Guidelines of the French Society of ENT (SFORL): Drug-induced sleep endoscopy in adult obstructive sleep apnea syndrome.

OBJECTIVES: To determine the indications, anesthesiological and surgical procedure and interest of drug-induced sleep endoscopy in the treatment of adult obstructive sleep apnea syndrome. DESIGN: A redactional committee of 17 experts was set up. Conflicts of interest were disclosed and followed up throughout the process of drawing up the guidelines. The work received no funding from any firm dealing in health products (drugs or devices). The GRADE (Grading of Recommendations Assessment, Development and Evaluation) method was applied to assess the quality of the data on which the guidelines were founded. It was stressed that strong recommendations should not be made on the basis of poor-quality or insufficient data. METHODS: The committee studied 29 questions on 5 topics: indications and contraindications, anesthetic technique, surgical technique, interpretation and reporting of results, and management guided by results. RESULTS: Expert review and application of the GRADE method led to 30 guidelines: 10 with high level of evidence (Grade 1+ or 1-), 19 with low level (GRADE 2+ or 2-) and 1 expert opinion. CONCLUSION: Experts fully agreed on the strong guidelines formalizing the indications and modalities of drug-induced sleep endoscopy for adult obstructive sleep apnea syndrome.

OSAS and upper pharynx surgery: Does basilingual collapsus always rhyme with failure?

OBJECTIVE: Drug-induced-sedation endoscopy (DISE) has proved superior to awake clinical examination for diagnosis of upper-airway obstruction sites and surgical planning. Our question is: does multilevel obstruction on DISE systematically entail failure for surgery limited to the upper pharynx? MATERIAL & METHODS: We conducted a retrospective single-center study in patients with obstructive sleep apnea syndrome (OSAS) treated by single-level surgery of the upper pharynx (tonsillectomy with or without pharyngoplasty). Preoperative assessment included polysomnography (PSG) and DISE. Surgical efficacy was assessed on postoperative PSG. Treatment response was defined by postoperative apnea-hypopnea index (AHI) <20 events/h with 50% reduction, and cure by AHI <10 (patients with preoperative AHI ≤10 being excluded). Efficacy was compared between groups without (group A) and with basilingual or laryngeal collapsus on DISE (group B). RESULTS: We analyzed 63 patients, with mean preoperative AHI 33.8±17.9 events/h. The two groups (A, n=36; B, n=27) were clinically comparable. Postoperative PSG took place at a mean 8.5 ± 11.5 months. The success rate was 66.7% in group A (mean reduction in AHI, 57.3±36.2%) and 59.3% in group B (mean reduction, 53.9±39.2%). Cure rates were respectively 48.5% and 48.1%. There was no statistically significant difference between the two groups (P>0.1). CONCLUSIONS: Oropharyngeal surgery can alleviate associated obstructive sites found on DISE in the lower pharynx, and step-by-step treatment shows efficacy equal to that of single-step multilevel surgery.

Effect of sleeping alone on sleep quality in female bed partners of snorers.

The aim of the present study was to objectively measure the effect of sleeping alone for one night on sleep quality in female bed partners of male snorers. Females complaining of poor sleep due to snoring by their bed partner and having no known hearing loss or snoring were included in a prospective multicentre cross-sectional study. 23 females underwent one polysomnography recording while sleeping with their bed partner and another while sleeping alone. Their sleep parameters were compared between the two nights. We excluded seven couples because the female partner snored for >10% of the sleep time (n = 6) or had obstructive sleep apnoea syndrome (n = 1). In the remaining 16 females, sleep time, sleep efficiency, arousal index and percentages of deep sleep (stages 3-4) and rapid eye movement (REM) sleep were not significantly different between the two nights. Percentages of light sleep (non-REM stage 2) and awakening index were lower when sleeping alone (p = 0.023 and p = 0.046, respectively). Sleep quality was decreased and sleep fragmentation increased in females sleeping with male snorers. Some females had unrecognised snoring. However, our data do not suggest that objective sleep quality improves substantially in the female nonsnoring partner when she sleeps alone for one night.

Tongue weakness is associated with respiratory failure in patients with severe Guillain-Barré syndrome.

OBJECTIVE: Swallowing impairment may worsen respiratory weakness and conduct to respiratory complications such as aspiration pneumonia in Guillain-Barré syndrome (GBS). We prospectively evaluate how tongue weakness could be associated to bulbar dysfunction and respiratory weakness in severe GBS patients. MEASUREMENTS AND MAIN RESULTS: Tongue strength, dysphagia and respiratory parameters were measured in 16 GBS patients at intensive care unit (ICU) admission and discharge and in seven controls. Tongue strength was decreased in the GBS patients compared with the controls. At admission, patients with dysphagia and those requiring mechanical ventilation (MV) had greater tongue weakness. All the patients with initial tongue strength <150 g required MV during ICU stay. Tongue strength correlated significantly with respiratory parameters. CONCLUSION: This study confirms the strong association between bulbar and respiratory dysfunction in GBS admitted to ICU. Tongue weakness may be present in GBS, especially during the phase of increasing paralysis, and resolves during the recovery phase. Tongue strength and indices of global and respiratory strength vary in parallel throughout the course of GBS. Further studies are needed to assess if, when used in combination with other respiratory tests, tongue strength measurement could contribute to identify patients at high risk for respiratory complications.

Surgical ablation of lingual tonsils in the treatment of obstructive sleep apnea.

OBJECTIVES/HYPOTHESIS: The retrolingual space is one of the potential sites of obstruction identified in patients with obstructive sleep apnea syndrome (OSAS). Hypertrophied lingual tonsils (LT) can obstruct the airway at this level. The goal of this study was to measure the tolerance and efficacy of lingual tonsillectomy in patients with OSAS. STUDY DESIGN: A retrospective chart review was conducted recruiting all patients with OSAS confirmed on sleep recording, who either had failed or refused medical treatment and who underwent lingual tonsillectomy. MATERIALS AND METHODS: Diagnosis of LT hypertrophy was made by full ENT clinical examination using a flexible endoscopy, completed by MRI and followed by drug-induced sleep endoscopy. The surgical intervention was carried out endoscopically by diode laser or coblation. The primary endpoint to measure efficacy was drop in apnea-hypopnea index (AHI) on sleep recording at 6 months. Secondary endpoints comprised reduced snoring and Epworth Sleepiness Scale (ESS) and postoperative symptom tolerance. RESULTS: Eleven patients aged 44.3±12.6 years were included. AHI dropped from 29.5±21.7/h to 11.6±9.6/h: i.e., by 60% (P=0.005). Five patients had AHI<10/h: i.e., cure rate of 45%. ESS dropped from 13±3.4 to 8.1±4.9 (P=0.012). No complications were observed. CONCLUSIONS: LT ablation seemed effective in OSAS with retrolingual obstruction in failure of medical treatment. LEVEL OF EVIDENCE: 4.

Drug-induced sleep endoscopy: A new gold standard for evaluating OSAS? Part I: Technique.

Surgical results in obstructive sleep apnea syndrome (OSAS) vary greatly, whatever the surgical technique or site treated. Most authors agree that rigorous patient selection is logical and mandatory. Drug-induced sleep endoscopy (DISE) was introduced in 1991 and has been rediscovered and used extensively since the 2000s. It mimics sleep in order to observe the upper airway on flexible endoscopy. A review of the DISE literature was performed, and is reported in two parts. The present first part describes the technique: drugs, practical anesthesiologic and ENT modalities, reproducibility, and limitations.

Drug-induced sleep endoscopy: A new gold standard for evaluating OSAS? Part II: Results.

Surgical results in obstructive sleep apnea syndrome (OSAS) vary greatly, whatever the surgical technique or site. Most authors agree that rigorous patient selection is logical and mandatory. Drug-induced sleep endoscopy (DISE) was introduced in 1991 and has been rediscovered and used extensively since the 2000s. It attempts to mimic natural sleep in order to observe the upper airway on flexible endoscopy in a situation in which obstruction may occur. A review of the DISE literature was performed, and is reported in two parts. The present second part reports DISE results concerning obstruction sites, impact on treatment efficacy and the consequent indications for this exploration.

Radiofrequency volumetric reduction of the tongue. A porcine pilot study for the treatment of obstructive sleep apnea syndrome.

STUDY OBJECTIVE: To investigate, in an animal model, the feasibility of radiofrequency (RF) volumetric tongue reduction for the future purpose of determining its clinical applications in obstructive sleep apnea syndrome (OSAS). DESIGN: The study was performed in three stages, one in vitro bovine stage and two in vivo porcine stages. The last stage was a prospective investigation with histologic and volumetric analyses to establish outcomes. SETTING: Laboratory and operating room of veterinary research center. PARTICIPANTS: A homogeneous population of porcine animal models, including seven in stage 2 and 12 in stage 3. INTERVENTION: RF energy was delivered by a custom-fabricated needle electrode and RF generator to the tongue tissue of both the in vitro and in vivo models. MEASUREMENTS AND RESULTS: Microultransonic crystals were used to measure three-dimensional changes (volumetric reduction). Lesion size correlated well with increasing RF energy delivery (Sperman correlation coefficient of 0.986; p = 0.0003). Histologic assessments done serially over time (1 h through 3 weeks) showed a well-circumscribed lesion with a normal healing progression and no peripheral damage to nerves. Volumetric analysis documented a very mild initial edematous response that promptly tapered at 24 h. At 10 days after RF, a 26.3% volume reduction was documented at the treatment site (circumscribed by the microultrasonic crystals). CONCLUSION: RF, in a porcine animal model, can safely reduce tongue volume in a precise and controlled manner. Further studies will validate the use of RF in the treatment of OSAS.

Radiofrequency volumetric tissue reduction of the palate in subjects with sleep-disordered breathing.

STUDY OBJECTIVES: To evaluate pain, swallowing, speech, edematous response, tissue shrinkage, sleep, snoring, and safety (energy limits and adverse effects) following radiofrequency (RF) treatment to the palate in 22 subjects with sleep-disordered breathing. DESIGN: This investigation is a prospective nonrandomized study. Polysomnography, radiographic imaging, and infrared thermography, along with questionnaires and visual analog scales, were used to evaluate the effects of RF treatment to the palate. SETTING: Treatments were delivered on an outpatient basis at Stanford University Medical Center. PATIENTS: Twenty-two healthy patients (18 men), with a mean age of 45.3+/-9.1 years, were enrolled. All were snorers seeking treatment and met predetermined criteria: a respiratory disturbance index < or = 15, oxygen saturation > or = 85%, and a complaint of daytime sleepiness. INTERVENTION: RF was delivered to the submucosa of the palate with a custom-fabricated electrode for a mean duration of 141+/-30 s with a mean of 3.6+/-1.2 treatments per patient. Reduction of their snoring scores determined the end point of the study. RESULTS: Neither speech nor swallowing was adversely affected. Pain was of short duration (0 to 48 h) and was controlled with acetaminophen. There were no infections. Although there was documented edema at 24 to 48 h, there were no clinical airway compromises. Polysomnographic data showed improvement in esophageal pressure measurements of the mean nadir and the 95th percentile nadir (p=0.031, p=0.001) respectively, as well as the mean sleep efficiency index (p=0.002). Radiographic imaging showed a mean shrinkage of 5.5+/-3.7 mm (p< or =0.0001). Subjective snoring scores fell by a mean of 77% (8.3+/-1.8 to 1.9+/-1.7, p=0.0001) accompanied by improved mean Epworth sleepiness scores (8.5+/-4.4 to 5.2+/-3.3, p=0.0001). CONCLUSION: The results of this investigation allowed the formulation of safety parameters for RF in this defined population with mild sleep-disordered breathing. There was a documented tissue reduction and improvement in symptoms in all subjects. However, given the small sample size and short-term follow-up, these results should be confirmed by further investigation.

Tongue base reduction with hyoepiglottoplasty: a treatment for severe obstructive sleep apnea.

OBJECTIVE: To describe a surgical procedure for the treatment of severe obstructive sleep apnea syndrome (OSAS), the procedure's indications, and its results. STUDY DESIGN: A retrospective study of 10 male patients with OSAS treated by tongue base reduction with hyoepiglottoplasty (TBRHE) at the Foch Hospital (Suresnes, France) between 1994 and 1997. Patients had a mean body mass index (BMI) of 32 kg/m2, a mean respiratory disturbance index (RDI) of 70 events/h, and a mean minimal oxygen saturation of 78%. They had refused positive airway pressure therapy or wished to discontinue it. METHODS: Subtotal tongue base reduction preceded by lingual neurovascular bundle identification and derouting, epiglottal verticalization, mouth floor horizontalization, and hyoid bone repositioning was performed, associated in some cases to uvulopalatopharyngoplasty (UPPP). Indications were based on a site-related obstruction, on the absence of craniofacial deficiencies, and on the presence of hyolingual abnormalities determined by cephalometry and magnetic resonance imaging. RESULTS: TBRHE associated to UPPP in most cases had an 80% success rate, based on a postoperative RDI below 20 events/h and a reduction of the preoperative RDI of more than 50%. Snoring and excessive daytime sleepiness decreased or disappeared, respectively, in 100% and 90% of the cases. No neurovascular complications occurred. CONCLUSION: TBRHE is a safe procedure for the neurovascular bundle. Associated to a pharyngotomy, it is an effective treatment for severe OSAS attributable to tongue base obstruction. These results require confirmation in a larger series of patients.

Radiofrequency is a safe and effective treatment of turbinate hypertrophy.

OBJECTIVE: To evaluate the safety and efficacy of radiofrequency for reduction of inferior turbinate volume. STUDY DESIGN: Prospective before-and-after trial. METHODS: Fourteen patients complaining of chronic nasal obstruction and failing to respond to medical treatment were prospectively enrolled. All patients presented with inferior turbinate hypertrophy and no septal deformity. Radiofrequency inferior turbinate tissue reduction with three punctures in each turbinate (mean energy/puncture: 342 +/- 36 J, mean duration: 69 +/- 17 s, plateau tissue temperature: 75 +/- 6.4 degrees C). Patients were evaluated before and on days 3, 7, and 60 after intervention. RESULTS: No postoperative pain or complications were reported. Evaluation of nasal obstruction, quantified by visual analogue scale, showed a significant decrease of day time and nighttime obstruction after surgery. Acoustic rhinometry measurements showed that turbinate hypertrophy was significantly reduced in the sitting and supine positions on day 60 after surgery. Saccharin transit times decreased significantly on day 60 compared with preoperative measurements. Ciliary beat frequency, measured in vitro in nasal epithelial cells sampled from the inferior turbinate by brushing, was not significantly different before surgery and on day 60 after surgery. In the same samples, ciliated cells were the most abundant epithelial cell type before and after surgery, although in five cases, moderate numbers of squamous cells were detected on either day 7 or day 60 after surgery. CONCLUSION: Radiofrequency is a safe surgical procedure capable of reducing turbinate volume without altering the nasal mucosa, and causing minimal discomfort for the patient.

A comparative model: reaction time performance in sleep-disordered breathing versus alcohol-impaired controls.

OBJECTIVES/HYPOTHESIS: Patients with sleep-disordered breathing have reaction time deficits that may lead to catastrophic accidents and loss of life. Although safety guidelines do not exist for unsafe levels of sleepiness, they have been established for unsafe levels of alcohol consumption. Since reaction time performance is altered in both, we prospectively used seven measures of reaction time performance as a comparative model in alcohol-challenged normal subjects with corresponding measures in subjects with sleep-disordered breathing. STUDY DESIGN: Institutional Review Board-approved, nonrandomized prospective controlled study. METHODS: Eighty healthy volunteers (29.1+/-7.5 y of age, 56.3% female subjects) performed four reaction time trials using a psychomotor test at baseline and at three subsequent rising alcohol-influenced time points. The same test without alcohol was given to 113 subjects (47.2+/-10.8 y of age, 19.3% female subjects) with mild to moderate sleep-disordered breathing. RESULTS: Mean blood alcohol concentrations (BACs) in the alcohol-influenced subjects at baseline and three trials were 0, 0.057, 0.080, and 0.083 g/dL. The sleep-disordered subjects had mean respiratory disturbance indices of 29.2 events per hour of sleep. On all seven reaction time measures, their performance was worse than that of the alcohol subjects when BACs were 0.057 g/dL. For three of the measures, the sleep-disordered subjects performed as poorly as or worse than the alcohol subjects when alcohol levels were 0.080 g/dL. These results could not be explained by sex or age differences. CONCLUSION: The data demonstrate that sleep-disordered subjects in this study (with a mean age of 47 y) with mild to moderate sleep-disordered breathing had worse test reaction time performance parameters than healthy, nonsleepy subjects (with a mean age of 29 y) whose BAC is illegally high for driving a commercial motor vehicle in California. This comparative model points out the potential risks of daytime sleepiness in those with sleep-disordered breathing relative to a culturally accepted standard of impairment.

[Dilator muscles of the pharynx and their implication in the sleep apnea syndrome of obstructive type. Review of the literature]. / Les muscles dilatateurs du pharynx et leur implication dans le syndrome d'apnée du sommeil de type obstructif. Revue de la littérature.

Pathophysiology of the obstructive sleep apnea syndrome shows three components: intra and peripharyngeal obstacles, excessive pharyngeal wall compliance and upper airway dilator muscle dysfunction. The intent of this paper is to provide an overview of the anatomy, histology, physiology and pathophysiology of the upper airway dilator muscles based on previously published articles. The upper airway dilator muscles can be separated in three different systems, main and accessory dilators, local and regional. They act in synergy. Their contraction occurs at the beginning of inspiration, thus maintaining opened the pharyngeal lumen through inspiration. Their action is modulated by several chemo or physical stimuli. In some apneic patients, these muscles demonstrate a dysfunction: hyperactivity during wakefulness, electromyogram wave amplitude reduced, delayed contraction during sleep and abnormal response to stimuli. This dysfunction might be due to neuromuscular histological abnormalities, a "fatigue" phenomenon or a central nervous command abnormality. Current explorations underlining an upper airway dilator muscle dysfunction will enable practitioners to decide which treatment is best and understand therapeutical failures; it will also help develop new therapeutical techniques such as functional electrical stimulation of the hypoglossal nerve/upper airway dilator muscles.

[Treatment of snoring with controlled temperature radiofrequency: short- and mid-term tolerance and efficacy]. / Le traitement du ronflement par radiofréquence avec contrôle thermique (Somnoplasty): tolérance et efficacité à court et moyen terme.

UNLABELLED: Uvulopalatopharyngoplasty and laser pharyngotomy can provide effective and definitive cure of snoring. These methods are however very painful. The ideal treatment would be not only effective but also pain free. MATERIAL AND METHODS: We assessed prospectively the efficacy and tolerance to temperature controlled radiofrequency (somnoplasty). This technique was applied to the velar palate in 15 snoring patients. Self assessment was used to evaluate outcome. The patients daily recorded: uneasiness, pain, drug use, and food intake. Their spouse scored snoring for 6 to 8 weeks after the end of treatment and more than 6 months after the last treatment session. RESULTS: We achieved 80% success after 2.1 sessions. Pain was minimal. A sensation of uneasiness was frequent and led to minimal drug use. After a mean 13 months, half of the patients experienced a recurrence or an aggravation of their snoring level. Overall satisfaction rate was 69%. CONCLUSION: These preliminary results suggest that radiofrequency is well tolerated and effective in the short- and mid-term for the treatment of snoring.

[Tongue base reduction with hyoid-epiglottoplasty. A surgical alternative in severe sleep apnea syndromes]. / Basiglossectomie avec hyo-épiglottoplastie. Une alternative chirurgicale pour les syndromes d'apnées du sommeil sévères.

We present preliminary results and indications of tongue base reduction with hyo-epiglottoplasty for the treatment of severe obstructive sleep apnea syndrome (OSAS) due to isolated hyolingual abnormalities. The procedure consists in a subtotal resection of the tongue base after identification and derouting of the lingual neurovascular bundle. Hypopharyngeal enlargement, epiglottis verticalization, floor of the mouth tension and hyoid bone repositioning are also performed during the procedure. 14 severe OSAS male patients (mean apnea-hypopnea index of 71) were treated in our institution from November 1992 to February 1996. Indications were determined after a cephalometric analysis and a magnetic resonance imaging evaluation. Results were evaluated on clinical and polysomnographic criteria. No neurovascular complications occurred. Clinical results were excellent but success rate based on polysomnography was 50%. These preliminary results led us to change some of the steps in the technique. We also identified a predictive factor of success on the cephalometrics: an oropharyngeal area greater than 25 cm2.

Radiofrequency of the soft palate for sleep-disordered breathing: a 6-year follow-up study.

OBJECTIVE: To determine the long-term (>3 years) outcome of patients suffering from simple snoring or non-severe obstructive sleep apnea syndrome (OSAS) treated by radiofrequency ablation of the soft palate. STUDY DESIGN: Observational retrospective study. SETTING: Tertiary care university hospital. SUBJECTS AND METHODS: Seventy-seven subjects were included between 1999 and 2006. Twenty-seven suffered from mild or moderate OSAS. All patients were treated by radiofrequency-assisted stiffening of the soft palate, with or without uvulectomy. Snoring (assessed on a 10 cm visual analog scale (VAS)), marital status, presence of cardiovascular risk factors or pathologies and follow-up time were evaluated by postal questionnaire. RESULTS: Mean follow-up time was 6.3 ± 2.3 years. Mean snoring intensity decreased significantly in the immediate postoperative period (8.1 ± 2.9 to 3.5 ± 2.2 cm on VAS). Over the longer term, however, we observed a significant increase in snoring intensity (5.7 ± 2.9 cm), which nevertheless remained below the preoperative values (P<0.001). Bed-partners noticed a relapse of snoring in 92.7% of cases. Nine percent of couples separated. Hypertension and diabetes were diagnosed during follow-up in 12.1% and 6.6% of the subjects, respectively. A majority of patients failed to undergo repeat polysomnography or further treatment. CONCLUSION: Relapse of snoring was observed in nearly all patients in the long run, although intensity appears to remain lower than preoperatively. Most patients did not comply with the follow-up instructions and did not seek other forms of treatment when recurrence occurred.

[Glaucoma and sleep apnea syndrome]. / Glaucomes et syndrome d'apnées du sommeil.

Glaucomatous optic neuropathy is multifactorial, with currently one known and modifiable risk factor, with good results on the prognosis and intraocular pressure. Nevertheless, some patients may experience progression of their neuropathy even though their intraocular pressure seems appropriately controlled. Vascular risk factors are hypothesized and researched. Obstructive sleep apnea syndrome (OSAS) could be considered one of these risk factors. Screening for this cardiovascular risk factor in glaucomatous patients presenting evocative signs, should be proposed.

Writing an article for the European Annals of Otorhinolaryngology, Head and Neck Surgery: rights and responsibilities.

Based on a review of the literature published on medical writing, the authors discuss the rules to respect in terms of both structure and substance to facilitate publication of studies in the European Annals of Otorhinolaryngology, Head and Neck Surgery. The main errors leading to an article's being rejected are detailed and analyzed.

Primary open angle glaucoma and snoring: prevalence of OSAS.

INTRODUCTION: Obstructive sleep apnea syndrome (OSAS) may be suspected at interview, notably in case of snoring. Various studies suggested a link between primary open angle glaucoma (POAG) and OSAS. The present study sought to determine OSAS prevalence in POAG associated with snoring. MATERIAL AND METHODS: Thirty-one snoring glaucomatous patients prospectively underwent simplified polysomnography. Ophthalmologic examination ruled out secondary glaucoma and assessed the glaucomatous neuropathy. RESULTS: 49% of the patients included were diagnosed with OSAS. Ophthalmologically, glaucoma showed no specific characteristics. CONCLUSION: Given the high-prevalence of OSAS in patients with POAG, presence of snoring should be explored at interview. Conversely, patients who snore should be asked whether they have POAG, and if so, should undergo all-night sleep recording to explore for OSAS.