Rapid maxillary expansion (RME) for pediatric obstructive sleep apnea: a 12-year follow-up.

OBJECTIVE: The objective of this study was to prospectively evaluate the long-term efficacy of rapid maxillary expansion (RME) in a group of children with obstructive sleep apnea (OSA). MATERIAL AND METHOD: Thirty-one children diagnosed with OSA were involved in the study. These children had isolated maxillary narrowing and absence of enlarged adenotonsils at baseline. Twenty-three individuals (73% of the initial group) were followed up annually over a mean of 12 years after the completion of orthodontic treatment at a mean age of 8.68 years. Eight children dropped out over time due to either moving out of the area (n = 6) or refusal to submit to regular follow-up (n = 2). Subjects underwent clinical reevaluation over time and repeat polysomnography (PSG) in the late teenage years or in their early 20s. During the follow-up period, eight children dropped out and 23 individuals (including 10 girls) underwent a final clinical investigation with PSG (mean age of 20.9 years). The final evaluation also included computerized tomographic (CT) imaging that was compared with pre- and post-initial treatment findings. RESULTS: Yearly clinical evaluations, including orthodontic and otolaryngological examinations and questionnaire scores, were consistently normal over time, and PSG findings remained normal at the 12-year follow-up period. The stability and maintenance of the expansion over time was demonstrated by the maxillary base width and the distance of the pterygoid processes measured using CT imaging. CONCLUSION: A subgroup of OSA children with isolated maxillary narrowing initially and followed up into adulthood present stable, long-term results post RME treatment for pediatric OSA.

Assessment of Right Ventricular Function in Obstructive Sleep Apnea Syndrome and Effects of Continuous Positive Airway Pressure Therapy: A Pilot Study.

BACKGROUND: It is known that obstructive sleep apnea syndrome (OSAS) can affect right ventricular (RV) performance even in the absence of systemic hypertension and other known cardiac or obstructive pulmonary disease. The purpose of the present study was to assess RV function in OSAS using 3-D echocardiography and speckle tracking echocardiography (STE) and evaluate changes after continuous positive airway pressure (CPAP) treatment. METHODS: Thirty-seven patients with OSAS without comorbidities and thirty control subjects were studied using 3-D echocardiography and STE. Fifteen patients underwent CPAP therapy and were studied before and after treatment. RV 3-D ejection fraction was calculated. Peak systolic strain was determined. RV dyssynchrony was defined as SD of the 6 time to peak systolic strain values. RESULTS: 3-D RV ejection fraction was lower and RV dyssynchrony was greater in patients with moderate-severe OSAS compared with control subjects in the presence and absence of pulmonary hypertension. 3-D RV ejection fraction and RV dyssynchrony were independently associated with apnea-hypopnea index. Patients treated with CPAP had significant changes in RV parameters. CONCLUSIONS: 3-D RV ejection fraction and RV dyssynchrony were abnormal in OSAS patients compared with control subjects and associated with OSAS severity. RV 3-D STE abnormalities improved after chronic application of CPAP.

Sleep architecture variation in chronic tinnitus patients.

OBJECTIVES: The aim of the study was to evaluate the sleep architecture and its possible alterations in chronic tinnitus patients, and investigate any possible correlation between sleep architecture modifications and tinnitus perception, adaptation, and the degree of discomfort in these patients. DESIGN: In a prospective, case-control, nonrandomized study, 18 patients affected by chronic tinnitus were compared with a homogeneous control group consisting of 15 healthy subjects. The experimental group was enrolled at the Tinnitus ambulatory at Policlinico Umberto I Department of Sensory Organs, and the control group was composed of voluntary subjects. A full overnight polysomnography was performed on both groups. Tinnitus patients answered two questionnaires: the tinnitus handicap inventory (THI) and a questionnaire concerning their subjective sleep quality, tinnitus intensity before bedtime, tinnitus intensity at remembered nocturnal wake-up periods, and tinnitus intensity at morning wake-up. Controls completed only the sleep quality questionnaire. RESULTS: All tinnitus patients had a statistically significant alteration in sleep stages. Average percentage of stage 1 + stage 2 was 85.4% ± 6.3, whereas, in the control group, the average percentage of stage 1 + stage 2 was 54.9 ± 11.2 (p < 0.001). Stages 3 and 4 and rapid eye movement (REM) sleep was lacking in all tinnitus patients with an average percentage of 6.4 ± 4.9 of REM sleep, and 6.4 ± 4.9 of stages 3 + 4. The control group showed an average percentage of 21.5 ± 3.6 of REM sleep and 21.5 ± 3.6 of stages 3 + 4 (p < 0.001). No correlation was found between the decrease of REM and the increase of the THI score in the tinnitus group (r = 0.04). However, a mild correlation was found between the increase of light sleep (stage 1 + stage 2) and the THI score reported by the tinnitus group. Therefore, patients with light sleep report a higher THI score (r = 0.4). CONCLUSIONS: The significant alteration of sleep parameters assessed in tinnitus patients underlines the necessity to consider an adequate therapy that could improve patients' sleep quality and also opens avenues for further investigations.

Association of epicardial fat thickness with the severity of obstructive sleep apnea in obese patients.

BACKGROUND: The correlation between obesity and severity of obstructive sleep apnea (OSA) is controversial. Although fat excess is a predisposing factor for the development of OSA, it has not been determined whether fat distribution rather than obesity per se is associated with OSA severity. Epicardial fat thickness (EFT) is an independent index of visceral adiposity and cardiometabolic risk. We investigated the relation between fat distribution and cardiometabolic risk factors, including EFT and common carotid intima-media thickness (cIMT), with the severity of OSA in obese patients. METHODS: One hundred and fifteen obese patients (56 males, 59 females) with polysomnographic evidence of OSA (≥ 5 apnea/hypopnea events per hour) of various degrees, without significant differences in grade of obesity as defined by body mass index (BMI), were evaluated. The following parameters were measured: BMI, body composition by dual energy X-ray absorptiometry, EFT, right ventricular end-diastolic diameter (RVEDD) and cIMT by ultrasound, and parameters of metabolic syndrome (waist circumference, arterial blood pressure, fasting glucose, HDL-cholesterol and triglycerides). RESULTS: EFT, RVEDD, cIMT and trunk/leg fat mass ratio showed a positive correlation with OSA severity in univariate analysis (r=0.536, p<0.001; r=0.480, p<0.001; r=0.345, p<0.001; r=0.330, p<0.001, respectively). However, multiple linear regression analysis showed that EFT was the most significant independent correlate of the severity of OSA (R(2)=0.376, p=0.022). CONCLUSIONS: The present study suggests that, in obese patients, EFT may be included among the clinical parameters associating with OSA severity. The association of EFT with OSA, both cardiovascular risk factors, is independent of obesity as defined by classical measures.

Left ventricular torsion abnormalities in patients with obstructive sleep apnea syndrome: an early sign of subclinical dysfunction.

BACKGROUND: Previous echocardiographic studies using tissue Doppler imaging (TDI) and speckle tracking imaging (STI) have demonstrated that obstructive sleep apnea syndrome (OSAS) patients may develop subclinical left ventricular (LV) systolic and diastolic dysfunction. Our purpose was to evaluate the impact of OSAS on LV torsion dynamics and aortic stiffness by using TDI and STI echocardiography. METHODS: Forty-two patients with OSAS and no comorbidities were studied. They were classified into mild and severe OSAS according to the apnea-hypopnea index (AHI). Thirty-five healthy subjects were selected as controls. Fifteen patients with severe OSAS underwent chronic nocturnal nasal continuous positive airway pressure (CPAP) therapy. Standard echocardiographic parameters were assessed. Global LV longitudinal strain (LS), radial and circumferential strain were determined by STI. Averaged LV rotation and rotational velocities from the base and apex were obtained and used for calculation of LV torsion (LVtor). Mitral annular velocities and aortic wall velocities and strain (AoS) were also obtained by TDI. RESULTS: Severe OSAS had decreased LS compared with control subjects. LVtor increased significantly in severe OSAS compared to normals (p<.001) as a result of a predominant increase in apical rotation and was independently related to AHI and AoS in a multiple stepwise linear regression model. The group treated with CPAP had a significant decrease in LVtor and aortic stiffness index and significant increase in LS and AoS. CONCLUSIONS: LVtor, LS and AoS were identified as parameters demonstrating an association between LV dysfunction, aortic stiffness and severity of OSAS independently of other possible factors or comorbidities.

Obstructive sleep apnea and bone mineral density in obese patients.

CONTEXT: Obesity and its co-morbidities may adversely affect bone mineral density (BMD). Obstructive sleep apnea (OSA) is a major complication of obesity. To date, the effects of OSA on BMD in obese patients have been poorly studied. OBJECTIVE: To examine whether the severity of OSA independently correlates with BMD in obese patients. METHODS: One hundred and fifteen obese subjects with OSA (Apnea/Hypopnea Index [AHI] ≥5 events per hour) were included in the study. BMD was measured at lumbar spine, total hip, and femoral neck by dual energy X-ray absorptiometry. Body mass index, lean mass, and representative measures of metabolic syndrome (waist circumference, fasting plasma glucose, blood pressure, HDL-cholesterol, triglycerides) and inflammation (ESR, CRP, fibrinogen) were also evaluated. RESULTS: BMD did not differ among obese individuals regardless of OSA severity. Correlation coefficient analysis for all the covariates showed a lack of association between AHI and BMD that was strongly influenced by age and weight. CONCLUSION: Our study does not support an independent association between AHI and BMD in obese patients. Controlled studies involving a greater number of patients are warranted.

Relationships between body fat distribution, epicardial fat and obstructive sleep apnea in obese patients with and without metabolic syndrome.

BACKGROUND: Obstructive sleep apnea (OSA) and metabolic syndrome, both closely related to obesity, often coexist in affected individuals; however, body mass index is not an accurate indicator of body fat and thus is not a good predictor of OSA and other comorbidities. The aim of this study was to investigate whether the occurrence of OSA could be associated with an altered body fat distribution and a more evident cardio metabolic risk independently from obesity and metabolic syndrome. METHODS AND RESULTS: 171 consecutive patients (58 men and 113 women) were included in the study and underwent overnight polysomnography. Anthropometric data, blood pressure, lipid profile, glycaemic parameters were recorded. Body composition by DXA, two-dimensional echocardiography and carotid intima/media thickness measurement were performed. 67 patients (39.2%) had no OSA and 104 (60.8%) had OSA. The percentage of patients with metabolic syndrome was significantly higher among OSA patients (65.4%) that were older, heavier and showed a bigger and fatter heart compared to the control group. Upper body fat deposition index , the ratio between upper body fat (head, arms and trunk fat in kilograms) and lower body fat (legs fat in kilograms), was significantly increased in the OSA patients and significantly related to epicardial fat thickness. In patients with metabolic syndrome, multivariate regression analyses showed that upper body fat deposition index and epicardial fat showed the best association with OSA. CONCLUSION: The occurrence of OSA in obese people is more closely related to cardiac adiposity and to abnormal fat distribution rather than to the absolute amount of adipose tissue. In patients with metabolic syndrome the severity of OSA is associated with increase in left ventricular mass and carotid intima/media thickness.

Orthodontics and obstructive sleep apnea in children.

Children who suffer from respiratory problems and obstructive sleep apnea (OSA) commonly exhibit disturbances of craniofacial morphology. A significant number have nasal obstruction associated with a narrow maxilla; maxillary constriction may increase nasal resistance and alter the tongue posture, leading to narrowing of the retroglossal airway and OSA. Sixty children with a case history of oral breathing, snoring, and night time apneas were studied. An orthognathodontic investigation was performed using radiographs that included not only the usual examinations (posteroanterior cephalographs and intraoral radiographs) but also computed tomographic scans. This article discusses the materials and methods and the results of this study.

Obstructive Sleep Apnoea Syndrome (OSAS) and rhino-tubaric disfunction in children: therapeutic effects of RME therapy.

The aim of the study was to evaluate if RME (Rapid Maxillary Expansion) therapy could improve both the patency of the nasal airways and the Obstructive Sleep Apnoea Syndrome (OSAS). 42 children with a case history of oral breathing, snoring and night time apnoeas were studied. Selection criteria were: no adenotonsillar hypertrophy, Body Mass Index (BMI) below 24 and a malocclusion characterised by a narrow upper jaw, determined by postero-anterior cephalometric evaluation. Patients underwent an ENT visit with auditory and respiratory tests including daytime a sleepiness questionnaire, a 19-channel polysomnography, and an orthognatodontic examination; finally the patient underwent X-rays investigations. All the investigations were carried out before orthodontic therapy (T0), after one month (T1) with the device still on, and 4 months after the end of the orthodontic treatment which lasted for about 6-12 months (T2). All the changes induced by RME on the upper jaw and nasal septum were analysed by postero-anterior cephalometric evaluation in T0, T1 and T2. In all treated cases, the authors obtained an opening of the midpalatal suture; this was confirmed both by intraoral occlusal X-rays and postero-anterior cephalograms. The results reported by the 42 patients studied show that the R.M.E. therapy widens the nasal fossa and releases the septum thus restoring a normal nasal airflow with disappearance of obstructive sleep disordered breathing. Changing the anatomic structure, RME brought a significant functional improvement. Therefore the orthodontist can play an important role in the interdisciplinary treatment of OSAS patients.

Rapid maxillary expansion in children with obstructive sleep apnea syndrome.

OBJECTIVE: To evaluate the effect of rapid maxillary expansion on children with nasal breathing and obstructive sleep apnea syndrome. METHOD: Recruitment of children with maxillary contraction, without of adenoid hypertrophy, with a body mass index < 24 kg/m2, with obstructive sleep apnea syndrome demonstrated by polysomnography, and whose parents signed informed consent. Otolaryngologic and orthognathic-odontologic evaluation with clinical evaluation, anterior rhinometry and nasal fibroscopy, panoramic radiographs, anteroposterior and laterolateral telecephalometry were performed at entry and follow-up. INTERVENTION: Rapid maxillary expansion (ie, active phase of treatment) was performed for 10 to 20 days; maintenance of device (for consolidation) and orthodontic treatment on teeth lasted 6 to 12 months. RESULTS: 31 children (19 boys), mean age 8.7 years, participated in the study. The mean apnea-hypopnea index was 12.2 events per hour. At the 4-month follow-up, the anterior rhinometry was normal, and all children had an apnea-hypopnea index < 1 event per hour. The mean cross-sectional expansion of the maxilla was 4.32 +/- 0.7 mm. There was a mean increase of the pyriform opening of 1.3 +/- 0.3 mm. CONCLUSION: Rapid maxillary expansion may be a useful approach in dealing with abnormal breathing during sleep.