A multi-institutional study of radiofrequency volumetric tissue reduction for OSAS.

OBJECTIVES: Radiofrequency volume reduction (RFTVR) is a minor procedure directed at reducing the tongue base volume to treat obstructive sleep apnea. Subjective and objective treatment effectiveness was evaluated. STUDY DESIGN AND SETTING: Two separate prospective, matched, nonrandomized, open enrollment treatment groups (RFTVR, n = 73 and nasal continuous positive airway pressure (CPAP, n = 99) were concurrently enrolled in a multicenter study. RESULTS: Fifty-six (76.7%) RFTVR completed PSG with a mean 5.4 +/- 1.8 treatments (13,394 +/- 5459 joules). Perioperatively, acute pain was mild to moderate; edema, mucosal erosion, paresthesia, tinnitus were infrequent; and speech, swallowing taste, or throat irritation were unchanged. Self-reported outcomes did not differ between RFTVR and CPAP groups. Mean apnea/hypopnea index decreased (40.5 +/- 21.5 to 32.8 +/- 22.6 events/hr, P < 0.01). Electrolyte solution injected predicted results (r = 0.43, P < 0.001). The most severe complication was abscess (1.1%). CONCLUSION: RFTVR improves apnea/hypopnea index. Improvement may be related to solution injected with treatment. RFTVR and CPAP clinical outcomes improvement were similar. CLINICAL SIGNIFICANCE: In mild obstructive sleep apnea, treatment of symptomatic outcomes with RFTVR may be an alternative to CPAP.

Practice parameters for the use of laser-assisted uvulopalatoplasty: an update for 2000.

Laser-assisted uvulopalatoplasty (LAUP) is an outpatient surgical procedure which is in use as a treatment for snoring. LAUP also has been used as a treatment for sleep-related breathing disorders, including obstructive sleep apnea. The Standards of Practice Committee of the American Academy of Sleep Medicine reviewed the available literature, and developed these practice parameters as a guide to the appropriate use of this surgery. Adequate controlled studies on the LAUP procedure for sleep-related breathing disorders were not found in peer-reviewed journals. This is consistent with findings in the original practice parameters on LAUP published in 1994. The following recommendations are based on the review of the literature: LAUP is not recommended for treatment of sleep-related breathing disorders. However, it does appear to be comparable to uvulopalatopharyngoplasty (UPPP) for treatment of snoring. Individuals who are candidates for LAUP as a treatment for snoring should undergo a polysomnographic or cardiorespiratory evaluation for sleep-related breathing disorders prior to LAUP and periodic postoperative evaluations for the development of same. Patients should be informed of the best available information of the risks, benefits, and complications of the procedure.

Practice parameters for the treatment of narcolepsy: an update for 2000.

Successful treatment of narcolepsy requires an accurate diagnosis to exclude patients with other sleep disorders, which have different treatments, and to avoid unnecessary complications of drug treatment. Treatment objectives should be tailored to individual circumstances. Modafinil, amphetamine, methamphetamine, dextroamphetamine, methylphenidate, selegiline, pemoline, tricyclic antidepressants, and fluoxetine are effective treatments for narcolepsy, but the quality of published clinical evidence supporting them varies. Scheduled naps can be beneficial to combat sleepiness, but naps seldom suffice as primary therapy. Regular follow up of patients with narcolepsy is necessary to educate patients and their families, monitor for complications of therapy and emergent of other sleep disorders, and help the patient adapt to the disease.

A tongue suspension suture for obstructive sleep apnea and snorers.

OBJECTIVE: A tongue suture is postulated to prevent tongue base collapse in obstructive sleep apnea (OSA) and snoring. This procedure uses a permanent tongue base suture to support the pharynx and lessen collapse. This study evaluates 2-month results in 28 OSA and snoring patients. STUDY DESIGN AND SETTINGS: Forty-three patients have been enrolled in a multi-institutional prospective open enrollment study using the "Repose" bone screw system. Subjects were evaluated using polysomnography measures of general health (SF-36), snoring, and sleep (Epworth Sleepiness Scale and Functional Outcomes of Sleep) performed before and again 2 months after treatment. RESULTS: In 14 OSA patients (Apnea + Hypopnea (AHI) > 15) and 14 snorers (AHI < 15), no change was noted in sleep architecture or lowest oxygen saturation. AHI decreased in OSA (35.4 +/- 13.7 to 24.5 +/- 14.5, P < 0.00), but not in snorers. AHI decreased in the lateral (16.5 +/- 16.5 to 3.8 +/- 6.4, P < 0.01) but not the supine position. Epworth Sleepiness Scale, Functional Outcomes of Sleep, and snoring scales improved. Snoring decreased but remained bothersome to the bed partner. CONCLUSIONS: A tongue suspension suture partially reduces the respiratory severity of OSA. Small changes are noted in symptoms of sleepiness, snoring, and functional outcomes. Demonstration of efficacy of the technique and device will require further controlled trials.

Pharyngeal suspension suture with repose bone screw for obstructive sleep apnea.

OBJECTIVE: Multilevel surgery for obstructive sleep apnea syndrome (OSA) may improve success. This study's goal is to prospectively evaluate the feasibility and short-term subjective effectiveness of a new tongue-suspension technique. METHODS: A multicenter nonrandomized open enrollment trial used the Repose device to treat tongue obstruction in 39 snoring and OSA patients. Outcomes include 1- and 2-month subjective reports of general health, snoring, and sleep. RESULTS: Twenty-three patients completed 1 month and 19 completed 2 months of follow-up. In OSA patients, activity level, energy/fatigue, and sleepiness improved. Two-month outcomes were less (activity level, energy/fatigue, and sleepiness). Fewer changes were observed in snorers than in OSA patients. There were 6 complications (18%), including sialadenitis (4), gastrointestinal bleeding (1), and dehydration (1) after the procedure. CONCLUSION: A pharyngeal suspension suture changes subjective outcomes. Improvement is incomplete. The procedure is nonexcisional, but significant complications may occur. Further evaluation is required to demonstrate effectiveness.

Predicting which patients will benefit from surgery for obstructive sleep apnea: the ENT exam.

Airway evaluation is critical for surgical decision making. In patients with obstructive sleep apnea (OSA), a minimal evaluation should include a basic head and neck physical examination to evaluate for overt pathology. An upper airway examination will also provide insight into identifying patients with a higher risk of OSA. For patients who are evaluated for surgery, endoscopy combined with cephalometrics is the most accepted method of identifying patients with retroglossal collapse and obstruction. A new paradigm suggests that most patients have multilevel obstruction, so examination should be directed at assessing risk factors to direct the aggressiveness of surgical intervention.

Comparison of methods of airway evaluation in obstructive sleep apnea syndrome.

OBJECTIVE: Head and neck examination, endoscopy, and cephalometric x-ray films poorly predict surgical success in obstructive sleep apnea. It is hypothesized that accurate measures demonstrate agreement and may statistically "cluster." METHODS: Forty-two white men from a convenience sample of 60 patients had physical examinations, upper airway endoscopies, and cephalometric x-ray films reviewed. Clinically important groupings or those with linear correlation (> 0.05) were assessed with linear and logistic regression (P < 0.05). RESULTS: Apnea hypopnea index was related to body mass index (b = 3.4, p < 0.0001), posterior wall redundancy (b = 32.8, P = 0.0004), and endoscopic retropalatal size (b = 29.5, P = 0.0046). Endoscopic retropalatal area was negatively correlated to the cephalometric posterior airway space (b = 3.4, P < 0.0003). Müller's maneuver and Malampatti scores were not associated with any measures. CONCLUSIONS: Few features on airway evaluation associate or cluster in patients with obstructive sleep apnea syndrome. Supine endoscopy may be promising because it is associated with both the apnea hypopnea index and posterior airway space.

Surgical approaches to obstructive sleep apnea.

Obstructive sleep apnea results from a combination of a structurally small upper airway and loss of upper airway muscle tone. Surgical therapy is effective by enlarging the upper airway and decreasing collapsibility. Limited palatal surgery has been demonstrated successful for the treatment of snoring but less for the treatment of obstructive sleep apnea. More aggressive multilevel surgeries addressing several airway segments demonstrate improved success rates. Multilevel surgeries and combined with bimaxillary advancement surgery have demonstrated success rates of 90%. New surgical procedures, eg, radiofrequency volume reduction, offer the potential of altering the upper airway with low morbidity. Hypoglossal nerve stimulation is a potential innovative technique.

A method to evaluate upper airway mechanics following intervention in snorers.

PURPOSE: To describe a method that measures multisegment upper airway changes following intervention for snoring and obstructive apnea that controls for physiological fluctuations during sleep. PATIENTS AND METHODS: Retropalatal, retroglossal, and retrohyoid airway segments were evaluated before and after application of an oral appliance (OA) in four snoring subjects. Twelve airway segments were evaluated. Physiological fluctuations during sleep were controlled with variably applied nasal continuous positive pressure (CPAP), benzodiazepam-induced sleep, and obtaining measures at zero flow on the first test breath. Airway area was measured endoscopically. RESULTS: The methodology identified that following intervention with an OA, maximum retroglossal airway size increased 23.3% +/- 7.5% (P < .05) and retrohyoid size decreased -63.5% +/- 16.0% (P < .05). No changes in retropalatal area (-2.5% +/- 3.0%) or closing pressure were observed. The level of primary obstruction shifted inferiorly in one patient. Airway measures prior to intervention showed small alterations of applied pressure (1 cm H2O) changed retropalatal and retroglossal area an average of 10% +/- 0.9%/cm H2O. CONCLUSION: The mechanical effects of limited airway intervention can be measured with a hypotonic, pressure-controlled methodology. At small airway areas, the airway is highly collapsible and airway size fluctuates. Small changes in applied or physiological forces may alter the airway as significantly as the effects of the intervention being evaluated. The hypotonic upper airway method provides a method to control airway collapse and evaluate interventions, such as OA or surgery, for snoring and obstructive sleep apnea syndrome.

Surgical treatment of aspirin triad sinusitis.

Aspirin sensitivity, asthma, and chronic sinusitis with polyposis comprises the syndrome of Aspirin Triad (AT). The sinusitis associated with this disease is often fulminate and difficult to treat. In order to evaluate the surgical treatment of chronic sinusitis of AT a 17-year retrospective study of 80 patients was performed. Friedman Class III or IV sinus CT scans were present in 73 patients (90%) preoperatively. Twenty-five patients (30.1%) had steroid-dependent asthma and an additional 40 (50%) required intermittent oral steroids for asthma control. All patients underwent bilateral sinus surgery by either a conservative or a radical approach. Patients were followed from 3 weeks to 16 years postoperatively, with an average followup of 3 years. Sixty-eight patients (85%) had significant improvement in their sinus symptoms and 67 (83%) had relief of their asthma. The eight patients (10%) who remained steroid dependent required smaller doses of steroids. Seven patients (8.8%) had nonoperative orbital complications. There was a significant incidence of revision surgery after both conservative and radical sinus procedures. We conclude that surgical treatment by either a conservative or a radical approach controlled the sinusitis in the majority of AT patients, but neither was effective in eliminating the need for subsequent sinus surgery in a significant number of patients with severe sinus disease (Classes III and IV). Control of the sinus disease has a definite beneficial effect on steroid dependency and the need for intermittent oral steroids in managing the asthma in AT. We recommend conservative surgery in the surgical treatment of these patients. AT patients also require close long-term followup with intense medical management of their chronic respiratory inflammation that appears to put them at increased risk for nonoperative complications of their severe sinusitis.

Retropalatal airway characteristics in uvulopalatopharyngoplasty compared with transpalatal advancement pharyngoplasty.

Uvulopalatopharyngoplasty (UPPP) is reported successful in treatment of obstructive sleep apnea for approximately 50% of patients. Several modifications of the procedure have been described, including transpalatal advancement pharyngoplasty, which resects a portion of posterior hard palate and advances the soft palate anteriorly. Comparing effectiveness of different techniques based on sleep and respiratory data is confounded by multiple variables including clinical failure at nonsurgical sites and imprecise patient selection techniques. Since pharyngeal surgical procedures prevent collapse and obstruction by structurally modifying the upper airway, measuring structural changes in size and collapsibility provides a method to compare techniques. To evaluate whether transpalatal advancement pharyngoplasty is more effective in modifying upper airway characteristics than UPPP, upper airway cross-sectional size and collapsibility were measured after UPPP and transpalatal advancement pharyngoplasty. Six patients were evaluated using a quantitative endoscopic technique. After transpalatal advancement pharyngoplasty maximal retropalatal airway size increased 321% from 29.7 +/- 9.9 to 95.3 +/- 16 mm2 (P < 0.01), and retropalatal closing pressure decreased from 4.7 +/- 1.6 to -3.8 +/- 0.7 cm/H2O (P < 0.01) compared with UPPP. Respiratory disturbance index decreased from 74.5 +/- 13.5 to 29.2 +/- 9 events/hour postoperatively (P < 0.05). Results support the conclusion that transpalatal advancement pharyngoplasty increases retropalatal size and decreases retropalatal collapsibility compared with UPPP. Since these characteristics are postulated to contribute to increased stability during sleep, transpalatal advancement pharyngoplasty may potentially improve UPPP outcome in selected patients with small retropalatal airway areas after traditional surgery.

Prediction of uvulopalatopharyngoplasty response using cephalometric radiographs.

PURPOSE: To evaluate the relationship between facial cephalometric measures and response to uvulopalatopharyngoplasty (UPPP). PATIENTS AND METHODS: Retrospective analysis of skeletal cephalometric measures obtained from a consecutive sample of 43 patients with obstructive sleep apnea syndrome (OSAS) who underwent body mass index (BMI) measures, UPPP, upright lateral cephalometric radiographs, and preoperative and postoperative polysomnography. Significant clinical effect by uvulopalatopharyngoplasty was arbitrarily defined as having a 50% reduction in the respiratory disturbance index (RDI). The cephalometric measurements used were based solely on skeletal landmarks. RESULTS: No skeletal measurement predicted response to UPPP for the entire study population. When the patients were classified on the basis of retrognathia, 33 were identified without retrognathia. In that group, posterior airway length was the greatest predictor of response to UPPP (P < or = .05; odds ratio, 83.2). The distance between hyoid and mandible and the maxillary-mandibular relationship were also predictive of response (P < or = .05). CONCLUSION: The skeletal anatomy supporting the airway directly impacts the response to UPPP. Prediction of response requires stratification by skeletal subtype.

Posterior cephalometric radiographic analysis in obstructive sleep apnea.

Our objective was to evaluate the relationship between posterior facial cephalometric measures and obstructive sleep apnea syndrome (OSAS). We used a consecutive sample of 60 patients with OSAS who underwent upright lateral cephalograms, uvulopalatopharyngoplasty (UPPP), and preoperative and postoperative polysomnography. Successful responders to UPPP were arbitrarily defined as having a respiratory disturbance index reduced to fewer than 20 events per hour. Standard cephalometric measurements were used. Posterior facial height measures were constructed, based on a plane perpendicular to the Frankfort horizontal placed at hyoidale. The total and lower airway lengths were shorter and posterior mandibular height was longer in UPPP responders compared to nonresponders (p < or = .05). There was no difference between the two groups by standard cephalometric measurements. Responders and nonresponders to UPPP have significant differences in posterior airway measures that are not reflected in standard cephalometric measures. Airway length likely is a critical factor in OSAS and surgical response.

Changes in airway characteristics after transpalatal advancement pharyngoplasty compared to uvulopalatopharyngoplasty (UPPP).

Transpalatal advancement pharyngoplasty is postulated to enlarge the retropalatal airway compared to uvulopalatopharyngoplasty (UPPP) for treatment of the obstructive sleep apnea syndrome (OSAS). Surgical success in treating OSAS has been associated with increasing size and decreasing collapsibility of the retropalatal airway to prevent airway obstruction. To compare transpalatal advancement pharyngoplasty compared to UPPP, upper airway characteristics were measured following each procedure in seven patients using a quantitative endoscopic technique. Following transpalatal advancement pharyngoplasty, maximal retropalatal airway size increased 220% from 61.5 to 135.0 mm2 (p < 0.001), and retropalatal closing pressure decreased 9.2 cm H2O from 5 to -4.2 cm/H2O (p < 0.001) compared to UPPP. Results demonstrate that transpalatal advancement pharyngoplasty significantly increases retropalatal size and decrease retropalatal collapsibility compared to UPPP. Since these characteristics contribute to increased stability, transpalatal advancement pharyngoplasty may improve traditional UPPP. Studies of airway mechanics may assist in improving surgical treatment of OSAS.

Carcinoma of the larynx in patients with gastroesophageal reflux.

PURPOSE: To study the relationship between gastroesophageal reflux disease (GERD) and the development of laryngeal cancer in patients who lack other accepted risk factors for the development of squamous cell carcinoma of the larynx. PATIENTS AND METHODS: A retrospective review of patients either treated surgically or with radiation therapy for stage 1 or stage 2 laryngeal carcinoma with specific reference to smoking history and the presence of GERD. RESULTS: We present 9 lifetime nonsmoking patients with stage 1 or 2 laryngeal carcinoma in whom GERD was clinically and/or radiographically shown. Also, 14 patients are identified who quit smoking more than 15 years before the development of laryngeal cancer and who also had evidence of GERD. CONCLUSION: We propose that the development of laryngeal carcinoma in this cohort of patients who lack typical risk factors supports the notion that GERD plays a role in the etiology of carcinoma of the larynx. Because the accepted risk factors for laryngeal carcinoma such as smoking and alcohol use increase the likelihood of reflux, GERD may act as a cocarcinogen in smokers and drinkers. Of interest, the treatment of GERD can reverse the signs of chronic laryngitis and should be instituted in patients with laryngeal pathology who have GERD.

Orbital complications of sinusitis in the aspirin triad syndrome.

Orbital complications are uncommon in adult sinusitis. In contrast, the sinusitis of the aspirin triad syndrome is often fulminate, expansive, and recurrent, and complications may be more frequent. Of 81 patients with aspirin triad who were treated surgically, 7 patients (8.6%) had orbital complications, including sinus mucoceles in 3 patients, lacrimal gland extension in 2 patients, inflammatory orbital mass in 1 patient, and proptosis from expansile sinonasal polyposis in 1 patient. All complications manifested within 2 years of prior surgery. Two patients suffered blindness. In a group of 120 consecutively treated sinus surgery patients without aspirin triad syndrome (51 of whom were followed for more than 2 years), no patient manifested nonoperative orbital complications. The results of this study suggest that aspirin triad patients are at significant risk for orbital complications and therefore should have long-term follow-up with aggressive treatment of persistent disease.

Manometric and endoscopic localization of airway obstruction after uvulopalatopharyngoplasty.

The most widely reported surgical procedure for obstructive sleep apnea syndrome is uvulopalatopharyngoplasty. The success rate for this procedure is variable, and the reason for failure is incompletely understood. Failure in some patients is postulated to result from tongue-base obstruction. To investigate this, we identified the level of collapse and obstruction in 11 cases of uvulopalatopharyngoplasty failure, using upper airway manometry and videoendoscopy, while patients slept. Airway manometry measured the initial level of complete obstruction. Videoendoscopy identified significant resting airway narrowing (> 75%) at the tongue base on obstructed compared with nonobstructed breaths. Results of manometry indicated that the palate was the primary level of obstruction in eight (73%) compared with the tongue base in three (27%). However, collapse on videoendoscopy at the tongue base was observed in an additional three patients. A total of six patients (54%) demonstrated significant tongue-base abnormalities. In six patients with uvulopalatopharyngoplasty as the only pharyngeal surgery, one (17%) has an obstruction at the tongue base, as measured with manometry. Three of the six also had collapses at the tongue base, as measured endoscopically. Tongue-based abnormalities were identified in four of six (67%). Two additional patients who had failed uvulopalatopharyngoplasty and transpalatal advancement pharyngoplasty had obstructions on manometry at the level of tongue base. Six of eight (75%) palatopharyngoplasty failures demonstrated tongue-base collapse. In the three patients with tongue-base surgery, all had obstructions on manometry at the palate and none had endoscopic tongue-base collapse. These results indicate that in most uvulopalatopharyngoplasty failures the initial level of obstruction occurs at the palate.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of upper-airway evaluations during wakefulness and sleep.

The location of upper-airway obstruction during sleep has been predicted by using waking measures that include physical examination and endoscopic Müller's maneuver. However, this prediction remains speculative. To objectively evaluate these clinical measures, 22 patients with severe obstructive sleep apnea had upper-airway studies during nonsedated sleep with solid-state manometry and videoendoscopy. Objective tongue-base obstruction was measured with four methods, each identifying a different aspect of airway collapse during sleep. Manometry identified tongue obstruction during (1) early and (2) late inspiration, and videoendoscopy identified severe collapse without complete obstruction during (3) late inspiration, and (4) expiration. Twenty-eight waking upper-airway characteristics measured at waking clinical and endoscopic examination were then compared between patients with and without tongue-base segment obstruction to identify characteristics that would discriminate tongue-base obstruction. The results demonstrated that tongue-base/hypopharyngeal pathology during wakefulness was present on clinical examination in 19 of 22 (86%) patients. Objectively, during sleep tongue-base obstruction occurred on manometric early inspiration in 5 of 21 (24%) patients, on manometric late inspiration in 11 of 21 (52%), on endoscopic late inspiration in 14 of 19 (74%), and on endoscopic expiration in 8 of 19 (42%). Patients with tongue-base obstruction during sleep were primarily discriminated on waking examination by nonobstructive upper oropharyngeal features (p < 0.10). Near-total collapse of the tongue base on supine endoscopy was the only characteristic associated with tongue-base obstruction during sleep. Müller's maneuver did not discriminate patient groups. Results indicate that the incidence of tongue-base abnormalities measured during sleep varies significantly depending on the measure used. This variability may contribute to variability in surgical success rates. Identification of airway pathology relevant to sleep-related breathing disorders may require new methods of evaluation and a better understanding of upper-airway biomechanics.

Transpalatal advancement pharyngoplasty for obstructive sleep apnea.

Uvulopalatopharyngoplasty (UPPP) is a commonly performed procedure for obstructive sleep apnea (OSA). However, results are inconsistent. Patients in whom the UPPP procedure has failed have a smaller change in airway size as compared to responders, and also many demonstrate continued obstruction at the palate. We present a modification, transpalatal advancement pharyngoplasty, that increases upper oropharyngeal and retropalatal airway size by advancing the soft palate. Eleven patients with severe OSA and multiple sites of airway narrowing were corrected by this method. Three patients had prior UPPP and 5 patients had concomitant tongue-base procedures. Overall results demonstrate clinical enlargement of the retropalatal space. In the 6 patients who had transpalatal advancement pharyngoplasty alone, 4 (67%) were successful responders as defined by a respiratory disturbance index (RDI) of less than 20 events per hour. RDI decreased from 52.8 +/- 12.2 to 12.3 +/- 2.8 events per hour. For the entire group, RDI decreased from 73.3 +/- 29.4 to 25.1 +/- 28.2 events per hour (P < .001). There were four complications, including a transient oronasal fistula(1), transient dysphagia(2), and serous otitis media(1). Transpalatal advancement pharyngoplasty potentially may offer an alternative to increasingly aggressive resection with UPPP in an effort to increase the upper oropharyngeal and retropalatal airway and may be appropriate in careful selected patients as part of the surgical treatment of OSA.