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1.
JAMA ; 324(12): 1168-1179, 2020 09 22.
Artículo en Inglés | MEDLINE | ID: mdl-32886102

RESUMEN

Importance: Many adults with obstructive sleep apnea (OSA) use device treatments inadequately and remain untreated. Objective: To determine whether combined palatal and tongue surgery to enlarge or stabilize the upper airway is an effective treatment for patients with OSA when conventional device treatment failed. Design, Setting, and Participants: Multicenter, parallel-group, open-label randomized clinical trial of upper airway surgery vs ongoing medical management. Adults with symptomatic moderate or severe OSA in whom conventional treatments had failed were enrolled between November 2014 and October 2017, with follow-up until August 2018. Interventions: Multilevel surgery (modified uvulopalatopharyngoplasty and minimally invasive tongue volume reduction; n = 51) or ongoing medical management (eg, advice on sleep positioning, weight loss; n = 51). Main Outcomes and Measures: Primary outcome measures were the apnea-hypopnea index (AHI; ie, the number of apnea and hypopnea events/h; 15-30 indicates moderate and >30 indicates severe OSA) and the Epworth Sleepiness Scale (ESS; range, 0-24; >10 indicates pathological sleepiness). Baseline-adjusted differences between groups at 6 months were assessed. Minimal clinically important differences are 15 events per hour for AHI and 2 units for ESS. Results: Among 102 participants who were randomized (mean [SD] age, 44.6 [12.8] years; 18 [18%] women), 91 (89%) completed the trial. The mean AHI was 47.9 at baseline and 20.8 at 6 months for the surgery group and 45.3 at baseline and 34.5 at 6 months for the medical management group (mean baseline-adjusted between-group difference at 6 mo, -17.6 events/h [95% CI, -26.8 to -8.4]; P < .001). The mean ESS was 12.4 at baseline and 5.3 at 6 months in the surgery group and 11.1 at baseline and 10.5 at 6 months in the medical management group (mean baseline-adjusted between-group difference at 6 mo, -6.7 [95% CI, -8.2 to -5.2]; P < .001). Two participants (4%) in the surgery group had serious adverse events (1 had a myocardial infarction on postoperative day 5 and 1 was hospitalized for observation following hematemesis of old blood). Conclusions and Relevance: In this preliminary study of adults with moderate or severe OSA in whom conventional therapy had failed, combined palatal and tongue surgery, compared with medical management, reduced the number of apnea and hypopnea events and patient-reported sleepiness at 6 months. Further research is needed to confirm these findings in additional populations and to understand clinical utility, long-term efficacy, and safety of multilevel upper airway surgery for treatment of patients with OSA. Trial Registration: Australian New Zealand Clinical Trials Registry: ACTRN12614000338662.


Asunto(s)
Presión de las Vías Aéreas Positiva Contínua , Paladar Blando/cirugía , Apnea Obstructiva del Sueño/cirugía , Apnea Obstructiva del Sueño/terapia , Somnolencia , Lengua/cirugía , Adulto , Presión Sanguínea , Presión de las Vías Aéreas Positiva Contínua/instrumentación , Femenino , Humanos , Masculino , Persona de Mediana Edad , Oxígeno/sangre , Polisomnografía , Autoinforme , Índice de Severidad de la Enfermedad , Apnea Obstructiva del Sueño/fisiopatología , Latencia del Sueño
2.
Anesthesiology ; 133(4): 787-800, 2020 10 01.
Artículo en Inglés | MEDLINE | ID: mdl-32930728

RESUMEN

BACKGROUND: Obstructive sleep apnea is underdiagnosed in surgical patients. The cost-effectiveness of obstructive sleep apnea screening is unknown. This study's objective was to evaluate the cost-effectiveness of preoperative obstructive sleep apnea screening (1) perioperatively and (2) including patients' remaining lifespans. METHODS: An individual-level Markov model was constructed to simulate the perioperative period and lifespan of patients undergoing inpatient elective surgery. Costs (2016 Canadian dollars) were calculated from the hospital perspective in a single-payer health system. Remaining model parameters were derived from a structured literature search. Candidate strategies included: (1) no screening; (2) STOP-Bang questionnaire alone; (3) STOP-Bang followed by polysomnography (STOP-Bang + polysomnography); and (4) STOP-Bang followed by portable monitor (STOP-Bang + portable monitor). Screen-positive patients (based on STOP-Bang cutoff of at least 3) received postoperative treatment modifications and expedited definitive testing. Effectiveness was expressed as quality-adjusted life month in the perioperative analyses and quality-adjusted life years in the lifetime analyses. The primary outcome was the incremental cost-effectiveness ratio. RESULTS: In perioperative and lifetime analyses, no screening was least costly and least effective. STOP-Bang + polysomnography was the most effective strategy and was more cost-effective than both STOP-Bang + portable monitor and STOP-Bang alone in both analyses. In perioperative analyses, STOP-Bang + polysomnography was not cost-effective compared to no screening at the $4,167/quality-adjusted life month threshold (incremental cost-effectiveness ratio $52,888/quality-adjusted life month). No screening was favored in more than 90% of iterations in probabilistic sensitivity analyses. In contrast, in lifetime analyses, STOP-Bang + polysomnography was favored compared to no screening at the $50,000/quality-adjusted life year threshold (incremental cost-effectiveness ratio $2,044/quality-adjusted life year). STOP-Bang + polysomnography was favored in most iterations at thresholds above $2,000/quality-adjusted life year in probabilistic sensitivity analyses. CONCLUSIONS: The cost-effectiveness of preoperative obstructive sleep apnea screening differs depending on time horizon. Preoperative screening with STOP-Bang followed by immediate confirmatory testing with polysomnography is cost-effective on the lifetime horizon but not the perioperative horizon. The integration of preoperative screening based on STOP-Bang and polysomnography is a cost-effective means of mitigating the long-term disease burden of obstructive sleep apnea.


Asunto(s)
Análisis Costo-Beneficio , Procedimientos Quirúrgicos Electivos/economía , Tamizaje Masivo/economía , Cuidados Preoperatorios/economía , Apnea Obstructiva del Sueño/diagnóstico , Apnea Obstructiva del Sueño/economía , Anciano , Análisis Costo-Beneficio/métodos , Femenino , Humanos , Masculino , Cadenas de Markov , Tamizaje Masivo/métodos , Persona de Mediana Edad , Polisomnografía/economía , Cuidados Preoperatorios/métodos , Apnea Obstructiva del Sueño/cirugía
4.
Am J Orthod Dentofacial Orthop ; 158(4): 527-534, 2020 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-32807630

RESUMEN

INTRODUCTION: This study aimed to evaluate the follow-up observation of patients with obstructive sleep apnea treated with maxillomandibular advancement (MMA) procedure with or without genial tubercle advancement (GTA). METHODS: A total of 25 patients (mean age 37.1 ± 17.3 years) were included in the study. Cone-beam computed tomography scans were taken before treatment; after presurgical orthodontic treatment; immediately after MMA procedure; and follow-up visit. All Digital Imaging and Communications in Medicine files were analyzed using the Dolphin 3D Imaging software program (Dolphin Imaging and Management Solutions, Chatsworth, Calif) to determine the total airway volume (TAV), airway area (AA), and minimal cross-sectional area (MCA). Dolphin 3D voxel-based superimposition was used to determine the amount of skeletal advancement with MMA and changes after surgery. RESULTS: Significant increase in TAV, AA, and MCA was found with MMA treatment (40.6%, 28.8%, and 56.4%, respectively, P <0.0001). Smaller but significant decrease in TAV, AA, and MCA was found during a follow-up visit (20.0%, 9.7%, and 26.8%, respectively, P <0.0001) giving a net increase of TAV, AA and MCA (35.8%, 27.1%, and 45.9%, respectively). No significant differences were found in any of the airway measurements with or without the GTA procedure. The average forward movements of the maxilla, mandible, and chin were 6.6 mm, 8.2 mm, and 11.4 mm, respectively. A relapse of less than 1 mm was found in each of the variables during the follow-up period. No correlation was found between the magnitudes of skeletal advancement and the change in oropharyngeal airway space (OPAS). CONCLUSIONS: Significant increase in OPAS can be expected with MMA surgery with or without GTA procedure in patients diagnosed with obstructive sleep apnea. A partial loss in OPAS was found during the follow-up visit. The surgical movements were found to be stable, with less than 1 mm of relapse during the follow-up period, which was not clinically significant.


Asunto(s)
Avance Mandibular , Apnea Obstructiva del Sueño/diagnóstico por imagen , Apnea Obstructiva del Sueño/cirugía , Apnea Obstructiva del Sueño/terapia , Adulto , Cefalometría , Estudios de Seguimiento , Humanos , Maxilar/diagnóstico por imagen , Maxilar/cirugía , Persona de Mediana Edad , Osteotomía Le Fort , Faringe/diagnóstico por imagen , Resultado del Tratamiento , Adulto Joven
5.
Artículo en Chino | MEDLINE | ID: mdl-32842225

RESUMEN

Objective:The aim of this study is to investigate the effect of modified uvulopalatopharyngoplasty (UPPP) combined with endoscopic hypothermic Plasma glossectomy (Eco-TBR) on the severe Obstructive sleep apnea syndrome. Method:Sixty patients with severe OSAHS were diagnosed by polysomnography, and their obstructive plane located in the oropharynx and tongue base. Patients were divided into the control group (30 cases of simple H-UPPP) and the experimental group (30 cases of H-UPPP combined with Eco-TBR) according to their random hospital sequence. SPSS 20.0 software package was used to analyze the preoperative and postoperative data of the two groups. Result:Fifty-seven OSAHS patients had full data and a minimum 6 month follow up to assess the efficacy. The total effective rate in the control group was 41.38% lower than that in the experimental group 67.85%, and the difference was statistically significant (χ²=4.03, P<0.05). The postoperative data of the control group, AHI was 28.07±10.283, LSaO2 was 72.660±6.405, ESS was 12.620±2.731, and snoring VAS were 3.93±1.307. After the operation, in the experimental group, AHI was 25.74±14.140, LSaO2 was 75.360±7.299, ESS was 11.320±3.209, and snoring VAS were 3.00±1.305. The differences in AHI, LSaO2, ESS and snoring VAS before and after surgery in the two groups were statistically significant (P<0.001). After surgery, compared between the two groups, except for snoring VAS, the differences of AHI, LSaO2 and ESS were not statistically significant(P>0.05). Conclusion:The effect of H-UPPP combined with Eco-TBR on severe OSAHS patients with obstructive plane of oropharynx and tongue root is definite.


Asunto(s)
Glosectomía , Apnea Obstructiva del Sueño/cirugía , Lengua/cirugía , Humanos , Faringe , Temperatura , Resultado del Tratamiento , Úvula
7.
Rev. otorrinolaringol. cir. cabeza cuello ; 80(2): 137-146, jun. 2020. tab, graf
Artículo en Español | LILACS | ID: biblio-1115828

RESUMEN

INTRODUCCIÓN: La planificación de cirugías para el manejo del síndrome de apneahipopnea obstructiva del sueño (SAHOS) ha incrementado su precisión desde la introducción de la endoscopía del sueño inducido por fármacos (DISE). OBJETIVO: Evaluar la técnica de faringoplastía de reposición con suturas barbadas (BRP) para el colapso velofaríngeo y/o de paredes laterales orofaríngeas evaluado mediante DISE en pacientes con SAHOS. MATERIAL Y MÉTODO: Ochenta y ocho pacientes fueron evaluados para cirugía mediante antropometría, escala de somnolencia de Epworth (ESS) y poligrafía respiratoria. Veinte y seis de 88 pacientes fueron seleccionados. De los 26, 14 accedieron al tratamiento quirúrgico, el que se seleccionó en base a la DISE. En todos los casos, se realizó BRP. RESULTADOS: A los 3 meses de la cirugía hubo mejoría en 10/14 pacientes (criterios de Sher, disminución del índice de apnea-hipoapnea a <20 o 50% del basal). La ESS bajó en promedio de 12 a 5 puntos (p <0,05). No se reportaron incidentes en el posoperatorio y no han ocurrido eventos adversos. CONCLUSIÓN: La técnica de BRP es una técnica sencilla y útil para la expansión anterior y lateral del paladar blando y orofaringe, con una tasa de éxito similar en esta cohorte a la reportada internacionalmente.


INTRODUCTION: Surgical planning for the management of obstructive sleep apneahypopnea syndrome (OSAHS) has changed since the introduction of drug induced sleep endoscopy (DISE). AIM: To evaluate the technique of barbed sutures reposition pharyngoplasty (BRP) for velopharyngeal collapse and/or oropharyngeal lateral walls after DISE evaluation in OSAHS patients. MATERIAL AND METHOD: 88 patients were evaluated for surgery by anthropometry, Epworth sleepiness scale (ESS) and respiratory polygraphy. 26 of 88 patients were selected. Of the 26, 14 agreed to surgical treatment, which was selected on DISE findings. In all cases, BRP was performed. RESULTS: Three months after surgery there was improvement in 10/14 patients (Sher criteria, apnea-hypopnea index reduction at <20 or 50% of baseline). The ESS improved on average 12 to 5 (p <0.05). No incidents were reported in the post-operative period and no adverse events were reported. CONCLUSION: The BRP technique is a simple and useful technique for the anterior and lateral expansion of the soft palate and oropharynx, with a similar success rate in this cohort to that internationally reported.


Asunto(s)
Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Faringe/cirugía , Técnicas de Sutura , Apnea Obstructiva del Sueño/cirugía , Endoscopía/métodos , Insuficiencia Velofaríngea/cirugía , Índice de Masa Corporal , Antropometría , Apnea Obstructiva del Sueño/diagnóstico , Somnolencia , Hipnóticos y Sedantes/administración & dosificación
8.
Am J Otolaryngol ; 41(4): 102566, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32504854

RESUMEN

PURPOSE: To examine surgery performed for obstructive sleep apnea (OSA) in children with syndromic or neurologic comorbidities. MATERIAL AND METHODS: Medical records of 375 children with OSA were retrospectively reviewed, including 142 patients with trisomy 21, 105 with cerebral palsy, 53 with muscular dystrophy, 32 with spinal muscular atrophy, 18 with mucopolysaccharidoses, 14 with achondroplasia, and 11 with Prader-Willi. OUTCOME MEASURES: Apnea-hypopnea index (AHI), complications, length of postoperative stay, and endoscopic findings. RESULTS: 228 patients received 297 surgical interventions, with the remainder undergoing observation or positive pressure ventilation. Adenoidectomy was the most common procedure performed (92.1% of patients), followed by tonsillectomy (91.6%). Average AHI decreased following tonsillectomy, from 12.4 to 5.7 (p = 0.002). The most common DISE finding was the tongue base causing epiglottic retroflexion. Lingual tonsillectomy also resulted in an insignificant decrease in the AHI. CONCLUSIONS: Adenotonsillectomy, when there is hypertrophy, remains the mainstay of management of syndromic and neurologically-impaired children with OSA. However, additional interventions are often required, due to incomplete resolution of the OSA. DISE is valuable in identifying remaining sites of obstruction and guiding future management.


Asunto(s)
Adenoidectomía/métodos , Tonsila Faríngea/cirugía , Endoscopía/métodos , Hipnóticos y Sedantes , Enfermedades del Sistema Nervioso/epidemiología , Tonsila Palatina/cirugía , Apnea Obstructiva del Sueño/cirugía , Tonsilectomía/métodos , Tonsila Faríngea/patología , Niño , Comorbilidad , Femenino , Humanos , Hipertrofia , Masculino , Tonsila Palatina/patología , Estudios Retrospectivos , Apnea Obstructiva del Sueño/epidemiología
9.
Medicine (Baltimore) ; 99(18): e19793, 2020 May.
Artículo en Inglés | MEDLINE | ID: mdl-32358351

RESUMEN

RATIONALE: Many previous studies have investigated the necessity of routine histopathological analysis of tonsillectomy specimen, and most recent studies have suggested that such an analysis is not justified in asymptomatic patients or those with no risk factors for malignancy. PATIENT CONCERNS: A 59-year-old man diagnosed with obstructive sleep apnea underwent surgery, including tonsillectomy; a tonsil specimen was sent to the department of pathology. DIAGNOSIS: Although the patient did not exhibit any tonsil-related signs or symptoms, nor did the appearance of the tonsil appear to be pathological, the right tonsil specimen was diagnosed with squamous cell carcinoma, with detection of human papilloma virus 16. INTERVENTIONS: Chemotherapy and radiotherapy were used to treat the tonsil cancer. OUTCOMES: No recurrence was observed during the 4-year follow-up. LESSONS: In the future, it may be necessary to reinvestigate the necessity of routine histopathological analysis of tonsillectomy specimens in asymptomatic patients, considering the drastically increased rate of detection of human papilloma virus-related oropharyngeal squamous cell carcinomas in these patients.


Asunto(s)
Carcinoma de Células Escamosas/diagnóstico , Neoplasias Primarias Desconocidas/diagnóstico , Apnea Obstructiva del Sueño/cirugía , Neoplasias Tonsilares/diagnóstico , Tonsilectomía , Humanos , Hallazgos Incidentales , Masculino , Persona de Mediana Edad
10.
Am J Otolaryngol ; 41(4): 102500, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32402692

RESUMEN

BACKGROUND: Obstructive sleep apnea syndrome (OSAS) is caused by a complete or partial obstruction of the upper airway. A new Cahali lateral pharyngoplasty as a stand-alone procedure for the treatment of OSA patients, whatever the level and pattern of airway obstruction in patients with CPAP failure or non-compliant patients, is it? PATIENTS AND METHODS: 40 patients with known OSAS non-compliant with CPAP or CPAP failures included. BMI, Stop-Bang score, and sleep study parameters were reported before and after the new Cahali pharyngoplasty operation. Preoperative DISE was done for all cases. RESULTS: There were 28 (70%) cases with successful operation outcomes, and 12 (30%) failed cases. Postoperative Stop Bang score, AHI, snoring index were significantly reduced in comparison to preoperative data (p-value <0.001); however, minimal SpO2 and baseline SpO2 were significantly increased in comparison to preoperative data. There was a significant improvement in AHI postoperative. Patients collapse at the level of lateral wall hypopharynx, high tongue collapse, laryngeal collapse, tongue palate interaction, all significantly predict failure outcome of the operation (p-value = 0.022). However, the absence of laryngeal collapse (L0) had a successful prediction outcome. The high snoring index significantly predicts operation failure. However, preoperative high baseline SpO2 predicts operation success significantly. CONCLUSION: The new Cahali lateral pharyngoplasty can be used as a stand-alone procedure in the absence of lateral wall collapse at the level of the hypopharynx (LH), high tongue base collapse (TH), laryngeal collapse (L1) or tongue palate interaction.


Asunto(s)
Faringe/cirugía , Procedimientos Quirúrgicos Reconstructivos/métodos , Apnea Obstructiva del Sueño/cirugía , Femenino , Humanos , Masculino , Apnea Obstructiva del Sueño/terapia , Resultado del Tratamiento
11.
Int J Pediatr Otorhinolaryngol ; 134: 110066, 2020 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-32361254

RESUMEN

Tonsillectomy is a common procedure in the pediatric population, with subsequent microscopic examination of the specimen for cancer and other rare diagnoses occurring routinely. A 17 year-old female with a history of autoimmune vasculitis underwent adenotonsillectomy for severe obstructive sleep apnea. Pathology demonstrated small, medium and large lymphocytes and plasma cells obscuring the lymphoid follicles and germinal centers, with few Epstein-Barr virus positive lymphocytes. Tingible body macrophages were seen in the vaguely nodular areas. This reactive histologic pattern represents an atypical lymphoproliferative disorder never before documented in tonsils. Histopathologic images will be shown.


Asunto(s)
Trastornos Linfoproliferativos/patología , Tonsila Palatina/patología , Apnea Obstructiva del Sueño/cirugía , Tonsilectomía , Adenoidectomía , Adolescente , Femenino , Humanos , Hiperplasia , Linfocitos/patología , Tonsila Palatina/inmunología
12.
Int J Pediatr Otorhinolaryngol ; 134: 110077, 2020 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-32402922

RESUMEN

OBJECTIVES: Obstructive sleep apnea (OSA) can have a negative impact on quality of life in children. The OSA-18 is a disease-specific quality of life questionnaire for children. The questionnaire has been found to be a poor predictor of OSA diagnosed with polysomnography (PSG), yet OSA-18 scores do markedly improve after adenotonsillectomy. The aim of this study was to examine the correlations between OSA-18 and PSG findings, beyond the apnea hypopnea index (AHI). METHODS: This study was a prospective study of children 2-6 years of age who were referred to an Ear, Nose and Throat department for adenoidectomy and/or tonsillectomy. Prior to surgery, all of the children underwent PSG and a physical examination, and their parent completed the OSA-18 questionnaire. Spearman correlations were used to determine the associations between OSA-18 scores and PSG parameters. RESULTS: The sample consisted of 97 children who underwent PSG and their parents who answered the OSA-18 questionnaire. We found positive correlations between the AHI and both the OSA-18 total score (rho = 0.21, p = 0.04) and the sleep disturbance subscale (rho = 0.51, p < 0.01). The only other PSG parameter that significantly correlated with the OSA-18 was the number of awakenings and arousals per hour of sleep (rho = 0.29, p < 0.01). CONCLUSION: We only found weak correlations between the OSA-18 score and PSG findings, suggesting the two methods are measuring different aspects of pediatric OSA. CLINICAL TRIAL: NCT02233166.


Asunto(s)
Polisomnografía , Calidad de Vida , Apnea Obstructiva del Sueño , Trastornos del Sueño-Vigilia , Niño , Preescolar , Femenino , Humanos , Masculino , Padres , Estudios Prospectivos , Índice de Severidad de la Enfermedad , Apnea Obstructiva del Sueño/complicaciones , Apnea Obstructiva del Sueño/diagnóstico , Apnea Obstructiva del Sueño/cirugía , Trastornos del Sueño-Vigilia/etiología , Encuestas y Cuestionarios
13.
Ann Otol Rhinol Laryngol ; 129(9): 856-862, 2020 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-32316740

RESUMEN

OBJECTIVE: To explore the application of lingual artery ultrasound (US) for midline glossectomy in patients with obstructive sleep apnea (OSA). METHODS: Lingual artery US was performed in 57 OSA patients (OSA group) and 20 normal persons (control group). The differences in the depths of the lingual arteries and the distances between the bilateral lingual arteries were compared between two groups. The correlations between apnea-hypopnea index (AHI), AHI after the nasopharyngeal tube insertion (NPT-AHI), Friedman tongue position (FTP) and all the parameters of lingual arteries were analyzed. RESULTS: Both the depths of the lingual arteries and the distances between the bilateral lingual arteries in the OSA group were larger than those in the control group (P < .01). All the parameters of the lingual arteries in OSA patients were positively correlated with AHI, NPT-AHI and FTP (P < .05). While controlling for body mass index (BMI), all the parameters of the lingual arteries in OSA patients were still correlated with NPT-AHI positively (P ≤ .01). CONCLUSION: Pre-operative US can show the course of the lingual artery clearly for pre-operative planning. The depth and width of the lingual artery in OSA patients were different from controls. NPT-AHI has high sensitivity in predicting all the parameters of the lingual arteries. FTP is closely correlated with the depth of the lingual arteries.


Asunto(s)
Glosectomía , Apnea Obstructiva del Sueño/cirugía , Lengua/irrigación sanguínea , Lengua/diagnóstico por imagen , Adulto , Anciano , Arterias/diagnóstico por imagen , Femenino , Glosectomía/métodos , Humanos , Masculino , Persona de Mediana Edad , Ultrasonografía , Adulto Joven
14.
Cochrane Database Syst Rev ; 4: CD011365, 2020 04 29.
Artículo en Inglés | MEDLINE | ID: mdl-32347984

RESUMEN

BACKGROUND: Obstructive sleep-disordered breathing (oSDB) is a condition encompassing breathing problems when asleep due to upper airway obstruction. In children, hypertrophy of the tonsils and/or adenoids is thought to be the commonest cause. As such, (adeno)tonsillectomy has long been the treatment of choice. A rise in partial removal of the tonsils over the last decade is due to the hypothesis that tonsillotomy is associated with lower postoperative morbidity and fewer complications. OBJECTIVES: To assess whether partial removal of the tonsils (intracapsular tonsillotomy) is as effective as total removal of the tonsils (extracapsular tonsillectomy) in relieving signs and symptoms of oSDB in children, and has lower postoperative morbidity and fewer complications. SEARCH METHODS: We searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The search date was 22 July 2019. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing the effectiveness of (adeno)tonsillectomy with (adeno)tonsillotomy in children aged 2 to 16 years with oSDB. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods and assessed the certainty of the evidence for our pre-defined outcomes using GRADE. Our primary outcomes were disease-specific quality of life, peri-operative blood loss and the proportion of children requiring postoperative medical intervention (with or without hospitalisation). Secondary outcomes included postoperative pain, return to normal activity, recurrence of oSDB symptoms as a result of tonsil regrowth and reoperation rates. MAIN RESULTS: We included 22 studies (1984 children), with predominantly unclear or high risk of bias. Three studies used polysomnography as part of their inclusion criteria. Follow-up duration ranged from six days to six years. Although 19 studies reported on some of our outcomes, we could only pool the results from a few due both to the variety of outcomes and the measurement instruments used, and an absence of combinable data. Disease-specific quality of life Four studies (540 children; 484 (90%) analysed) reported this outcome; data could not be pooled due to the different outcome measurement instruments used. It is very uncertain whether there is any difference in disease-specific quality of life between the two surgical procedures in the short (0 to 6 months; 3 studies, 410 children), medium (7 to 13 months; 2 studies, 117 children) and long term (13 to 24 months; 1 study, 67 children) (very low-certainty evidence). Peri-operative blood loss We are uncertain whether tonsillotomy reduces peri-operative blood loss by a clinically meaningful amount (mean difference (MD) 14.06 mL, 95% CI 1.91 to 26.21 mL; 8 studies, 610 children; very low-certainty evidence). In sensitivity analysis (restricted to three studies with low risk of bias) there was no evidence of a difference between the groups. Postoperative complications requiring medical intervention (with or without hospitalisation) The risk of postoperative complications in the first week after surgery was probably lower in children who underwent tonsillotomy (4.9% versus 2.6%, risk ratio (RR) 1.75, 95% CI 1.06 to 2.91; 16 studies, 1416 children; moderate-certainty evidence). Postoperative pain Eleven studies (1017 children) reported this outcome. Pain was measured using various scales and scored by either children, parents, clinicians or study personnel. When considering postoperative pain there was little or no difference between tonsillectomy and tonsillotomy at 24 hours (10-point scale) (MD 1.09, 95% CI 0.88 to 1.29; 4 studies, 368 children); at two to three days (MD 0.93, 95% CI -0.14 to 2.00; 3 studies, 301 children); or at four to seven days (MD 1.07, 95% CI -0.40 to 2.53; 4 studies, 370 children) (all very low-certainty evidence). In sensitivity analysis (restricted to studies with low risk of bias), we found no evidence of a difference in mean pain scores between groups. Return to normal activity Tonsillotomy probably results in a faster return to normal activity. Children who underwent tonsillotomy were able to return to normal activity four days earlier (MD 3.84 days, 95% CI 0.23 to 7.44; 3 studies, 248 children; moderate-certainty evidence). Recurrence of oSDB and reoperation rates We are uncertain whether there is a difference between the groups in the short (RR 0.26, 95% CI 0.03 to 2.22; 3 studies, 186 children), medium (RR 0.35, 95% CI 0.04 to 3.23; 4 studies, 206 children) or long term (RR 0.21 95% CI 0.01 to 4.13; 1 study, 65 children) (all very low-certainty evidence). AUTHORS' CONCLUSIONS: For children with oSDB selected for tonsil surgery, tonsillotomy probably results in a faster return to normal activity (four days) and in a slight reduction in postoperative complications requiring medical intervention in the first week after surgery. This should be balanced against the clinical effectiveness of one operation over the other. However, this is not possible to determine in this review as data on the long-term effects of the two operations on oSDB symptoms, quality of life, oSDB recurrence and need for reoperation are limited and the evidence is of very low quality leading to a high degree of uncertainty about the results. More robust data from high-quality cohort studies, which may be more appropriate for detecting differences in less common events in the long term, are required to inform guidance on which tonsil surgery technique is best for children with oSDB requiring surgery.


Asunto(s)
Tonsila Palatina/cirugía , Apnea Obstructiva del Sueño/cirugía , Tonsilectomía/métodos , Adolescente , Pérdida de Sangre Quirúrgica/estadística & datos numéricos , Niño , Preescolar , Humanos , Dolor Postoperatorio/epidemiología , Complicaciones Posoperatorias/epidemiología , Calidad de Vida , Ensayos Clínicos Controlados Aleatorios como Asunto , Recurrencia , Reoperación/estadística & datos numéricos , Índice de Severidad de la Enfermedad , Tonsilectomía/efectos adversos
15.
JAMA ; 323(14): 1389-1400, 2020 04 14.
Artículo en Inglés | MEDLINE | ID: mdl-32286648

RESUMEN

Importance: Obstructive sleep apnea (OSA) affects 17% of women and 34% of men in the US and has a similar prevalence in other countries. This review provides an update on the diagnosis and treatment of OSA. Observations: The most common presenting symptom of OSA is excessive sleepiness, although this symptom is reported by as few as 15% to 50% of people with OSA in the general population. OSA is associated with a 2- to 3-fold increased risk of cardiovascular and metabolic disease. In many patients, OSA can be diagnosed with home sleep apnea testing, which has a sensitivity of approximately 80%. Effective treatments include weight loss and exercise, positive airway pressure, oral appliances that hold the jaw forward during sleep, and surgical modification of the pharyngeal soft tissues or facial skeleton to enlarge the upper airway. Hypoglossal nerve stimulation is effective in select patients with a body mass index less than 32. There are currently no effective pharmacological therapies. Treatment with positive airway pressure lowers blood pressure, especially in patients with resistant hypertension; however, randomized clinical trials of OSA treatment have not demonstrated significant benefit on rates of cardiovascular or cerebrovascular events. Conclusions and Relevance: OSA is common and the prevalence is increasing with the increased prevalence of obesity. Daytime sleepiness is among the most common symptoms, but many patients with OSA are asymptomatic. Patients with OSA who are asymptomatic, or whose symptoms are minimally bothersome and pose no apparent risk to driving safety, can be treated with behavioral measures, such as weight loss and exercise. Interventions such as positive airway pressure are recommended for those with excessive sleepiness and resistant hypertension. Managing asymptomatic OSA to reduce cardiovascular and cerebrovascular events is not currently supported by high-quality evidence.


Asunto(s)
Presión de las Vías Aéreas Positiva Contínua , Apnea Obstructiva del Sueño/diagnóstico , Apnea Obstructiva del Sueño/terapia , Ejercicio Físico , Femenino , Conductas Relacionadas con la Salud , Humanos , Masculino , Avance Mandibular/instrumentación , Pronóstico , Factores de Riesgo , Apnea Obstructiva del Sueño/etiología , Apnea Obstructiva del Sueño/cirugía , Pérdida de Peso
16.
Am J Otolaryngol ; 41(4): 102467, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32234256

RESUMEN

OBJECTIVES: Recommendations for polysomnography (PSG) in pediatric sleep disordered breathing (SDB) vary between the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and the American Academy of Pediatrics (AAP). We determined the rates of preoperative PSG in children without risk factors outlined in the AAO-HNS Clinical Practice Guidelines and described the postoperative course of those patients following T&A. METHODS: Patients aged 3-17 undergoing T&A for SDB or OSA who did not have an indication for preoperative PSG were included. We conducted retrospective review to describe the rate, type, and timing of respiratory complications for patients with and without PSG following T&A, and discuss cases where disposition was changed due to PSG results. RESULTS: 1135 patients without risk factors underwent T&A for SDB or OSA. 196 (17%) had a preoperative PSG, of whom 85 (43.3%) had AHI >10 and 38 (24.8%) had an O2 nadir <80%. 69 (85%) patients with PSG-diagnosed severe OSA were admitted overnight. Of the entire cohort, 5 patients (0.44%) had hypoxemia requiring blow-by oxygen or repositioning. 4 (0.43%) patients without PSG experienced respiratory events and were converted to overnight stay. The timing of respiratory events for all children ranged from immediately following extubation in the operating room to 3 h postoperatively. CONCLUSION: PSG in children without risk factors results in admission of otherwise healthy patients following T&A who would have otherwise undergone ambulatory surgery. PSG alone in pediatric patients with no AAO-HNS risk factors should not influence postoperative disposition. These patients should be monitored for 3 h post-T&A and discharged in the absence of complications. EVIDENCE LEVEL: 2b.


Asunto(s)
Procedimientos Quirúrgicos Ambulatorios/métodos , Apnea Obstructiva del Sueño/cirugía , Tonsilectomía/métodos , Adolescente , Niño , Preescolar , Femenino , Humanos , Masculino , Monitoreo Fisiológico , Polisomnografía , Periodo Posoperatorio , Estudios Retrospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Apnea Obstructiva del Sueño/diagnóstico
17.
Am J Otolaryngol ; 41(4): 102478, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32303392

RESUMEN

OBJECTIVE: To determine the success of epiglottopexy with or without aryepiglottic fold division for treatment of patients with obstructive sleep apnea (OSA) with epiglottic obstruction. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary care academic hospital. METHODS: Children with sleep study proven OSA who underwent epiglottopexy with or without aryepiglottic fold division from January 2013 to June 2017 were included. The epiglottis contributed to airway obstruction in all patients. Pre- and post-operative apnea-hypopnea index (AHI) were compared. Age, sex, body mass index (BMI) z-score and post-operative complications were also evaluated. Success was defined by post-operative AHI < 5.0 with resolution of OSA symptoms or AHI ≤ 1.0 events per hour. RESULTS: Twenty-eight children (age 2-17 years) underwent either epiglottopexy with division of aryepiglottic folds (N = 18) or epiglottopexy alone (N = 10). There was no difference in preoperative age, AHI, or BMI between the groups. Post-operative AHI was lower in the group undergoing epiglottopexy alone (AHI 1.50) versus with aryepiglottic fold division (AHI 3.17) (P < 0.05). No difference was found in mean AHI improvement between the two groups. For the entire cohort, success criteria were met by 53.6% of patients for AHI < 5.0 without symptoms and 25.0% of patients for AHI ≤ 1.0, with no difference in surgical success between procedures (P > 0.05). CONCLUSIONS: Children undergoing epiglottopexy with division of aryepiglottic folds for laryngeal collapse were as likely to have improved OSA symptoms as children undergoing epiglottopexy alone.


Asunto(s)
Epiglotis/cirugía , Cartílagos Laríngeos/cirugía , Procedimientos Quirúrgicos Otorrinolaringológicos/métodos , Apnea Obstructiva del Sueño/cirugía , Adolescente , Niño , Preescolar , Femenino , Humanos , Masculino , Polisomnografía/métodos , Estudios Retrospectivos , Apnea Obstructiva del Sueño/diagnóstico , Apnea Obstructiva del Sueño/fisiopatología , Resultado del Tratamiento
18.
Otolaryngol Head Neck Surg ; 162(5): 737-745, 2020 May.
Artículo en Inglés | MEDLINE | ID: mdl-32122243

RESUMEN

OBJECTIVE: Heart rate variability (HRV), a noninvasive indicator of autonomic regulation of cardiac rhythm, may represent the physiologic burden of obstructive sleep apnea (OSA). We hypothesized that the treatment-related effects of OSA on HRV in children are causally attributable to the improvement in OSA severity. STUDY DESIGN: Secondary analysis of outcomes from the Childhood Adenotonsillectomy Trial (CHAT). SETTING: Analysis of database. SUBJECTS AND METHODS: Time- and frequency-domain HRV parameters along with polysomnographic (PSG) and demographic variables were obtained from the CHAT study, which compared early adenotonsillectomy (eAT) to watchful waiting (WW) in children with OSA. The relative contributions of PSG variables and covariates to each HRV parameter were quantified. The proportion of changes in HRV parameters causally attributable to changes in OSA severity, measured by the apnea-hypopnea index (AHI) and oxygen desaturation index (ODI), was estimated. RESULTS: In total, 404 children aged 5 to 10 years were included. The median (interquartile range) age was 6 (3-9) years. The median body mass index percentile was 82 (53), 195 (48%) children were male, and 147 (36%) were African American. The average heart rate during PSG was the strongest independent predictor of each HRV parameter (P < .001). Although eAT resulted in statistically significant changes in the majority of HRV parameters, these effects were not causally attributable to treatment-related changes in AHI or ODI. CONCLUSIONS: The average heart rate strongly modulates HRV in children with OSA. Although eAT results in discernible changes in HRV, it appears to not be causally attributable to specific treatment-related changes in AHI or ODI.


Asunto(s)
Frecuencia Cardíaca/fisiología , Apnea Obstructiva del Sueño/fisiopatología , Apnea Obstructiva del Sueño/cirugía , Adenoidectomía , Niño , Preescolar , Femenino , Humanos , Masculino , Polisomnografía , Índice de Severidad de la Enfermedad , Tonsilectomía
19.
Otolaryngol Head Neck Surg ; 162(6): 839-852, 2020 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-32204654

RESUMEN

OBJECTIVES: To compare the effectiveness of transoral robotic surgery (TORS) versus plasma ablation (PA) in tongue base reduction surgery for obstructive sleep apnea (OSA). DATA SOURCES: PubMed, Scopus, Cochrane Library, OVID. REVIEW METHODS: Keywords searched included OSA, tongue base surgery, TORS, and coblation. Outcomes included pre- to postoperative apnea-hypopnea index, Epworth Sleepiness Scale (ESS), and lowest oxygen saturation. Additional outcomes included surgical success rate, postoperative bleeding, operative time, and length of stay. RESULTS: A total of 690 unique articles were identified, of which 60 underwent full-text review. Twenty-six articles were included in final analysis, comprising 18 studies on TORS (834 patients) and 11 studies on PA (294 patients). Mean differences of apnea-hypopnea index, ESS, and lowest oxygen saturation for TORS were -23.92, -7.6, and 5.83% (all P < .01). Corresponding values for PA were -22.07, -4.14, and 5.48% (all P < .00001). TORS had greater ESS reduction than PA (P = .02). Follow-up duration was shorter in TORS than PA (mean ± SD: 4.2 ± 2.6 vs 4.6 ± 1.4 months, P = .0482). Surgical success rates in TORS and PA were similar (57.6% vs 60.3%, P = .4474). Postoperative bleeding occurred less frequently in TORS versus PA (3.3% vs 7.5%, P = .0103). Operative time was longer for TORS than PA (77.9 ± 16.4 minutes vs 44.0 ± 12.9 minutes, P < .0001). Length of stay was similar between TORS and PA (3.9 ± 1.6 days vs 3.9 ± 2.5 days, P = .9047). CONCLUSION: Tongue base reduction with TORS or PA each effectively treats OSA and provides comparable results. The choice between techniques might depend on patient factors, availability of technology, and associated costs.


Asunto(s)
Glosectomía/métodos , Cirugía Endoscópica por Orificios Naturales/métodos , Procedimientos Quirúrgicos Robotizados/métodos , Apnea Obstructiva del Sueño/cirugía , Humanos , Boca , Resultado del Tratamiento
20.
Artículo en Inglés | MEDLINE | ID: mdl-32121007

RESUMEN

Background: The purpose of this study was to evaluate long-term subjective outcomes of barbed reposition pharyngoplasty for obstructive sleep apnea syndrome (OSAS) treatment using a specific questionnaire, the Palate Postoperative Problem Score (PPOPS). Methods: 140 patients who underwent barbed reposition pharyngoplasty (BRP) surgery in the Morgagni Pierantoni Hospital of Forlì, Italy were enrolled in the study. Postoperative outcomes were evaluated in a short- and long-term follow-up using the PPOPS questionnaire. The average period of follow-up was 26 months. All patients received the PPOPS questionnaire by telephone in a period between April and August 2019. Results: 51% of patients complained of swallowing problems after surgery. In 91% of cases, the problem cleared up spontaneously. At the time of the interview, only 9% of patients had a residual swallowing difficult. At the time of PPOPS evaluation, rhinolalia was observed in 8% of patients, whereas nose regurgitation was present in 2% of patients. In 20% of patients, the foreign body sensation was present during follow-up. The value of apnea-hypopnea index (AHI) reduced from the preoperative value of 31.5 to the postoperative value of 11.4. Conclusions: BRP surgery proved to be an effective technique, appreciated by the majority of patients. Use of the PPOPS questionnaire has demonstrated that the BRP technique seems to ensure efficacy and lower morbidity, with few complications after surgery.


Asunto(s)
Faringe/cirugía , Apnea Obstructiva del Sueño/cirugía , Adulto , Anciano , Femenino , Humanos , Italia , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Encuestas y Cuestionarios , Resultado del Tratamiento
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