Corrective Nasal Surgery after Maxillomandibular Advancement for Obstructive Sleep Apnea: Experience from 379 Cases.

Objective Efficacy of maxillomandibular advancement (MMA) in the treatment of obstructive sleep apnea (OSA) is associated with degree of maxillary advancement. Large maxillary advancement leads to profound changes of the nasolabial region. We present the incidence and indications of post-MMA corrective nasal surgery in a large cohort. Study Design Case series with chart review. Setting University medical center. Subjects and Methods A total of 379 subjects with OSA underwent MMA at Stanford Hospital (surgeons: S.Y.L., R.W.R.) from August 1992 to December 2015. Data were collected on age, sex, American Society of Anesthesiologists score, polysomnography parameters, and history of nasal surgery. Primary outcome parameters were the incidence and indications of post-MMA corrective nasal surgery. Results Of 379 subjects, the surgical success rate was 76.3% based on the change in respiratory disturbance index. Seventy-one subjects (18.7%) underwent corrective nasal surgery after MMA, whereas 48 underwent functional nasal surgery and 23 underwent both functional and aesthetic nasal surgery. Lower oxygen saturation nadir and higher baseline respiratory disturbance index were associated with increased likelihood of post-MMA corrective nasal surgery. Conclusion MMA surgical success is associated with degree of maxillary advancement, which is especially significant in patients with severe OSA. Patients must be counseled on its impact in nasal function and aesthetics. Our series, the largest to date to address this question, suggests that the incidence of post-MMA corrective nasal surgery is at least 18.7%. Prospectively, refinement in MMA techniques is needed to minimize postoperative compromise in nasal form and function.

Sleep surgery tool: A medical checklist to review prior to operating.

OBJECTIVE: The objective of this study was to systematically review the international literature for studies providing a preoperative checklist for medical disorders to be evaluated or treated before performing sleep surgery. If no checklist exists, then studies providing recommendations would be used to develop a checklist de novo. STUDY DESIGN: Systematic review combined with expert opinion. METHODS: Four databases, including PubMed/Medline were searched through August 10, 2016. RESULTS: 453 potentially relevant studies were screened, 32 were downloaded for full review. No study included a preoperative checklist. No study provided guidance for specific medical disorders to evaluate or screen for prior to sleep surgery. Therefore, we reviewed articles in adults that provided recommendations such as: (1) labs to review, (2) non-operative disorders to evaluate and treat, and (3) comorbidities to optimize prior to performing sleep surgery. These articles were utilized in conjunction with expert opinion to develop a preoperative checklist for surgical guidance. CONCLUSION: There are several items to review prior to performing sleep surgery on obstructive sleep apnea patients. This systematic review and expert opinion-based checklist provides over twenty items for reviewing prior to performing sleep surgery to reduce the chance of operating prematurely.

Maxillomandibular Advancement for Treatment of Obstructive Sleep Apnea: A Meta-analysis.

IMPORTANCE: Maxillomandibular advancement (MMA) is an invasive yet effective surgical option for obstructive sleep apnea (OSA) that achieves enlargement of the upper airway by physically expanding the facial skeletal framework. OBJECTIVE: To identify criteria associated with surgical outcomes of MMA using aggregated individual patient data from multiple studies. DATA SOURCES: The Cochrane Library, Scopus, Web of Science, and MEDLINE from June 1, 2014, to March 16, 2015, using the Medical Subject Heading keywords maxillomandibular advancement, orthognathic surgery, maxillary osteotomy, mandibular advancement, sleep apnea, surgical, surgery, sleep apnea syndrome, and obstructive sleep apnea. STUDY SELECTION: Inclusion criteria consisted of studies in all languages of (1) adult patients who underwent MMA as treatment for OSA; (2) report of preoperative and postoperative quantitative outcomes for the apnea-hypopnea index (AHI) and/or respiratory disturbance index (RDI); and (3) report of individual patient data. Studies of patients who underwent adjunctive procedures at the time of MMA (including tonsillectomy, uvulopalatopharyngoplasty, and partial glossectomy) were excluded. DATA EXTRACTION: Three coauthors systematically reviewed the articles and updated the review through March 16, 2015. The PRISMA statement was followed. Data were pooled using a random-effects model and analyzed from July 1, 2014, to September 23, 2015. MAIN OUTCOMES AND MEASURES: The primary outcomes were changes in the AHI and RDI after MMA for each patient. Secondary outcomes included surgical success, defined as the percentage of patients with more than 50% reduction of the AHI to fewer than 20 events/h, and OSA cure, defined as a post-MMA AHI of fewer than 5 events/h. RESULTS: Forty-five studies with individual data from 518 unique patients/interventions were included. Among patients for whom data were available, 197 of 268 (73.5%) had undergone prior surgery for OSA. Mean (SD) postoperative changes in the AHI and RDI after MMA were -47.8 (25.0) and -44.4 (33.0), respectively; mean (SE) reductions of AHI and RDI outcomes were 80.1% (1.8%) and 64.6% (4.0%), respectively; and 512 of 518 patients (98.8%) showed improvement. Significant improvements were also seen in the mean (SD) postoperative oxygen saturation nadir (70.1% [15.6%] to 87.0% [5.2%]; P < .001) and Epworth Sleepiness Scale score (13.5 [5.2] to 3.2 [3.2]; P < .001). Rates of surgical success and cure were 389 (85.5%) and 175 (38.5%), respectively, among 455 patients with AHI data and 44 (64.7%) and 13 (19.1%), respectively, among 68 patients with RDI data. Preoperative AHI of fewer than 60 events/h was the factor most strongly associated with the highest incidence of surgical cure. Nevertheless, patients with a preoperative AHI of more than 60 events/h experienced large and substantial net improvements despite modest surgical cure rates. CONCLUSIONS AND RELEVANCE: Maxillomandibular advancement is an effective treatment for OSA. Most patients with high residual AHI and RDI after other unsuccessful surgical procedures for OSA are likely to benefit from MMA.

Large maxillomandibular advancements for obstructive sleep apnea: An operative technique evolved over 30 years.

OBJECTIVE: Obstructive sleep apnea (OSA) can be a challenging disorder to treat. Maxillomandibular advancements (MMAs) generally have high success rates; however, larger advancements have higher success and cure rates. Our aim is to present and to describe the current technique used by the senior authors, which has been successful for performing large advancements, thereby improving post-operative outcomes. METHODS: The senior authors have developed and modified their maxillomandibular advancement operative techniques significantly over the past 30 years. The current version of the Riley-Powell MMA technique is described in a step-by-step fashion in this article. RESULTS: Initially, as part of the MMAs, patients underwent maxillomandibular fixation with wires, lag screws and harvested split calvarial bone grafts. The current technique utilizes plates, screws, Erich Arch Bars, and suspension wires which are left in place for 5-6 weeks. Guiding elastics are worn for the first week. The MMA technique described in this article has yielded a success rate over 90% for patients with a body mass index (BMI) <40 kg/m(2) and 81% for patients with a BMI ≥40 kg/m(2). CONCLUSION: Large advancements during maxillomandibular advancement surgeries can help improve post-operative obstructive sleep apnea outcomes.

Genome sequencing provides insight into the reproductive biology, nutritional mode and ploidy of the fern pathogen Mixia osmundae.

Mixia osmundae (Basidiomycota, Pucciniomycotina) represents a monotypic class containing an unusual fern pathogen with incompletely understood biology. We sequenced and analyzed the genome of M. osmundae, focusing on genes that may provide some insight into its mode of pathogenicity and reproductive biology. Mixia osmundae has the smallest plant pathogenic basidiomycete genome sequenced to date, at 13.6 Mb, with very few repeats, high gene density, and relatively few significant gene family gains. The genome shows that the yeast state of M. osmundae is haploid and the lack of segregation of mating genes suggests that the spores produced on Osmunda spp. fronds are probably asexual. However, our finding of a complete complement of mating and meiosis genes suggests the capacity to undergo sexual reproduction. Analyses of carbohydrate active enzymes suggest that this fungus is a biotroph with the ability to break down several plant cell wall components. Analyses of publicly available sequence data show that other Mixia members may exist on other plant hosts and with a broader distribution than previously known.

Genome sequence of the button mushroom Agaricus bisporus reveals mechanisms governing adaptation to a humic-rich ecological niche.

Agaricus bisporus is the model fungus for the adaptation, persistence, and growth in the humic-rich leaf-litter environment. Aside from its ecological role, A. bisporus has been an important component of the human diet for over 200 y and worldwide cultivation of the "button mushroom" forms a multibillion dollar industry. We present two A. bisporus genomes, their gene repertoires and transcript profiles on compost and during mushroom formation. The genomes encode a full repertoire of polysaccharide-degrading enzymes similar to that of wood-decayers. Comparative transcriptomics of mycelium grown on defined medium, casing-soil, and compost revealed genes encoding enzymes involved in xylan, cellulose, pectin, and protein degradation are more highly expressed in compost. The striking expansion of heme-thiolate peroxidases and ß-etherases is distinctive from Agaricomycotina wood-decayers and suggests a broad attack on decaying lignin and related metabolites found in humic acid-rich environment. Similarly, up-regulation of these genes together with a lignolytic manganese peroxidase, multiple copper radical oxidases, and cytochrome P450s is consistent with challenges posed by complex humic-rich substrates. The gene repertoire and expression of hydrolytic enzymes in A. bisporus is substantially different from the taxonomically related ectomycorrhizal symbiont Laccaria bicolor. A common promoter motif was also identified in genes very highly expressed in humic-rich substrates. These observations reveal genetic and enzymatic mechanisms governing adaptation to the humic-rich ecological niche formed during plant degradation, further defining the critical role such fungi contribute to soil structure and carbon sequestration in terrestrial ecosystems. Genome sequence will expedite mushroom breeding for improved agronomic characteristics.

Resting energy expenditure in adults with sleep disordered breathing.

OBJECTIVE: To examine the association between sleep disordered breathing severity and resting energy expenditure (REE). DESIGN: Cross-sectional. SETTING: University-based academic medical center. PARTICIPANTS: Two hundred twelve adults with signs or symptoms of sleep disordered breathing underwent medical history, physical examination, level I attended polysomnography, and determination of REE using an indirect calorimeter. MAIN OUTCOME MEASURE: Mean REE. RESULTS: Seventy-one percent (151 of 212) of the study population were male, and the mean (SD) age was 42.3 (12.6) years. The mean (SD) body mass index, calculated as weight in kilograms divided by height in meters squared, was 28.3 (7.3). The mean (SD) apnea-hypopnea index was 25.4 (27.2), and the lowest oxygen saturation during the sleep study was 86.9% (9.5%). The mean (SD) REE was 1763 (417) kcal/d. Analysis of variance and univariate regression analysis showed an association between REE and several measures of sleep disordered breathing severity that persisted after adjustment for age, sex, and self-reported health status in multiple regression analysis. Only REE and the apnea-hypopnea index demonstrated an independent association after additional adjustment for body mass index (or body weight and height separately). This association did not differ between individuals with normal vs elevated body mass index. CONCLUSIONS: Sleep disordered breathing severity is associated with REE. Although this association is largely confounded by body weight, there is an independent association with the apnea-hypopnea index.

Facial skeletal surgery in the management of adult obstructive sleep apnea syndrome.

Obstructive sleep apnea (OSA) remains a significant public health problem because of its neurocognitive sequelae. Additionally, with persistent obstruction, it has an impact on the cardiovascular system, leading to hypertension and cardiac failure as one of its causative or comorbid factors. For the surgeon managing OSA, there is a stepwise sequence of surgical procedures, from improving nasal airflow to facial skeletal maxillary-mandibular advancement, with the cumulative goal of volumetrically increasing the retropharyngeal airway space. Familiarity with conventional orthognathic principles is essential in achieving this goal.

Sleepy driver near-misses may predict accident risks.

STUDY OBJECTIVES: To quantify the prevalence of self-reported near-miss sleepy driving accidents and their association with self-reported actual driving accidents. DESIGN: A prospective cross-sectional internet-linked survey on driving behaviors. SETTING: Dateline NBC News website. RESULTS: Results are given on 35,217 (88% of sample) individuals with a mean age of 37.2 +/- 13 years, 54.8% women, and 87% white. The risk of at least one accident increased monotonically from 23.2% if there were no near-miss sleepy accidents to 44.5% if there were > or = 4 near-miss sleepy accidents (P < 0.0001). After covariate adjustments, subjects who reported at least one near-miss sleepy accident were 1.13 (95% CI, 1.10 to 1.16) times as likely to have reported at least one actual accident as subjects reporting no near-miss sleepy accidents (P < 0.0001). The odds of reporting at least one actual accident in those reporting > or = 4 near-miss sleepy accidents as compared to those reporting no near-miss sleepy accidents was 1.87 (95% CI, 1.64 to 2.14). Furthermore, after adjustments, the summary Epworth Sleepiness Scale (ESS) score had an independent association with having a near-miss or actual accident. An increase of 1 unit of ESS was associated with a covariate adjusted 4.4% increase of having at least one accident (P < 0.0001). CONCLUSION: A statistically significant dose-response was seen between the numbers of self-reported sleepy near-miss accidents and an actual accident. These findings suggest that sleepy near-misses may be dangerous precursors to an actual accident.

Incidence of complications in radiofrequency treatment of the upper airway.

OBJECTIVES: To investigate the incidence of complications after temperature-controlled radiofrequency (TCRF) treatment of the inferior turbinates, palate, and tongue. To compare these complication rates with those reported in the literature. STUDY DESIGN: Prospective, observational study. METHODS: All patients treated with TCRF to the inferior turbinates, palate, and tongues during a 12-month period were included. Data were collected for parameters of energy delivery and the development of complications. RESULTS: One hundred thirty-six patients were treated with a total of 470 TCRF lesions. The overall incidence of minor complications was 1.2% (6/470 lesions); there were no complications of moderate or major severity. CONCLUSION: The incidence of minor complications after TCRF in this series was low, and there were no complications of greater severity. These findings are in stark contrast with some previously published papers with higher complication rates. These significantly higher rates may be caused by a marked learning curve, problems in patient selection and the technique of application, excessive energy delivery, and perioperative management.

An adjunctive method of radiofrequency volumetric tissue reduction of the tongue for OSAS.

OBJECTIVES: Temperature-controlled radiofrequency volumetric reduction (TCRF), a minimally invasive procedure, has been used to treat tongue base obstruction in Obstructive Sleep Apnea Syndrome (OSAS). An adjunctive method was objectively evaluated. METHOD: A prospective, nonrandomized clinical study was undertaken on 20 consecutive OSAS patients with isolated tongue base obstruction. Under local anesthesia, multiple lesions of the ventral tongue (genioglossus insertion) and dorsal tongue were given at each treatment session. A visual analog scale was used to assess changes in speech and swallowing. Polysomnography and Epworth Sleepiness Scale (ESS) were used to assess outcome. Patients were maintained on nasal continuous positive airway pressure after each treatment. RESULTS: Patients received a mean 4.6 +/- 0.6 treatments for a mean total of 7915 +/- 1152 joules. There was no significant change in speech or swallowing at 3 months after completion of treatment. Patients reported a significant decrease in sleepiness with a mean change in ESS from 12.4 +/- 2.9 to 7.3 +/- 3.0 (P < 0.001). Mean apnea/hypopnea index decreased from 35.1 +/- 18.1 to 15.1 +/- 17.4 (P < 0.001). Transient mild to moderate pain and swelling occurred after each treatment. There were no significant complications (ulceration, paresthesia, infection). CONCLUSION: TCRF can successfully treat the OSAS patient with tongue base obstruction. Combined treatment of the ventral (genioglossus insertion) and dorsal tongue appears safe and may improve outcome with less total energy when compared with traditional dorsal-only applications.

Temperature-controlled radiofrequency tongue base reduction for sleep-disordered breathing: Long-term outcomes.

OBJECTIVE: Our goal was to evaluate the long-term outcomes of temperature-controlled radiofrequency reduction of the tongue base in sleep-disordered breathing. METHODS: The 18 patients from our initial pilot study were reevaluated. Clinical examinations, polysomnography (PSG), questionnaires, visual analog scales, and a comparative SF-36 were used to assess long-term outcomes. RESULTS: Sixteen of the original 18 patients completed this study; 2 patients were lost to follow-up. The mean follow-up was 28 months. There was a mean weight increase of 3.1 +/- 7.9 kg. The original pretreatment Respiratory Disturbance Index (RDI) was a mean of 39.5 with a mean mean oxygen saturation nadir (LSAT) of 81.9%, and the posttreatment RDI was a mean of 17.8 with a mean LSAT of 88.3%. Follow-up PSG data showed a persistent improvement of the mean Apnea Index compared with pretreatment (5.4 vs 22.1) without significant changes compared with posttreatment (4.1). However, there were changes in the follow-up Hypopnea Index (HI) of 22.9 compared with the pretreatment and posttreatment HI values of 17.4 and 13.6, respectively. This resulted in a relapse of the RDI from a posttreatment value of 17.8 to 28.7. The LSAT also worsened from 88.3% to 85.8%. However, there was no significant deterioration in the quality-of-life measurements by SF-36 or in daytime sleepiness by Epworth Sleepiness Scale. CONCLUSION: The success of temperature-controlled radiofrequency tongue base reduction for sleep-disordered breathing may reduce with time. PSG demonstrated that long-term relapse is primarily reflected in the HI without significant detrimental effects on the patient's quality of life (SF-36) and sleepiness (Epworth Sleepiness Scale). Continual evaluation of this treatment modality is warranted.

Obstructive sleep apnea and maxillomandibular advancement: an assessment of airway changes using radiographic and nasopharyngoscopic examinations.

PURPOSE: The study aim was to evaluate the resultant changes in the upper airway after maxillomandibular advancement (MMA) for obstructive sleep apnea. METHODS: Twelve patients were evaluated before and after MMA using fiberoptic nasopharyngoscopy (NPG) with Müller maneuver. An inspiratory force meter was used to ensure the consistency of the inspiratory efforts between the 2 examinations. Preoperative and postoperative lateral cephalometric radiographs were also compared. RESULTS: Decrease in the airway obstruction was shown by the lateral cephalometric radiograph as well as by fiberoptic NPG during passive respiration. Fiberoptic NPG with Müller maneuver also revealed a decrease in airway collapsibility. Although the retrodisplacement of the tongue base was improved, the improvement in lateral pharyngeal wall stability was the most striking. CONCLUSIONS: MMA achieved expansion of the upper airway. In addition, MMA decreased the collapsibility of the airway, especially the lateral pharyngeal walls. These findings may explain the highly successful outcomes of MMA for the treatment of obstructive sleep apnea.

Sleepy driving: accidents and injury.

OBJECTIVE: The study goals were to evaluate the associated risks of driving and to assess predictors of accidents and injury due to sleepiness. STUDY DESIGN: A cross-sectional Internet-linked survey was designed to elicit data on driving habits, sleepiness, accidents, and injuries during the preceding 3 years. Statistical analysis included logistic models with covariate-adjusted P values of <0.01 (odds ratios and 95% confidence intervals or limits). Independent accident predictors were sought. RESULTS: Responses from 10,870 drivers were evaluated. The mean +/- SD age was 36.9 +/- 13 years; 61% were women and 85% were white. The Epworth Sleepiness Scale overall baseline score was 7.4 +/- 4.2 (for drivers with no accidents) and ranged to 12.7 +/- 7.2 (for drivers with > or = 4 accidents) (P = < 0.0001). Twenty-three percent of all respondents experienced > or = 1 accident. Among respondents who reported > or = 4 accidents, a strong association existed for the most recent accident to include injury (P < 0.0001). Sleep disorders were reported by 22.5% of all respondents, with a significantly higher prevalence (35%, P = 0.002) for drivers who had been involved in > or = 3 accidents. CONCLUSION: Factors of sleepiness were strongly associated with a greater risk of automobile accidents. Predictors were identified that may contribute to accidents and injury when associated with sleepiness and driving.

Distraction osteogenesis in adult obstructive sleep apnea surgery: a preliminary report.

PURPOSE: This study evaluated the potential application of distraction osteogenesis (DO) for skeletal expansion in the management of adult patients with obstructive sleep apnea syndrome (OSAS). PATIENTS AND METHODS: Five consecutive adult patients (3 male, 2 female) underwent a DO procedure with intraoral distraction devices for the management of OSAS. The surgical procedures were mandibular advancement (n = 4, with 3 bilateral advancement and 1 unilateral advancement) and simultaneous maxillomandibular advancement (n = 1). Starting 7 days after surgery, the distraction devices were activated 4 times daily at a rate of 1.0 mm/d until the desired skeletal expansion was achieved. All of the patients underwent pre- and postoperative radiographic analysis and polysomnography. The distraction devices were removed 3 months after the completion of the distraction process. RESULTS: The amount of skeletal advancement by distraction ranged from 5.5 to 12.5 mm, with the mean distance being 8.1 mm. The postoperative polysomnographic results showed improvement of OSAS in all 5 patients with an improvement of the mean RDI from 49.3 events per hour to 6.6 events per hour. The lowest oxygen saturation improved from 79.8% to 85.8%. The mean follow-up period was 12 months. Complications included localized inflammation at the distraction device site (n = 2), temporary temporomandibular joint (TMJ) discomfort during distraction process (n = 1), and temporary paresthesia of the inferior alveolar nerve distribution (n = 2). A moderate amount of pain during the activation of the distraction devices was reported (n = 3) and was adequately treated with analgesics. None of the complications led to permanent problems. CONCLUSION: This limited case series shows that DO is applicable in selected adult patients for skeletal advancement in the treatment of OSAS. However, there are disadvantages with the use of DO, and further investigations are necessary to determine the potential of this technique.

Long-Term Results of Maxillomandibular Advancement Surgery.

Surgery is a major modality in the treatment of obstructive sleep apnea syndrome (OSAS), and maxillomandibular advancement (MMA) has been shown to be the most effective surgical option. However, despite the successful short-term (6-9 months) results reported by various investigators, little is known of the long-term clinical outcomes. A review of our long-term clinical results demonstrated that MMA achieves long-term cure in most patients. Aging and minor weight gain did not appear to have a significant adverse effect on the long-term results; however, major weight gain did seem to have a significant negative impact on the long-term outcomes. Therefore, long-term follow-up with proper counseling on weight maintenance or reduction is essential in improving long-term results.