Obstructive Sleep Apnea Research Articles

12562 Extraocular Muscle Enlargement With Proptosis In A Patient With Non Thyroidal Disease

Abstract Disclosure: S.S. Bantu: None. P.N. Kabir: None. A. Gondhi: None. T.B. Vaughan: None. Extraocular muscle enlargement with proptosis in a patient with Nonthyroidal disease Introduction: Majority of cases with extraocular muscle enlargement (EOME) is due to Graves’ disease, commonly in about 95% cases and another 5% make up other causes including inflammatory, neoplastic, vascular, infectious and acromegaly. We present a patient with sudden loss of vision, retroorbital pain with visual field deficits found to have EOME and subsequently a pituitary macroadenoma on imaging. Case: We present a 54-year-old male with history of hypertension, obstructive sleep apnea and morbid obesity who presented to us with complains of left sided vision loss. Patient was evaluated by ophthalmology and noted to have unilateral, left-sided, change in visual acuity. Physical exam was notable for macrognathia, skin tags, enlarged hands, excessive sweating. MRI brain revealed bilateral EOME with proptosis and a pituitary macroadenoma measuring 1.5x1.7x1.3cm, abutting the pre-chiasmatic left optic nerve. On biochemical evaluation he was noted to have elevated IGF1 of 979 confirming the diagnosis of acromegaly. ((hemoglobin A1C of 5.5%, prolactin 5.1, FT4 0.89, TSH 0.692, total testosterone 61, IGF1 level was 979)). He underwent transsphenoidal resection of the pituitary macroadenoma. Pathology showed sparsely granulated somatotroph adenoma. Discussion: Acromegaly has an incidence of 3-4 cases per million per year. The characteristics of the disease are due to chronic growth hormone hypersecretion resulting in the excessive growth of tissue due to the stimulation of insulin-like growth factor 1 (IGF-1). EOME with proptosis in acromegaly is seen rarely. Visual symptoms may manifest as visual field deficits due to compression of the optic pathway in 18-25% cases, increased intraocular pressure, increase in corneal thickness and a diffuse symmetrical enlargement of the extraocular muscles which cannot be distinguished from thyroid orbitopathy on imaging. The degree of enlargement appears to correlate with the duration of the disease rather than the levels of IGF1. EOME improves with the treatment of acromegaly. Although visual symptoms may be a rare presentation of acromegaly, if the clinical suspicion exists, one may consider obtaining an IGF-1 level to complete the evaluation of EOME if the thyroid levels are normal. Presentation: 6/3/2024

7944 Elevated Serum Alkaline Phosphatase without other Abnormalities of Liver Associated Enzymes as an early Indicator of Glucose Intolerance: A Case Series

Abstract Disclosure: B.K. Bowens: None. C. Godar: None. D. LaChance: None. T.D. Hoang: None. M.K. Shakir: None. Glucose intolerance (GI) is defined as dysglycemia and includes impaired fasting glucose, impaired glucose tolerance, and prediabetes. Early detection of GI could lead to appropriate treatment and delay the progression to diabetes mellitus. The cases below detail two patients with elevated serum alkaline phosphatase (ALP) without other liver-associated enzyme abnormalities as an early indicator of GI. Case 1: A 54-year-old woman with a history of multinodular goiter status post thyroidectomy (2020), adrenal incidentaloma (2016), and asthma was incidentally found to have an elevated HbA1C (A1C) of 6.3% on screening labs in 2015. At that time, her ALP was 73 IU/L (ref 44−121). Her ALP levels slowly rose from 88 to 152 IU/L by September 2020. Work up did not reveal any etiological factors for the elevated ALP. One month later, HbA1C was found to be 7.6%. Metformin was initiated with improvement in A1C to 6.3% with an ALP of 130 IU/L. However, metformin was discontinued due to intolerance. In April 2023, her A1C was 9.3% with an ALP of 134 IU/L. A1C rose to 12.8% in Jun 2023 at which time she was started on insulin glargine, insulin aspart, sitagliptin, and was restarted on metformin. Her A1C decreased to 8.6% in August 2023 with normalization of ALP to 88 IU/L. Case 2: A 53-year-old woman with a history of hypertension, hyperlipidemia, obstructive sleep apnea, and non-ischemic cardiomyopathy in 2004 was found to have an elevated A1C of 5.8% on her screening labs in Jun 2019. Her ALP was notably in the high-normal range until Oct 2021 when it was found to be 138 IU/L. Her most recent A1C was 5.9% with an ALP of 142 IU/L. The patient was started on semaglutide (WegovyTM) briefly but was unable to tolerate the side effects. She was then started on metformin 500mg BID and dulaglutide with normalized ALP level. Discussion: Emerging evidence has shown that serum ALP activity is modestly increased in cardiometabolic diseases such as type 2 diabetes, dyslipidemia, hypertension, and peripheral arterial disease. These are increasingly being considered as inflammatory disorders and it has been shown that serum ALP level was positively and independently associated with metabolic syndrome both in men and women. It is possible that ALP could be an indicator of non-alcoholic fatty liver disease (NAFLD) which is associated with GI. Typically, NAFLD presents with higher ALT and GGT, however, occasionally isolated enzyme elevations or no elevated enzymes at all may occur. Conclusion: These cases suggest that an isolated elevation in ALP could be indicative of GI. Patients incidentally found to have an elevated ALP should be worked up further for possible evidence of GI. Early detection of GI could delay progression to diabetes and decrease morbidity. Presentation: 6/1/2024

8267 A Case of Pineal Gland Cyst and Adrenal Adenoma- Is this a New Syndrome?

Abstract Disclosure: M. Siddiqui: None. U. Rafat: None. S. Shaik: None. J.L. Gilden: None. Background: The Pineal Gland receives information through a complex multi-neuronal pathway and is responsible for the secretion of melatonin, a hormone regulated by circadian rhythm and suppressed by light stimuli. Melatonin is involved in biological rhythms and regulates immunomodulation, temperature homeostasis and maturation of hypothalamic-pituitary and gonadal axis, and can also modulate thyroid, prolactin, growth hormone, cortisol, and ACTH activity. Other effects include downregulation of thyroid activity. In addition, studies have shown that pineal body extracts can cause a minor increase in the zona glomerulosa and fasciculata of the adrenal gland. Case: A 54-year-old male with recurrent nephrolithiasis, obstructive sleep apnea and chronic rhinosinusitis, first presented to Endocrinology Clinic in 2018 for evaluation of an incidental adrenal adenoma (CT abdomen -2.8 cm, less than 10 Hounsfield units, left sided lipid rich adrenal adenoma). He had new onset erectile dysfunction, decreased libido, and fatigue. Initial lab work including LH, FSH, TSH, midnight salivary cortisol, ACTH, plasma cortisol AM, free and total testosterone, aldosterone, plasma and urine metanephrines/normetanephrines were all normal. MRI brain-1 cm thin-walled pineal cyst with internal characteristics compatible with proteinaceous benign pineal cyst. He was then lost to follow-up for 5 yrs due to the COVID pandemic. He had tried taking “testosterone protein builders”, but his symptoms remained. In addition, he now has twice weekly dull occipital headaches, relieved by ibuprofen. Lab tests-elevation in 1of 2 MN salivary cortisol samples at 0.58 mcg/dL (nl≤0.09), ACTH 12pg/mL(0-47), IGF1 261 ng/mL(50-317), and low total testosterone 222 ng/dl (250-1100) Free testosterone 36 pg/mL(35-155), borderline low TSH 0.386 µIU/ml(0.55-4.78), Free T3 and Free T4 were normal, thyroid antibodies-negative . Rest of the hormone evaluation was otherwise normal, LH 4.90 mIU/mL(1.5-9.3), FSH 11.10 mIU/mL (1.4-18.1), Prolactin 6.8 ng/mL(2.1-17.7). Thyroid Ultrasound-homogeneous echogenicity of the thyroid gland without discrete thyroid nodules. Repeat MRI brain- benign pineal cyst which was stable with no midline shift or mass effect. Repeat CT adrenal gland-lipid rich adrenal adenoma slightly reduced in size from 2.8 to 2.4 cm. Lab tests returned to normal one month later. Conclusion: Although it is unclear whether there is an exact association between this patient’s pineal cyst and adrenal adenoma, there have been intermittent hormonal abnormalities and symptoms consistent with hypogonadism and/or adrenal, also possibly related to the pineal abnormality. Although more research needs to be conducted explaining the relationship between the pineal and pituitary, and the adrenal gland, this clinical case suggests that there may be a relationship between these two abnormalities and symptoms. Presentation: 6/2/2024

8162 A Unique Presentation of Ovarian Steroid Cell Tumor Causing Hyperandrogenism in a Postmenopausal Woman

Abstract Disclosure: A. Rehan: None. M. Pandey: None. I. Goyal: None. E. Punni: None. N. Shakir: None. Background:­­­ Steroid cell tumors of the ovary are a rare entity, constituting less than 0.1% of all ovarian tumors. These tumors can present with diverse endocrine and paraneoplastic effects, including androgen excess and polycythemia. Hyperandrogenism in females can lead to hirsutism, virilization, alopecia, menstrual irregularities, acne, and emotional changes, with complications including hyperlipidemia and insulin resistance. There are various causes of androgen excess in a female including polycystic ovary syndrome (PCOS), androgen-secreting tumors, Cushing’s syndrome, and congenital adrenal hyperplasia. In a postmenopausal woman displaying signs of androgen excess, one must consider androgen-secreting tumors, and even the rare ovarian steroid cell tumor as a possible cause. Clinical Case: A 62-year-old female with type 2 diabetes mellites, obstructive sleep apnea, anxiety and depression initially presented to her primary care provider with fatigue, light-headedness, and weight loss. Initial blood work done revealed a hemoglobin greater than 20 g/dL (NR 12-16) and hematocrit greater than 60% (NR 36-48), requiring several sessions of phlebotomy. Symptoms persisted and she was finally referred to a hematologist who noted physical exam findings of hirsutism and virilization, including temporal hair loss and excess facial/body hair growth. Other concerning signs included clitoromegaly, decrease in chest size, and deepening voice. Menopause had occurred at age 50, and the patient did not have any issues with fertility during her reproductive years. Biochemical evaluation revealed testosterone level of greater than 1500 ng/dL (NR 19-82) with normal sex hormone binding globulin level, DHEA-S 652 ug/dL (NR 29-220), appropriately suppressed FSH/ LH, and normal salivary cortisol levels. Tumor markers showed normal CEA, and alpha fetoprotein but elevated CA 125 to 80.5 U/ml (NR < 38.1). Pelvic ultrasound demonstrated a 12 cm heterogeneously echoic, vascular right adnexal mass concerning for ovarian malignancy. Pelvic MRI showed a 9.8 cm right sided cystic and solid adnexal mass. The patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy, peritoneal biopsies, and omentectomy. Pathology revealed a stage IA steroid cell tumor measuring 11.4 cm. After resection, the patient reported improvement in facial hair and fatigue. Labs showed normalization of hemoglobin, hematocrit, and testosterone levels. Conclusion: This rare case highlights the importance of considering steroid cell tumor as a cause of polycythemia with hyperandrogenism. Timely diagnosis and intervention play a critical role in preventing irreversible virilization, mitigating malignant risks, and, in certain instances, preserving fertility. Generally, the prognosis is favorable, and symptom and lab normalization is often achieved through surgical resection. Presentation: 6/2/2024

6694 A Case of an Extraneous Organ: A Uterus Found in a Genotypic and Phenotypic Male

Abstract Disclosure: R.A. Zielinski: None. S. Shteyman: None. A.G. Samat: None. Background: Persistent Mullerian Duct Syndrome (PMDS) is a rare entity that occurs when a phenotypic male is found to have female reproductive organs. In our case we describe an XY male who was found to have an abdominal mass consistent with a uterus on pathology. Clinical Case: Our patient is a 58-year-old male with hypertension, obesity, and obstructive sleep apnea who presented to the ED with 3 weeks of left upper quadrant pain. Abdominal CT showed two homogeneous enhancing oval lesions in the pelvis superior to the urinary bladder; 8.3 x 4.6 cm on the right and 3.6 x 3 cm on the left. Exploratory laparotomy was performed, and intraoperatively the mass was firm with a left satellite lesion and two fibrous bands that appeared similar in structure to round ligaments. Microscopically the tissue contained mullerian-type epithelium and smooth muscle with cystic degeneration. It was CK7 positive, estrogen receptor variable positive, and CK20 negative. Genetic testing confirmed the patient’s karyotype to be XY without genetic mosaicism. Our patient had two children spontaneously, regular spontaneous erections, and occasional hot flashes. Physical exam revealed an obese male (BMI 51) with bilateral gynecomastia and normal testicular size. He had no history of intra-abdominal or undescended testes requiring surgery. Labs showed increased total estrogen (283.7 pg/mL, n 60-190 pg/mL) and estradiol (39 pg/mL, n <= 29 pg/mL), decreased total testosterone (86 ng/dL, n 250-1,100 ng/dL), and normal free testosterone when corrected for SHBG (140 ng/dL, n 110-574 ng/dL). Testicular ultrasound was unrevealing. 3 years postoperatively his estradiol level normalized (34 pg/mL) and his total testosterone improved from 86 ng/dL to 223 ng/dL after losing 40 pounds on semaglutide. Discussion and Conclusion: Although the exact incidence of PMDS is unknown, it is a rare phenomenon. Only 200 cases between 1964 and 2000 and 34 cases between 2013 and 2017 have been reported. Mullerian ducts are embryologic structures present in both XY and XX fetuses until week 8 of life, when XY fetuses produce anti-mullerian hormone (AMH). In PMDS, the XY fetus either fails to produce AMH, or there is a defect in the AMH receptors, leading to the persistence of mullerian ducts. These ducts can then differentiate into a uterus, fallopian tubes, and/or the upper vagina. Our patient is a genotypical and phenotypical male with a uterus-like organ. The mild elevation in his estrogen level is likely secondary to his obesity. The estrogen could have increased the size of the uterus, causing the patient’s initial symptoms of abdominal pain which prompted his presentation to the hospital.

8197 A Captivating Case Report of Teprotumumab Induced Hyperglycemic Hyperosmolar State

Abstract Disclosure: K.M. Tuna: None. J.P. Perdomo Rodriguez: None. Introduction: Teprotumumab, a monoclonal antibody targeting the IGF-1 receptor, is increasingly utilized for moderate to severe thyroid eye disease. Initial trials noted mild hyperglycemia in patients with diabetes, while recent trials revealed a significant elevation in Hemoglobin A1c (HbA1c) among those with diabetes or pre-diabetes post-infusion. Here, we discuss a case of a patient with diet-controlled diabetes who developed hyperglycemic hyperosmolar state (HHS) two months after Teprotumumab infusion. Case Presentation: A 43-year-old male, with class III obesity, obstructive sleep apnea, dyslipidemia, coronary artery disease, and diet-controlled diabetes (HbA1c 6.5%) presented with worsening proptosis, decreased color vision, severe visual field depression. Laboratory evaluation revealed elevated TSH (6.3 mIU/ml), normal free T4 (0.67 ng/dl, ref: 0.60-1.2 ng/dl), and undetectable Thyroid Stimulating Immunoglobulin (<0.1 IU/L). Blood cell count, renal and liver function tests were normal. Due to high clinical suspicion of thyroid eye disease, he was treated with timolol, dorzolamide, brimonidine, and methylprednisolone 1g daily for 3 days. Glycemic control was achieved with 30 units of daily insulin while on pulse steroids. On outpatient ophthalmology follow-up, Teprotumumab was initiated and he received 2 doses. Eight weeks later, the patient was hospitalized with altered mental status caused by HHS (glucose 617 mg/dl, serum osmolality 316 osm). HbA1c was found to be significantly increased to 12% and the patient required 150 units total daily insulin and metformin upon discharge. Of note, the patient did not have significant weight changes during this time. GAD, IA2, and Zinc Transporter-8 antibodies were obtained prior to discharge and results are pending. Discussion: The IGF-1 receptor, a partial homologue of the insulin receptor, plays a pivotal role in glucose homeostasis. Inhibiting this receptor can lead to hyperglycemia. Initial randomized controlled trials (RCTs) reported a 10% incidence of mild hyperglycemia. A recent RCT from a cohort of 42 patients demonstrated a 50% incidence of hyperglycemia, in which two-thirds of the patients remained in a dysglycemic state with one patient with pre-existing prediabetes developing diabetic ketoacidosis (DKA). Our patient mirrored this scenario with no identifiable confounding factors. Conclusion: Teprotumumab-induced hyperglycemia, though rare, can lead to life-threatening complications. Baseline glycemic assessment, identification of high-risk patients, and comprehensive discussions on risks and benefits are crucial before initiating therapy. Close monitoring, especially in those with prediabetes, is recommended. Patient education plays a pivotal role in early symptom recognition, averting delayed diagnoses, and subsequent hospitalization. Presentation: 6/3/2024

8088 Connecting the Dots: Semaglutide, Constipation, and Diverticulitis - A case report

Abstract Disclosure: K. Tiwari: None. F. Sajid: None. J.G. Karam: None. Introduction: Semaglutide is a glucagon-like peptide-1 (GLP-1) receptor agonist used for the treatment of type 2 diabetes mellitus and weight management. Common side effects, primarily gastrointestinal (>10%), include nausea, vomiting, diarrhea, and constipation. Here, we present a case of acute sigmoid diverticulitis with an adjacent abscess in a patient who was recently initiated on GLP-1 receptor agonist therapy. Case presentation: A 76-year-old female with a medical history of type 2 diabetes mellitus on metformin and empagliflozin, hypertension, chronic kidney disease stage 3A, obesity (BMI: 43), and no known history of diverticulosis was started on semaglutide for additional glycemic, renal, and weight loss benefits, given suboptimal control of her obstructive sleep apnea, blood pressure, and knee arthritis. She received semaglutide subcutaneously at a dose of 0.25 mg weekly for 4 weeks, followed by an increased dosage of 0.5 mg for one week. However, she experienced a slight worsening of underlying constipation as a side effect. On the sixth week of therapy, she started having progressive lower abdominal pain with nausea, chills, and diarrhea, for which she presented to the Emergency Department. She was found to have leukocytosis, and a Computed Tomography (CT) of the abdomen/pelvis revealed peri-colonic fat stranding in the mid-ascending colon, wall thickening in the distal sigmoid colon, and a low-density fluid collection abutting the sigmoid/descending colonic wall, indicative of diverticulitis with a small abscess. She was admitted to the hospital for six days and was treated conservatively with Intravenous (IV) antibiotics, and her diet was slowly advanced as tolerated. Semaglutide was discontinued, and the patient was discharged home with outpatient endocrinology and gastrointestinal follow-up. A post-discharge colonoscopy showed diffuse diverticulosis. Conclusion: Constipation and old age are common risk factors for diverticulitis. While GLP1-1 receptor analogs have proven significant and multiple benefits, more knowledge about associated gastrointestinal complications resulting from slower food transit in the gastrointestinal tract is emerging. Older patients with underlying constipation and/or diverticulosis should particularly be monitored and treated for worsening constipation to avoid complications such as acute diverticulitis. Vigilance and awareness in recognizing and managing this potential complication are crucial with the wider indications and use of GLP-1 receptor analogs. Presentation: 6/3/2024

7698 A case of Pheochromocytoma in a patient with severe aortic stenosis

Abstract Disclosure: C. Lane: None. L.E. Aguirre: None. J. Azocar-Villalobos: None. R.I. Dorin: None. Background: Pheochromocytomas are rare neuroendocrine tumors derived from chromaffin tissue of the adrenal medulla and can secrete catecholamines. Pre-operative management of pheochromocytoma involves initiation of a- followed by b-adrenergic receptor blockade. In critical aortic stenosis (AS), adrenergic blockade may be complicated by decreased cardiac output and hypotension owing to dependence of venous return on maintenance of high afterload (1). We report a case of critical AS and incidentally discovered pheochromocytoma and describe our management strategy, which involved prioritization of aortic valve repair prior to adrenal surgery and multidisciplinary approach to initiation and titration of a- and b-adrenergic blockade prior to cardiac catheterization and transcutaneous aortic valve replacement (TAVR) procedures. Clinical Case: A 75-year-old Caucasian male with past medical history of obstructive sleep apnea, tobacco use, and cocaine use disorder was admitted with progressive dyspnea, decreased exercise tolerance, and involuntary weight loss of 18 kg over 3 months, and community acquired pneumonia. On admission, he was found to have critical aortic stenosis (valve area of 0.59 cm2, mean gradient 83 mmHg) and new HFrEF (EF 40-45%). CT chest demonstrated incidental right adrenal mass (5.6 x 5.0 x 4.7 cm) with central necrosis, HU units >10, and evidence of internal hemorrhage. Subsequent laboratory and functional imaging studies confirmed diagnosis of pheochromocytoma. Pre-procedural a-adrenergic blockade with doxazosin followed by beta-blockade was managed by a multidisciplinary team with ICU admission for monitoring and uncomplicated completion of cardiac catheterization and TAVR. Conclusions: Pre-procedural diagnosis of pheochromocytoma, multidisciplinary management, and intensive care setting for monitoring hemodynamic response to initiation and titration of a and b-adrenergic blockade appeared to be key factors in achieving uncomplicated completion of cardiac interventions prior to surgical resection of pheochromocytoma and critical AS. Successful TAVR was associated with marked improvement in hemodynamic status. Maintenance of b-adrenergic blockade to reduce myocardial contractility was critical to preservation of the prosthetic aortic valve and in preparation for planned robotic resection of the pheochromocytoma.

Surgical Outcomes Following Combined Barbed Palato-Pharyngeal Surgery and Coblator-Assisted Midline Glossectomy for Obstructive Sleep Apnea

Surgical Outcomes Following Combined Barbed Palato-Pharyngeal Surgery and Coblator-Assisted Midline Glossectomy for Obstructive Sleep Apnea

A cross-sectional study of the correlation of the ratio of non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol (NHHR) with obstructive sleep apnea (OSA) in adult populations: NHANES (2005-2008 and 2015-2020).

The ratio of non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol, abbreviated as NHHR, represents a brand-new lipid biomarker for assessing cardiovascular disease risk. Research has suggested a link between lipid metabolism and obstructive sleep apnea (OSA). To delve deeper, this study was carried out using data derived from the NHANES to ascertain whether NHHR and OSA are associated. In this research, a cross-sectional analysis was executed based on data derived from NHANES across the years 2005 to 2008 and 2015 to 2020. After adjusting for confounders such as demographic characteristics, lifestyle, and health status, the link between NHHR and the likelihood of developing OSA was examined via weighted binary logistic regression as well as restricted cubic spline (RCS) models. In addition, subgroup analysis was completed to check if the obtained results were reliable. The study included 16,265 adult participants. Following comprehensive adjustment for confounders, results obtained suggested that, for each additional unit increment of NHHR, there is a 9% increased chance of developing OSA. Compared to the lowest quartile, the highest quartile of NHHR notably increased the risk of developing OSA in the overall population (OR: 1.65; 95% CI: 1.38-1.98; P < .001). The RCS curve indicated a linear positive correlation between NHHR and OSA, which remained significant in subsequent subgroup analyses (all P for interaction > .05). This suggested that the correlation between NHHR and OSA was stable across populations with different characteristics. Confounders such as demographics, lifestyle, and health status did not significantly affect this positive correlation. Findings from this study uncovered a strong connection between NHHR and an increased possibility of developing OSA in American adults. Further exploration of NHHR could offer insights into OSA prevention and treatment. However, owing to the constraints inherent in cross-sectional studies, more studies are required to establish a concrete link between NHHR and OSA.

Cone beam computed tomography changes upon oral appliance therapy for adult patients with obstructive sleep apnea: A non-randomized clinical trial

Background: Obstructive sleep apnea (OSA) is caused by narrowing or obstruction of the airway lumen at single or multiple levels of the airway, starting from the nasal cavity up to the larynx. Oral appliance therapy for the management of OSA is prescribed as an alternative treatment option for patients with mild to moderate OSA who fail to adhere to Continuous Positive Airway Pressure (CPAP) therapy. Treatment with oral appliances addresses the craniofacial deficiencies that cause OSA by providing means to mandibular advancement and palatal expansion, thus opening the airways and potentially preventing airway collapse during sleep. Imaging the upper airway is employed to investigate the narrowing or the obstruction in the airway. Three-dimensional imaging modalities such as cone beam computed tomography (CBCT) allow for detecting obstructions before commencing treatment and for evaluating changes in the upper airway dimensions after treatment. To evaluate the effect of the biomimetic oral appliance therapy (BOAT) device on the airway measurements taken from a CBCT before and after treatment in correlation with the changes in the AHI. Trial design: A non-randomized clinical trial. Methods: About 17 patients with mild-moderate OSA (9 males, 8 females; age, mean [SD]: 45.76 [10.31]) underwent BOAT therapy. Subjects had 2 months of follow-up visits, including examinations for progress and adjustment of the appliances. The mean apnea–hypopnea index (AHI) with no appliance in the mouth before BOAT and after treatment was recorded. The midpalate screw mechanism of the appliance was advanced once per week. The subjects were asked to wear the appliance for 10 to 12 h/d and night. Pre and Post CBCT were taken. Paired T-test was used to analyze the results. Results: The treatment duration was 15.4 ± 6.3 months. Before treatment, at the diagnosis stage, the mean AHI of the sample (n = 17) was 24.0. After treatment, the mean AHI fell by 5% to 22.8% (P = .019), indicating enhanced upper airway functions. Airway measurements from the CBCT were not statistically significant despite improvement in the polysomnographic parameters. Conclusion: CBCT is a valuable tool for airway assessment and the determination of upper airway anatomic risk factors for OSA.

The association between endothelial dysfunction and subclinical myocardial injury in male OSA patients

BackgroundEndothelial dysfunction was shown to contribute significantly to the elevated cardiovascular risk observed in the general population. However, the relationship between endothelial dysfunction and subclinical myocardial injury in obstructive sleep apnea (OSA) patients remains unclear.MethodsThis cross-sectional study recruited 165 consecutive male patients diagnosed with OSA. All participants underwent overnight polysomnography to confirm the diagnosis and assess the severity of OSA. Subclinical myocardial injury was evaluated using high-sensitivity cardiac troponin I (hs-cTnI) measurements, while endothelial dysfunction was assessed through the peripheral arterial tonometry.ResultsEndothelial dysfunction was present in 80 (48.5%) of the subjects. Hs-cTnI was detectable in 147 (89.1%) of the participants. When compared to OSA patients without endothelial dysfunction, those with endothelial dysfunction exhibited significantly lower percentages of hypertension (23.8%versus43.5%, p=0.007) and abdominal obesity (76.3%versus88.2%, p=0.043). Patients with endothelial dysfunction frequently manifest a lower apnea-hypopnea index and oxygen desaturation index. Despite comparable median hs-cTnI levels, a higher proportion of subjects with detectable hs-cTnI levels was observed among those with endothelial dysfunction (95%versus83.5%, p=0.018). Logistic regression analysis indicated that endothelial dysfunction was significantly associated with a detectable level of hs-cTnI after adjustment for multiple confounders.ConclusionsIn male OSA patients, endothelial dysfunction appears to be potentially correlated with an increased risk of subclinical myocardial injury, as evidenced by the higher prevalence of detectable hs-cTnI levels. Further investigations are warranted to elucidate the role of endothelial dysfunction in predicting future cardiovascular mortality in this population.

The bidirectional interplay of obstructive sleep apnea and viral respiratory infections in children: A novel opportunity for primary prevention.

Obstructive sleep apnea (OSA) and viral respiratory infections are highly prevalent conditions in children and a major cause of respiratory morbidity in this age group. Severe viral respiratory infections are a known risk factor for pediatric OSA, which is primarily caused by hypertrophy of upper airway lymphoid tissues (adenoids and tonsils). This review examines recent progress in understanding early-life development of lymphoid tissues in the human upper airway, with a particular focus on how respiratory viruses may influence this process and contribute to OSA pathogenesis. It also explores the bidirectional relationship between OSA and severe viral infections, highlighting the need for ongoing monitoring and novel primary prevention strategies to address these interconnected conditions.

Impact of frenectomy on the oral exercise in patients with ankyloglossia and obstructive sleep apnea: double-blind randomized controlled clinical trials.

This study compares the efficacy of oral exercise alone to oral exercise with frenectomy in improving obstructive sleep apnea (OSA) symptoms and quality of life (QOL) in patients with ankyloglossia. A prospective, controlled, double-blind clinical study enrolled fifteen adults (20-60 years) newly diagnosed with mild to moderate OSA and ankyloglossia. Participants were randomly assigned to either oral exercise alone (control group; n = 8) or oral exercise with frenectomy (intervention group; n = 7). Outcomes were assessed after a 3-month therapy period using polysomnography, the Epworth Sleepiness Scale (ESS), tongue strength (measured in kPa), and QOL questionnaires. Both control (-2.88 ± 1.73; p = 0.02) and intervention (-4.00 ± 3.65; p = 0.03) groups showed a significant reduction in ESS scores, indicating both improved sleepiness. Although the apnea-hypopnea index (AHI) increased in both groups after treatment, these changes were not statistically significant (control 4.73 ± 15.55; p = 0.48, intervention 10.42 ± 14.66; p = 0.12). Tongue strength significantly increased in both groups: control group (p = 0.04) and intervention group (p = 0.03). Satisfaction rates with the overall treatment process were 100% in the control group and 57.1% in the intervention group. Furthermore, 75.0% and 57.1% of participants in the respective groups reported an improvement in QOL. Frenectomy improved tongue mobility and the ability to perform oral exercises in individuals with OSA and ankyloglossia. However, these exercises did not significantly improve OSA-related symptoms or QOL. While frenectomy enhances tongue mobility, thereby enabling better engagement in oral exercises. These exercises alone did not significantly improve OSA-related symptoms or QOL. This suggests that oral exercises focusing solely on tongue mobility may not be sufficient for managing OSA. The Thai Clinical Trials Registry was TCTR20220429002.

Posterior fossa decompression in patients with Chiari malformation type 1: effect on sleep apnea and follow-up outcomes.

Sleep apnea, posing significant health risks, is frequently associated with Chiari malformation (CM), characterized by cerebellar tonsil herniation through the foramen magnum. Central sleep apnea (CSA) in CM results from impaired brain-to-muscle signaling and requires treatment. Conversely, obstructive sleep apnea (OSA), arising from throat muscle relaxation, typically unrelated to CM, often coexists. This study evaluates the effectiveness of posterior fossa decompression (PFD) on sleep apnea. A retrospective chart review was conducted of pediatric patients with CM-1 and sleep apnea who underwent PFD between April 1, 2004, and September 30, 2022. Data collected included demographics, clinical characteristics, adenotonsillectomy status, PFD details, and sleep study parameters like the apnea-hypopnea index and respiratory disturbance index. Statistical analysis assessed the surgery's impact on sleep apnea severity. The study included eleven patients, predominantly male (63.6%). All had OSA (100%), with 63.6% also having CSA. Preoperative sleep studies classified OSA severity as 36.4% mild, 18.2% moderate, and 45.5% severe, with no change post-surgery. CSA severity initially included seven mild cases, which became three mild, one moderate, and three resolved cases post-surgery. Among seven patients who had adenotonsillectomy before decompression, five showed no improvement in OSA severity post-surgery. This study elucidates the complex relationship between CM-1, sleep apnea, and PFD. The findings show the persistence of sleep apnea in some patients and highlight the need for continuous monitoring of these patients in order to optimize their care after surgery.

Clinical characteristics of obstructive sleep apnea patients with residual sleepiness

ObjectiveThis meta-analysis examines the clinical characteristics of CPAP-treated obstructive sleep apnea (OSA) patients with residual excessive sleepiness (RES).MethodWe conducted a search for articles published from inception to March 16, 2024, in PubMed, Embase, Cochrane Library, and Web of Science. Seven studies were included in this meta-analysis.ResultsThe meta-analysis revealed that continuous positive airway pressure (CPAP)-treated OSA patients with RES were characterized by higher Epworth Sleepiness Scale and Depression Scale scores, lower body mass index (BMI) and apnea-hypopnea index (AHI) before CPAP treatment. RES patients also exhibit poorer CPAP adherence. Being female was also associated with RES.ConclusionBeing female, having lower BMI and AHI, and more severe daytime sleepiness and depressive symptoms before CPAP treatment, and lower CPAP adherence were characteristics of OSA patients with RES. These factors may prove helpful in identifying CPAP-treated OSA patients who may need additional treatment to minimize RES.

Arousal burden is highest in supine sleeping position and during light sleep.

Arousal burden (AB) is defined as the cumulative duration of arousals during sleep divided by the total sleep time. However, in-depth analysis of AB related to sleep characteristics is lacking. Based on previous studies addressing the arousal index (ArI), we hypothesized that the AB would peak in the supine sleeping position and during non-rapid eye movement stage 1 (N1) and show high variability between scorers. Nine expert scorers analyzed polysomnography recordings of 50 participants, the majority with an increased risk for obstructive sleep apnea. AB was calculated in different sleeping positions and sleep stages. A generalized estimating equation was utilized to test the association between AB and sleeping positions, sleep stages, and scorers. The correlation between AB and ArI was tested with Spearman's rank-order correlation. AB significantly differed between sleeping positions (p<0.001). The median AB in the supine sleeping position was 47-62% higher than in the left and right position. The AB significantly differed between the sleep stages (p<0.001); the median AB was more than 200% higher during N1 than during other sleep stages. In addition, the AB differed significantly between scorers (p<0.001) and correlated strongly with ArI (r=0.935, p<0.001). AB depends on the sleeping position, sleep stage, and scorer as hypothesized. AB behaved similarly as the ArI, but the high variability in the ABs between scorers indicates a potential limitation caused by subjective manual scoring. Thus, the development of more accurate techniques for scoring arousals is required before AB can be reliably utilized.

Multidimensional phenotyping to distinguish among central (CSA), obstructive (OSA) and co-existing central and obstructive sleep apnea (CSA-OSA) phenotypes in real-world data

PurposeWhen navigating the landscape of obstructive sleep apnea (OSA), central sleep apnea (CSA) and intersection of the two diseases (co-existing CSA-OSA), there are significant knowledge gaps. Data are scarce regarding the respective prevalence and differences in clinical presentation of the three conditions. One major issue for characterization of the prevalence of the different sleep apnea entities is the scoring of central versus obstructive hypopneas which is not included in the routine practice of many sleep laboratories. MethodWe prospectively assessed multidomain symptoms and collected data on comorbidities, medications and treatment indications in a large monocentric real-life dataset (n > 2400) of patients referred for suspicion of sleep apnea. We have systematically distinguished central versus obstructive hypopneas to define OSA, CSA and co-existing CSA-OSA. ResultsWhen CSA was defined by the proportion of central apneas (and hypopneas were considered obstructive by default), the prevalence of CSA was 4.59 % (co-existing CSA-OSA: 11.03 %, and OSA: 84.37 %). When the distinction between obstructive and central hypopneas was used to classify the sleep disordered breathing, the prevalence of CSA was fourfold higher at 19.69 % (co-existing: 19.16 %, OSA: 61.16 %). The burden of cardiovascular and metabolic comorbidities was the highest in the CSA and co-existing sleep apnea subgroups. The three sleep apnea groups exhibited different constellations of symptoms but most of the patients with CSA, co-existing and OSA were symptomatic after comprehensive evaluation. The CSA group exhibited the most severe disturbances in sleep architecture on polysomnography. Therapeutic indications differed depending on the subtype of respiratory events. ConclusionOur findings imply that not differentiating between central and obstructive hypopneas will underestimate the severity of central sleep disordered breathing abnormalities that mislead therapeutic decisions and might limit improvements in quality of life and sleepiness that are expected in appropriately treated patients with CSA.

Associations between type of bariatric surgery and obstructive sleep apnoea, employment outcomes, and body image satisfaction: A systematic review and meta-analysis.

Bariatric surgery has been shown to provide significant patient benefits in terms of weight loss and mitigation of obesity linked co-morbidities, as well as providing improvements in occupational productivity and patient quality of life. However, the choice of which bariatric surgery procedure provides the most patient benefit in each of these cases is still in question. In this study we provide a systematic review, with the objective of evaluating associations between different bariatric surgery procedures and mitigation of obesity linked co-morbidities, improvement in occupational productivity, and patient quality of life, concentrating on three areas: obstructive sleep apnoea (OSA), employment prospects and body image. The CINAHL, PubMed, Web of Science, and CENTRAL databases were searched for eligible studies. Summary risk ratio (RR) and 95% confidence intervals were estimated using random-effects models. Thirty-three studies were included in this review, including 29 cohort studies and 4 randomised clinical trials (RCTs). Pooled analysis of the observational studies showed significantly lower OSA remission in sleeve gastrectomy (SG) compared to Roux-en-Y gastric bypass (RYGB) across both short-term (1-2 years) and longer-term (3+ years) follow-up periods, (RR=0.91, 95% CI = 0.84-0.99, p=0.02 and RR=0.88, 95% CI = 0.65-0.99, p=0.03 respectively). In contrast, a metanalysis of the RCT studies found no difference in OSA remission between SG and RYGB (RR=1.01, 95% CI = 0.81-1.25, p=0.93). An analysis of four studies showed significantly higher OSA remission for SG versus Adjustable Gastric Band (RR=1.83, 95% CI = 1.57-2.14, p&lt;0.001). No significant difference was observed regarding improvement in employment status between SG and RYGB (RR=0.77, 95% CI = 0.32-1.87, p = 0.57). A narrative synthesis of studies on body image reported no significant differences between body image scores and surgery types. This review found significantly lower OSA remission in SG as compared to RYGB across different follow up periods, while no significant statistical difference was observed in RCTs studies. Further studies are recommended to assess the effectiveness of the various bariatric surgeries in relation to improving employment status and body image, where primary studies are lacking.

Should Mouth Taping and Obstructive Sleep Apnea Therapies Be Regulated?

Should Mouth Taping and Obstructive Sleep Apnea Therapies Be Regulated?