International Consensus Statement on Obstructive Sleep Apnea.

BACKGROUND: Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA). METHODS: Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus. RESULTS: The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated. CONCLUSION: This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Contributions of the Melanopsin-Expressing Ganglion Cells, Cones, and Rods to the Pupillary Light Response in Obstructive Sleep Apnea.

Purpose: To investigate the impact of obstructive sleep apnea (OSA) on the contribution of inner and outer retinal photoreceptors to the pupillary light response (PLR). Methods: Ninety-three eyes from 27 patients with OSA and 25 healthy controls were tested. OSA severity was graded according to the apnea-hypopnea index. PLR was measured monocularly with an eye tracker in a Ganzfeld in response to 1-second blue (470 nm) and red (640 nm) flashes at -3, -2, -1, 0, 1, 2, and 2.4 log cd/m2. Peak pupil constriction amplitude, peak latency, and the postillumination pupil response were measured. The Cambridge Colour Test, standard automatic perimetry, spectral domain optical coherence tomography, polysomnography, and the Pittsburgh Sleep Quality Index were used. Results: OSA patients have a significantly decreased peak pupil constriction amplitude for blue stimuli at -3, -2, -1, 1 log cd/m2 and at all red flash luminances (P < 0.050), revealing reduction of outer retina contributions to PLR. OSA patients showed reduced peak latency for blue (-2, 0, 2, 2.4 log cd/m2) and red stimuli (-2, 0 log cd/m2; P < 0.040). No significant difference was found in the melanopsin-mediated PLR. Conclusions: This study is the first to evaluate the inner and outer retinal contributions to PLR in OSA patients. The results showed that the outer retinal photoreceptor contributions to PLR were affected in moderate and severe OSA patients. In contrast, the inner retina contributions to PLR are preserved.

Lateral pharyngoplasty reduces nocturnal blood pressure in patients with obstructive sleep apnea.

OBJECTIVES/HYPOTHESIS: To compare the values of 24-hour ambulatory blood pressure monitoring (ABPM) in patients with obstructive sleep apnea (OSA), before and after lateral pharyngoplasty, and to investigate the influence of pre- and post-treatment polysomnographic and anthropometric variations on changes in ABPM. STUDY DESIGN: Prospective study. METHODS: Arterial blood pressure with 24-hour ABPM and nocturnal polysomnography were measured before and 6 months after surgery in 18 consecutively evaluated adults with OSA at a tertiary center. RESULTS: A total of 83.3% were normotensive patients. Nocturnal measurements showed a decrease of 5.3 mmHg in mean arterial pressure (MAP; P = .01), 7.4 mmHg in mean arterial systolic pressure (SP; P = .006), and 4.2 mmHg in mean arterial diastolic pressure (DP; P = .03), leading to significant reductions in all 24-hour measurements: 3.6 mmHg in MAP, 4.8 mmHg in SP, and 2.9 mmHg in DP. There were also significant mean reductions in the apnea-hypopnea index (AHI), from 33.5 to 20.9 (P = .02), arousal index, from 31.6 to 16.7 (P = .005), and percentage of total sleep time with oxyhemoglobin saturation < 90%, from 10.6% to 0.9% (P = .008). No correlations were noted between the measurements of arterial blood pressure and polysomnographic or anthropometric variations. CONCLUSIONS: In this small case series, lateral pharyngoplasty reduced the values obtained in the 24-hour ABPM due to a significant reduction of blood pressures during sleep in patients with OSA 6 months after surgery. Although the patients presented with reductions in AHI, arousals, and desaturation time, this was not correlated with the improvement in arterial blood pressure.

The extracellular matrix of the lateral pharyngeal wall in obstructive sleep apnea.

STUDY OBJECTIVES: To compare the components of the extracellular matrix in the lateral pharyngeal muscular wall in patients with and without obstructive sleep apnea (OSA). This may help to explain the origin of the increased collapsibility of the pharynx in patients with OSA. DESIGN: Specimens from the superior pharyngeal constrictor muscle, obtained during pharyngeal surgeries, were evaluated using histochemical and immunohistochemical analyses to determine the fractional area of collagen types I and III, elastic fibers, versican, fibronectin, and matrix metalloproteinases 1 and 2 in the endomysium. SETTING: Academic tertiary center. PATIENS: A total of 51 nonobese adult patients, divided into 38 patients with OSA and 13 nonsnoring control subjects without OSA. INTERVENTIONS: Postintervention study performed on tissues from patients after elective surgery. MEASUREMENTS AND RESULTS: Pharyngeal muscles of patients with OSA had significantly more collagen type I than pharyngeal muscles in control subjects. Collagen type I was correlated positively and independently with age. The other tested components of the extracellular matrix did not differ significantly between groups. In a logistic regression, an additive effect of both the increase of collagen type I and the increase in age with the presence of OSA was observed (odds ratio (OR), 2.06; 95% confidence interval (CI), 1.17-3.63), when compared with the effect of increased age alone (OR, 1.11; 95% CI, 1.03-1.20). CONCLUSION: Collagen type I in the superior pharyngeal constrictor muscle was more prevalent in patients with OSA and also increased with age. It was hypothesized that this increase could delay contractile-relaxant responses in the superior pharyngeal constrictor muscle at the expiratory-inspiratory phase transition, thus increasing pharyngeal collapsibility.

Papiloma escamoso de orelha média: relato de um caso e revisão da literatura

O papiloma escamoso é uma neoplasia benigna. A ocorrência de lesão isolada de orelha média é rara, sendo mais comumente encontrada em associação à patologia nasossinusal. Os autores relatam um caso de papiloma escamoso acometendo apenas orelha média e discutem seus aspectos diagnósticos.

[Middle ear squamous papilloma: report of a case and literature review]. / Papiloma escamoso de orelha média: relato de um caso e revisão da literatura.

Squamous papillomas are benign neoplasms. The occurrence of middle ear squamous papilloma is rare. It is usually associated with nasosinusal pathology. The authors report a case of middle ear squamous papilloma and discuss its diagnostic aspects.

Endoscopia do meato acústico interno pelo acesso retrolabiríntico / Endoscopy of the internal auditory canal through the retrolabyrinthine approach

O acesso direto à região do ângulo pontocerebelar pela via retrolabiríntica é seguro, entretanto, não permite a visão direta de todo o meato acústico interno (MAI) pela otomicroscopia. Os endoscópios podem ser utilizados na exploração do MAI por esta via. OBJETIVO: Nosso objetivo é avaliar a capacidade de inspeção do MAI com endoscópios de diferentes angulações. FORMA DE ESTUDO: Estudo anatômico. MATERIAL E MÉTODO: Estudamos 40 ossos temporais humanos nos quais realizamos acessos retrolabirínticos. Nestes ossos, medimos as distâncias ocultas do MAI, em seus quatro quadrantes, utilizando o microscópio cirúrgico e os endoscópios de 0°, 30° e 70°. RESULTADOS: Observamos que as distâncias ocultas medidas foram diminuindo, com significância estatística, conforme o instrumento utilizado, nesta seqüência: microscópio, endoscópio de 0°, 30° e 70°. Somente o endoscópio de 70° permitiu a visão do fundo do MAI em todos os quadrantes, o que ocorreu em 27,5 por cento dos casos. A visão parcial do fundo do MAI foi obtida em 67,5 por cento dos ossos com o endoscópio de 70° e em 12,5 por cento com o endoscópio de 30°, não tendo sido obtida em nenhum caso com o uso do endoscópio de 0° ou do microscópio. As médias de distâncias ocultas no quadrante ântero-superior, medidas com o microscópio e endoscópios de 0°, 30° e 70° foram respectivamente: 10,4mm, 7,3mm, 4,3mm e 1,1mm. CONCLUSÕES: O endoscópio de 70° demonstrou ser significativamente superior aos demais instrumentos na inspeção do MAI e sugerimos que ele seja considerado o instrumento de escolha na inspeção do MAI nos acessos retrolabirínticos.

Lateral pharyngoplasty versus uvulopalatopharyngoplasty: a clinical, polysomnographic and computed tomography measurement comparison.

STUDY OBJECTIVE: To compare the lateral pharyngoplasty procedure with uvulopalatopharyngoplasty (UPPP) in the treatment of obstructive sleep apnea hypopnea syndrome (OSAHS). DESIGN: Prospective randomized study. SETTING: Academic tertiary center. PATIENTS: Twenty-seven adults with OSAHS originally selected for treatment with UPPP. INTERVENTIONS: Patients were randomly assigned to 2 groups: in one group, we performed the lateral pharyngoplasty (15 cases), and in the other, we did the UPPP (12 cases). MEASUREMENTS AND RESULTS: We compared treatment outcomes through the evaluation of OSAHS-related symptoms and the analysis of polysomnographic tests and computed tomography measurements of pharyngeal airway. The lateral pharyngoplasty group achieved a statistically greater reduction in body weight, excessive daytime sleepiness, and apnea-hypopnea index. In addition, only in this group did we observe a statistically significant increase in the amount of deep sleep stages and improvement in morning headaches. Patients from the UPPP group did not present significant changes in the polysomnographic parameters. Pharyngeal airway measurement outcomes were similar in both groups and did not reflect the clinical and polysomnographic differences we observed. CONCLUSIONS: Lateral pharyngoplasty produces better clinical and polysomnographic outcomes in the treatment of OSAHS than does UPPP, without resultant differences in the cross-sectional measurements of the pharyngeal airway between these treatments.

Lateral pharyngoplasty: a new treatment for obstructive sleep apnea hypopnea syndrome.

OBJECTIVE: The role of the lateral pharyngeal muscular walls in the pathogenesis of obstructive sleep apnea hypopnea syndrome (OSAHS) is crucial. My objective is to describe a surgical procedure for splinting the lateral pharyngeal walls in patients with OSAHS and report the initial results. STUDY DESIGN: Prospective randomized pilot study performed in an academic tertiary center as part of a doctoral thesis. PATIENTS AND METHODS: Ten adults with OSAHS, originally selected for treatment with uvulopalatopharyngoplasty, underwent the lateral pharyngoplasty procedure, which consists of a microdissection of the superior pharyngeal constrictor muscle within the tonsillar fossa, sectioning of this muscle, and suturing of the created laterally based flap of that muscle to the same-side palatoglossus muscle. In addition, a palatopharyngeal Z-plasty is performed to prevent retropalatal collapse. RESULTS: Lateral pharyngoplasty improved sleep and daytime symptoms related to OSAHS. After at least 6 months of follow-up, the median apnea-hypopnea index decreased from 41.2 to 9.5 (P =.009) and the median total sleep time spent in rapid eye movement (REM) sleep and in stages 3 plus 4 non-REM sleep increased from 14.1% to 22.1% (P =.059) and from 5.3% to 16.3% (P =.037), respectively. Also, there was statistically significant improvement in snoring, daytime sleepiness, and overall impact of the disease on quality of life. Swallowing disturbances lasted a median of 14.5 days after the surgeries, and all patients returned to normal subjective swallowing function in the follow-up. CONCLUSIONS: Lateral pharyngoplasty is a safe and straightforward approach to lateral pharyngeal muscles and has produced appreciable benefits for OSAHS patients.

Cistos supraglóticos de laringe: aspectos etiológicos, clínicos e terapêuticos / Supraglottic cysts of the larynx: ethiologic, clinical and therapeutical aspects

Objetivo: O objetivo deste trabalho foi o de estudar o diagnóstico, etiologia, evoluçäo e tratamento de pacientes com cistos ductais e saculares de laringe na Divisäo de Clínica Otorrinolaringológica do Hospital das Clínicas da Faculdade de Medicina da Universidade de Säo Paulo. Forma de estudo: Clínico randomizado. Material e método: Procurou-se enfatizar a populaçäo em que säo mais prevalentes, o quadro clínico, a terapêutica e seus resultados. Foram analisados 19 pacientes, mostrando que a apresentaçäo inicial dos cistos pode consistir desde sintomas comuns ao otorrinolaringologista até obstruçäo respiratória grave. Conclusäo: É necessário, portanto, o conhecimento do especialista acerca dessa patologia, no sentido de realizar o diagnóstico adequado e adotar a conduta que proporcione o melhor prognóstico ao seu paciente