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

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

Comparative Efficacy of Obstructive Sleep Apnea Patients Undergoing Multilevel Surgery Followed by Upper Airway Stimulation Versus Isolated Upper Airway Stimulation.

PURPOSE: Upper Airway Stimulation (UAS) of the hypoglossal nerve is a rapidly growing management option for patients with obstructive sleep apnea (OSA). Our study compares the treatment efficacy of UAS between those who were initially ineligible for UAS but subsequently met eligibility after multilevel surgery versus those who underwent isolated UAS for the treatment of moderate to severe OSA. METHODS: The investigators implemented a retrospective single-center cohort study of patients aged 18+ years who presented for surgical evaluation of OSA from 2016-2019 and underwent UAS implantation. The predictor variable was eligibility status for UAS. Initially ineligible subjects were defined as having an apnea-hypopnea (AHI) > 65 events/hr, body mass index (BMI) > 32 kg/m2, or complete concentric collapse (CCC) on drug-induced sleep endoscopy. Eligible subjects were defined as having an AHI between 15 and 65, with no CCC on drug-induced sleep endoscopy. The primary outcome was change in AHI which was measured preoperatively and 6 months post UAS implantation. Secondary outcomes were change in Epworth sleepiness scale and Fatigue severity scale. Covariates were age, sex, and BMI. Data analysis involved descriptive statistics and multivariable statistical models; P < .05 was considered significant. RESULTS: Thirty six patients underwent UAS implantation from 2016-2019. Eighteen patients who were initially ineligible for UAS underwent multilevel surgery, including uvulopalatopharyngoplasty, distraction osteogenesis maxillary expansion, or maxillomandibular advancement. Mean age was 62.4 ± 9 years and BMI of 29.1 ± 4 kg/m2 with 5 female patients. The cohort of 17 patients who met criteria for UAS from the start had a mean age of 62.9 ± 14 years and mean BMI of 26.7 ± 4 kg/m2 with 2 female patients. Mean AHI reduction for the multilevel group was 37.6 ± 21.2 events per hour (P < .001). Mean AHI reduction for the UAS-only group was 31.5 ± 13 events per hour (P < .001). When adjusted for age, BMI, and sex, the multilevel group had a more significant reduction (18 AHI events) compared to the isolated group (P < .001). CONCLUSIONS: For patients who are ineligible for UAS due to severity of OSA or CCC of the velum, multilevel surgery including maxillomandibular advancement followed by UAS confers effective post-treatment results, which was superior to the UAS-only group.

Endonasal Septoplasty Using a Septal Cartilaginous Batten Graft for Managing Caudal Septal Deviation.

Caudal nasal septal deviation is an important condition altering nasal obstruction and cosmetic appearance and many surgical techniques have been published on how to correct caudal septal deviation, as successful management of caudal septal deviation is challenging. The goal of our study was to explore the effect of endonasal septoplasty using a septal cartilaginous batten graft for managing caudal septal deviation. We tested 26 participants with caudal septal deviation who received endonasal septoplasty using a septal cartilaginous batten graft from 1 April 2019 to 29 June 2022, and followed up for at least 6 months. Nasal Obstruction Symptom Evaluation (NOSE) Scale and visual analog scale (VAS) were recorded at baseline, 1 month, and 6 months after surgery. Valid samples were analyzed by repeated measures ANOVA and paired sample t-test. Average participant age was 36.15 ± 11.02 years old. The preoperative, 1-month postoperative, and 6-month postoperative NOSE scale decreased significantly (75.38 ± 15.62, 13.85 ± 7.79, and 14.04 ± 9.90; p < 0.001), while preoperative, 1-month postoperative, and 6-month postoperative VAS (convex/concave side) also improved (7.50 ± 0.81/3.38 ± 0.94, 2.27 ± 0.53/1.54 ± 0.58, and 2.31 ± 0.55/1.58 ± 0.58; p < 0.001). Our results showed that endonasal septoplasty using a septal cartilaginous batten graft had good surgical outcomes without an open scar or severe complications.

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

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

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

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

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

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

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

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

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

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

CPAP Treatment Improves Pure Tone Audiometry Threshold in Sensorineural Hearing Loss Patients with Sleep-Disordered Breathing.

This article investigates the effects of continuous positive airway pressure (CPAP) on hearing impairment in sensorineural hearing loss (SNHL) patients with sleep-disordered breathing (SDB). This retrospective and observational study took place from September 2016 to February 2021, accumulating 77 subjects with SNHL and SDB (60.7 ± 11.1 years). Of which, 28 received CPAP treatment (63.0 ± 8.5 years). In our methodology, hearing thresholds at low, medium, high, and average frequencies are assessed by pure-tone audiometry at baseline (BL), three (3 m), six (6 m), and 12 (12 m) months. Our results show that the BL of at least three frequencies in all subjects is positively associated with old age, males, smoking, alcohol, coronary artery disease, hypertension, and apnea-hypopnea index [AHI] (all p < 0.05). Moreover, low, medium, and average frequencies are negatively correlated at CPAP-6 m (-5.60 ± 2.33, -5.82 ± 2.56, and -5.10 ± 2.26 dB; all p < 0.05) and CPAP-12 m (-7.97 ± 2.74, -8.15 ± 2.35, and -6.67 ± 2.37 dB; all p < 0.01) against corresponding measures of CPAP-BL. High, medium, and average frequencies positively correlated with age (p < 0.001 for high and average frequencies and <0.01 for medium frequencies). We conclude that in SNHL patients with SDB, hearing thresholds at low and medium frequencies improves under CPAP use after six months, which persists at least to the end of one year.

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

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

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

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

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

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

Does the Lack of Gender-Specific Apnea-Hypopnea Index Cutoff for Obstructive Sleep Apnea Impact Surgical Selection?

PURPOSE: The apnea-hypopnea index (AHI) is the parameter on which the severity of obstructive sleep apnea (OSA) is based and is also the determinant for both clinicians and third-party payers for surgical procedures. The purpose of this retrospective cross-sectional chart review is to examine differences in symptoms and AHI between men and women with OSA and whether this may impact timing and selection of surgical care. METHODS: Retrospective cross-sectional study of patients aged 18 years and older who presented at a single center for surgical evaluation of OSA from January 2017 to 2020. AHI, oxygen desaturation index, respiratory disturbance index, and lowest oxygen saturation were obtained from polysomnography. The predictor variable was gender, and the outcome variable was AHI. Unadjusted and multivariate adjusted linear regression models were used to compare differences in AHI between gender, controlling for age, body mass index (BMI), Epworth sleepiness scale, and fatigue severity scale. Poisson regression analysis with robust error was used to assess the relative risks of antidepressant and anxiolytic medication use between genders. RESULTS: A total of 408 consecutive new patients seen for surgical evaluation to treat OSA (248 men and 160 women) were included. Median patient age was 40 years for men and 41 years for women. Median AHI for men was 22.1 events per hour and 13.7 for women (P < .001). When adjusted for age and BMI, men have 33.2% higher AHI than women, with age contributing to 2% and BMI contributing to 6% of the difference. When controlling for age, BMI, Epworth sleepiness scale, and fatigue severity scale, women have a 2.2 increased relative risk of taking anxiolytic or antidepressant medications. CONCLUSIONS: Women with OSA seeking surgery in a dedicated sleep practice have 33% lower AHI than men when controlling for age, BMI, and symptoms. Based on our findings, non-gender-specific AHI may handicap the surgeon from offering the full range of available procedures to women with OSA.

Role of drug-induced sleep endoscopy in evaluation of positional vs non-positional OSA.

BACKGROUND: The study aimed to evaluate the anatomical differences between positional and non-positional OSA, and to identify the potential predictors for distinguishing between these two types of OSA. METHODS: A cross-sectional study of 230 consecutive patients with OSA undergoing DISE (Drug-induced Sleep Endoscopy) was carried out at a tertiary academic medical center. The factors correlating with positional and non-positional OSA were analyzed, including clinical characteristics, polysomnography data, and DISE findings. RESULTS: Univariate analysis revealed that non-positional dependency was correlated with a higher BMI (p < 0.001), neck circumference (p < 0.001), modified Mallampati score (p = 0.003), AHI (p < 0.001), degree of velum concentric collapse (p = 0.004), degree of oropharyngeal lateral wall collapse (p < 0.001), and degree of tongue base anteroposterior collapse (p = 0.004). Multivariate analysis revealed that oropharyngeal lateral wall collapse (OR = 1.90, p = 0.027) was the only anatomical factor significantly predicted non-positional dependency in OSA patients. AHI (OR = 1.04, p < 0.001), although significant, made only a marginal contribution to the prediction of non-positional dependency. CONCLUSIONS: Oropharyngeal lateral wall collapse was identified as the only anatomical predictor for non-positional dependency in OSA patients. Therefore, further treatment modalities should address the distinct anatomical trait between positional and non-positional OSA.

Maxillomandibular Advancement and Upper Airway Stimulation: Extrapharyngeal Surgery for Obstructive Sleep Apnea.

There are many ways to categorize surgery for obstructive sleep apnea (OSA), one of which is to distinguish between intrapharyngeal and extrapharyngeal procedures. While the general otolaryngologist treating OSA is familiar with intrapharyngeal procedures, such as uvulopalatopharyngoplasty and tongue base reduction, extrapharyngeal sleep operations such as maxillomandibular advancement (MMA) and upper airway stimulation (UAS) have evolved rapidly in the recent decade and deserve a dedicated review. MMA and UAS have both shown predictable high success rates with low morbidity. Each approach has unique strengths and limitations, and for the most complex of OSA patients, the two in combination complement each other. Extrapharyngeal airway operations are critical for achieving favorable outcomes for sleep surgeons.

Surgical Algorithm for Obstructive Sleep Apnea: An Update.

Sleep surgery is part of a continuum of care for obstructive sleep apnea (OSA) that involves medical, pharmacologic, and behavioral therapy. Upper airway surgery for OSA can significantly improve stability by way of modulating the critical negative closing pressure. This is the same mechanism of action as positive airway pressure or oral appliance therapy. The updated surgical algorithm in this review adds precision in three areas: patient selection, identification of previously unaddressed anatomic phenotypes with associated treatment modality, and improved techniques of previously established procedures. While the original Riley and Powell phase 1 and 2 approach to sleep surgery has focused on individual surgical success rate, this algorithm strives for an overall treatment success with multi-modal and patient-centric treatments.

Safeness, subjective and objective changes after turbinate surgery in pediatric patients: A systematic review.

OBJECTIVE: Inferior turbinates are the main structure related to impaired nasal breathing. When medical treatment fails, surgery is the next step, according to clinical guidelines. However, despite the widespread acceptance of this procedure, there is some controversy about performing it in children. DATA SOURCES: Pubmed (Medline), the Cochrane Library, EMBASE, Scopus, Science direct, SciELO and Trip Database. REVIEW METHODS: We looked for articles in which the individual outcome of turbinate surgery in pediatric patients was investigated independently of whether it was the main objective of the study or not. RESULTS: 13 papers (1111 patients) met the inclusion criteria. 6 authors performed diverse objective assessment and 11 authors used subjective scales. All of them found improvement after surgery. Due to the heterogeneity of the methods used, they could not be included in a metanalysis. Eleven out of the 13 authors reported 3.12% complication rates, being minor bleeding the most common (1.30%), followed by crust (0.49%) and pain (0.47%). CONCLUSIONS: There is a lack of high quality studies in children. Turbinate surgery in children is a safe technique with low complication rates. The available evidence suggests improvement in subjective outcomes after turbinate surgery in children. We cannot make a formal recommendation of a surgical technique in children given the lack of high quality studies, and since comparison between available papers is not possible. Although the evidence at our disposal is weak, it suggests that the safest techniques are MAIT, radiofrequency, coblation and laser.

The role of pediatric maxillary expansion on nasal breathing. A systematic review and metanalysis.

OBJECTIVE: A reduced transversal dimension of the maxilla leads to narrower nasal cavities, which may reduce airflow to the lungs. Maxillary expansion widens nasal floor. However, there is huge controversy regarding whether this increase does actually lead to increased airflow. In this systematic review and meta-analysis we aim to resolve this question by evaluating studies that have undertaken rhinomanometric measurements. REVIEW METHODS: Pubmed (Medline), the Cochrane Library, EMBASE and Trip Database were checked by two authors. Two authors extracted the data. Main outcome was expressed as the difference between resistance before and after treatment and the 95% confidence interval. RESULTS: 30 studies were selected for full text reading. A total of 12 studies (301 patients) met the inclusion criteria. All selected articles found reduced resistance after palatal expansion. The data pooled in the meta-analysis reveals a statistically significant difference of 0.12 Pa s/cm3 mean reduction after palatal expansion (CI 95% 0.06, 0.18) for nine uncontrolled studies. Regarding nasal airflow, the pooled data show a statistically significant difference of 29.9 cm3/s increase after palatal expansion (CI 95% 9.17, 50.64). CONCLUSION: According to the available evidence, palatal expansion in pediatric patients decreases nasal resistance and increases nasal flow.

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

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

Palatopharyngoplasty Resolves Concentric Collapse in Patients Ineligible for Upper Airway Stimulation.

OBJECTIVE: To determine if a modified tissue-preserving palatopharyngoplasty could convert retropalatal concentric collapse to anteroposterior or lateral patterns of collapse on drug-induced sleep endoscopy (DISE) in patients who are not candidates for upper airway stimulation due to complete circumferential collapse at the velum. METHODS: A prospective, nonconsecutive, single-blinded cohort study was performed by two sleep surgeons at a tertiary care center from 2015 to 2018. Inclusion criteria included adults > 18 years of age with a diagnosis of obstructive sleep apnea with an Apnea-Hypopnea Index (AHI) > 15, a body mass index (BMI) < 32, and < 25% central apneas on polysomnography. Twelve patients with complete circumferential collapse underwent a modified palatopharyngoplasty. Postoperatively, a repeat sleep study was performed. A repeat DISE was recommended for those with incomplete surgical response (clinically and/or AHI). RESULTS: Twelve patients with complete circumferential collapse were eligible for the study. Mean BMI was 30.5. Mean preoperative AHI was 54.0 events per hour. Following a modified palatopharyngoplasty, the mean AHI was reduced to 33.1 events per hour, and 100% (12 of 12) of the patients converted from a pattern of complete circumferential collapse to either no collapse at the level of the velum (3) or an anteroposterior pattern of collapse (9). CONCLUSION: We demonstrate that a modified palatopharyngoplasty can successfully convert collapse patterns in patients with complete circumferential collapse. Further studies are required to determine the outcome of these patients following upper airway stimulation implantation. LEVEL OF EVIDENCE: 1B Laryngoscope, 2020.