What changes in maxillary morphology from distraction osteogenesis maxillary expansion (DOME) correlate with subjective and objective OSA measures?

OBJECTIVES: To correlate skeletal and airway measures on imaging with polysomnographic and self-reported measures after distraction osteogenesis maxillary expansion (DOME), in the effort to identify clinically relevant sites of expansion to guide treatment for adult patients with obstructive sleep apnea (OSA). MATERIALS AND METHODS: This is a retrospective study reviewing subjects who underwent DOME and had the complete set of the following data: peri-treatment cone-beam computed tomography (CBCT) scans, polysomnography (PSG), Epworth Sleepiness Scale (ESS), and nasal obstruction symptom (NOSE) scores. RESULTS: Of 132 subjects who underwent DOME, 35 met inclusion criteria (71% men, mean age 27.7 ± 6.5 years, mean BMI 26.0 ± 6.4 kg/m2) and were enrolled in the study. There was a significant reduction in the NOSE score from 11.4 ± 5.5 to 3.6 ± 3.1, in the ESS score from 12.0 ± 4.6 to 7.1 ± 4.7, and in the apnea-hypopnea index (AHI) from 17.1 ± 15.8 to 7.01 ± 6.2 (p < 0.0001), after DOME. Nasal floor width at the nasopalatine canal level showed a statistically significant correlation with AHI reduction (p < .0001). CONCLUSIONS: DOME is significantly associated with reduction of nasal obstruction, sleepiness, and severity of OSA. The findings suggest that expansion at the anterior third of the bony nasal passage, specifically where the nasopalatine canal is located predicts its clinical efficacy. This site may be a useful target anatomically via imaging.

Correlation between craniofacial changes and respiratory improvement after nasomaxillary skeletal expansion in pediatric obstructive sleep apnea patients.

PURPOSE: The aim of this study was to investigate the correlation between the changes in respiratory function and dimensions of the nasomaxillary complex (NMC) and upper airway (UA) compartments after nasomaxillary skeletal expansion (NMSE) treatment for pediatric patients with obstructive sleep apnea (OSA). METHODS: Nonobese OSA patients (mean age, 13.6 ± 2.9 years; mean body mass index, 18.1 ± 3.0 kg/m2); mean apnea-hypopnea index (AHI, 7.0 ± 5.4 events/h) presenting with transverse nasomaxillary constriction were evaluated before and after NMSE using cone-beam computed tomography (CBCT), home sleep test, and modified pediatric sleep questionnaire (m-PSQ). Paired t tests were performed to examine the treatment-related changes in all the parameters, and a multiple regression analysis adjusted for age and sagittal and vertical skeletal patterns was conducted to determine the dimensional parameters to affect the functional improvement. RESULTS: Among 26 patients, NMSE treatment significantly increased NMC dimensions at all tested levels and all UA compartments in CBCT, except glossopharyngeal airway. Concurrently, AHI, oxygen desaturation index, the lowest oxygen saturation (LSaO2), flow limitation (FL), snoring, and m-PSQ were significantly improved. AHI reduction was correlated with UA enlargement with no correlation with NMC expansion, whereas FL reduction was affected by NMC expansion. The minimal cross-sectional area was the most predictive of functional improvement, presenting correlations with AHI, LSaO2, and m-PSQ. CONCLUSION: NMSE can be a good treatment for pediatric OSA patients when applied to enhance the nasal and pharyngeal airway patencies beyond the NMC, ultimately to improve pharyngeal collapsibility as well as nasal airflow.

Multi-perspective clustering of obstructive sleep apnea towards precision therapeutic decision including craniofacial intervention.

PURPOSE: Previous studies focusing on phenotyping obstructive sleep apnea (OSA) have outlined its heterogeneity in clinical symptoms, comorbidities, and polysomnographic features. However, the role of anatomical or pathophysiological causality including craniofacial skeletal deformity has not been studied. We aimed to identify and characterize phenotypes of OSA based on multi-perspective clustering by incorporating craniofacial risks with obesity, apnea severity, arousability, symptom, and comorbidity. METHODS: A total of 421 Korean patients with OSA (apnea-hypopnea index, AHI ≥ 5; age ≥ 20 years old) were recruited. A K-means cluster analysis was performed following principal component analysis with sagittal and vertical skeletal variables (ANB and mandibular plane angle), AHI, body mass index, and Epworth sleepiness scale. Inter-cluster comparison was conducted using demographic, cephalometric, and polysomnographic variables in addition to presence of diabetes and hypertension. Risk factors contributing to OSA severity were evaluated in each cluster using multivariable regression analysis with adjustment for age and gender. RESULTS: Three phenotypic clusters were identified and characterized as follows: Cluster-1 (noncraniofacial phenotype, 39%), non-obese moderate-to-severe OSA with no skeletal discrepancy representing low arousal threshold (ArTh), little sleepiness, and low comorbidity; Cluster-2 (craniofacial skeletal phenotype, 33%), non-obese moderate OSA with definite skeletal discrepancy showing low ArTh, mild sleepiness, and low comorbidity; and Cluster-3 (complicated phenotype, 28%), obese severe OSA with skeletal discrepancy exhibiting high ArTh, excessive daytime sleepiness, and high incidence of hypertension. CONCLUSIONS: The three OSA phenotypes from multi-perspective clustering may provide a basis for precise therapeutic decision-making including craniofacial skeletal intervention beyond usual characterization of OSA subgroups.

Role of rhinomanometry in the prediction of therapeutic positive airway pressure for obstructive sleep apnea.

BACKGROUND: This study was conducted to evaluate the relationship between nasal resistance in different posture and optimal positive airway pressure (PAP) level. Other potential factors were also assessed for possible influence on PAP pressure. METHODS: Forty- three patients diagnosed with obstructive sleep apnea (OSA) were prospectively recruited in this study. Nasal resistance was assessed by active anterior rhinomanometry in a seated position and then in a supine position at pressures of 75, 150, and 300 pascal. The factors correlating with PAP pressure were analyzed, including nasal resistance and patients' clinical data. RESULTS: Univariate analysis revealed that PAP pressure was correlated to nasal resistance in the supine position at 75 and 150 pascal (SupineNR75 and SupineNR150) (P = 0.019 and P = 0.004 in Spearman's correlation coefficient analysis), but not correlated to nasal resistance in the seated position at different pressures or in the supine position at 300 pascal. The multiple linear regression analysis revealed that both SupineNR150 and body mass index (BMI) significantly predicted PAP pressure (ß = 0.308, p = 0.044; ß = 0.727, p = 0.006). The final PAP pressure predictive model was: PAP pressure = 0.29 BMI + 2.65 SupineNR150 + 2.11. CONCLUSIONS: Nasal resistance in the supine position measured at 150 pascal may provide valuable information regarding optimal PAP pressure. Rhinomanometry should be included in the treatment algorithm of OSA patients when PAP therapy is considered.

Optimizing mandibular sagittal split of large maxillomandibular advancements for obstructive sleep apnea: patient and surgical factors.

OBJECTIVES: Maxillomandibular advancement (MMA) confers consistent and high rates of surgical success for obstructive sleep apnea (OSA). In the era of value-based medicine, identifying factors that affect the stability of rigid fixation and allow rapid return to function are important targets for improvement. The aim of this study was to identify patient and surgical factors associated with mandibular sagittal split outcomes associated with optimal postoperatively skeletal stability. STUDY DESIGN: Retrospective cohort study. MATERIALS AND METHODS: Forty-six subjects (43 males and 3 females) with postoperative CT scans including three-dimensional reconstruction from which mandibular split patterns could be analyzed were enrolled. Patient factors (age and polysomnographic measures) and surgical factors (extent of osteotomy prior to controlled fracture) were assessed. Outcome measures include (1) bone thickness for rigid fixation and (2) area of passive bony overlap after advancement. RESULTS: Age and severity of disease did not contribute significantly to optimal mandibular split patterns. For optimal area for passive bony overlap and thickness of buccal and lingual plates for rigid fixation, the most important factors are related to surgical technique. CONCLUSIONS: Anterior osteotomy just to the midline of inferior border and horizontal osteotomy to the mandibular foramen are associated with split patterns that result in optimal rigid fixation and passive bony overlap for OSA patients undergoing MMA. CLINICAL RELEVANCE: Optimal surgical technique has the most significant influence in allowing rapid return to function after MMA in patients with OSA.

Tongue retaining devices for obstructive sleep apnea: A systematic review and meta-analysis.

OBJECTIVE: Tongue Retaining Devices (TRD) anteriorly displace the tongue with suction forces while patients sleep. TRD provide a non-surgical treatment option for patients with Obstructive Sleep Apnea (OSA). Our objective was to conduct a systematic review of the international literature for TRD outcomes as treatment for OSA. METHODS: Three authors independently and systematically searched four databases (including PubMed/MEDLINE) through June 26, 2016. We followed guidelines set within the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). RESULTS: Sixteen studies with 242 patients met criteria. The overall means±standard deviations (M±SD) for apnea-hypopnea index (AHI) decreased from 33.6±21.1/h to 15.8±16.0/h (53% reduction). Seven studies (81 patients) reported lowest oxygen saturation (LSAT), which improved from 79.8±17.5% to 83.9±8.6%. Four studies (93 patients) reported Epworth sleepiness scale (ESS), which decreased from 10.8±4.8 to 8.2±4.5, p <0.0001. Four studies (31 patients) reported Oxygen Desaturation Index (ODI) which decreased from 29.6±32.1 to 12.9±8.7, a 56.4% reduction. CONCLUSION: Current international literature demonstrates that tongue retaining devices reduce apnea-hypopnea index by 53%, increase lowest oxygen saturation by 4.1 oxygen saturation points, decrease oxygen desaturation index by 56% and decrease Epworth sleepiness scale scores by 2.8 points. Tongue retaining devices provide a statistically effective alternative treatment option for obstructive sleep apnea.

Transpalatal advancement pharyngoplasty for obstructive sleep apnea: a systematic review and meta-analysis.

The objective is to determine if apnea-hypopnea index (AHI) and lowest oxygen saturation (LSAT) improve after transpalatal advancement pharyngoplasty (TPAP) with obstructive sleep apnea (OSA) in adults, using a systematic review and meta-analysis. Nine databases, including PubMed/MEDLINE, were searched through April 1, 2016. All studies that included patients who underwent TPAP alone were included in this analysis. Fifty-six studies were potentially relevant, 37 were downloaded and five studies met criteria with 199 patients (age: 42.5 ± 9.7 years and body mass index: 29.0 ± 4.0 kg/m2). The grand mean (M) and standard deviation (SD) for AHI (199 patients) pre and post-TPAP decreased from 54.6 ± 23.0 [95 % CI 51.4, 57.8] to 19.2 ± 16.8 [95 % CI 16.9, 21.5] events/h (relative reduction: 64.8 %). Random effects modeling demonstrated a mean difference (MD) of -36.3 [95 % CI -48.5, -24.1], overall effect Z = 5.8 (p < 0.00001), and I 2 = 85 % (significant inconsistency). The standardized mean difference (SMD) for TPAP demonstrated a large magnitude of effect for AHI -1.76 [95 % CI -2.4, -1.1]. For LSAT (70 patients), the pre and post-TPAP M ± SD improved from 81.9 ± 8.1 [95 % CI 80.0, 83.8] to 85.4 ± 6.9 [95 % CI 83.8, 87.0], with a MD of 3.55, overall effect Z = 1.79 (p = 0.07). Thus far, few studies have evaluated transpalatal advancement pharyngoplasty; therefore, we recommend additional studies, especially prospective studies. Research comparing TPAP to pharyngoplasty procedures without palatal advancement would help determine the optimal role for this procedure.

The association between ophthalmologic diseases and obstructive sleep apnea: a systematic review and meta-analysis.

PURPOSE: The purpose of this study was to evaluate the association between obstructive sleep apnea (OSA) and ophthalmologic diseases, specifically glaucoma, nonarteritic anterior ischemic optic neuropathy (NAION), retinal vein occlusion (RVO), central serous chorioretinopathy (CSR), and floppy eyelid syndrome (FES), by performing a systematic review and meta-analysis of published studies. METHODS: PubMed, Embase, and Scopus databases were searched for observational studies on OSA and its association with select ophthalmologic diseases. Data was pooled for random-effects modeling. The association between OSA and ophthalmologic diseases was summarized using an estimated pooled odds ratio with a 95 % confidence interval. RESULTS: Relative to non-OSA subjects, OSA subjects have increased odds of diagnosis with glaucoma (pooled odds ratio (OR) = 1.242; P < 0.001) and floppy eyelids syndrome (pooled OR = 4.157; P < 0.001). In reverse, the overall pooled OR for OSA was 1.746 (P = 0.002) in the glaucoma group, 3.126 (P = 0.000) in the NAION group, and 2.019 (P = 0.028) in the CSR group. For RVO, one study with 5965 OSA patients and 29,669 controls demonstrated a 1.94-fold odds increase in OSA patients. CONCLUSIONS: Our results suggest significant associations between OSA and glaucoma, NAION, CSR, and FES. Screening for OSA should be considered in patients with glaucoma, NAION, CSR, or FES.

Dynamic upper airway collapse observed from sleep MRI: BMI-matched severe and mild OSA patients.

Dynamic magnetic resonance imaging (MRI) allows real-time characterization of upper airway collapse in sleeping subjects with obstructive sleep apnea (OSA). The aim of our study was to use sleep MRI to compare differences in upper airway collapse sites between BMI-matched subjects with mild OSA and severe OSA. This is a prospective, nested case-control study using dynamic sleep MRI to compare 15 severe OSA subjects (AHI >40) and 15 mild OSA (AHI <10) subjects, who were matched for BMI. Upper airway imaging was performed on sleeping subjects in a 3.0 T MRI scanner. Sleep MRI movies were used by blinded reviewers to identify retropalatal (RP), retroglossal (RG), and lateral pharyngeal wall (LPW) airway collapse. Mean AHI in the severe OSA group was 70.3 ± 23 events/h, and in the mild group was 7.8 ± 1 events/h (p < 0.001). All mild and severe OSA subjects demonstrated retropalatal airway collapse. Eighty percent in the mild group showed single-level RP collapse (p < 0.001). All subjects in the severe group showed multi-level collapse: RP + LPW (n = 9), RP + RG + LPW (n = 6). All severe OSA subjects showed LPW collapse, as compared with three subjects in the mild group (p < 0.001). LPW collapse was positively associated with AHI in simple regression analysis (ß = 51.8, p < 0.001). In conclusion, severe OSA patients present with more lateral pharyngeal wall collapse as compared to BMI-matched mild OSA patients.

Subtypes of Maxillomandibular Advancement Surgery for Patients With Obstructive Sleep Apnea.

Maxillomandibular advancement (MMA) surgery, which is the most effective treatment modality for patients with moderate-to-severe obstructive sleep apnea with apparent skeletal discrepancies, has been modified in conjunction with segmental osteotomies, counterclockwise rotation of maxillomandibular complex, and other adjunctive procedures. However, any single type of MMA could not treat or cure all the patients with obstructive sleep apnea showing different dentofacial and pharyngeal patterns. We aimed to suggest critical decision factors for the selective application of MMA subtypes, categorized as straight MMA with genioplasty, rotational MMA, segmental MMA, and segmental-rotational MMA, in the surgical treatment objective process: anteroposterior position of maxilla, upper lip projection, overjet, lower incisor inclination as sagittal factors, and upper incisor exposure and occlusal plane angle as vertical factors. This case series deserves a clinical basis on the way of case-by-case application of the optimal MMA subtype based on the successful treatment outcomes with short-term stability.

Static craniofacial measurements and dynamic airway collapse patterns associated with severe obstructive sleep apnoea: a sleep MRI study.

OBJECTIVES: Using sleep MRI, we aimed to identify static craniofacial measurements and dynamic upper airway collapse patterns associated with severe obstructive sleep apnoea (OSA) during natural sleep in age and BMI-matched patients. DESIGN: Nested case-control study. SETTING: Sleep MRI images (3.0 Tesla scanner) and synchronised acoustic recording were used to observe patterns of dynamic airway collapse in subjects with mild and severe OSA. Midsagittal images were also used for static craniofacial measurements. PARTICIPANTS: Fifteen male subjects with severe OSA (mean AHI 70.3 ± 23 events/h) were matched by age and BMI to 15 subjects with mild OSA (mean AHI 7.8 ± 1.4 events/h). Subjects were selected from a consecutive sleep MRI study cohort. MAIN OUTCOME MEASURES: Static craniofacial measurements selected a priori included measurements that represent maxillomandibular relationships and airway morphology. Axial, sagittal and coronal views of the airway were rated for dynamic collapse at retropalatal, retroglossal and lateral pharyngeal wall regions by blinded reviewers. Bivariate analysis was used to correlate measures associated with severity of OSA using AHI. Statistical significance was set at P < 0.01. RESULTS: Lateral pharyngeal wall collapse from dynamic sleep MRI (ß = 51.8, P < 0.001) and upper airway length from static MRI images (ß = 27.2, P < 0.001) positively correlated with severity of OSA. CONCLUSIONS: Lateral pharyngeal wall collapse and upper airway length are significantly associated with severe OSA based on sleep MRI. Assessment of these markers can be readily translated to routine clinical practice, and their identification may direct targeted surgical treatment.

Lateral Pharyngeal Wall Tension After Maxillomandibular Advancement for Obstructive Sleep Apnea Is a Marker for Surgical Success: Observations From Drug-Induced Sleep Endoscopy.

PURPOSE: The efficacy of maxillomandibular advancement (MMA) for obstructive sleep apnea (OSA) with anatomic airway changes has previously been studied using static imaging and endoscopy in awake subjects. The aim of the present study was to use drug-induced sleep endoscopy (DISE) to evaluate the dynamic upper airway changes in sleeping subjects before and after MMA and their association with the surgical outcome. PATIENTS AND METHODS: This was a retrospective cohort study of subjects with OSA who had undergone MMA at the Stanford University Sleep Surgery Division from July 2013 to July 2014. The subjects were included if perioperative polysomnography and DISE had been performed. The predictor variable was the perioperative DISE velum-oropharynx-tongue-epiglottis score. The outcome variables were the apnea-hypopnea index (AHI), oxygen-desaturation index (ODI), and Epworth Sleepiness Scale (ESS). A subgroup analysis was performed for the subjects who had undergone primary and secondary MMA. The statistical analyses included Cronbach's α coefficient, the McNemar test, and the independent Student t test. The P value was set at <.01. RESULTS: A total of 16 subjects (15 males, 1 female) were included in the present study, with an average age of 47 ± 10.9 years and body mass index of 29.4 ± 5.1 kg/m(2). Significant post-MMA decreases were found in the AHI (from 59.8 ± 25.6 to 9.3 ± 7.1 events/hr) and ODI (from 45 ± 29.7 to 5.7 ± 4.1 events/hr; P < .001). Greater improvement in the AHI occurred in the primary MMA group (P = .022). The post-MMA change in airway collapse was most significant at the lateral pharyngeal wall (P = .001). The subjects with the most improvement in lateral pharyngeal wall collapsibility demonstrated the largest changes in the AHI (from 60.0 ± 25.6 events/hr to 7.5 ± 3.4 events/hr) and ODI (from 46.7 ± 29.8 to 5.3 ± 2 events/hr; P = .002). CONCLUSIONS: Using DISE, we observed that after MMA, the greatest reduction in upper airway collapsibility is seen at the lateral pharyngeal wall of the oropharynx, followed by the velum, and then the tongue base. The stability of the lateral pharyngeal wall is a marker of surgical success after MMA using the AHI, ODI, and ESS.

CO2 laser lingual tonsil reduction as a treatment for tongue discomfort during hypoglossal nerve stimulation: a case report.

STUDY OBJECTIVES: The purpose of this investigation is to demonstrate a multimodality approach to the surgical management of obstructive sleep apnea. Hypoglossal nerve stimulator (HGNS) implantation has been a lifechanging potion for many obstructive sleep apnea patients. When activated it produces tongue protrusion via electrical stimulation of the hypoglossal nerve. This advances the lingual tonsil, making the pharynx diameter greater. Unfortunately, for some patients the electrical stimulation required is too high and awakens the patient. METHODS: Case report. RESULTS: In this case the patient's fragmented sleep is not improved with the HGNS. Here we present a case where HGNS and CO2 laser lingual tonsil reduction are used in conjunction to reduce the HGNS setting required for airway patency, thereby allowing the patient to sleep through the night. CONCLUSIONS: For those patients who are unable to tolerate hypoglossal nerve stimulator settings, a combined approach with lingual tonsil reduction may be an alternative.

Feasibility of distraction osteogenesis maxillary expansion in patients with persistent nasal obstruction after septoplasty.

BACKGROUND: Distraction osteogenesis maxillary expansion (DOME) is an emerging surgical concept for obstructive sleep apnea patients with a high-arched and narrow hard palate presenting with nasal obstruction. Herein we demonstrate the feasibility of DOME in the treatment of patients with persistent nasal obstruction after primary septoplasty. METHODS: A total of 32 consecutive patients with persistent nasal obstruction after septoplasty who underwent DOME were enrolled in this study. The efficacy of DOME in treating persistent nasal obstruction in septoplasty failure patients was evaluated using the validated Nasal Obstruction Symptom Evaluation (NOSE) scale. Pre- and postoperative computed tomography (CT) scans were performed to measure the change of nasal floor width after surgery. RESULTS: NOSE score improved significantly from 13.62 ± 4.74 to 5.15 ± 3.50 (p < 0.001) after DOME. The postoperative CT scan showed a significant increase of the nasal floor width from 22.4 ± 4.21 to 28.06 ± 4.52 (p < 0.01). No patient had major complications such as wound infection, oronasal fistula, sinusitis, loss of incisor teeth, or malunion. CONCLUSION: We found that DOME appears to improve persistent nasal obstruction after septoplasty in patients with a narrow and high-arched hard palate.

A Minimally Invasive Nasal Endoscopic Approach to Distraction Osteogenesis Maxillary Expansion to Restore Nasal Breathing for Adults with Narrow Maxilla.

Background: Patients with narrow high-arch palate present with limited response to standard septal, turbinate, and valve procedures for nasal obstruction. Objective: To measure the effectiveness of minimally invasive nasal endoscopic (MINE) Lefort I osteotomy among subjects with narrow high-arched palate in managing nasal obstruction. Methods: Prospective cohort study was performed where subjects with narrow high-arched palate underwent MINE distraction osteogenesis maxillary expansion (DOME) from August 2019 to January 2021. Nasal obstruction symptom evaluation (NOSE) score, mean time to opioid cessation, and mean duration of cranial nerve V2 hypoesthesia were evaluated. Results: Among 12 subjects, the. mean NOSE score decreased from 58.89 to 15.83 (p = 0.004). There were no complaints of lip mobility or deformity. Conclusion: MINE-DOME can reduce nasal obstruction in a certain phenotype of patients and further improve patient-centric outcomes by limiting the approach to the Lefort I osteotomy to an endoscopic nasal approach.

Impact of rapid palatal expansion on the size of adenoids and tonsils in children.

INTRODUCTION: Adenoid and tonsillar hypertrophy in children often leads to adverse respiratory symptoms and obstructive sleep apnea (OSA). Current clinical guidelines from the American Academy of Pediatrics and American Academy of Otolaryngology-Head and Neck Surgery recommend tonsillectomy as the first line of pediatric OSA treatment for children with tonsillar hypertrophy. Rapid palatal expansion (RPE) performed by orthodontists improves obstructive sleep apnea in children by reducing nasal airway resistance, increasing nasal volume, raising tongue posture, and enlarging pharyngeal airway. However, the role of RPE in alleviating adenoid and tonsillar hypertrophy remains elusive. In this study, we aim to evaluate the changes in adenoid and palatine tonsil sizes following RPE using 3D volumetric analysis of cone beam computational tomography (CBCT) imaging. MATERIALS AND METHODS: In this retrospective cohort study, a total of 60 pediatric patients (mean age: 8.00, range: 5-15, 32 females and 28 males) who had tonsillar hypertrophy (size 3 and 4) were included and divided into the control group (n = 20) and expansion group (n = 40). The control group did not undergo any treatment. The expansion group underwent RPE using a conventional Hyrax expander, activated 0.25 mm per day for 4-6 weeks. Final CBCT scans (T2) were performed 13.8 ± 6.5 months after the initial scan (T1). Pediatric sleep questionnaire (PSQ) and BMI were obtained at each timepoint. Volumetric analysis of adenoid and palatine tonsils was performed using a combination of bony and soft tissue landmarks in CBCT scans through Anatomage Invivo 6 imaging software. Paired t-tests were used to evaluate the difference between the initial and final adenoid and tonsil volumes. p values less than 0.05 were considered statistically significant. RESULTS: Compared to the control group, the expansion group experienced a statistically significant decrease in both adenoid and tonsil volume. There was non-statistically significant increase in volume from T1 to T2 for the control group. For the expansion group, 90.0% and 97.5% of patients experienced significant reduction in adenoid and tonsil volume, respectively. The average volume decrease of adenoids was 16.8% while that of tonsils was 38.5%. The patients had up to 51.6% and 75.4% reduction in adenoid and tonsil size, respectively, following RPE orthodontic treatment. Pearson correlation ranged from 0.88 to 0.99 for each measurement, representing excellent internal consistency. There was a significant reduction in the PSQ scores from 5.81 ± 3.31 to 3.75 ± 2.38 in expansion group (p < 0.001). CONCLUSIONS: Our results demonstrated that RPE significantly reduced the size of both adenoid and palatine tonsils and revealed another long-term benefit of RPE treatment. To our knowledge, this is the first study to quantify the changes of adenoids and tonsils following RPE. RPE treatment can be considered as a valid and effective treatment option for pediatric OSA population with narrow high arch palate and adenotonsillar hypertrophy.

Holistic care for obstructive sleep apnea (OSA) with an emphasis on restoring nasal breathing: A review and perspective.

Obstructive sleep apnea (OSA) is characterized by partial or complete airway blockage during sleep. Nocturnal nasal obstruction usually leads to mouth breathing while sleeping, which worsens sleep apnea by aggravating tongue base and lateral pharyngeal wall collapse. The pathogenesis of OSA is multifactorial, and the precipitating factors vary significantly among individuals. Although continuous positive airway pressure (CPAP) is considered the first-line therapy for OSA, its adherence rate remains a challenge. Oral appliances are more suitable for simple snorers or patients with mild OSA. Maxillomandibular advancement (MMA) is highly effective for treating those with mandibular retrognathia and moderate-to-severe OSA. Intrapharyngeal surgeries yield favorable outcomes in patients with large tonsils and low tongue resting position (Friedman Stage I); however, their efficacy declines with time. Each therapy has its own strength and weakness; thus, the principle of multimodality treatment should be adopted. Nasal surgery plays an indispensable role in the holistic care for OSA. In addition to alleviating nasal congestion, nasal surgery significantly reduces snoring intensity and daytime sleepiness, which improves the quality of life of patients with OSA. Although it significantly reduces the respiratory disturbance index, its effect on the apnea-hypopnea index remains controversial. A combination of nasal surgery and multilevel pharyngeal surgery may result in better prognosis. Nasal surgery can significantly reduce the therapeutic pressure and improve the CPAP compliance of patients undergoing CPAP therapy. In conclusion, multimodality treatment and holistic care for OSA should involve nasal surgery for optimizing treatment outcomes.

A Comprehensive Strategy for Improving Nasal Outcomes After Large Maxillomandibular Advancement for Obstructive Sleep Apnea.

Background: Rate of corrective nasal surgery after maxillomandibular advancement (MMA) for obstructive sleep apnea (OSA) has been reported to be 18.7% for functional and aesthetic indications. Objective: Describe a comprehensive strategy to optimize nasal outcomes with MMA for OSA. Methods: A retrospective review of patients undergoing MMA for OSA in a tertiary referral center was performed, with a comprehensive perioperative intervention to optimize nasal outcomes from January 2014 to February 2018. Outcomes included the Apnea-Hypopnea Index (AHI), oxygen saturation (SpO2) nadir, corrective nasal surgery needed after MMA, and Nasal Obstruction Symptom Evaluation (NOSE) scores. Results: AHI after MMA showed significant reduction (-34.65, p < 0.001), SpO2 nadir increased (+6.08, p < 0.001), and NOSE scores decreased (-5.96, p < 0.001). Corrective nasal surgery needed after MMA was reported in 6.5% (8 of 122) subjects at a mean of 8.5 months, ranging from 1 to 24.7 months. Six subjects underwent either septoplasty and/or valve stenosis repair, and two subjects underwent functional and aesthetic rhinoplasty. Conclusion: A perioperative strategy was applied since 2014 that showed effectiveness in reducing post-MMA corrective nasal surgery to 6.5%.

Deep Neck Infection Risk in Patients with Sleep Apnea: Real-World Evidence.

(1) Background: Sleep apnea may be a risk factor for deep neck infection (DNI). The objective of this study was to investigate the effects of sleep apnea on DNI. (2) Methods: In this first nationwide retrospective cohort study on the sleep apnea-DNI correlation, we obtained data from the Longitudinal Health Insurance Database 2005, a subset of the Taiwan National Health Insurance Research Database. Patients who were newly diagnosed with sleep apnea between 1997 and 2012 were identified, and patients without sleep apnea were matched at a 1:4 ratio in age, sex, socioeconomic status, and urbanization level. The primary outcome of this study was DNI occurrence. The treatment modalities for sleep apnea and the comorbidities that occurred during the study period were also analyzed. (3) Results: Our sleep apnea and comparison (non-sleep apnea) cohorts comprised 6114 and 24,456 patients, respectively. We compared the cumulative incidence of DNI between these cohorts and found a greater incidence of DNI in the sleep apnea cohort (p < 0.001). A strong sleep apnea-DNI association was found following analysis via the adjusted Cox proportional-hazards model (full model hazard ratio, 1.71; 95% confidence interval, 1.28-2.28; p < 0.001). In the subgroup analysis, sleep apnea increased DNI risk in men, in those aged < 50 years, and in those without diabetes mellitus, end-stage renal disease, liver cirrhosis, autoimmune disease, obesity, tonsillectomy, or adenotonsillectomy. (4) Conclusions: Our results confirmed sleep apnea to be an independent risk factor for DNI. Physicians should be aware of the potential occurrence of DNI in patients with sleep apnea.

Distraction Osteogenesis Maxillary Expansion (DOME) for adult obstructive sleep apnea patients with narrow maxilla and nasal floor.

OBJECTIVES: This study correlates objective and subjective measurements associated with obstructive sleep apnea (OSA) to define the efficacy of Distraction Osteogenesis Maxillary Expansion (DOME) to treat adult OSA patients with narrow maxilla and nasal floor. METHODS: This is a retrospective study reviewing cases from September 2014 through April 2018 with 75 eligible subjects. Inclusion criteria required OSA confirmed by attended polysomnography (PSG). Pre- and Post-operative clinical data were measured at the Stanford Sleep Medicine and Stanford Sleep Surgery Clinics. DOME is a two-step process starting with insertion of custom-fabricated maxillary expanders anchored to the hard palate by mini-implants followed by minimally invasive osteotomies. After maxillary expansion was complete, orthodontic treatment to restore normal occlusion was initiated. Perioperative Apnea-Hypopnea Index (AHI), Epworth Sleepiness Scale (ESS), Nasal Obstruction Symptom Evaluation (NOSE), and Oxygen Desaturation Index (ODI) were measured for 43, 72, 72, and 34 subjects respectively. Statistical analysis was performed using paired T-test with significance set at p-value < 0.05. RESULTS: The mean age of test subjects was 30.5 ± 8.5 years with a gender distribution of 57 males and 18 females. There was a significant reduction in pre and post-operative NOSE score (10.94 ± 5.51 to 3.28 ± 2.89, p < 0.0001), mean ESS score (10.48 ± 5.4 to 6.69 ± 4.75, p < 0.0001), and AHI (17.65 ± 19.30 to 8.17 ± 8.47, p < 0.0001) with an increased percentage of REM sleep (14.4 ± 8.3% to 22.7 ± 6.6%, p = 0.0014). No significant adverse effects were identified. CONCLUSIONS: DOME treatment reduced the severity of OSA, refractory nasal obstruction, daytime somnolence, and increased the percentage of REM sleep in this selected cohort of adults OSA patients with narrow maxilla and nasal floor.