Management of Persistent, Post-adenotonsillectomy Obstructive Sleep Apnea in Children: An Official American Thoracic Society Clinical Practice Guideline.

Background: Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder. Although adenotonsillectomy is first-line management for pediatric OSA, up to 40% of children may have persistent OSA. This document provides an evidence-based clinical practice guideline on the management of children with persistent OSA. The target audience is clinicians, including physicians, dentists, and allied health professionals, caring for children with OSA. Methods: A multidisciplinary international panel of experts was convened to determine key unanswered questions regarding the management of persistent pediatric OSA. We conducted a systematic review of the relevant literature. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to rate the quality of evidence and the strength of the clinical recommendations. The panel members considered the strength of each recommendation and evaluated the benefits and risks of applying the intervention. In formulating the recommendations, the panel considered patient and caregiver values, the cost of care, and feasibility. Results: Recommendations were developed for six management options for persistent OSA. Conclusions: The panel developed recommendations for the management of persistent pediatric OSA based on limited evidence and expert opinion. Important areas for future research were identified for each recommendation.

The new face of war: Craniofacial injuries from Operation Inherent Resolve.

BACKGROUND: During the last 20 years of conflict in the Middle East, improvements in body armor and the use of improvised explosive devices have resulted in an increased incidence of complex craniofacial trauma (CFT). Currently, CFT comprises up to 40% of all casualties. We present new data from the recent conflict in Iraq and Syria during Operation Inherent Resolve. METHODS: Data were collected for patients treated at role 1, role 2, and role 3 facilities in Iraq and Syria over a 1-year period. During this time, a specialized head & neck surgical augmentation team was deployed and colocated with the central role 3 facility. Data included for this cross-sectional study are as follows: injury type and mechanism, triage category, initial managing facility and subsequent levels of care, and procedures performed. RESULTS: Ninety-six patients sustained CFT over the study period. The most common injuries were soft tissue (57%), followed by cranial (44%) and orbital/facial (31%). Associated truncal and/or extremity injuries were seen in 46 patients (48%). There were marked differences in incidence and pattern of injuries between mechanisms (all p < 0.05). While improvised explosive devices had the highest rate of cranial and truncal injuries, gunshot wounds and blunt mechanisms had higher incidences of orbital/facial and neck injuries. Overall, 45% required operative interventions including complex facial reconstruction, craniotomy, and open globe repair. Mortality was 6% with 83% due to associated severe brain injury. Most patients were local nationals (70%) who required discharge or transfer to the local health care system. CONCLUSION: Complex craniofacial trauma is increasingly seen by deployed surgeons, regardless of subspecialty training or location. Deployment of a centrally located head and neck team greatly enhances the capabilities for forward deployed management of CFT, with excellent outcomes for both US and local national patients. LEVEL OF EVIDENCE: Therapeutic/care management; Level V.

Dynamic sleep MRI in obstructive sleep apnea: a systematic review and meta-analysis.

PURPOSE: The objective of this study is to systematically review the international literature for dynamic sleep magnetic resonance imaging (MRI) as a diagnostic tool in obstructive sleep apnea (OSA), to perform meta-analysis on the quantitative data from the review, and to discuss its implications in future research and potential clinical applications. STUDY DESIGN: A comprehensive review of the literature was performed, followed by a detailed analysis of the relevant data that has been published on the topic. METHODS: Clinical key, Uptodate, Ovid, Ebscohost, Pubmed/MEDLINE, Scopus, Dynamed, Web of Science and The Cochrane Library were systematically searched. Once the search was completed, dynamic sleep MRI data were analyzed. RESULTS: Nineteen articles reported on 410 OSA patients and 79 controls that underwent dynamic sleep MRI and were included in this review. For meta-analysis of dynamic sleep MRI data, eight articles presented relevant data on 160 OSA patients. Obstruction was reported as follows: retropalatal (RP) 98%, retroglossal (RG) 41% and hypopharyngeal (HP) in 5%. Lateral pharyngeal wall (LPW) collapse was found in 35/73 (48%) patients. The combinations of RP + RG were observed in 24% and RP + RG + LPW in 16%. If sedation was used, 98% of study participants fell asleep compared to 66% of unsedated participants. CONCLUSIONS: Dynamic sleep MRI has demonstrated that nearly all patients have retropalatal obstruction, retroglossal obstruction is common and hypopharyngeal obstruction is rare. Nearly all patients (98%) who are sedated are able to fall asleep during the MRI. There is significant heterogeneity in the literature and standardization is needed.

Effect of myofunctional therapy on children with obstructive sleep apnea: a meta-analysis.

OBJECTIVE: To systematically review the current literature for articles describing the effect of myofunctional therapy on pediatric obstructive sleep apnea (OSA) and to perform a meta-analysis on the sleep study data. METHODS: Three authors (A.B., K.K. and M.C.) independently searched from inception through April 20, 2020 in PubMed/MEDLINE, Scopus, Embase, Google Scholar and The Cochrane Library. Mean difference (MD), standard deviations and 95% confidence intervals were combined in the meta-analysis for apnea-hypopnea index (AHI), mean oxygen saturations, and lowest oxygen saturations (nadir O2). RESULTS: 10 studies with 241 patients met study criteria and were further analyzed. The AHI reduced from 4.32 (5.2) to 2.48 (4.0) events/hr, a 43% reduction. Random effects modeling demonstrated a mean difference in AHI of -1.54 (95% CI -2.24,-0.85)/hr, z-score is 4.36 (p < 0.0001). Mean oxygen saturation increased by 0.37 (95% CI 0.06,0.69) percent, z-score is 2.32 (p = 0.02). There was no significant increase in nadir O2. CONCLUSIONS: Despite heterogeneity in exercises, myofunctional therapy decreased AHI by 43% in children, and increased mean oxygen saturations in children with mild to moderate OSA and can serve as an adjunct OSA treatment.

Impact of Alcohol Consumption on Snoring and Sleep Apnea: A Systematic Review and Meta-analysis.

OBJECTIVE: To systematically review the international literature for studies evaluating the effect of alcohol consumption on the occurrence and severity of snoring and obstructive sleep apnea and to use the available data to perform a meta-analysis. DATA SOURCES: MEDLINE, Embase, The Cochrane Library, CINAHL/EBASCO, and Scopus. REVIEW METHODS: The protocol was registered in PROSPERO in March 2018. Following PRISMA guidelines, 2 independent researchers conducted a search from their inception through July 2018. Polysomnography (PSG) data were collected for sleep stages, apnea-hypopnea index (AHI), respiratory disturbance index, and/or lowest oxygen saturation (LSAT). Data concerning the frequency and severity of snoring intensity and sleep architecture were also collected. Only studies with PSG data were evaluated, with exclusion of studies with home sleep testing data. A multivariate regression and pooled analysis with forest plot was performed. RESULTS: A total of 1266 manuscripts were screened, and 13 manuscripts with 279 patients met inclusion criteria. Pooled analysis of AHI for control versus alcohol consumption revealed a mean difference (MD) of 3.98 events per hour (95% CI, 3.27 to 4.68; P < .001). Pooled analysis of LSAT for control versus alcohol consumption revealed an MD of -2.72% (95% CI, -3.69 to -1.76; Z score, 5.53; P < .00001). CONCLUSION: Alcohol consumption is associated with worsening severity of snoring, altered sleep architecture, AHI, as well as lowest oxygen saturation among patients susceptible to snoring and obstructive sleep apnea.

Nasal cannula technique for ventilating during the administration of general anesthesia in neonates and pediatric patients.

Objective: Minor surgeries on the oral cavity, e.g., frenulectomies, are often performed under general mask anesthesia. The objective is to present the nasal cannula technique for ventilating step-by-step method for ventilating during general anesthesia for minor surgeries in neonates and pediatric patients. Technique: The nasal cannula technique for ventilating has been used in over 20 pediatric cases (neonates and toddlers), without the need to re-mask during the procedure and without complications or oxygen desaturations. After induction of general mask anesthesia, propofol with or without adjunctive ketamine is administered. The anesthesia mask is exchanged with a nasal cannula, using the largest sized prongs that accommodate the nares, and the nasal cannula is connected to the anesthesia circuit. This permits administration of inspired fractions of oxygen. Conclusion: The nasal cannula technique for ventilating provides a safe method for delivering general anesthesia and ventilating during minor surgeries for neonates and pediatric patients.

Genial tubercle position and genioglossus advancement in obstructive sleep apnea (OSA) treatment: a systematic review.

BACKGROUND: To systematically review the literature for methods to localize the genial tubercle as a means for performing an advancement of the genioglossus muscle. METHODS: PubMed, Google Scholar, CRISP, EMBASE, CINAHL, and Scopus were searched from inception through June 16, 2015. RESULTS: One hundred fifty-two articles were screened, and the full text versions of 12 articles were reviewed in their entirety and 7 publications reporting their methodology for localizing the genial tubercle. Based upon these measurements and the results published from radiographic imaging and cadaveric dissections of all the papers included in this study, we identified the genial tubercle as being positioned within the mandible at a point 10 mm from the incisor apex and 10 mm from the lower mandibular border. CONCLUSION: Based upon the results of this review, the genial tubercles were positioned within the mandible at a point 10 mm from the incisor apex and 10 mm from the lower mandible border. It may serve as an additional reference for localizing the genial tubercle and the attachment of the genioglossus muscle to the mandible, although the preoperative radiological evaluation and the palpation of the GT are recommended to accurately isolate.

Laser-assisted uvulopalatoplasty (LAUP) complications and side effects: a systematic review.

Objective: Laser-assisted uvulopalatoplasty (LAUP) has been used as a treatment option for snoring and obstructive sleep apnea for almost three decades. It has been previously reported that some patient's sleep-disordered breathing worsened following surgery. The aim of this paper is to further elucidate the specific complications of LAUP. Data sources: A systematic search of the electronic databases MEDLINE/PubMed, Google Scholar, and Embase. Review methods: The PRISMA statement was followed. Databases were searched from inception through September 2, 2018. The following search was applied to MEDLINE/PubMed ((laser AND uvul*) OR (LAUP) OR (LAVP) OR (laser AND (apnea OR apnoea OR sleep))). Results: Forty-two studies with a mean follow-up of 16.1 months reported complications on 3,093 total patients who underwent LAUP. The percentages and associated complications of LAUP are as follows: bleeding (2.6%), candidiasis (0.3%), dryness (7.2%), dysgeusia (0.3%), dysosmia (0.2%), globus sensation (8.2%), surgical site infection (1.3%), velopharyngeal (VP) insufficiency (3.9%), and VP stenosis (1.6%). The mean duration of patient-reported pain in studies that reported pain was 11.65 days. Only globus and VP insufficiency had a significant incidence compared with either the general population or the post-oropharyngeal surgery population with relative risks of 1.48 and 2.25, respectively. Overall, there were approximately 26 complications per 100 patients who underwent LAUP. Conclusion: LAUP is associated with a statistically significant rate of VP insufficiency and globus sensation; however, studies lack details of surgical approaches, suggesting that in a population identified as good candidates, a tissue-sparing approach may result in fewer complications.

Changing practice: Trends in skeletal surgery for obstructive sleep apnea.

OBJECTIVES/HYPOTHESIS: The objective of this study was to systematically review the English literature for articles that have described skeletal surgeries in the treatment of obstructive sleep apnea in both adults and children. From these articles trends and patterns in the treatment of OSA with skeletal procedures are described. STUDY DESIGN: Three databases including MEDLINE, Google Scholar and the Cochrane Library were searched through May 1, 2018. METHODS: The systematic and independent literature reviews were performed and the determination of included studies was made by consensus. Relevant studies were examined based on six categories of skeletal surgery: 1) Hyoid Advancement 2) Genioplasty/Genioglossus Advancement 3) Maxillary Expansion 4) Maxillomandibular Advancement 5) Mandibular Distraction and 6) Maxillomandibular Expansion. RESULTS: 1875 studies were analyzed for inclusion of which 414 were ultimately included in our analysis. A steady increase in the publication of articles pertaining to maxillary expansion and maxillomandibular advancement was identified. Research interest in hyoid advancement and genioplasty/genioglossus advancement has declined in the past decade. CONCLUSIONS: Changing trends in skeletal surgery for OSA offer exciting and efficacious therapeutic surgical modalities. MMA is the most widely studied and efficacious multi-level surgery for OSA today. Newer modalities such as adult maxillary expansion offer encouraging early results with minimal complication rates, and further study should be directed in this area.

Unilateral vs Bilateral Supraglottoplasty: A Meta-analysis of Rates of Return to Surgery and Supraglottic Stenosis.

OBJECTIVE: To perform a systematic review with meta-analysis of data to determine the rates of repeat surgery and supraglottic stenosis in unilateral versus bilateral supraglottoplasty for laryngomalacia. DATA SOURCES: PubMed/Medline, Cochrane Central, Scopus, Google Scholar, Web of Science, and Embase. REVIEW METHODS: Databases were searched through January 30, 2018. Studies with unilateral or bilateral supraglottoplasty techniques for laryngomalacia were included. The need for repeat (revision or completion) surgery and rates of supraglottic stenosis were primary outcomes. Data were substratified and a meta-analysis performed. RESULTS: A total of 251 articles were reviewed, and 20 articles met inclusion criteria (1186 patients: 663 bilateral, 523 unilateral). Regarding the need to return to surgery, the rate of revision for bilateral surgery was 4.1%, compared to the revision and combined revision/completion rates for unilateral surgery which respectively were 1.1% (odds ratio [OR] 0.27; 95% CI 0.11-0.67; P = .002) and 18.0% (OR 5.16; 95% CI 3.31-8.06; P < .0001). The unilateral versus bilateral supraglottic stenosis rates were 0% versus 1.2% (P = .011). CONCLUSION: Unilateral supraglottoplasty has a significantly higher rate of repeat surgery, mainly attributed to contralateral surgery, when compared with bilateral supraglottoplasty. There is a small but statistically significant risk of supraglottic stenosis in bilateral procedures. The benefit of a unilateral procedure should be weighed against the cost of subjecting patients to a 4-fold increased risk of repeat surgery.

Cautery-assisted palatal stiffening operation for obstructive sleep apnea: A systematic review and meta-analysis.

OBJECTIVE: To systematically review outcomes for cautery-assisted palatal stiffening operation (CAPSO) as a treatment for adult obstructive sleep apnea (OSA). METHODS: Five databases (including PubMed/MEDLINE) were searched through July 12, 2017. RESULTS: Eight studies (307 patients) met criteria. Overall, CAPSO alone (80 patients) improved AHI from a mean ± standard deviation (M ± SD) of (16.8 ± 11.9) to (9.9 ± 10.9) events/h (41.1% decrease). Mixed CAPSO with/without tonsillectomy (92 patients) improved AHI from a M ± SD of (24.8 ± 12.6) to (10.6 ± 9.5) events/h (61.7% decrease). CAPSO with expansion pharyngoplasty (EP), (78 patients) improved AHI from a M ± SD of (26.3 ± 17.7) to (12.6 ± 5.8) events/h (52.1% decrease). CAPSO alone (90 patients) improved lowest oxygen saturation (LSAT) by 5.4 points. Mixed CAPSO with/without tonsillectomy (77 patients) improved LSAT by 10.6 points, and CAPSO with EP (78 patients) improved LSAT by 5.2 points. Sleepiness improved (182 patients) from an Epworth Sleepiness Scale score of 11.8 to 5.1, P < 0.001. Snoring reduced (120 patients) from 7.9 to 2.5 on visual analog scales (0-10 scale), P < 0.001. CONCLUSIONS: Apnea-hypopnea index has improved by 41.0% for CAPSO alone, 61.7% for CAPSO with tonsillectomy and 52.1% for CAPSO with expansion pharyngoplasty. Additionally, lowest oxygen saturation, sleepiness and snoring have also improved after CAPSO.

Long-term Results for Maxillomandibular Advancement to Treat Obstructive Sleep Apnea: A Meta-analysis.

OBJECTIVE: To examine outcomes in the intermediate term (1 to <4 years), long term (4 to <8 years), and very long term (≥8 years) for maxillomandibular advancement (MMA) as treatment for obstructive sleep apnea (OSA). DATA SOURCES: The Cochrane Library, Google Scholar, Embase, Cumulative Index to Nursing and Allied Health, and PubMed/MEDLINE. REVIEW METHODS: Three authors systematically reviewed the international literature through July 26, 2018. RESULTS: A total of 445 studies were screened, and 6 met criteria (120 patients). Thirty-one patients showed a reduction in apnea-hypopnea index (AHI) from a mean 48.3 events/h (95% CI, 42.1-54.5) pre-MMA to 8.4 (95% CI 5.6, 11.2) in the intermediate term. Fifty-four patients showed a reduction in AHI from a mean 65.8 events/h (95% CI, 58.8-72.8) pre-MMA to 7.7 (95% CI 5.9, 9.5) in the long term. Thirty-five showed a reduction in AHI from a mean 53.2 events/h (95% CI 45, 61.4) pre-MMA to 23.1 (95% CI 16.3, 29.9) in the very long term. Improvement in sleepiness was maintained at all follow-up periods. Lowest oxygen saturation improvement was maintained in the long term. CONCLUSION: The current international literature shows that patients with OSA who were treated with MMA maintained improvements in AHI, sleepiness, and lowest oxygen saturation in the long term; however, the mean AHI increased to moderate OSA in the very long term. Definitive generalizations cannot be made, and additional research providing individual patient data for the intermediate term, long term, and very long term is needed.

Montelukast and Nasal Corticosteroids to Treat Pediatric Obstructive Sleep Apnea: A Systematic Review and Meta-analysis.

OBJECTIVE: To systematically review the literature on anti-inflammatory medications for treating pediatric obstructive sleep apnea and perform meta-analysis of the available data. DATA SOURCES: PubMed/MEDLINE and 4 additional databases. REVIEW METHODS: Three authors independently and systematically searched through June 28, 2018, for studies that assessed anti-inflammatory therapy for treatment of pediatric obstructive sleep apnea (OSA). Data were compiled and analyzed using Review Manager 5.3 (Nordic Cochrane Centre). RESULTS: After screening 135 studies, 32 were selected for review with 6 meeting inclusion criteria. In total, 668 patients aged 2 to 5 years met inclusion criteria for meta-analysis. Of these, 5 studies (166 children) that evaluated montelukast alone as treatment for pediatric OSA found a 55% improvement in the apnea-hypopnea index (AHI) (mean [SD] 6.2 [3.1] events/h pretreatment and 2.8 [2.7] events/h posttreatment; mean difference [MD] of -2.7 events/h; 95% confidence interval [CI], -5.6 to 0.3) with improvement in lowest oxygen saturation (LSAT) from 89.5 (6.9) to 92.1 (3.6) (MD, 2.2; 95% CI, 0.5-4.0). Two studies (502 children) observing the effects of montelukast with intranasal corticosteroids on pediatric OSA found a 70% improvement in AHI (4.7 [2.1] events/h pretreatment and 1.4 [1.0] events/h posttreatment; MD of -4.2 events/h; 95% CI, -6.3 to -2.0), with an improvement in LSAT from 87.8 (3.1) to 92.6 (2.2) (MD, 4.8; 95% CI, 4.5-5.1). CONCLUSIONS: Treatment with montelukast and intranasal steroids or montelukast alone is potentially beneficial for short-term management of mild pediatric OSA.

Pediatric Considerations for Dental Sleep Medicine.

Pediatric obstructive sleep apnea (OSA) is a serious medical condition with numerous health consequences. Dentists are well suited to recognize and provide medical referrals for pediatric patients at risk for OSA. Timely dental sleep medicine interventions may improve signs and symptoms of OSA in growing children. Orthodontic and dentofacial orthopedic treatment may decrease obstructive respiratory events in some pediatric patients. Palatal expansion may be part of a comprehensive orthodontic treatment plan to correct a malocclusion and treat OSA. Orthognathic surgery, mandibular advancement devices, and oropharyngeal exercises may have a role in the management of OSA in pediatric and adolescent patients.

Inner ear barotrauma in divers: an evidence-based tool for evaluation and treatment.

OBJECTIVE: To systematically search the literature for studies evaluating the typical presentation and testing that is performed for divers with inner ear symptoms and then to create a tool for clinicians when evaluating a diver with inner ear symptoms. METHODS: Nine databases, including PubMed/MEDLINE were systematically searched through 31 January 2018. The PRISMA statement was followed. RESULTS: Three-hundred and two manuscripts were screened, 69 were downloaded and 21 met criteria to be included in this review. The articles were evaluated for symptomatic trends and initial evaluation work-up primarily focusing on inner-ear barotrauma (IEBt) and inner ear decompression sickness (inner ear DCS). The trends for IEBt were compared to typical inner ear DCS presentation based on large study inner ear DCS results consistent with the plethora of research available. Finally, the HOOYAH Tool was developed to assist the receiving provider to better determine the most likely diagnosis and thus initiate appropriate treatment. The HOOYAH Tool is comprised of the following: 1) H: hard to clear; 2) O: onset of symptoms; 3) O: otoscopic exam; 4) Y: your dive profile; 5) A: additional symptoms and 6) H: hearing. For each of these components, the typical presentation is described allowing the provider better to discern the correct diagnosis. CONCLUSION: The diagnosis of IEBt remains difficult to define short of visualization through surgical exploration. Early treatment is defined by conservative management with a subsequent observational period to determine symptomatic resolution and need for surgery. However, a similar differential diagnosis is inner ear DCS which requires early recompression. The HOOYAH tool provides a method for assisting the provider in forming a more confident decision regarding the underlying pathology and facilitation of the appropriate treatment.

Thirty-five alternatives to positive airway pressure therapy for obstructive sleep apnea: an overview of meta-analyses.

INTRODUCTION: Positive airway pressure (PAP) devices are generally considered to be the first-line treatment of choice for most adults with obstructive sleep apnea (OSA). However, there are several alternatives. It is important for patients and their sleep providers to be aware of the most up-to-date information regarding the current international literature. Areas covered: The objective is to provide an overview of the meta-analyses evaluating non-PAP treatments for OSA. Four authors searched four databases, including PubMed/MEDLINE through 30 November 2017, for meta-analyses evaluating non-PAP therapies as treatment for OSA. Thirty-five non-PAP treatments were identified and were categorized based on the following anatomical subsites: (1) nose, (2) palate and oropharynx, (3) tongue, (4) skeletal surgery and jaw repositioning, and (5) other surgical and medical interventions. Treatments identified included surgeries, drugs, behavior modifications, nonsurgical weight loss, medical devices, body positioning, and oxygen treatment. Expert commentary: The 35 treatments described vary in their effectiveness in treating OSA in adults. In general, isolated nasal treatments are the least effective, whereas treatments that bypass the upper airway, significantly open the upper airway, and/or address multiple levels of the upper airway are more effective in improving apnea-hypopnea index and lowest oxygen saturation.

Supraglottoplasty surgery types 1-3: A practical classification system for laryngomalacia surgery.

OBJECTIVE: The objective of this study is to review the published literature on supraglottoplasty techniques for correcting laryngomalacia, and to subsequently provide a standardized classification system. METHODS: Three authors independently and systematically searched Pubmed/MEDLINE and six additional databases for all studies that included descriptions of supraglottoplasty techniques for correcting laryngomalacia. Sub-sites operated on and specific technique descriptions were reviewed, cataloged and subsequently categorized. This data was then used to develop a new classification system. RESULTS: 231 articles were identified, downloaded and reviewed in full text. 53 articles with 1669 patients from the included articles described in detail the supraglottoplasty procedure. 84 articles with 5731 patients had to be excluded secondary to not providing detail about the supraglottoplasty procedure. The resultant data identifies the need for a more standardized reporting of the supraglottoplasty procedure in order to more accurately evaluate technique specific outcomes. Currently 77% of the patients in the literature cannot be assessed for outcomes as they did not describe the details for the procedures. Eight variations of supraglottoplasty and four variations of epiglottis surgery were described. Based on the literature, we consolidated the surgery into the following types: Type 1: Debulking of arytenoids, Type 2: Division of aryepiglottic folds, Type 3: Epiglottis surgery. CONCLUSION: This descriptive review identified 53 articles with 1669 patients from the included articles detailing multiple variations of supraglottoplasty techniques. The new classification supplements a previously established system describing laryngomalacia, and simplifies the supraglottoplasty into three descriptive and logical types of categories. Our classification system would give surgeons a universal language to describe the supraglottoplasty performed, which could improve reporting of techniques, and facilitate future communication and research.

Mandibular advancement for pediatric obstructive sleep apnea: A systematic review and meta-analysis.

OBJECTIVES: Mandibular distraction osteogenesis and mandibular advancement, collectively referred to as mandibular advancement surgeries (MAS), have been used to treat children with mandibular insufficiency and obstructive sleep apnea (OSA). The objective is to perform a systematic review and meta-analysis for MAS as treatment for obstructive sleep apnea. METHODS: Three authors searched multiple databases (including PubMed/Medline) from inception through April 25, 2018. RESULTS: 1198 studies were screened, 128 were downloaded and 37 met inclusion criteria (376 patients, mean age: 1.5 years). Meta-analysis demonstrated a reduction in the apnea-hypopnea index (AHI), from a mean ± SD of 41.1 ± 35.8 to 4.5 ± 6.0 events per hour (89.1% decrease). The lowest oxygen saturation (LSAT) in 211 patients increased from a mean ± SD of 76.8 ± 13.0 to 91.1 ± 8.6 (14.3 oxygen saturation point increase). Individual patient data (105 patients) demonstrated AHI surgical success in 73.4% of patients and respiratory disturbance index (RDI) surgical success in 100% of patients. AHI surgical cure was seen in 25.5% of patients and RDI surgical cure was seen in 37.5% of patients. CONCLUSIONS: This study's major finding is that obstructive sleep apnea has dramatically improved in pediatric patients with mandibular insufficiency when they have been treated with mandibular advancement or mandibular distraction osteogenesis.

Double Barrel Nasal Trumpets to Prevent Upper Airway Obstruction after Nasal and Non-Nasal Surgery.

OBJECTIVES: During anesthesia emergence, patients are extubated and the upper airway can become vulnerable to obstruction. Nasal trumpets can help prevent obstruction. However, we have found no manuscript describing how to place nasal trumpets after nasal surgery (septoplasties or septorhinoplasties), likely because (1) the lack of space with nasal splints in place and (2) surgeons may fear that removing the trumpets could displace the splints. The objective of this manuscript is to describe how to place nasal trumpets even with nasal splints in place. MATERIALS AND METHODS: The authors describe techniques (Double Barrel Technique and Modified Double Barrel Technique) that were developed over three years ago and have been used in patients with obstructive sleep apnea (OSA) and other patients who had collapsible or narrow upper airways (i.e., morbidly obese patients). RESULTS: The technique described in the manuscript provides a method for placing one long and one short nasal trumpet in a manner that helps prevent postoperative upper airway obstruction. The modified version describes a method for placing nasal trumpets even when there are nasal splints in place. Over one-hundred patients have had nasal trumpets placed without postoperative oxygen desaturations. CONCLUSIONS: The Double Barrel Technique allows for a safe emergence from anesthesia in patients predisposed to upper airway obstruction (such as in obstructive sleep apnea and morbidly obese patients). To our knowledge, the Modified Double Barrel Technique is the first description for the use of nasal trumpets in patients who had nasal surgery and who have nasal splints in place.