Postoperative Apnea-hypopnea Index Research Articles

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.

Does Sleep Endoscopy Staging Pattern Correlate With Outcome of Advanced Palatopharyngoplasty for Moderate to Severe Obstructive Sleep Apnea?

Although drug-induced sleep endoscopy (DISE) is an accepted method to localize upper airway obstruction, it is not known whether all sites identified by DISE must be treated to achieve sufficient apnea-hypopnea index (AHI) improvement. The aim of this study was to compare outcomes for unilevel (upper) versus multilevel DISE collapse patterns in a patient cohort that only underwent modern palatopharyngoplasty. Our hypothesis was that not all tongue base-level obstructions on DISE must be treated. Thirty-eight patients with mean AHI of 45 events/h underwent DISE followed by palatopharyngoplasty. Outcome was measured by polysomnography or home sleep apnea testing. Eleven patients (29%) had multilevel, complete tongue base obstruction and nineteen (50%) had no obstruction. These two groups were similar in age, body mass index, and AHI; the complete group had smaller tonsils and higher tongue position. The postoperative success rate and AHI in the group without tongue base obstruction were not significantly different from those of the complete group (68%; 17.4 ± 11.0 versus 73%; 15.4 ± 20.5, P > .99). Seventeen patients (45%) had circumferential collapse of velum. The postoperative AHI was higher for patients with circumferential collapse (23.6 ± 15.8 from 55.3 ± 22.1 versus 10.5 ± 9.94 from 36.4 ± 16.7, P < .0001), but both groups had clinically and statistically significant AHI reductions. Patients with multilevel obstruction on DISE, treated with palatopharyngoplasty alone, had similar AHI outcome as those with unilevel obstruction. Multilevel surgery may not be needed in some patients with a multilevel obstruction pattern. Circumferential collapse of velum, however, was associated with a higher residual AHI.

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.

A Comparison of Uvulopalatopharyngoplasty and Modified Radiofrequency Tissue Ablation in Mild to Moderate Obstructive Sleep Apnea: A Randomized Clinical Trial

To compare the efficacy of modified radiofrequency tissue ablation (MRFTA) with uvulopalatopharyngoplasty (UPPP) based on both subjective and objective outcome measures in patients with mild to moderate obstructive sleep apnea (OSA). Forty patients with mild to moderate OSA were randomly divided into UPPP and MRFTA groups. Evaluation was made based on the apneahypopnea index (AHI), Sleep Apnea Quality of Life Index (SAQLI) and Epworth Sleepiness Scale (ESS), immediately before the surgery and 6 months postoperatively. The postoperative AHI scores were improved significantly in both groups, although the postoperative AHI in the UPPP group was significantly lower than in the MRFTA group (P = .02). The difference between success rates for moderate OSA in UPPP and MRFTA was significant (77% versus 30%, P = .03) but there was no significant difference between success rates for mild OSA in UPPP and MRFTA groups (70% versus 50%, P = .36). Comparing postoperative ESS scores in the 2 groups showed no significant difference (P = .24). The postoperative scores in social interaction, treatment-related symptoms domain, and SAQLI total score were significantly higher in the MRFTA group. MRFTA as well as UPPP can greatly improve daytime sleepiness and AHI, especially in patients with mild OSA. MRFTA proved to be more effective than UPPP to enhance quality of life of patients with OSA. Further studies with longer follow-up are required to evaluate long-term safety and efficacy of these procedures. A commentary on this article appears in this issue on page 1023. Trial name: Comparison of RFTA (Radio-Frequency-Tissue-Ablation) and UPPP (Uvulopalatopharyngoplasty) in patients with mild to moderate obstructive sleep apnea. URL: http://en.search.irct.ir/view/18617. Registration number: IRCT2014060910160N3.

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.

Maxillomandibular advancement as the initial treatment of obstructive sleep apnoea: Is the mandibular occlusal plane the key?

Maxillomandibular advancement (MMA) can be effective for managing obstructive sleep apnoea (OSA); however, limited information is available on the predictor surgical variables. This study investigated whether normalization of the mandibular occlusal plane (MOP) was a determinant factor in curing OSA. Patients with moderate or severe OSA who underwent MMA were evaluated by preoperative and postoperative three-dimensional (3D) scans and polysomnograms. The postoperative value of MOP and the magnitude of skeletal advancement were the predictor variables; change in the apnoea–hypopnoea index (AHI) was the main outcome variable. Thirty-four subjects with a mean age of 41±14years and 58,8% female were analysed. The Epworth Sleepiness Scale (ESS) was 17.4±5.4 and AHI was 38.3±10.7 per hour before surgery. Postoperative AHI was 6.5±4.3 per hour (P<0.001) with 52.94% of the patients considered as cured, and 47.06% suffering from a mild residual OSA with ESS 0.8±1.4 (P<0.001). 3D changes revealed a volume increase of 106.3±38.8%. The mandible was advanced 10.4±3.9mm and maxilla 4.9±3.2mm. MOP postoperative value was concluded to be the best predictor variable. Treatment planning should include MOP normalization and a mandibular advancement between 6 and 10mm. The maxillary advancement would depend on the desired aesthetic changes and final occlusion.

Various combinations of velopharyngeal and hypopharyngeal surgical procedures for treatment of obstructive sleep apnea: Single-stage, multilevel surgery

ObjectiveThe aim of this study was to investigate the safety and outcomes of velopharyngeal surgeries combined with hypopharyngeal surgeries as single-stage interventions for treatment of obstructive sleep apnea (OSA). MethodsRetrospective analysis of operated patients. The velopharyngeal surgical interventions were uvulopalatal flap, anterior palatoplasty, expansion sphincter pharyngoplasty, transpalatal advancement pharyngoplasty, Cahali lateral pharyngoplasty, Z-palatoplasty, and modified uvulopalatopharyngoplasty. The hypopharyngeal surgical interventions were tongue base suspension, mucosal sparing partial glossectomy, genioglossus advancement, mandibulohyoid suspension, thyrohyoid suspension, and epiglottoplasty. ResultsForty-one patients were enrolled after inclusion and exclusion criteria. The evaluation of symptoms and polysomnographic findings were performed preoperatively and at a minimum of 3months postoperatively. The mean age was 42.17±9.50years and the mean follow-up time was 6.8±6.0months. After single-stage multilevel surgery, the mean apnea hypopnea index (AHI) improved from 29.13±15.87events/h to 14.28±16.14events/h (p<0.001). According to the classical definition of success criteria (>50% reduction in AHI and postoperative AHI<20events/h), the surgical success rate was 56%, with cure of OSA (AHI<5events/h) in 41% of study population. The combined surgeries also improved Epworth scores, snoring scores, and respiratory parameters significantly (in all p<0.05). The major complications were bleeding requiring re-admission in surgery room and severe tongue base edema which regressed by steroid administration. The minor complications were pain, difficulty in swallowing, velopharyngeal insufficiency, regurgitation, minor bleeding, and occlusion disorder. The mean postoperative period to beginning of normal feeding was 1.81±1.01days. The percentage of pain, the number of patients with major bleeding, and the need for patient-controlled analgesia were higher in patients undergoing tissue resection/ablative hypopharyngeal procedures. The mean postoperative period to beginning of normal feeding was shorter in patients undergoing suture/repositioning hypopharyngeal procedures. ConclusionAccording to outcomes of this study, OSA patients with multilevel obstructions can benefit from combined surgeries for velopharyngeal and hypopharyngeal regions at the same operation stage, without experiencing persistent complaints. It is promising that, despite multiple levels of obstruction was operated at single-stage, airway safety was preserved in all patients.

0561 UPPER AIRWAY STIMULATION FOR OBSTRUCTIVE SLEEP APNEA: COMBINED NORTHEAST OUTCOMES

Obstructive sleep apnea (OSA) is associated with cardiopulmonary disorders such as hypertension, cardiac arrhythmias, and heart failure. Continuous positive airway pressure, oral appliances, and surgeries to alter upper airway anatomy, are currently in use to treat OSA. However in some patients, these treatments are either ineffective or fail due to inadequate adherence. The hypoglossal nerve stimulation (HNS) system has been shown to reduce airway collapse and improve sleep measures. This multicenter study aims to review preoperative characteristics, somnography outcomes, quality-of-life measures, compliance, complications, and effects on cardiopulmonary morbidity in patients with HNS implantation. Patients with moderate to severe OSA who have failed traditional interventions and exhibit anterior-posterior velopharyngeal airway collapse on drug-induced sleep endoscopy (DISE) underwent HNS implantation. Demographics, cardiopulmonary comorbidities, Epworth Sleepiness Scores (ESS), and polysomnography measures were collected preoperatively. Postoperatively, device titration parameters, compliance, repeat polysomnography, tongue protrusion patterns, ESS, cardiopulmonary conditions, and complications were assessed. A nonparametric Wilcoxon signed-rank test was used to compare pre- and postoperative Apnea-Hypopnea Index (AHI). Twenty-seven patients (5 female, 22 male) from Middlesex Hospital and New York Presbyterian Hospital underwent HNS implantation between December 2014 and September 2016. Mean age was 53.4 ± 8.2 years. Mean preoperative body mass index was 28.5 ± 3.5 kg/m2. Postoperative AHI was significantly reduced (44.8 ± 16.8 to 6.3 ± 8.8, p<0.001). Of the 27 patients, 14 (51.9%) achieved cure AHI < 5. Twenty-three (85.2%) achieved an AHI < 15. Mean compliance was 50.3 ± 9.2 hours/week. There was a low rate of complications: one patient had syncope on postoperative day two, two reported persistent pain at the first postoperative visit, one patient developed a hypertrophic scar, and there was one case of mild tongue paresis, which resolved spontaneously. Preliminary data show that HNS is a safe procedure associated with improved OSA outcomes. Efforts are ongoing to examine the influence of airway collapse pattern, device titration, and tongue protrusion on device efficacy. As patients are followed for multiple years, the effect of HNS on cardiopulmonary comorbidities will be further assessed. N/A.

Contribution of Hyoid and Tonsillar Procedures to Outcome in Multilevel Surgery for Obstructive Sleep Apnea Syndrome

Background/Objective: In multilevel surgery for obstructive sleep apnea (OSA), the contribution of distinct operative steps is still unclear. The aim of the present study is to retrospectively compare different combinations of multilevel surgeries in order to estimate the contribution of hyoid and tonsillar procedures to the outcome. Methods: A total of 45 patients were selected in a retrospectively matched case-control study from a database of patients who underwent surgery for OSA at our institution: group A (n = 15) had hyoid suspension, tonsillectomy, and radiofrequency-assisted uvulopalatoplasty (RAUP); group B (n = 15) had hyoid pharyngoplasty with resection of the hyoid body and preepiglottic fat tissue, tonsillectomy, and RAUP; and group C (n = 15) had hyoid suspension and RAUP but no tonsillectomy, because the tonsils had already been removed. The apnea-hypopnea index (AHI) was defined as the primary outcome measure. Results: The postoperative AHI significantly improved in groups A and B, in which all patients had a tonsillectomy. However, the improvement in the patients of group C, who had no tonsillectomy, was not significant (p = 0.08). Conclusion: The patients having undergone multilevel surgery without tonsillectomy showed significantly poorer postoperative results, suggesting that the effectiveness of hyoid procedures at the level of the hypopharynx may be limited. However, removal of the tonsils is a major predictive factor for postoperative success.

Lingual Tonsillectomy for Treatment of Pediatric Obstructive Sleep Apnea

Evidence indicates correlations between lingual tonsil hypertrophy and pediatric obstructive sleep apnea (OSA). However, to our knowledge, a meta-analysis of surgical outcomes for lingual tonsillectomy in children with OSA has not been conducted. To evaluate the therapeutic outcomes of lingual tonsillectomy for treatment of pediatric OSA. The study protocol was registered on PROSPERO (CRD42015027053). PubMed, MEDLINE, EMBASE, and the Cochrane Reviews databases were searched independently by 2 authors for relevant articles published by September 2016. The literature search identified English-language studies that used polysomnography to evaluate children with lingual tonsil hypertrophy and OSA after lingual tonsillectomy alone. The search keywords were lingual tonsil, lingual tonsillectomy, sleep endoscopy, sleep apnea, and child. Polysomnographic data from each study were extracted. A random-effects model pooled postoperative sleep variable changes and success rates for lingual tonsillectomy in treating pediatric OSA. Four outcomes for lingual tonsillectomy were analyzed. These included net postoperative changes in the apnea-hypopnea index (AHI), net postoperative changes in the minimum oxygen saturation, the overall success rate for a postoperative AHI less than 1, and the overall success rate for a postoperative AHI less than 5. This meta-analysis consisted of 4 studies (mean sample size, 18.25 patients), with a total of 73 unique patients (mean [SD] age, 8.3 [1.1] years). Fifty-nine percent (27 of 46) of the patients were male, and 1 of the 4 studies did not specify number of males. Lingual tonsillectomy was indicated for persistent OSA after adenotonsillectomy in all cases. Lingual tonsil hypertrophy was evaluated using computed tomography or magnetic resonance imaging in 1 study, sleep endoscopy in 2 studies, and cine magnetic resonance imaging in 1 study. The mean change in the AHI after lingual tonsillectomy was a reduction of 8.9 (95% CI, -12.6 to -5.2) events per hour. The mean change in the minimum oxygen saturation after lingual tonsillectomy was an increase of 6.0% (95% CI, 2.7%-9.2%). The overall success rate was 17% (95% CI, 7%-35%) for a postoperative AHI less than 1 and 51% (95% CI, 25%-76%) for a postoperative AHI less than 5. Postoperative complications that developed included airway obstruction, bleeding, and pneumonia. Lingual tonsillectomy is an effective surgical management for children with OSA caused by lingual tonsil hypertrophy, and it achieves significant improvement in the AHI and the minimum oxygen saturation. However, children frequently have residual OSA after lingual tonsillectomy, and postoperative complications must be carefully managed.

Adenotonsillectomy outcomes in patients with Down syndrome and obstructive sleep apnea.

To review the literature for studies examining polysomnography (PSG) outcomes in patients with Down syndrome (DS) and obstructive sleep apnea (OSA) following adenotonsillectomy (T&A), and to review our experience with these patients. PubMed-NCBI, Scopus, Ovid, EBSCO, Cochrane, and EMBASE databases; tertiary academic center medical records. A systematic review of the medical literature identified articles reporting objective outcomes following T&A for OSA treatment in patients with DS. Articles were critically appraised to assess level of evidence and bias, and the results of articles were summarized. A case series of confirmed patients with DS and OSA was conducted, evaluating T&A efficacy by comparing pre- and posttreatment PSG data. Six articles were identified, which demonstrated some improvement after T&A in the treatment of OSA; however, subjects frequently had persistent disease. At our institution, preoperative Apnea-Hypopnea Index (AHI) improved from 13.75 (interquartile range [IQR] = 6.65-23.43) to 3.5 (IQR = 1.96-9.63) postoperatively; P = 0.004. Ten percent of patients had preoperative AHIs < 5; this proportion increased to 60% following surgery. Twenty percent of patients had postoperative AHIs < 1. There is little objective data in the medical literature addressing T&A efficacy in treating OSA in patients with DS patients. Patients show objective improvement in sleep parameters following T&A for OSA. Adenotonsillectomy should be suggested as a first-line treatment for children with DS and OSA, keeping in mind that monotherapy may be insufficient. Future studies utilizing objective measures are required to further quantify the effect in this patient population. Laryngoscope, 127:1465-1470, 2017.

Comparison of treatment outcomes between intracapsular and total tonsillectomy for pediatric obstructive sleep apnea

BackgroundIntracapsular tonsillectomy (IT) has been advocated as a treatment for pediatric obstructive sleep apnea (OSA). However, evidence in the literature utilizing polysomnography (PSG) is limited. ObjectiveTo examine the experience at a tertiary children's hospital to evaluate the effectiveness and risks of intracapsular tonsillectomy compared to total tonsillectomy (TT) for treating pediatric OSA. MethodsA retrospective study was undertaken of pediatric tonsillectomy cases performed for OSA at a tertiary children's hospital from 2005 to 2010. Patients with recurrent tonsillitis, craniofacial abnormalities, chromosomal abnormalities, neuromuscular disease, and congenital malformations were excluded. Main outcome measures were apnea-hypopnea index (AHI), minimum oxygen saturation (minO2), and surgical complications. ResultsOf the 1583 patients reviewed in this study, there were 75 IT and 93 TT patients with pre- and post-operative PSG results. The IT patients were younger, had lower BMI, larger tonsil size, lower pre-operative (AHI) and lower post-operative AHI (p < 0.05). There was a similar percentage of patients that showed improvement in AHI and minimum oxygen saturation between the IT and TT groups. There were statistically similar average change in AHI and minimum oxygen saturation between the IT and TT groups at 5.6 ± 8.6 and 8.6 ± 12.9, respectively (p = 0.8) as well as similar improvement in minimum oxygen saturation between the two groups at 3.3% ± 4.3% and 3.0% ± 5.2%, respectively (p = 0.66). Of TT patients, 2.9% experienced post-operative bleeding with 1.6% requiring OR for control of hemorrhage. Of IT patients, 2.2% were found to have tonsillar regrowth with 2.0% returning to the OR for secondary tonsillectomy. ConclusionsIntracapsular tonsillectomy, like total tonsillectomy, is effective in improving polysomnogram results in appropriately selected children. Intracapsular tonsillectomy is a suitable option for the surgical treatment of pediatric OSA consequent to its demonstrated efficacy in relieving OSA and its favorable safety profile.

Positional therapy in patients with residual positional obstructive sleep apnea after upper airway surgery

A considerable portion of patients has residual positional obstructive sleep apnea (POSA) after upper airway surgery. Those patients could benefit from additional treatment with positional therapy (PT). The objective of this prospective study was to assess the additional effect of PT in patients with residual POSA after upper airway surgery for sleep apnea. A polysomnography (PSG) was used to diagnose a patient with residual POSA after surgery. After informed consent, patients were treated with PT for 3months and underwent a follow-up PSG while using the sleep position trainer (SPT). Changes in apnea-hypopnea index (AHI) and sleep position parameters were analyzed. Compliance rates and mean disease alleviation (MDA) were determined. Thirty-three patients with a median postoperative AHI of 18.3/h sleep were included. With the SPT median AHI dropped to 12.5/h sleep and the Epworth Sleepiness Scale (ESS) improved from 10.0 to 7.0. After 3months, 37.5% patients were considered responders of whom 31.3% had treatment success. The compliance rate with SPT was 89.0%. MDA was 44.7% for SPT alone. With the combination of both surgery and SPT, MDA was 65.6%. The results of this study indicate that additional PT in a complex OSA patient population with residual POSA after surgery can increase overall therapeutic effectiveness by improving the median MDA from 39.5% (effect of surgery alone) to 65.6% (effect of combining surgery and PT).

Total analysis of clinical factors for surgical success of adenotonsillectomy in pediatric OSAS.

The objective of this study is the total evaluation of most common clinical factors influencing the successful rate of adenotonsillectomy for pediatric obstructive sleep apnea syndrome (OSAS). Retrospectively, 63 pediatric patients ranged from 2 to 16 years old were included. Syndromics and patients who had received orthodontic treatment or orthognathic surgery were excluded. All patients received pre-operative and postoperative polysomnography and cephalometry. Each patient received adenotonsillectomy by single surgeon. Surgical success was defined as apneahypopnea index (AHI) decreased ≧50% or post-operative AHI <5. Total evaluated clinical factors related to success of adenotonsillectomy for pediatric OSAS include age, gender, body mass index (BMI), tonsil size, adenoid/nasopharynx ratio (A/N Ratio), pre-operative data of polysomnography, including AHI, apnea index (AI), hypopnea index (HI), mean O2 saturation and nadir O2 saturation, and 18 cephalometry parameters. Mean age of the total 63 patients was 7.78 years old. Mean BMI of the patients was 19.02. The proportion of obese patients was 25.4% (16/63). Surgical success was achieved in 42 out of 63 patients (66.7%). The surgical success was not statistically significant related to all pre-operative cephalometric parameters, age, gender, BMI and adenoid size by multiple logistic regression model. However, the surgical success was significantly related to pre-operative AHI and tonsil size. In addition, all patients who received adenotonsillectomy showed improved polysomnography parameters, including AHI, AI, HI, mean O2 saturation and nadir O2 saturation which all reached statistically significant improvement. Although adenotonsillectomy cannot cure pediatric OSAS in our research, all patients showed significant improvement of polysomnography parameters after this procedure. Pre-operative cephalometry parameters, BMI and age did not show significant correlation with surgical success, however, pre-op AHI and tonsil size correlated with surgical success. Higher pre-op AHI value and higher tonsil grade showed higher rate of surgical success. Based on the total evaluation of clinical data, surgical success after adenotonsillectomy might be predicted by pre-op AHI severity and tonsil grade.

Transoral robotic base of tongue reduction for obstructive sleep apnea: A systematic review and meta-analysis.

To determine the effect of transoral robotic surgery (TORS) base of tongue (BOT) reduction on sleep-related outcomes in patients with obstructive sleep apnea (OSA). PubMed, Scopus, EMBASE, CINAHL, Cochrane, and Ovid. Literature search by two independent authors was conducted using the abovementioned databases. Studies on TORS BOT reduction as part of OSA treatment in adult patients with pre- and postoperative apnea-hypopnea index (AHI) scores were included. Studies on TORS as treatment for diseases other than OSA were excluded. A total of six articles with 353 patients treated with TORS BOT reduction met inclusion criteria. Pooled analyses (baseline vs. postsurgery) showed significant improvement in the following: AHI (44.3 ± 22.4 to 17.8 ± 16.5, P < .01), Epworth Sleepiness Scale (12.9 ± 5.4 to 5.8 ± 3.7, P < .01), lowest oxygen saturation (79.0 ± 9.5 to 84.1 ± 6.5, P < .01), and snoring visual analog scale (9.3 ± 0.8 to 2.4 ± 2.43, P < .01). Surgical success rate, defined as a >50% reduction of AHI with a postoperative AHI < 20, was 68.4% (95% confidence interval [CI] = 63.0%-73.5%). Cure rate (postoperative AHI < 5) was 23.8% (95% CI = 19.1%-29.2%). TORS BOT reduction decreases AHI and symptoms of sleepiness in adult patients with OSA. It is considered successful in a majority of cases; however, further studies must be performed to optimize patient selection criteria to achieve higher rates of success. Laryngoscope, 127:258-265, 2017.

Multilevel Combined Surgery With Transoral Robotic Surgery for Obstructive Sleep Apnea Syndrome.

To evaluate the results of combined multilevel surgery with transoral robotic surgery (TORS) in patients with obstructive sleep apnea/hypopnea syndrome for multilevel upper airway obstruction. Subjects who underwent combined sleep surgery via TORS were evaluated. The drug-induced sleep endoscopy was used in diagnosing the presence of level-specific upper airway collapse and to detect the type of surgery. Pre- and postoperative Apnea-hypopnea index, Epworth sleepiness scale lowest oxygen saturation, total operation time, robotic set-up time and robotic surgery time, blood loss value, and complications were recorded. Twenty five subjects were identified. All subjects underwent base of tongue (BOT) + epiglottoplasty. The tracheotomy was not performed for any patient. Overall, 72% of patients met the criteria for cure, 8% met the criteria for cure, and 20% of patients met the criteria for failure. There was a significant decrease between preoperative and postoperative Apnea-hypopnea index scores (28.7 ± 17.8 SD versus 9.4 ± 12.4, P = 0.000) and Epworth sleepiness scale scores (13.5 ± 2.8 versus 3.4 ± 1.6, P = 0.000). There was a significant increase between preoperative and postoperative ED SPO2 levels (80.7 ± 7.6 versus 82.6 ± 18.1, P = 0.001). TORS BOT, epiglottoplasty, and multilevel procedures in patients with obstructive sleep apnea/hypopnea syndrome can be regarded as feasible, safe, and effective technique.

State of the art transoral robotic surgery for obstructive sleep apnea-hypopnea syndrome.

ObjectiveTo review the existing literature on the role of transoral robotic surgery (TORS) for tongue base reduction in the management of adult obstructive sleep apnea-hypopnea syndrome (OSAHS).MethodsWe searched PubMed, MEDLINE, and Scopus databases from the first literature report of this surgical technique to July 30, 2015 for studies investigating the use of TORS for tongue base reduction in treating adult OSAHS. Our primary outcome measures were Apnea– Hypopnea Index (AHI), lowest oxygen saturation (LSAT), Epworth Sleepiness Score (ESS), and the rates of surgical cure (AHI<5) and success (50% reduction in AHI accompanied by a postoperative AHI<20). Our secondary outcome measures were the volume of tissue resected and correlation to AHI, polysomnographic parameters, subjective outcomes, and body mass index. Complications of surgery were also analyzed.ResultsThirteen articles were critically evaluated for this research. However, only four case series qualified for statistical analysis of postoperative polysomnographic outcomes and six case series for analysis of postoperative complications. They were case series with a total of 451 adult patients. Pooled analysis revealed statistically significant improvements in AHI, LSAT, and ESS after surgery by 26.83/hour, 5.28% and −8.03, respectively. The average rates of surgical cure and success were 23.8% and 66.7%, respectively. No study reported any deaths or complications related to the use of robotic equipment. The major complication rate was 6.9%, and the minor complication rate was 30.0%. Major complications included major bleeding (2.9%), severe odynophagia with dehydration (3.3%), and oropharyngeal stenosis (0.7%). Minor complications included transient bleeding (0.5%), transient dysphagia (3.8%), and dysgeusia (6.6%).ConclusionTORS for tongue base reduction, as a component of multilevel surgery, is an effective treatment option for OSAHS with an acceptable morbidity. This conclusion is based on the analysis of the results of multiple case series. Future studies should entail prospective randomized controlled trials with larger sample size for longer follow-up period.

Modified barbed soft palatal posterior pillar webbing flap palatopharyngoplasty.

The soft palate and the lateral pharyngeal walls contribute to the collapse of the upper airway in patients with snoring and obstructive sleep apnea. In this study, the original soft palatal webbing flap palatopharyngoplasty for both soft palatal and oropharyngeal lateral wall collapse has been modified to include all tonsil grades and to apply the barbed suture technique. Twenty-one adults with significant soft palatal webbing, lateral pharyngeal wall collapse, and tonsil hypertrophy of any grade were selected for the study with a minimum follow-up period of 6months. Snoring was improved with snoring scale reduced from 9.4±1.6 to 1.7±3.2 (p<0.005). The preoperative to postoperative apnea-hypopnea index (AHI) statistically improved from 45.7±2.6 to 12.3±3.9 (p<0.005) and lowest O2 saturation from 73.8±3.6 to 89.4±1.9% (p<0.005). Postoperative endoscopic findings showed significant improvement in soft palatal and lateral pharyngeal wall collapse. There were no significant intraoperative or postoperative complications. Modified barbed soft palatal webbing flap palatopharyngoplasty provided objective improvement of obstructive sleep apnea (OSA) in adults with soft palatal, lateral pharyngeal wall collapse and tonsillar hypertrophy, with no significant complications and has the potential to serve as an effective alternative for these cases.

Persistent moderate or severe obstructive sleep apnea after laparoscopic Roux-en-Y gastric bypass: which patients?

BackgroundPatients with severe obesity and obstructive sleep apnea (OSA) might decide to undergo bariatric surgery to improve this disease or, more specifically, to become independent of continuous positive airway pressure (CPAP) therapy, which is generally indicated in case of moderate and severe OSA. Knowledge of this topic is important for patient education on expectations of surgical outcome. ObjectivesTo evaluate the prevalence and phenotypes of patients with persistent moderate to severe OSA after bariatric surgery. SettingObesity Center Amsterdam, Amsterdam, the Netherlands. MethodsPatients who underwent a laparoscopic Roux-en-Y gastric bypass, had a preoperative apnea-hypopnea index (AHI)≥15/hr, and of whom a follow-up AHI/hr was available were included. ResultsOut of 437 patients, 205 underwent pre- and postoperative polysomnography; 232 (53.1%) were lost to follow-up. Median AHI was 32.3/hr (range, 15–138) and mean body mass index was 46 (standard deviation 7.2) kg/m2. A postoperative AHI<15/hr was achieved in 152 patients (74.1%), whereas 53 (25.9%) still had moderate or severe disease 8.6 (standard deviation 4.8) months postoperatively. Predictive factors for persistent moderate to severe disease were age≥50 years, preoperative AHI≥30/hr, excess weight loss (EWL)<60%, and hypertension (area under the curve: .772). ConclusionAfter bariatric surgery, around three quarters of the moderate to severe OSA patients had no or mild OSA, whereas one quarter (25.9%) still had moderate to severe OSA. Age≥50 years, preoperative AHI≥30/hr, EWL<60%, and hypertension were predictive factors for this persistent postoperative AHI≥15/hr.