The Effect of Upper Airway Surgery on Continuous Positive Airway Pressure Levels and Adherence: A Systematic Review and Meta-Analysis.

UNLABELLED: Background /Aims: The aim of this study was to determine the effect of upper airway surgery (UAS) on continuous positive airway pressure (CPAP). A secondary objective was to determine if a decrease in CPAP from UAS increases CPAP adherence. METHODS: Studies were eligible for inclusion if a CPAP titration was performed both prior and following UAS in patients with obstructive sleep apnea (OSA). Studies that compared adherence to CPAP before and after UAS were included to evaluate the secondary objective. RESULTS: A total of 11 articles involving 323 patients were included in the review. The results show that there was a mean reduction in CPAP of 1.40 cm H2O (95% CI -2.08 to -0.73). Four of the 11 papers, with a total of 80 patients, evaluated CPAP adherence and found a significant 0.62-hour improvement on average (95% CI 0.22-1.01). CONCLUSION: Due to high levels of nonadherence, surgical intervention will play a role even in patients who are unlikely to be fully cured by surgery. UAS decreases the apnea-hypopnea index and modestly reduces CPAP while improving CPAP adherence in the majority of patients. The evidence suggests that UAS may have an adjunctive role in the management of OSA.

Application of drug-induced sleep endoscopy in patients treated with upper airway stimulation therapy.

OBJECTIVE: To determine the level of agreement among experienced operators of candidacy for upper airway stimulation (UAS) based on evaluation of drug-induced sleep endoscopy (DISE). METHODS: The trial was designed as a single-blinded cross-sectional study. Four otolaryngologists with extensive DISE experience were given 63 video clips from the STAR trial video library. These videos were graded using the VOTE classification. Percentage agreement and Cohen's κ (for inter-rater reliability) were calculated between pairs of reviewers, assessing palatal complete concentric collapse (CCC) and determining UAS eligibility. Subjects were also grouped based on collapse severity for each reviewer. RESULTS: The reviewers had excellent (approximately 90%) agreement on findings at the level of the soft palate and tongue base. The inter-rater reliability for palatal CCC ranged from moderate to substantial. The agreement on determining the criteria for UAS implantation ranged from poor to moderate. All 4 upper airway structures as classified by the criteria of the VOTE were graded by all the reviewers as contributing to obstruction in a majority of subjects who were performed via application of DISE. CONCLUSION: Application of DISE remains a subjective examination, even among those experienced operators, therefore more studies need to be performed for evaluation of improvement in inter-rater reliability after implantation of training videos.

Thyroid disease and compressive symptoms.

OBJECTIVES/HYPOTHESIS: Compressive symptoms are common in thyroid disease, but few studies have focused on the presence, associated factors, and etiology of compressive symptoms. STUDY DESIGN: Retrospective review. METHODS: Patients who underwent thyroidectomy from 2005 through 2009 were reviewed. The data included demographics, indication for surgery, compressive symptoms, complications, diagnosis, volume of thyroid gland, presence of inflammation, and follow-up. RESULTS: Three hundred thirty-three patients were identified. The mean age was 51 years, and 82% were female. Fifty-two percent (n=172) of patients experienced compressive symptoms preoperatively, including dysphagia (n=131) and shortness of breath (n=83). Twenty-six percent (n=86) of patients presented with voice changes, and 8% (n=27) complained of odynophagia. Postoperatively, 25 patients (8%) continued to have compressive symptoms (P<.0001), and 10 patients (3%) developed new compressive symptoms. Compressive symptoms were present in 72% (n=21) of patients with lymphocytic thyroiditis, 71% (n=5) of patients with anaplastic thyroid cancer, and 60% (n=92) of patients with goiter. The average volume of the gland in patients with compressive symptoms was 75.5 mL compared to 37.1 mL in asymptomatic patients (P<.0001). There was not a significant relationship between compressive symptoms and the presence of inflammation (P=.869). CONCLUSIONS: Patients with thyroid disease frequently present with compressive symptoms, and the majority of patients experience relief postoperatively. The volume of the thyroid gland is associated with compressive symptoms along with additional contributing factors.

Outcomes of hyoid myotomy and suspension using a mandibular screw suspension system.

OBJECTIVE: To review the outcomes of hyoid myotomy and suspension with a mandibular screw anchoring device. STUDY DESIGN: Case series with chart review. SETTING: Academic and private sleep surgery clinics. METHODS: The study is a consecutive case series of patients undergoing hyoid myotomy and suspension using a mandibular screw suspension device as part of multilevel treatment of obstructive sleep apnea (OSA). Outcomes of interest included complication rates, change in daytime sleepiness scores, and change in apnea-hypopnea index (AHI). RESULTS: Ten women and 23 men with a mean age of 54 years (range, 33-73 years) underwent hyoid myotomy and suspension using a mandibular screw suspension device. Four (12%) patients experienced minor complications, including neck seroma (3 patients) and tongue edema (1 patient). Epworth Sleepiness Scale scores fell from a preoperative median of 12 to a postoperative median of 6 (P = .002). Ten patients (30%) refused the postoperative sleep study. In the 23 patients who underwent postoperative sleep studies, AHI scores decreased from a preoperative mean ± SD of 40.9 ± 25.1 to 18.6 ± 21.2 postoperatively (P = .001). Ten patients (30%) achieved a postoperative AHI below 10. The Repose system was initially applied using a standard hyoid dissection but was later modified using a minimally invasive small incision (<2 cm) approach that demonstrated significantly fewer complications (P = .04). CONCLUSION: Hyoid myotomy and suspension with a mandibular screw anchor is an effective method with which to address hypopharyngeal collapse in multilevel surgery for OSA. The procedure can be performed with a small-incision, minimally invasive approach with minimal complications and patient morbidity.