Does Functional Septorhinoplasty Provide Improvement of the Nasal Passage in Validated Patient-Reported Outcome Measures?

OBJECTIVE: The aim of this study was to determine whether functional septorhinoplasty provides improvement of the nasal passage in validated patient-reported outcome measures (PROMs) for adults with an anatomical obstruction of the nasal valve. All patients with an anatomical obstruction of the nasal valve area due to nasal valve pathology and/or septal deviations in this area were included. METHODS: A systematic PubMed, Embase and Cochrane Library search was performed to identify relevant articles. The articles were critically appraised and ranked according to validity and relevance. RESULTS: Sixteen articles met our inclusion criteria, and after critical appraisal, 10 were eligible for further analysis. In 9 studies, the Nose Obstruction Symptom Evaluation (NOSE) score improved from 35 to 60 points. In 1 study, the Sino-Nasal Outcome Test (SNOT-22) improved 3.5 points. CONCLUSION: The results suggest that there is a significant improvement of the validated PROMs after functional septorhinoplasty in the first postoperative year. We recommend that adults with nasal breathing problems due to an anatomical problem of the nasal valve area should consider undergoing functional septorhinoplasty.

Evaluation of a new simple treatment for positional sleep apnoea patients.

Obstructive sleep apnoea syndrome is a common clinical problem. Positional sleep apnoea syndrome, defined as having a supine apnoea-hypopnoea index of twice or more compared to the apnoea-hypopnoea index in the other positions, occurs in 56% of obstructive sleep apnoea patients. A limited number of studies focus on decreasing the severity of sleep apnoea by influencing sleep position. In these studies an object was strapped to the back (tennis balls, squash balls, special vests), preventing patients from sleeping in the supine position. Frequently, this was not successful due to arousals while turning from one lateral position to the other, thereby disturbing sleep architecture and sleep quality. We developed a new neck-worn device which influences sleep position by offering a vibration when in supine position, without significantly reducing total sleep time. Thirty patients with positional sleep apnoea were included in this study. No side effects were reported. The mean apnoea-hypopnoea index dropped from 27.7 ± 2.4 to 12.8 ± 2.2. Seven patients developed an overall apnoea-hypopnoea index below 5 when using the device in ON modus. We expect that positional therapy with such a device can be applied as a single treatment in many patients with mild to moderate position-dependent obstructive sleep apnoea, while in patients with a more severe obstructive sleep apnoea such a device could be used in combination with other treatment modalities.

Complications of hyoid suspension in the treatment of obstructive sleep apnea syndrome.

The objectives of the study are to assess adverse events and complications of hyoid suspension (HS) as a treatment of obstructive sleep apnea syndrome (OSAS). The study design was cohort. Thirty-nine patients with OSAS and obstruction at tongue base level, as assessed by sleep endoscopy, underwent HS. Information about adverse events and complications were obtained by reviewing charts and patient-completed questionnaires. The mean follow-up period from surgery to last control visit was 13.1 months (range 2-38). The charts demonstrated mainly adverse events. Minor complications occurred in six patients. No major complications were observed. The mean admission duration was 3.3 days (range 2-5). Twenty-six patients (67%) returned their questionnaires. No association was found between completing questionnaires and the success of the intervention (p = 0.73). The questionnaires were completed on average 25.9 months (range 3.5-51.5) after surgery. VAS scores showed a fast decline in complaints regarding taste, speech, swallowing and pain. No significant long-term differences were found, when comparing the postoperative VAS scores with the preoperative VAS scores. Of the 26 evaluable questionnaires, 20 patients (77%) would recommend HS to an acquaintance if they suffered from sleep apnea syndrome, when only taking side effects into consideration. The intention to give a positive recommendation did not seem to be related to the therapeutic success of the intervention. In conclusion, this study demonstrates that the complication rate of HS is low and that the discomfort is very acceptable.

Efficacy of the Epley maneuver for posterior canal BPPV: a long-term, controlled study of 81 patients.

We assessed the efficacy of the Epley maneuver (canalith repositioning) in a study of 81 patients with posterior semicircular canal benign paroxysmal positional vertigo (BPPV). A group of 61 patients underwent the maneuver, while a control group of 20 patients received no therapy. All patients were evaluated at 1 and 6 months. The percentage of patients who experienced subjective improvement was significantly higher in the treatment group at both 1 month (89% vs. 10%) and 6 months (92% vs. 50%). Three patients in the treatment group who did not improve after treatment underwent a second maneuver, and all achieved a positive result. In addition, 4 successfully treated patients experienced a recurrence between 1 and 6 months following treatment; 3 were retreated, and 2 of them responded well. We conclude that the Epley maneuver provides effective and long-term control of symptoms in patients with BPPV.

UPPP combined with radiofrequency thermotherapy of the tongue base for the treatment of obstructive sleep apnea syndrome.

We investigated the outcome of uvulopalatopharyngoplasty (UPPP) combined with radiofrequency thermotherapy of the tongue base (RFTB) in patients with obstructive sleep apnea syndrome (OSAS) with both palatal and retroglossal obstruction, and we compared these results with the results of single level surgery (UPPP). A retrospective cohort study was performed in patients with mild to severe OSAS who underwent UPPP with or without RFTB. Seventy-five patients with both palatal and retroglossal obstruction underwent UPPP, 38 patients without RFTB (group 1) and 37 patients with RFTB (group 2). The outcome of the surgery was measured by both objective success (defined as a reduction of AHI >50% and AHI below 20) and subjective improvement. In group 1 the overall success rate was 42%, and in group 2 49%. Other polysomnographic values (AI, DI, mean SaO2) improved after surgery (not significant). No serious adverse events occurred. Surgical treatment of combined palatal and retroglossal obstruction remains a challenge. Adding RFTB to UPPP results in a mild improvement compared to UPPP alone. Although the addition of RFTB to UPPP seems to result in only a limited improvement, there is no major downside to it. RFTB is well tolerated and safe.

One stage multilevel surgery (uvulopalatopharyngoplasty, hyoid suspension, radiofrequent ablation of the tongue base with/without genioglossus advancement), in obstructive sleep apnea syndrome.

We evaluated the surgical results of a one tempo multilevel surgical approach of the upper airway to treat patients with obstructive sleep apnea syndrome (OSAS) in a prospective case series. Twenty-two patients with OSAS and obstruction at both palatinal and tongue base level, as assessed by sleep endoscopy, underwent UPPP, RFTB, HS with or without GA in one operative session. The mean apnea hypopnea index (AHI) decreased from 48.7 (range 17.4-100.9) to 28.8 (P < 0.0001). The success rate (AHI <20 and >50% reduction in AHI) was 45%, the response rate (reduction in AHI of 20-50%) was 27%. The overall response rate was 72%. The success rates of patients with an AHI <55 and >55 were 56 and 0%, respectively. The overall response rate of patients with an AHI <55 was 78% and >55 was 50%. Improvement of desaturation index was significant from 31.9 to 17.6 (P < 0.0001). Visual analogue scales for snoring and hypersomnolence and the Epworth Sleepiness Scores showed significant improvements too (all P < 0.0001). There was no difference in objective and subjective outcomes between the group with and without GA. This study demonstrates that one stage multilevel surgery, in which genioglossus advancement is not of additional value, is a valuable addition to the therapeutic armentarium and can be considered a viable alternative, objective as well as subjective, to NCPAP or as primary treatment in well selected patients with moderate to severe OSAS with an AHI <55.

Acceptance and long-term compliance of nCPAP in obstructive sleep apnea.

In a retrospective cohort study, we evaluated whether improvements in nasal continuous positive airway pressure (nCPAP) technology, particularly the introduction of automatic adjustment of the nCPAP pressure (auto-CPAP), have led to better acceptance and (long-term) compliance in patients with obstructive sleep apnea syndrome (OSAS) as compared to earlier reported data. Questionnaires were sent to 256 patients, who were referred to our clinic for an overnight polysomnography from January 1997 to July 2005 and received nCPAP therapy for OSAS. Of the 256 patients, 24 patients were unavailable for follow-up. Of the remaining 232 patients, 58 patients (25%) had discontinued therapy, while 174 patients (75%) were still using nCPAP after 2 months to 8 years of follow-up. One Hundred and thirty eight (79%) of these 174 patients used nCPAP for at least 4 h/night during >or= 5 nights/week, 82,1% of the conventional nCPAP (fixed pressure CPAP) group (n = 78) and 77,1% of the auto-CPAP group (n = 96). Therefore, including the 58 failures, only 59.5% of patients can be seen as compliant. There were no statistical differences between the fixed pressure CPAP and auto-CPAP users, and between the compliant and non-compliant users according to age, BMI, AHI and Epworth sleepiness scale (ESS). Auto-CPAP patients used significantly more cm H2O. The long-term compliance of nCPAP therapy has have increased only slightly since the introduction of the fixed pressure CPAP 25 years ago, in spite of many efforts to improve it. It seems that a plateau has been reached and that it is unrealistic to aim at a substantially higher compliance rate.

The role of sleep position in obstructive sleep apnea syndrome.

We analyzed the role of sleep position in obstructive sleep apnea syndrome (OSAS). The polysomnograms of 120 patients with sleep apnea syndrome were analyzed. We associated the apnea hypopnea index (AHI) of the supine position with the AHI of the other positions. Patients were stratified in a group of positional patients (PP) (AHI supine >or= 2 x AHI other positions) and a group of non-positional patients (NPP). In 55.8% of our patients, OSAS was position dependent. PP patients were significantly (6.7 years) younger. BMI and AHI were higher in the NPP group, but the difference was not significant. Level of obstruction in the upper airway (retropalatinal vs retrolingual vs both levels) as assessed by sleep endoscopy was not significantly different between the two groups. Total sleep time (TST) was equal in both groups, but the average time in supine position was 37 min longer in the PP group. This study confirms the finding that in more than 50% of patients, OSAS is position dependent. Apart from age, no patient characteristics were found indicating the position dependency. Overall AHI does not identify positional OSAS.