Surgery For Obstructive Sleep Apnea Research Articles

The Importance of Subjectivity in Assessing the Efficiency of Surgery for Obstructive Sleep Apnea. Comment on Kuik et al. Subjective Efficiency Evaluation after Maxillomandibular Advancement Surgery in Obstructive Sleep Apnea Patients. J. Clin. Med. 2023, 12, 4023.

We recently read with interest the study by Kuik et al. [...].

Assessment of Surgical Accuracy in Maxillomandibular Advancement Surgery for Obstructive Sleep Apnea: A Preliminary Analysis.

This retrospective study aimed to: (1) investigate the surgical accuracy of maxillomandibular advancement (MMA) in obstructive sleep apnea (OSA) patients, with a specific focus on maxillary and mandibular advancement and counter-clockwise rotation and (2) investigate the correlation between the amount of achieved advancement and the reduction in the relative apnea hypopnea index (AHI). Sixteen patients, for whom a three-dimensional virtual surgical plan was generated preoperatively and a computed tomography scan (CT) or cone-beam computer tomography (CBCT) was acquired postoperatively, were included. The postoperative CT or CBCT was compared to the virtual surgical plan, and differences in the mandibular and maxillary advancement and counter-clockwise rotation were assessed. Maxillary and mandibular advancement (median 3.1 mm, p = 0.002 and 2.3 mm, p = 0.03, respectively) and counter-clockwise rotation (median 3.7°, p = 0.006 and 4.7°, p = 0.001, respectively) were notably less than intended. A significant correlation was found between the planned maxillary advancement and the difference between the planned and actual maxillary advancement (p = 0.048; adjusted R2 = 0.1979) and also between the planned counter-clockwise rotation and the difference between the planned and actual counter-clockwise rotation for the mandible (p = 0.012; adjusted R2 = 0.3261). Neither the maxilla-first nor the mandible-first surgical sequence proved to be superior in terms of the ability to achieve the intended movements (p > 0.45). Despite a significant reduction (p = 0.001) in the apnea hypopnea index (AHI) from a median of 62.6 events/h to 19.4 events/h following MMA, no relationship was found between the extent of maxillary or mandibular advancement and AHI improvement in this small cohort (p = 0.389 and p = 0.387, respectively). This study underlines the necessity for surgeons and future research projects to be aware of surgical inaccuracies in MMA procedures for OSA patients. Additionally, further research is required to investigate if sufficient advancement is an important factor associated with MMA treatment outcome.

The Effect of Multilevel Surgery for Obstructive Sleep Apnea on Fatigue, Stress and Resilience.

To evaluate the effects of surgical treatment on fatigue, stress, and resilience in patients with obstructive sleep apnea (OSA). Sixty patients who underwent multilevel sleep surgery for OSA (OSA group) and 32 non-OSA participants (control group) were recruited at a university hospital in Korea between January 2020 and March 2022. Fatigue, stress, and resilience levels were evaluated in both groups using the Chalder fatigue scale (CFS), daily hassles scale revised (DHS-R), and Connor-Davidson resilience scale (CD-RISC), respectively. The scores of each group were compared before and 6 months after surgery. The initial CFS and DHS-R scores were significantly higher, while the CD-RISC score was significantly lower, in the OSA group than in the control group (p < 0.05). In the patients with OSA, all three scores significantly improved after surgery (p < 0.05). Additionally, when compared between the groups at 6 months, there were no differences in the CFS, DHS-R, or CD-RISC scores (p > 0.05). Even when the OSA group was divided into a success group and a failure group according to surgical outcomes and compared with the control group, the three scores of both groups did not show statistical differences from the control group (p > 0.05). Multilevel surgery may reduce fatigue as well as stress and increase resilience in patients with OSA to levels similar to those in non-OSA individuals.

Safety and efficacy of lingual tonsillectomy in multilevel airway surgery for pediatric obstructive sleep apnea.

Prior studies have demonstrated the efficacy of lingual tonsillectomy in treating pediatric obstructive sleep apnea. The goal of this study is to describe the postoperative outcomes following lingual tonsillectomy as a part of drug-induced sleep endoscopy-directed multilevel sleep surgery. A retrospective review was performed for pediatric patients with obstructive sleep apnea who underwent lingual tonsillectomy as a part of drug-induced sleep endoscopy-directed sleep surgery. Data collected included age, sex assigned at birth, body mass index z-score, polysomnography results, past medical and surgical history, and postoperative outcomes. A total of 174 patients were included in the study with a mean age of 8.29 ± 3.49 years (range 1.89-15.62) and mean preoperative apnea-hypopnea index of 7.88 ± 13.42 (range 1.10-123.40). Complications occurred in 26 patients (14.9%) including 14 patients (8.0%) requiring emergency department visit or readmission and 12 patients (6.9%) experiencing postoperative bleeding. Asthma (P = .033) and developmental delay (P = .016) correlated with postoperative complications. For patients with preoperative and postoperative polysomnography data (n = 145; 83.3%), there was significant improvement (P < .001) in apnea-hypopnea index with a mean postoperative apnea-hypopnea index of 4.02 ± 7.81 (range 0.00-54.46). Surgical failure, defined as postoperative apnea-hypopnea index ≥ 5, was identified in 25 patients (17.2%). Surgical failure was associated with body mass index z-score > 2 (P = .025) and Trisomy 21 (P = .005). This study highlights the promising surgical success rate of drug-induced sleep endoscopy-directed lingual tonsillectomy in multilevel sleep surgery (82.8%) and infrequent complications including postoperative bleeding (6.9%) and readmission (2.3%). Williamson A, Morrow VR, Carr MM, Coutras SW. Safety and efficacy of lingual tonsillectomy in multilevel airway surgery for pediatric obstructive sleep apnea. J Clin Sleep Med. 2024;20(2):189-199.

Nasal surgery for pediatric obstructive sleep apnea

Nasal surgery for pediatric obstructive sleep apnea

A New Lighting System for Surgical Vision Optimization in Barbed Pharyngoplasty for OSA.

Obstructive sleep apnea (OSA) surgery is now a viable solution in selected patients and the "remodeling" palatopharyngeal surgery is the most common one. Recently, it has become less invasive with the introduction of barbed sutures (BS). An optimization of surgical techniques is represented by barbed pharyngoplasty (BP), which requires surgical precision and needs efficient and precise oropharyngeal visualization. Consequently, the lighting system is of pivotal importance in BP. The aim of this work is to describe the first experience on the use of a new lighting system, called KLAROTM in BP for OSA. We evaluated the KLARO™ system in 15 consecutives BP for OSA in comparison with conventional headlamp illumination. The visualization of palatopharyngeal muscle in the bottom of the tonsillar fossa, entry and exit needle, such as needle tip, were statistically better with KLAROTM than headlamp illumination for both the surgeon and resident (p < 0.05). No significant differences for the visualization of the posterior pharyngeal wall and uvula were reported. The KLAROTM lighting system allows a satisfied illumination of oral cavity and oropharynx in the majority of cases. We encourage the use of KLAROTM not only in BP for OSA, but in all oral and pharyngeal surgeries, including tonsillectomy and oncological surgery.

The efficacy of muscle function training combined with occlusal inducer in the treatment of malocclusion in children with OSA

Objective:This study aims to investigate the clinical effectiveness of muscle function training combined with occlusal inducers in the treatment for children's malocclusion after obstructive sleep apnea（OSA） surgery. Methods:A total of 40 pediatric patients who underwent surgery for OSA at Shanghai Children's Medical Center, affiliated with Shanghai Jiao Tong University School of Medicine, from January 2020 to December 2021 were involved in this study. They were divided into a treatment group（n=20） and a control group（n=20）. The treatment group received muscle function training combined with occlusal inducers, while the control group received muscle function training alone. Cephalometric measurements of hard tissues were compared between the two groups before and 12 months after surgery. Additionally, the OSA-18 questionnaire, which includes 18 items to assess the life quality of children with OSA, was filled out before surgery, 6 months after surgery, and 12 months after surgery by these patients. Results:①The scores of sleep disorders, physical symptoms, emotional status, daytime sleepiness and energy status and the degree of influence on guardians in the two groups were significantly improved at 12 months after operation（P<0.05）. The scores of sleep disorders, physical symptoms, emotional status and the degree of influence on guardians in the treatment group were better than those in the control group（P<0.05）. ②Cephalometric data at 12 months after operation showed that the upper and lower alveolar seat angle（ANB）, Overbite, upper and lower central incisor angle（U1-L1） and Overjet in the treatment group were lower than those in the control group at 12 months after operation, and the difference was statistically significant（P<0.05）. Conclusion:Children with OSA can improve the dentition irregularity by muscle function training combined with occlusal inducer after operation, and the effect is better than that of muscle function training alone.

Does DISE increase the success rate of surgery for obstructive sleep apnea in children? A systematic review of DISE directed treatment of children with OSAS

ObjectiveA systematic review of the evidence on the success of Drug-Induced Sleep Endoscopy (DISE) directed surgery in children with obstructive sleep apnea (OSA) defined as cure rate. Data sourcesThe PRISMA guidelines were followed and three databases (PubMed, Embase and Cochrane Library) were searched for studies on DISE directed surgery in children. Endpoints: Pre- and post-surgical change in polysomnography (PSG); change in surgical target; side effects. Review methodsStudy quality was assessed using the modified Delphi technique quality appraisal tool for case series. Risk of bias was assessed using the Cochrane Collaboration's tool for assessing risk of bias. ResultsA total of 1805 studies were found. The most important reasons for exclusion were as follows: none-DISE studies, reports on adults, conflation of results on syndromic and healthy patients, no relevant outcome measurements. Five studies with a total of 376 patients (range: 26–126) were included. The surgeons changed the planned strategy in 50.4 % of patients according to the DISE findings. Comparison of pre- and post-surgical sleep monitoring revealed an average decrease in apnea-hypopnea index (AHI) of 11.1 and a treatment success (AHI < 5) and cure (AHI < 2) of 78 % and 53 %, respectively.The quality of the included studies was moderate especially due to small populations, designs without randomization or control groups, lack of analysis of drop outs, short follow-up, and considerable level of bias. ConclusionDISE directed surgery has been shown to change the surgical approach when treating children with OSA. If this can be transferred into a better outcome compared to standard surgical treatment is unknown, due to the current poor level of evidence. To decide whether or not DISE should be included in the treatment of children with OSA, we suggest further data, preferably an RCT, to increase the level of evidence.

Functional Endoscopic Sinonasal Surgery in Obstructive Sleep Apnea

Abstract Background: Functional Endoscopic Sinonasal Surgery needs indicators to determine success outcomes in the management of nasal obstruction-related obstructive sleep apnea (OSA). Materials and Methods: Preexperimental pretest and posttest designed studies were performed to evaluate the percentage changes value of Visual Analog Scale (VAS) nasal obstruction, Nasal Obstruction Symptom Evaluation (NOSE), Epworth Sleepiness Scale (ESS), polysomnographic parameters, and upper airway collapsibility examined by drug-induced sleep endoscopy. Results: Seventeen patients from 2 studies were recruited with mean Apnea-Hypopnea Index of 3.74 ± 3.30 and respiratory disturbance index of 7.03 ± 3.56. The first study showed a significant percentage change in inferior turbinate size, nasal obstruction VAS, peak nasal inspiratory flow, and ESS Score as well as the second study of significant differences pre- and postoperatively of NOSE (from 49.50 ± 19.2 to 4.50 ± 4.4) and ESS (from 12.60 ± 3.6 to 6.60 ± 3.9). Both studies significantly changed the percentage of the duration of Rapid Eye Movement (REM) to 81.4% ±100% (95% confidence interval − 23.6, 186.3) and a significant difference from preoperative of 4.93 ± 4.40% to post-operative of 11.89 ± 6.19%. Three subjects with preoperative epiglottic collapse (EC) showed a mean value of NOSE 60 ± 5 compared to the non-EC collapse of 45 ± 21.6. In postoperative, there were 4 subjects with EC collapse with a NOSE of 6.25 ± 4.7 and 6 subjects without EC collapse with a NOSE of 3.33 ± 4.1. Conclusion: Functional Endoscopic sinonasal surgery improves NOSE, ESS score, and REM sleep in OSA.

Multi-Level 3D Surgery for Obstructive Sleep Apnea: Could It Be the Future?

(1) Background: Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder and is characterized by recurrent episodes of complete or partial obstruction of the upper airway, leading to reduced or absent breathing during sleep. A nocturnal upper airway collapse is often multi-levelled. The aim of this communication is to describe a 3D multi-level surgery setting in OSA pathology, introducing new surgical approaches, such as 4K-3D endoscopic visualization for the tongue base approach with the aid of a coblator and exoscopic visualization in the palatal approach. (2) Methods: Seven patients affected by OSA underwent 3D Barbed Reposition Pharyngoplasty (BRP) surgery associated with transoral coblation tongue base reduction and nose surgery. (3) Results: No patients experienced intra-operative, post-operative or delayed complications. For OSA multi-level 3D surgery, it took less than 2 h: the median 3D system setting time was 12.5 ± 2.3 min; the overall procedure time was 59.3 ± 26 min. (4) Conclusions: The use of the 4K-3D endoscope and coblator for tongue base resectioning and of the 3D exoscope for lateral pharyngoplasty represents an excellent system in multi-level OSA related surgery that could reduce the time and the costs compared to those of robotic surgery.

Subjective Efficiency Evaluation after Maxillomandibular Advancement Surgery in Obstructive Sleep Apnea Patients.

To investigate subjective efficiency outcomes after maxillomandibular advancement (MMA) surgery in obstructive sleep apnea (OSA) patients. A prospective cohort study was carried out between December 2016 and May 2021, including 30 severe or treatment-refractory OSA patients treated by MMA surgery. All patients answered four validated questionnaires: the Epworth Sleepiness Scale (ESS), Functional Outcomes of Sleep Questionnaire (FOSQ), Mandibular Function Impairment Questionnaire (MFIQ), and EQ-5D-3L (i.e., EQ-5D and EQ-VAS). They also answered one custom-made questionnaire (AMCSQ). Questionnaires were requested to be filled out 1 week before surgery and at least 6 months after surgery. The total preoperative and postoperative scores on the questionnaires were compared. The mean total ESS (p < 0.01), FOSQ (p < 0.01), EQ-5D (p < 0.05), and EQ-VAS (p < 0.01) scores showed significant improvement, which was in accordance with an improvement in the mean postoperative apnea/hypopnea index score (p < 0.01). In contrast, the mean total MFIQ score (p < 0.01) indicated a decline in mandibular function. This study confirms the hypothesis that MMA surgery in OSA patients improves outcomes, both objectively and subjectively, with the exception of postoperative mandibular function.

Efficacy of coblation assisted surgery in obstructive sleep apnea with obstruction at the retropalatal level

Obstructive sleep apnoea syndrome (OSAS) is a common sleep disorder caused by abnormalities in the pharynx and upper airway muscles. Uvulopalatopharyngoplasty (UPPP) is the commonly indicated surgical procedure for the management of OSA. Recent studies state that coblation assisted UPPP can improve the outcomes of OSA. : To study the efficacy of coblation assisted uvulopalatopharyngoplasty in Obstructive Sleep Apnea Syndrome with isolated obstruction at the retropalatal level. This prospective before-after analysis was conducted in Government Kilpauk Medical College Hospital and Government Royapettah Hospital attached to Kilpauk Medical College from September 2016 to September 2017. After a thorough examination, patients with moderate and severe OSA with obstruction at the retropalatal level were selected for the study. Institutional ethical clearance was obtained and all patients signed the written informed consent form.A total of 25 patients were selected for the study and a male predominance was observed (80%). Tonsil size was graded using the Friedman grading scale and the majority of the patients had grade II tonsillar enlargement (52%). Based on tonsil size and Friedman's palate position, the patients were classified using Friedman's system. 11 patients were classified as stage 1, 10 patients were classified as stage 2, 4 patients were classified as stage 3. A success rate of 68% was observed following surgery based on the 50% reduction in the AHI criterion. Uvulopalatopharyngoplasty is effective in the management of OSA. Coblation assisted procedures can reduce postoperative pain and improve the outcomes of surgical therapy.

Role of ApneaGraph® in the Surgery for Obstructive Sleep Apnoea.

To evaluate the utility of ApneaGraph® AG 200 in diagnosing Obstructive Sleep Apnoea (OSA) as compared to Polysomnography, localization of the site of upper airway obstruction, and the success rate of surgery. A prospective study was conducted including fifteen patients of OSA undergoing surgical treatment. All patients underwent sequential overnight ApneaGraph (AG) and Polysomnogram (PSG) before and after 3 months following surgery. The preoperative and post-operative Apnoea-Hypopnoea Index (AHI) values were compared between AG and PSG. The success of surgery was defined as mean reduction in AHI by ≥ 50% and post-operative AHI < 20. The mean preoperative AHI using PSG was 53.7 and using AG was 44.9 (r = 0.83, p = 0.0001). All patients underwent AG-directed site-specific surgery. The mean postoperative AHI using PSG was 15.3 and using AG was 13.8 (r = 0.67, p = 0.0062). There was significant improvement in AHI post-surgery (p < 0.05, AG & PSG). The surgical success was achieved in 93.3%. The median follow-up was 14 months. ApneaGraph is a reliable alternative to PSG to diagnose OSA with an added advantage to localize the site of obstruction, yielding good surgical outcomes.

The clinical influence of nasal surgery on PAP compliance and optimal application among OSA subjects uncomfortable with PAP device wear

This study aimed to evaluate the alteration of PAP compliance after nasal surgery and to determine the optimal indications of nasal surgery in obstructive sleep apnea (OSA) subjects. Among OSA subjects using PAP devices, 29 subjects who underwent septoturbinoplasty due to nasal obstruction were included and their pre- and postoperative medical and PAP records were reviewed retrospectively. Postoperative autoPAP usage data was further assessed by grouping the compliance (the percentage of days with usage ≥ 4 h) data (group 1: the good compliance group; group 2: the poor compliance group). The data showed that 56% of subjects in group 1 complained of nasal obstruction as the only barrier to using a PAP device and about 89% reported experiencing the efficacy of PAP usage. Both the mean and peak average PAP pressures were significantly reduced in group 1 following nasal surgery. Group 2 had multiple subjective problems that interfered with wearing a PAP device and reported a lack of experiencing the efficacy of PAP usage. Preoperative nasal cavity volume values were smaller and absolute blood eosinophil counts were significantly lower in group 1. The current data demonstrate that nasal surgery might increase the compliance of PAP device wear in OSA subjects who complained of only nasal obstruction as a barrier to wearing PAP and who had small nasal cavity volumes combined with allergic inflammation.

Characteristics of Adults Undergoing Soft Tissue and Orthognathic Surgery for Obstructive Sleep Apnea.

To identify clinical and demographic characteristics of adults with obstructive sleep apnea (OSA) undergoing soft tissue and orthognathic sleep surgery, assess temporal trends in surgery type and proportion of women undergoing surgery, and provide clinical perspective before wide-spread implementation of hypoglossal nerve stimulation (HGNS). In a retrospective cohort study, adults diagnosed with OSA from 2009 to 2016 were identified in a large integrated healthcare system. Characteristics between cohort members who did and did not undergo sleep surgeries were compared. Multivariable logistic regression models examined associations of different characteristics with whether surgery was performed. Of 172,216 adults with OSA, 2,262 (1.3%) underwent sleep surgery during 2009-2017. The most common sleep surgery was palate surgery (56.9%), which decreased proportionately over time. In multivariable analysis, older age and obesity were associated with lower odds of undergoing surgery. Those who underwent tonsillectomy and adenoidectomy were more likely to have larger tonsils and not require additional surgery, whereas tongue reduction recipients were more likely to have severe OSA and require multiple surgery types. The proportion of women undergoing surgery increased over time (p< 0.001 from trend test). Clinical and demographic characteristics associated with soft tissue and orthognathic sleep surgery were identified in a large adult cohort prior to widespread implementation of HGNS. An increase in sleep surgery among women and a decrease in palate surgery over time were observed. The findings provide clinical perspective on sleep surgery performed prior to implementation of HGNS and may inform future studies examining its associations with patient characteristics. 3 Laryngoscope, 133:1262-1270, 2023.

Orthognathic Surgery for Obstructive Sleep Apnea.

Obstructive sleep apnea (OSA) involves obstruction or reduction of an individual's airway during sleep and is associated with several comorbidities. Patient evaluation includes detailed history, clinical and radiographic examination, endoscopy, and polysomnography. Management may be nonsurgical or surgical, and Phase II of the Stanford Protocol of surgical management involves maxillomandibular advancement (MMA). Surgical considerations (eg, degree of movement, timing of surgery) and potential complications specific to MMA are discussed in this review. With adequate planning and communication with the patient, MMA is effective in treating OSA, as measured with objective and subjective measures.

Inflammatory biomarkers of neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios in 563 severe OSA patients before and after surgery

BackgroundEvidence has proved that high neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were risk factors for cardiovascular comorbidities. The alterations of NLR and PLR following obstructive sleep apnea (OSA) treatment were under studied and thus should be investigated. This study aimed to evaluate the changes of inflammatory biomarkers including NLR and PLR in severe OSA patients after surgical interventions of the upper airway, and their relationships with improvements in polysomnographic (PSG) parameters.MethodsThis retrospective cohort study included 563 consecutive severe OSA patients at a tertiary academic medical center who received OSA surgery, as well as underwent pre- and post-operative polysomnographic (PSG) examinations and blood tests. The changes of major PSG estimates, NLR, and PLR before and at least 3 months after OSA surgery were analyzed using paired t-tests with subgroup analyses. Pearson’s correlations were performed to discover which PSG parameter contributed to the improvement of the values.ResultsAfter OSA surgery, the major PSG estimates, NLR and PLR dropped significantly in the overall population. In those with a higher preoperative NLR (pre-operative NLR≧3) and PLR (pre-operative PLR≧150), the mean (SD) difference of NLR (− 0.8 [1.6], 95% CI − 1.5 to − 0.2) and PLR (− 41.6 [40], 95% CI − 52.8 to − 30.5) were even more substantial. The changes of the “apnea, longest (r = 0.298, P = .037)” and “hypopnea, longest (r = 0.321, P = .026)” were found significantly related to the improvement of PLR.ConclusionNLR and PLR did significantly drop in severe OSA patients following OSA surgery, and this could be related to the alterations of sleep indices. The findings could possess clinical importance for severe OSA patients after OSA surgeries in reducing possible OSA-associated cardiovascular comorbidities.

30-Day Postoperative Outcomes in Adults with Obstructive Sleep Apnea Undergoing Upper Airway Surgery.

Obstructive sleep apnea (OSA) is a chronic disorder of the upper airway. OSA surgery has oftentimes been researched based on the outcomes of single-institutional facilities. We retrospectively analyzed a multi-institutional national database to investigate the outcomes of OSA surgery and identify risk factors for complications. We reviewed the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database (2008-2020) to identify patients who underwent OSA surgery. The postoperative outcomes of interest included 30-day surgical and medical complications, reoperation, readmission, and mortality. Additionally, we assessed risk-associated factors for complications, including comorbidities and preoperative blood values. The study population included 4662 patients. Obesity (n = 2909; 63%) and hypertension (n = 1435; 31%) were the most frequent comorbidities. While two (0.04%) deaths were reported within the 30-day postoperative period, the total complication rate was 6.3% (n = 292). Increased BMI (p = 0.01), male sex (p = 0.03), history of diabetes (p = 0.002), hypertension requiring treatment (p = 0.03), inpatient setting (p &lt; 0.0001), and American Society of Anesthesiology (ASA) physical status classification scores ≥ 4 (p &lt; 0.0001) were identified as risk-associated factors for any postoperative complications. Increased alkaline phosphatase (ALP) was identified as a risk-associated factor for the occurrence of any complications (p = 0.02) and medical complications (p = 0.001). OSA surgery outcomes were analyzed at the national level, with complications shown to depend on AP levels, male gender, extreme BMI, and diabetes mellitus. While OSA surgery has demonstrated an overall positive safety profile, the implementation of these novel risk-associated variables into the perioperative workflow may further enhance patient care.

Should Mandibular Symphyseal Distraction Osteogenesis be considered in OSA Surgery?

Surgical maxillary expansion for the treatment of obstructive sleep apnea (OSA) has become common place. To maximize airway improvement, over-expansion of the maxilla can occur, resulting in an excessively widened maxilla that creates a mismatch to the mandible. Therefore, mandibular symphyseal distraction osteogenesis (MSDO) to widen the mandible along with maxillary expansion is being increasingly advocated in OSA surgery. The authors discuss their 20-year experience with MSDO and surgical maxillary expansion. They also analyze the airway impact between Distraction Osteogenesis Maxillary Expansion (DOME) and Endoscopically-Assisted Surgical Expansion (EASE) based on currently available computational fluid dynamic (CFD) data, which has implications in whether MSDO needs to be considered. The goal of surgical maxillary expansion is to enlarge the nasal cavity and reduce the airway resistance. CFD data demonstrates that EASE results in a much greater reduction in airway resistance as compared to DOME. EASE achieved a 12-fold reduction in nasal airway resistance compared to 3-fold reduction by DOME; a 12-fold reduction of retropalatal airway resistance as compared to 3-fold reduction by DOME; a 10-fold reduction of oropharyngeal airway resistance as compared to a 3-fold reduction by DOME, and an 8-fold reduction of hypopharygeal airway resistance as compared to a 3-fold reduction by DOME. Because there is no physiologic basis or data that demonstrates mandibular widening improves OSA, an airway centric surgical expansion technique such as EASE can achieve a much greater airway impact without needing excessive maxillary widening, thus eliminating the necessity MSDO.

Is drug-induced sleep endoscopy associated with better outcomes after soft tissue surgery for sleep apnea? A systematic review and meta-analysis.

The aim was to estimate the effect of drug-induced sleep endoscopy (DISE) on surgical outcomes after soft tissue surgery for obstructive sleep apnea (OSA). Systematic review and meta-analysis. Adult patients with OSA and candidates for soft tissue surgery, with and without preoperative DISE, were included. A systematic literature search of Medline, Web of Science, and Cochrane databases was performed from inception to December 31, 2021. Studies directly comparing patients with and without preoperative DISE were included. Success rate, change in apnea-hypopnea index (AHI), change in minimum SpO2 and change in Epworth Sleepiness Scale (ESS) score were extracted. Random-effect models were used to pool estimates. Seven out of 619 articles were included, representing 791 patients (389 in the DISE group and 402 in the no DISE group). DISE was neither associated with a higher success rate (pooled OR 1.34, 95% CI 0.69-2.59, p=0.39) after soft tissue surgery for OSA, nor a significant change in AHI (-4.69 events/hour, 95% CI -11.10 to 1.72, p=0.15), minimal SpO2 (mean increase of 2.02%, 95% CI -0.26 to 4.29, p=0.08) and ESS (mean difference of 1.29, 95% CI -0.48 to 3.05, p=0.15) when compared to patients without preoperative DISE. Soft tissue surgery does not give better results after DISE compared to when DISE is not performed. However, given the overall low level of evidence of included studies, future well-conducted studies should confirm or overturn these results and clarify the added value of DISE.