Changing of facial skeleton for treatment of obstructive sleep apnoea syndrome.

Obstructive sleep apnoea syndrome (OSAS) is a potentially life-threatening disorder. It is characterized by at least five episodes of apnoea or hypopnoea during sleep lasting for more than 10 seconds. Apnoea or hypopnoea are accompanied by respiratory efforts. Changes of the facial skeleton by mandibular or maxillo-mandibular advancement belong to surgical techniques which might affect moderate and severe OSAS. In the surgical procedure mandible alone or the upper and lower jaws are moved forward by at least 10 mm. Thus also muscles fixed to the facial skeleton and upper airway dilatators are moved forward. The discussion also mentions possible complications and limitations of this surgical technique.

[Injuries of the upper and middle thirds of the face. Analysis of the cause of injury] ]. / Poranení horní a strední tretiny obliceje. Rozbor prícin poranení.

BACKGROUND: From the point of traumatologist, the size, locality and direction of the injuring force give the extent of the injury of facial skeleton. The aim of the paper is to present an overview on aetiology of injuries of the upper and medial third of face in relation with the incidence, gender and age of patients. METHODS AND RESULTS: 282 adult patients (208 males and 74 females, average age 40 years) and 25 children (18 boys and 7 girls, average age 9 years) were treated since 1.1.1998 till 31.8.1999. 25 of them (9%, 19 males and 6 females) had fracture of the middle third of the face. In 5 patients (20%), fractures were accompanied by commotion of the brain. Conservative treatment was used in 16 patients (64%) and surgical approach in 9 of them (36%). Isolated fractures of nasal bones were diagnosed in 230 adult patients (82%, 168 males, 62 females, 25 children). In 19 adult patients (8%) the fracture was open, in 25 of them the reposition of dislocated bones was done in general anaesthesia. 27 patients (10%, 21 males, 6 females) had polytrauma, accompanied by the facial bones fractures of the upper and middle third. Facial fractures of the upper and middle third were caused by violence of other person (criminal injury) in 15 patients (60%), downfall in 66 patients (29%), sport injury in 38 patients (17%), traffic injury in 16 patients (7%). The most common cause of isolated fracture of nasal bones in children was downfall in 12 patients (48%), violence of other person or schoolmate in 7 patients (28%) sport injury in 5 patients (20%), traffic injury in 1 patient (4%). In 27 persons with polytrauma and facial fractures of the upper and middle third, the injury was caused by traffic accident in 13 patients (48%), downfall in 8 patients (30%), sport injury in 2 patients (7.4%), criminal injury in 2 patients (7.4%), work injury in 1 patients (7.4%). CONCLUSIONS: Polytrauma belongs to the most serious injuries both due to their extent and their significance because in most of them the life of patients is directly threatened. Criminal injuries represent very common cause of the facial fractures of the upper and middle third with maximum prevalence in males of the third decade. Part of those injuries belong to polytrauma.

[Surgical treatment of sleep apnea syndrome in otorhinolaryngology]. / Chirurgická lécba syndromu spánkové apnoe v ORL oblasti.

Sleep apnea syndrome must be exactly confirmed by the standard set or collection of examinations from rhonchopathy. The diagnosis is distinguished and identify by ENT examination, nocturnal recording by polyMESAM or by complete polysomnography. Then is performed neurological and maxillomandibular examination, X-rays pictures (cephalometric data), and CT of pharynx. Part of patient is indicated to undergo surgery. In region of velopharyngeal space we performed classical uvulopalatopharyngoplasty (UPPP), described first time by Fujita 1981 in Detroit [4]. It means, that we take out both tonsils and then remove part of soft palate to enlarging the velopharyngeal space. The findings of retrobasilingual obstruction and obesity are negative predictors for success of UPPP. Narrowing of posterior airway space is indication for the alternative therapy called maxillomandibular advancement. We prefer the surgery by classical method without laser. Adenotomy is performed in children population since residuum of adenoids, and sometimes tonsillectomy should be added for good postoperative results. Part of patient should undergo septoplasty due to local findings of obstruction or another anatomical abnormalities on the level of nasal cavity or nasopharynx. This surgery is very important for this reason of treatment by CPAP.

[The sleep apnea syndrome in hypophyseal disorders with the exception of acromegaly]. / Syndrom spánkové apnoe pri hypofyzárních afekcích s výjimkou akromegalie.

The aim of the study was to ascertain the occurrence of the sleep apnoea syndrome (SAS) in patients after pituitary afunctional adenoma operation or in patients with other affection in sella turcica region except acromegaly patients. Eighty-one patients were addressed. Sixteen patients (eight men, eight women) underwent the examination; the rest of them had no interest to be explored. Afunctional pituitary adenoma was diagnosed in twelve patients, afunctional pituitary adenoma and subsequently optic glioma in one patient, craniopharyngioma in one patient, prolactinoma in one patient and undifferentiated cystic pituitary tumour in one patient. Neurological examination was done in all patients (standardized sleep questionnaire was included). SAS was quantified using PolyMESAM. Severity of SAS were set up from the value of M index (M = ODI.delta saturation; ODI--oxygen desaturation index). Mild SAS: 40 < M < 100; middle SAS: 100 < M < 210; severe SAS: M > 210. SAS was diagnosed in 13 patients: mild SAS in three of them (average value of M index: 81.0 +/- 12.7), moderate SAS in seven patients (average value of M index: 129.0 +/- 18.7) and severe SAS in three patients (average value of M index: 790.0 +/- 563.0). Therapy by continuous positive airway pressure (CPAP) was recommended in six patients. Five of them continue in using of CPAP--four patients with good compliance. The occurrence of SAS was 16.05% in measured group, higher than in normal population.

Prevalence of the sleep apnea syndrome in acromegaly population.

The prevalence of sleep apnea syndrome (SAS) in acromegaly is high. Consequences of SAS are serious and are associated with increased morbidity and mortality. The aim of this study was to assess the relative frequency and predictive factors for SAS in a group of patients with acromegaly (n=55). The presence of SAS was evaluated using the Polymesam device. Hormonal and clinical examination consisted of assessment of growth hormone, insulin-like growth factor I plasma levels, body mass index (BMI), neck circumference, age, sex, treatment modes of acromegaly and ear, nose and throat (ENT) examination. The relative frequency of SAS in our group of patients with acromegaly was 75%. Independent predictors of SAS were: increased activity of acromegaly, higher age and neck circumference. No association between SAS and BMI and ENT findings was observed. The role of gender was controversial.

[Sleep apnea syndrome in acromegaly. Treatment and development-- retrospective analysis]. / Spánkový apnoický syndrom (SAS) u akromegalie. Lécení a vývoj--retrospektivní analýza.

In total 56 subjects with acromegaly (37 men and 19 females) were examined in attempt to find sleep apnoea syndrome (SAS). The examination consisted of clinical examination and of all-night monitoring MESAM4 or polyMESAM. The diagnosis of SAS was established in 76.4% of subjects: 31 men and 11 females, average age 51.8 (SD +/- 9.6) years. The average ODI (oxygen desaturation index--number of oxygen saturation drops per 1 hour of sleep) of SAS patients was 29.2 (+/- 20.7). The therapy of SAS was recommended to 27 patients: sleeping position on the side (3 patients), reduction of the weight (8 patients), change of hypnotic drug (1 patient) and CPAP--continuous positive airway pressure (24 patients). CPAP titration was performed in 18 patients (in one subject the titration was repeated 4 years later). CPAP was titrated within all-night polysomnography in 10 subjects and in 9 subjects using self adjusting CPAP. Primary acceptance of CPAP was 94.4%. The average CPAP pressure was 7.8 (+/- 2.1) mbar. The theoretical duration of CPAP use was 546.6 (+/- 533.7) days. Long term compliance was considered as sufficient (weekly 25 hours or more) in 66.7% of patients. Ten patients underwent important acromegaly therapy or its change during the follow up and the improvement or the disappearance of SAS symptoms occurred in 6 of them.