea (OSA) who cannot tolerate continuous positive airways pressure. However, the response to surgery is variable, potentially because it does not improve the nonanatomical factors (ie, loop gain [LG] and arousal threshold) causing OSA. Measuring these traits clinically might predict responses to surgery. Our primary objective was to test the value of LG and arousal threshold to predict surgical success defined as 50% reduction in apnea-hypopnea index (AHI) and AHI <10 events/hour post surgery. We retrospectively analyzed data from patients who underwent upper airway surgery for OSA (n = 46). Clinical estimates of LG and arousal threshold were calculated from routine polysomnographic recordings presurgery and postsurgery (median of 124 [91-170] days follow-up). Surgery reduced both the AHI (39.1 ± 4.2 vs. 26.5 ± 3.6 events/hour; p < .005) and estimated arousal threshold (-14.8 [-22.9 to -10.2] vs. -9.4 [-14.5 to -6.0] cmH2O) but did not alter LG (0.45 ± 0.08 vs. 0.45 ± 0.12; p = .278). Responders to surgery had a lower baseline LG (0.38 ± 0.02 vs. 0.48 ± 0.01, p < .05) and were younger (31.0 [27.3-42.5] vs. 43.0 [33.0-55.3] years, p < .05) than nonresponders. Lower LG remained a significant predictor of surgical success after controlling for covariates (logistic regression p = .018; receiver operating characteristic area under curve = 0.80). Our study provides proof-of-principle that upper airway surgery most effectively resolves OSA in patients with lower LG. Predicting the failure of surgical treatment, consequent to less stable ventilatory control (elevated LG), can be achieved in the clinic and may facilitate avoidance of surgical failures.

Changing Rates of Morbidity and Mortality in Obstructive Sleep Apnea Surgery.

Objective Whereas uvulopalatopharyngoplasty (UPPP) was the standard surgical procedure for obstructive sleep apnea prior to 2007, multilevel surgery has become the standard since that time. This study compares morbidity and mortality rates of the stand-alone UPPP with those of multilevel sleep surgery that includes UPPP. Methods Patients undergoing UPPP between 2007 and 2014 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. UPPP was defined by Current Procedural Terminology codes 42145 and 42950. Primary outcomes were incidence of morbidity and mortality. Rates were compared between a control group with UPPP only and a group with multilevel surgery. Results A total of 2674 cases were analyzed. The incidence of complications in the UPPP-only group was 1.6% (0.09% fatal); in the multilevel surgery group, 4.63% (0.19% fatal). The difference in overall and nonfatal complications is statistically significant ( P < .01); however, values for fatal complications are too low for comparison. There is a statistically significant ( P < .01) positive correlation ( R2 = 0.92) between year of operation and rate of complications, with increased incidence of complications in more recent years. Discussion Complication rates for multilevel sleep surgery are higher than those of stand-alone UPPP, and overall complication rates have been increasing in recent years. As UPPP supplemented with multilevel surgery is now the standard surgical treatment for most cases of obstructive sleep apnea-hypopnea syndrome, historical complication rates based predominantly on patients undergoing UPPP only underestimate complication rates of modern sleep surgery. Implications for Practice It is reasonable to inform patients that multilevel procedures bring an increased risk of complications, and patient selection should be guided accordingly.

Where to position osteotomies in genioglossal advancement surgery based on locations of the mental foramen, canine, lateral incisor, central incisor, and genial tubercle.

The study aimed to provide precise measurements of anterior mandibular structural anatomy and to explore potential osteotomies for genioglossal advancement. Cone beam computed tomography was used to analyze 33 randomly selected patients undergoing surgery for obstructive sleep apnea (OSA) between 2014 and 2016 at an academic surgical hospital. The locations of relevant mandibular structures were measured and statistical modeling was performed. Mean horizontal distances from midline to the mental foramina and the roots of the canine, lateral incisor, and central incisor were 22.11±1.92, 13.56±3.01, 6.19±1.58, and 2.04±0.87mm, respectively. Mean vertical distances from the inferior border of the mandible were 15.15±1.77, 17.11±3.28, 20.48±3.10, and 21.81±3.49mm, respectively. The superior border of the genial tubercle was 15.63±2.75mm, and the inferior border was 6.87±3.29, from the inferior border of the mandible. The angle of decline of the best-fit line through the important structures was about 18° from the occlusion plane at the midline. A straight line estimating the mental foramen, canine, lateral incisor, and central incisor tooth roots crosses at a mean of 22.3-22.6mm above the inferior border of the mandible at the midline and has an angle of decline of about 18°. Potential osteotomies made parallel to and below this line result in tradeoffs between maximizing capture of the genioglossus muscle attachment and risk of dental/neurovascular injury.

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.