[Oral appliances or maxillomandibular advancement osteotomy for severe obstructive sleep apnoea in patients refusing CPAP]. / Orthèse d'avancée mandibulaire ou ostéotomie maxillo-mandibulaire pour le traitement des syndromes d'apnées obstructives du sommeil sévères refusant la PPC.

OBJECTIVES: The management of patients with severe obstructive sleep apnea syndrome (OSAS) refusing or not tolerating continuous positive pressure ventilation (CPAP) remains problematic. We evaluated the effectiveness of oral appliances and of maxillomandibular advancement osteotomy. METHODS: One hundred and two patients with severe OSAS were included between 2001 and 2006. Maxillo-mandibular advancement osteotomy was proposed to patients less than 60 years of age, non obese and without comorbidities. The other patients were treated with oral appliances. All patients underwent polysomnography at 3 months. RESULTS: Group A: 25 patients with mean apnea-hypopnea index (AHI) at 45/h were treated by maxillo-mandibular advancement. Three months after the surgery, AHI had decreased from 45 to 7. The success rate was 89% when AHI was less than 15/h and 74% when AHI was less than 10/h. Sixteen patients performed a polysomnography one year after surgery with similar results. There were no major postoperative complications. Group B: 77 patients with a mean AHI at 41/h were treated with oral appliances. Only 23 patients underwent polysomnography at 3 months. The mean AHI had decreased from 41/h to 22/h. The success rate was 56% when AHI was less than 15/h and 30% when AHI was less than 10/h. DISCUSSION: We are confronted with an increasing number of severe OSAS patients with CPAP failure or intolerance. Surgery for maxillo-mandibular advancement is an effective alternative. However, it is not always indicated or accepted by the patient. So an oral appliance remains a useful therapeutic option despite its moderate success rate.

Non-CPAP therapies in obstructive sleep apnoea.

In view of the high prevalence and the relevant impairment of patients with obstructive sleep apnoea syndrome (OSAS) lots of methods are offered which promise definitive cures for or relevant improvement of OSAS. This report summarises the efficacy of alternative treatment options in OSAS. An interdisciplinary European Respiratory Society task force evaluated the scientific literature according to the standards of evidence-based medicine. Evidence supports the use of mandibular advancement devices in mild to moderate OSAS. Maxillomandibular osteotomy seems to be as efficient as continuous positive airway pressure (CPAP) in patients who refuse conservative treatment. Distraction osteogenesis is usefully applied in congenital micrognathia or midface hypoplasia. There is a trend towards improvment after weight reduction. Positional therapy is clearly inferior to CPAP and long-term compliance is poor. Drugs, nasal dilators and apnoea triggered muscle stimulation cannot be recommended as effective treatments of OSAS at the moment. Nasal surgery, radiofrequency tonsil reduction, tongue base surgery, uvulopalatal flap, laser midline glossectomy, tongue suspension and genioglossus advancement cannot be recommended as single interventions. Uvulopalatopharyngoplasty, pillar implants and hyoid suspension should only be considered in selected patients and potential benefits should be weighed against the risk of long-term side-effects. Multilevel surgery is only a salvage procedure for OSA patients.

The vascular system of the upper eyelid. Anatomical study and clinical interest.

Thorough knowledge of the vascular supply is indispensable for repair and oncologic surgery of the eyelids, and has a significant impact on the management of complex defects of this region. This anatomic study was performed with five fresh cadavers after arterial injection of coloured neoprene latex. The distribution of the vascular system of the upper eyelid was examined after dissection and photographic study. It is made up of three arcades: the preseptal arcade, the supratarsal arcade, and the marginal arcade, under the orbicularis oculi muscle. These arcades are supplied by branches of the ophthalmic artery (supraorbital artery, supratrochlear artery and medial palpebral artery) and branches of the facial artery and temporal artery. Small vertical branches arising out of these arcades provide an anastomotic network. This anatomical study aimed to describe the vascular system of the upper eyelid in order to search for constant features and to map the blood supply of the principal upper lid flaps.

[Osirix: free and open-source software for medical imagery]. / Osirix: logiciel libre d'imagerie médicale.

Osirix is a tool for diagnostic imagery, teaching and research tasks, which presents many possible applications in maxillofacial and oral surgery. It is a free and open-source software developed on Mac OS X (Apple) by Dr Antoine Rosset and Dr Osman Ratib, in the department of radiology and medical computing of Geneva (Switzerland).

[Neurosensory disorders and functional impairment after bilateral sagittal split osteotomy: role of the anatomical situation of the alveolar pedicle in 76 patients]. / Troubles de la sensibilité consécutifs aux ostéotomies sagittales des branches montantes de la mandibule: rôle de la position du pédicule alvéolaire chez 76 patients.

INTRODUCTION: Bilateral sagittal split osteotomy (BSSO) of the mandibular ramus is the most frequent orthognatic surgery. The risk of neurosensory disorders remains high even their incidence varies according to numerous publications. The anatomical location of the alveolar pedicle seems to be one of the most important factors in these disorders. The aim of this study was to determine its exact role. MATERIAL AND METHOD: We performed a retrospective study on 76 patients and 152 osteotomy sides, all of them operated according to the Epker technique by the same surgeon between 2000 and 2004. For each operative side we noted the position of the inferior alveolar nerve during the split: Type I entirely in the internal cortical bone, Type II partially in the external cortical bone, Type III mostly or completely in the external cortical bone. The neurosensory disorders were recorded during clinical examination and simply classified into two categories: "absent" or "present". The outcome was noted during the postoperative follow-up at D1; D15; M1,5, M6, and M12. After that, it was documented through a written questionnaire or telephone conversation. RESULTS: Since there was no difference between the right and the left sides, the study enclosed all of the operative sides together (152). The anatomical distribution was: 97 Type I (63.8%), 28 Type II (18.4%), and 27 Type III (17.8%). Immediate postoperative neurosensory disorders (D1) occurred on 74.3% of sides, with important significant differences between Type I (64.9%) on one hand, Type II (89.2%) and Type III (92.6%) on the other hand. At one year of follow-up, the rate of neurosensory disorders was 20.4% with also a difference between Type I (13.4%) and Types II and III (35.7% and 29.6%). DISCUSSION: The anatomical location of the alveolar pedicle seems to be important. This study confirms previously published studies and raises the question of CT scan assessment before performing BSSO.

[Evulsion of the optic nerve, a diagnosis to be recognised!]. / L'avulsion du nerf optique, un diagnostic à connaître!

INTRODUCTION: Evulsion of the optic nerve is a rare but serious injury. It occurs generally after an ocular contusion and may cause blindness. CASE: We report the case of a 53-year-old woman who presented with a blunt ocular trauma after having been punched by her husband. Initial examination of the left eye was impossible due to a major palpebral oedema. A CT scan of the orbit revealed a thickened optic nerve. No improvement was noted. DISCUSSION: Optic nerve avulsion is often caused by sudden and forceful rotation of the eye with tearing of the optic nerve as its globe entry level. The diagnosis can be confirmed by examination of the ocular fundus or by medical imaging such as CT scan of the orbital cavity as in our case report. The prognosis is usually poor.

Vascular territories of the tongue: anatomical study and clinical applications.

The goal of this cadaver study has to propose the concept of angiosomes of the tongue (arterial cartography) from the notion of lingual artery segmentation, known in the literature since 1998. Fifteen fresh cadaver heads were used in this study. Four selective ink injections were made in specific location of the lingual artery like the segmentation concept. Three mucosal territories of the tongue were defined and they appear dependent on the precise segments of the lingual artery. The territory of the deep lingual artery is the dorsal side of the tongue, the territory of the sublingual artery is the ventral side and the territory depending of the dorsal artery is the root of tongue. No study was published yet about the vascular territories of the tongue. This study brings an additional knowledge and a review about the vascular risk of the tongue resections. The originality of this study consists of the description of vascular territories of tongue proceeding to different segment of lingual artery, which has not been described in the literature since now. The knowledge of these two notions is useful before every tongue resection, which can compromise the vascularity of the remaining tongue, and at the time of the lingual revascularization, once this vascularity is compromise.

[Mandibular advancement surgery in patients with severe obstructive sleep apnea uncontrolled by continuous positive airway pressure. A retrospective review of 25 patients between 1998 and 2004]. / Prise en charge par chirurgie d'avancée des maxillaires des patients porteurs d'un syndrome d'apnées du sommeil sévère en échec d'un traitement par pression positive continue: étude rétrospective de 25 patients entre 1998 et 2004.

INTRODUCTION: Continuous positive airway pressure (CPAP) is ineffective in some patients with obstructive sleep apnoea syndrome (OSAS) and some patients do not tolerate it. This study evaluated the outcomes of maxillo-mandibular advancement in OSAS patients without morbid obesity or severe maxillo-mandibular deformity who had first been treated with CPAP for at least 6 months. METHODS: A retrospective study reporting on the experience of the CHU Toulouse Rangueil sleep disorder centre between 1998 and 2004. We performed polysomnography and cephalometry before and 3 months after surgery. RESULTS: 25 male patients with mean apnoea hypopnoea index at 45/hour (+/-15) were treated by maxillo-mandibular advancement. The mean age of participants was 48 years (+/-7), and the mean body mass index was 28 kg/m2 (+/-3.4). Cephalometry demonstrated a retroposition of the mandible (SNB < 80 degrees +/-5) and narrow linguopharyngeal space (ELP = 8 mm+/-3). 3 months after surgery the apnoea hypopnoea index (AHI) had decreased from 45+/-15 to 7+/-7 (p < 0.0001), the Epworth sleepiness scale decreased from 11+/-5 to 6+/-4 (p < 0.01). The linguopharyngeal space was larger (ELP = 14 mm). Success rate defined as an AHI < 15/hour was 89%, and 74% for an AHI < 10/hour. 16 patients underwent polysomnography one year after surgery. The results were the same. There were no post surgical complications, except for one patient who developed permanent labial hypoesthesia. CONCLUSIONS: Maxillo-mandibular advancement seems to be an effective 2nd line therapy for the treatment of severe OSAS.

Pseudoaneurysm of internal carotid artery following mandibular reconstruction treated by covered stent.

SUMMARY: We describe the case of a 68-year-old woman who had a mandibular titanium plate reconstruction following surgery for a parotid carcinoma. Fifteen months later she presented bleeding episodes related to a pseudoaneurysm of the internal carotid artery located just above the bulb. This was probably related to the weakening of the arterial wall following friction with the mandibular plate and radiotherapy.We successfully obliterated this pseudoaneurysm using a covered stent. This rare diagnosis should be evoked in case of bleeding following a mandibular reconstruction. Stenting is an effective treatment strategy obviating the need for open surgery.

Maxillofacial intraoral distraction osteogenesis followed by elastic traction in cleft maxillary deformity.

We present a case of severe maxillary hypoplasia in a 16 years old cleft patient treated by distraction osteogenesis maxillary advancement. Initial evaluation showed vertical and antero-posterior maxillary deficiencies, and a Class III malocclusion. Two intraoral distractors (Zurich Pediatric Maxillary Distractor, KLS Martin, Tuttlingen, Germany) were placed in a high Le Fort I osteotomy. An initial advancement of 11 mm was obtained, but the resulting occlusion was unsatisfactory (end-to-end occlusion). The consolidation period was reduced to 3 weeks to allow the mechanical manipulation of the newly formed bone with Class III elastics. An additional advancement of 3 mm, caused by elastic orthodontic traction produced both normal skeletal relationship and satisfactory occlusion. This observation shows that it is possible to carry on a skeletal maxillary displacement by interdental elastics before the complete fusion of the callus. After 12 months of postoperative follow-up no osseous relapse could be detected and the occlusal result was stable.

[Clinical significance of the Krogh-Poulsen bite test in mandibular dysfunction]. / Signification sémiologique du test de Krogh-Poulsen dans les dysfonctions mandibulaires.

INTRODUCTION: The bite test was initially described as the Krogh-Poulsen test consists of biting a flat and thin wedge placed unilaterally between the molars. Temporomandibular joint (TMJ) pain located on the ipsilateral side is considered as muscular, when on the contralateral side pain signifies a joint problem. Although this test is widely used, no scientific evaluation of its real clinical value has been published. MATERIAL AND METHOD: A prospective study is conducted in 32 patients exhibiting temporomandibular pain (n=40) at the bite test. The results of the bite test were compared with results of computed tomography of the TMJ. Several criteria are studied: joint space narrowing, retrusion of the mandibular condyle in occlusal position, bony signs of joint degeneration. Chi-square and Student's t test were used for statistical analysis of correlations between clinical findings and radiological abnormalities. RESULTS: Significant results demonstrated a high degree of radiologically detectable disorders in patients with joint pain as defined by the bite test. All of these patients presented at least one radiological sign of joint disease. There was also a low degree of radiologically detected joint disturbance in patients with muscular pain according to the bite test, 70% of them presenting no radiological abnormality. DISCUSSION: It is concluded that the bite test is of significant value for evaluation of TMJ disorders and can be useful for the indication of complementary radiological examinations.

Symptomatic macroglossia and tongue myositis in polymyositis: treatment with corticosteroids and intravenous immunoglobulin.

Symptomatic macroglossia occurs in some rare congenital muscle diseases, such as Becker's and Duchenne's dystrophies or Pompe's disease. Herein we describe a case of symptomatic macroglossia with myositis of the tongue occurring in a patient with polymyositis. Tongue myositis was evidenced by dysarthria, frequent biting during mastication, swallowing difficulties without aspiration, and noisy breathing. Magnetic resonance imaging showed homogeneous hypertrophy of the tongue, especially the mouth's floor muscles. The diagnosis of tongue myositis was established by electromyography and biopsy. No other cause for the macroglossia was found. Symptoms resolved quickly with corticosteroid and intravenous immunoglobulin treatment. To our knowledge, this is the first reported case of symptomatic tongue myositis occurring in the course of polymyositis.

[Our experience with geniopexy in the treatment of OSAS]. / Notre expérience de la géniopexie dans le traitement du SAHOS.

OBJECTIVE: We examine geniopexy efficacy in OSAS treatment. STUDY DESIGN: Seven patients, aged 36 to 61 years, were studied. The mean body mass index was normal. RESULTS: Surgical late complications (modified symphysis proprioception) occurred in 4 patients. No patient was improved in sleep problems. Retromaxilly and retromandibuly were found in all patients by cephalometric study. DISCUSSION: Our results are quite different from these described successfully by other centers. Geniopexy do not move maxillar and mandibular skeletal bones, which are retruded in our serie. This explains maybe our bad results. Actually, we propose for this patients maxillo-mandibular advancement.

Craniofacial differences according to the body mass index of patients with obstructive sleep apnoea syndrome: cephalometric study in 85 patients.

We examined the craniofacial characteristics of patients with obstructive sleep apnoea syndrome (OSAS) and correlated them with the body mass index (BMI (weight (kg) x height (m2)). Eighty-five men with OSAS diagnosed by conventional polysomonography were divided into two groups according to their BMI (< 30 and > or = 30). Cephalometry was analysed by using 31 measurements of the size of the bone structures, their relationships and the size of the airways. The groups were comparable for age and the apnoea-hypopnoea index (mean 49, standard deviation (SD) 23). Patient with a BMI < 30 had a shorter anterior floor of cranial base, a smaller mandible and retroposition of the mandible compared with severly obese patients. These skeletal differences were associated with narrower velopharyngeal and linguopharyngeal spaces. This study sh ows that there is a craniofacial difference between two populations, divided according to their BMI.

[Comparison of the cephalometric characteristics of snoring patients and apneic patients as a function of the degree of obesity. Apropos of 162 cases]. / Comparaison des caractéristiques céphalométriques de patients ronfleurs et apnéiques en fonction du degré d'obésité. A propos de 162 cas.

BACKGROUND: The purpose of our study was to compare cephalometric analysis of craniofacial features in normal weight or obese subjects who are habitual snorers or apneic. We conducted a retrospective comparison of their clinical and cephalometric features by degree of obesity. PATIENTS AND METHODS: One hundred and sixty two male subjects with obstructive sleep apnea syndrome (OSAS) diagnosed by conventional polysomnography were included in the study. Patients were divided into four groups according to their body mass index (BMI) and their apnea/hypopnea index (AHI: Group 1 = normal-weight snorers (34 patients), Group 2 = normal-weight apneic subjects (40 patients), Group 3 = obese snorers (20 patients), Group 4 = obese apneic subjects (68 patients). Lateral cephalometry was performed in all patients. Intergroup comparisons (2/4, 1/2, 3/4) were made using 32 parameters to study the influence of the size of bone structures, their relationships, and size of the upper airways. RESULTS: The four groups were comparable for age. AHI was higher for group 4 (obese apneic) compared with group 1 (normal-weight snorers). Compared with group 3 (obese snorers), group 1 (normal-weight snorers) had a retroposition of the mandible (smaller SNB and ANB angle), an accentuated facial divergence and a narrower pharyngeal space at the hyoid bone level. Compared with group 1 (normal-weight snorers), group 2 (normal-weight apneic) had a narrower pharyngeal space at different levels. Compared with group 3 (obese snorers), group 4 (obese apneic) had a lower hyoid bone evaluated with different cephalometric variables. CONCLUSION: This study mainly shows that apneic patients exhibit craniofacial differences when divided into two groups according to their body mass index. Our findings are consistent with previous reports and could suggest a dual etiology of OSAS.

[Upper airway changes after mandibular setback osteotomy. Concerns for obstructive sleep apnea]. / Modification des voies aériennes supérieures après ostéotomie de recul mandibulaire. Intérêt en pathologie obstructive du sommeil.

INTRODUCTION: Cases of obstructive sleep apnea syndrome have been described after setback osteotomy. Although such cases are rare, they emphasize the importance of taking into account the structure of the upper airways when performing this type of procedure. We studied the modifications provoked in the upper airways by mandibular setback osteotomy performed for dysmorphism. MATERIAL AND METHOD: We conducted a retrospective cephalometric study in a series of 25 patients. Preoperative and late postoperative films were digitalized to obtain a precise measurement of the bone displacements and changes in the caliber of the retrovelar and retrolingual spaces. The statistical analysis examined the parameters modified by surgery, particularly airway parameters, and those factors which influenced these modifications. RESULTS: We observed a reduction in the retrolingual space [mean 1.7 mm (p < 0.05)] and displacement of the hyoid bone [mean 2 mm lowering compared with the bi-spinal plane (p < 0.05) and 4.1 mm setback in the Francfort projection (p < 0.01)]. These modifications were not correlated with the mandibular setback (measured as the gonial mental angle) but were strongly dependent on variations in the gonial angle. In 20% of the cases, mandibular setback produced a paradoxical effect: enlargement of the airways. DISCUSSION: Little work has been done on the modifications in the upper airways provoked by osteotomies. Mandibular setback osteotomy can, though only a few cases have been reported, create an anatomic situation favoring obstructive sleep apnea. This series demonstrated the very wide variability of the effects on the upper airways. CONCLUSION: The risk of apnea should be included as an important parameter in assessing indications for setback osteotomy.

[Results of 248 patients with sleep apnea syndrome treated by continuous positive pressure ventilation between 1990 and 1995. A study of compliance and outcome of the apnea-hypopnea index]. / Suivi de 248 patients présentant un syndrome d'apnée du sommeil traités par pression positive continue entre 1990 et 1995. Etude de l'observance et du devenir de l'index d'apnée-hypopnée.

Between 1990 and 1995, 369 patients were investigated for obstructive sleep apnea syndrome (OSAS) by polysomnography. Among them, 248 patients with a mean Apnea-Hyponea index (AHI) of 37.7 per hour were treated by nasal continuous positive airway pressure (n-CPAP). Mean follow up was 39.5 +/- 20.4 months. In this group, 23 patients (9.2%) refused nCPAP immediately or after the first night and 39 (15.7%) gave up later. 15 patients (6%) died during the period of the study. The cumulative compliance reached 70% at 72 months. Non compliant patients usually gave up n-CPAP before the end of the first year. We compared the group of 150 patients always treated at the date of 31/12/95 with the group of 62 patients who refused nCPAP initially or gave up later. There was no difference in clinical parameters or polysomnographic data between the two groups. In 94 patients treated by nCPAP for more than a year we evaluated the outcome of AHI by a polysomnography performed after 72 hours of nCPAP cessation. Mean AHI of the group at this time was 38.2 +/- 20.3/h and was well correlated with the initial index (r = 0.41, p < 0.0001). However for 28 patients (29.7%) we observed, at the time of this second AHI determination, a variation (plus or minus) of at least 50% of the index. 6 patients, without any significative weigth loss, had an AHI below 5/h at this second determination. In this small group nCPAP was interrupted for 6 to 12 months, then another polysomnography was performed. At this time mean AHI was 42.4/h and clinical symptoms had reappeared in all patients. This study demonstrated that compliance to nCPAP in OSAS patients is good. No clinical or polysomnographic factors allow to predict non compliance. AHI is not modified by long term treatment with nCPAP.