Variables predictive of surgical outcomes after hyoid myotomy with suspension to thyroid cartilage.

OBJECTIVES: To evaluate variables predicting improvement in obstructive sleep apnea (OSA) with hyoid suspension to thyroid cartilage 4-suture technique. METHODS: Sixty adult patients (age range 23-78 years) with OSA underwent hyoid suspension to thyroid cartilage with or without concurrent multi-level surgery over an eight-year period from 2011 to 2019 at a tertiary academic center. All patients had a preoperative apnea hypopnea index (AHI) ≥ 5. Changes in mean AHI, Epworth Sleepiness Scale (ESS), and lowest oxygen saturation (LSAT) were measured with paired Student t-test. Linear and logistic regression models were used to predict change in AHI and surgical success respectively with respect to body mass index (BMI), age, sex, previous sleep surgery, concurrent retrolingual surgery, concurrent palatopharyngoplasty, and preoperative AHI. RESULTS: The mean AHI demonstrated a significant improvement from a preoperative AHI of 39.0 ± 25.5 to a postoperative AHI of 31.2 ± 23.4 (p = 0.005). The mean Epworth Sleepiness Score (ESS) significantly improved from 13.1 ± 6.0 to 9.2 ± 5.7 (p = 0.000012). Surgical success, defined as a 50% reduction in preoperative AHI to a postoperative AHI ≤ 20, was obtained in 18/60 (30.0%) patients. Preoperative BMI significantly correlates with variation of change in AHI in multivariable linear regression model (p = 0.003). Preoperative AHI was significant predictor of surgical success in multivariable logistic regression model. CONCLUSION: The magnitude of improvement in polysomnographic parameters after hyoid suspension to thyroid appears to be more significant in patients with lower BMI. Even patients with an obese BMI and severe OSA achieve significant improvement from this procedure.

Safety and efficacy of lingual tonsillectomy in multilevel airway surgery for pediatric obstructive sleep apnea.

STUDY OBJECTIVES: Prior studies have demonstrated the efficacy of lingual tonsillectomy in treating pediatric obstructive sleep apnea. The goal of this study is to describe the postoperative outcomes following lingual tonsillectomy as a part of drug-induced sleep endoscopy-directed multilevel sleep surgery. METHODS: A retrospective review was performed for pediatric patients with obstructive sleep apnea who underwent lingual tonsillectomy as a part of drug-induced sleep endoscopy-directed sleep surgery. Data collected included age, sex assigned at birth, body mass index z-score, polysomnography results, past medical and surgical history, and postoperative outcomes. RESULTS: A total of 174 patients were included in the study with a mean age of 8.29 ± 3.49 years (range 1.89-15.62) and mean preoperative apnea-hypopnea index of 7.88 ± 13.42 (range 1.10-123.40). Complications occurred in 26 patients (14.9%) including 14 patients (8.0%) requiring emergency department visit or readmission and 12 patients (6.9%) experiencing postoperative bleeding. Asthma (P = .033) and developmental delay (P = .016) correlated with postoperative complications. For patients with preoperative and postoperative polysomnography data (n = 145; 83.3%), there was significant improvement (P < .001) in apnea-hypopnea index with a mean postoperative apnea-hypopnea index of 4.02 ± 7.81 (range 0.00-54.46). Surgical failure, defined as postoperative apnea-hypopnea index ≥ 5, was identified in 25 patients (17.2%). Surgical failure was associated with body mass index z-score > 2 (P = .025) and Trisomy 21 (P = .005). CONCLUSIONS: This study highlights the promising surgical success rate of drug-induced sleep endoscopy-directed lingual tonsillectomy in multilevel sleep surgery (82.8%) and infrequent complications including postoperative bleeding (6.9%) and readmission (2.3%). CITATION: Williamson A, Morrow VR, Carr MM, Coutras SW. Safety and efficacy of lingual tonsillectomy in multilevel airway surgery for pediatric obstructive sleep apnea. J Clin Sleep Med. 2024;20(2):189-199.

Effects of Soft Tissue Sleep Surgery on Morbidly Obese Patients.

INTRODUCTION: Morbidly obese patients with obstructive sleep apnea (OSA) are often intolerant of continuous positive airway pressure (CPAP). The effects of sleep surgery in this population is not well documented, and sleep surgery is generally avoided due to the expectation of poor outcomes, leaving these patients untreated. METHODS: This retrospective study included 42 patients with a body mass index (BMI) ≥40.0 and OSA with a preoperative apnea hypopnea index (AHI) ≥5. Preoperative BMI ranged from 40.0 to 69.0 kg/m2. Preoperative AHI ranged from 7.2 to 130.0. Of 42 patients, 12 (28.6%) underwent concurrent pharyngeal and retrolingual surgery. Subgroup analysis of change in AHI was measured with respect to preoperative OSA severity, change in preoperative BMI, and BMI severity. Univariate linear and logistic regression was performed assessing change in AHI and surgical success with respect to age, sex, preoperative AHI, preoperative BMI, change in BMI, total procedures, palatal procedure, retrolingual procedure, nasal procedure, and multilevel procedures. RESULTS: The mean AHI improved from 45.9 ± 31.8 to 31.9 ± 31.6 (P = .007). Epworth sleepiness score (ESS) improved from 13.2 ± 5.5 to 9.6 ± 5.4 (P = .00006). Lowest oxygen saturation (LSAT) improved from 74.4 ± 10.7 to 79.9 ± 10.4 (P = .002). About 33.3% of patients had surgical success (AHI < 20 with at least 50% reduction in AHI). Preoperative AHI was the most significant factor for change in AHI in univariate and multivariate models (P = .015). CONCLUSION: Sleep surgery is effective in reducing OSA burden in most morbidly obese patients and can result in surgical cure for a third of patients.

Base of Tongue Surgery and Pediatric Obstructive Sleep Apnea.

OBJECTIVE: Drug-induced sleep endoscopy-directed lingual tonsillectomy and midline posterior glossectomy have been employed for the treatment of obstructive sleep apnea in children. The purpose of this study is to evaluate outcomes in children undergoing lingual tonsillectomy, midline posterior glossectomy, or combined base of tongue reduction procedures for obstructive sleep apnea. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care academic medical center. METHODS: A case series was performed with chart review of pediatric patients with obstructive sleep apnea who underwent base of tongue surgery as directed by drug-induced sleep endoscopy. Pre- and postoperative obstructive apnea-hypopnea index (oAHI) was compared. Age, sex, body mass index z score, and medical history were also evaluated. RESULTS: A total of 168 children were included, with a mean ± SD age of 8.3 ± 3.6 years. Of these patients, 101 underwent lingual tonsillectomy alone; 25, midline posterior glossectomy alone; and 42, both. Their mean oAHI improvement was 3.52 ± 8.39, 2.55 ± 5.59, and 3.70 ± 6.07, respectively. Each surgical group experienced significant improvement in sleep apnea when pre- and postoperative oAHI was compared (P < .01). Overall surgical success, as defined by oAHI <1 (or <5 without clinical symptoms), was 75% (126 patients). CONCLUSION: When guided by drug-induced sleep endoscopy, pediatric tongue base surgery can significantly improve oAHI and thus demonstrates promising success in treating pediatric obstructive sleep apnea.

Sleep Endoscopy Findings in Children With Obstructive Sleep Apnea and Small Tonsils.

OBJECTIVE: Obstructive Sleep Apnea (OSA) in children is treated primarily with adenotonsillectomy (AT). When clinical exam demonstrates small tonsils, the success of AT in resolving OSA is uncertain. The purpose of this study is to determine the utility of Drug induced Sleep Endoscopy (DISE) for children with OSA and small tonsils (Brodsky scale 1+) and to identify what obstructive trends exist in this subset of patients and to determine the utility of DISE-directed surgical intervention in patients with small tonsils. METHODS: A retrospective chart review was performed for patients who underwent DISE at a tertiary care center over a 2-year period. Inclusion criteria were 1+ tonsils and a positive sleep study. Data collected included DISE findings, BMI, comorbid conditions, and pre-op PSG data. RESULTS: Forty children were included with a mean age of 5.0 years (range 8 months-16 years). Mean preoperative AHI was 5.46 and mean oxygen saturation nadir was 87.1%. The most common contributor to airway obstruction was the adenoid (29 patients, 72.5%), followed by the tongue base or lingual tonsil (21 patients, 52.5%). The palatine tonsils (10 patients, 25.0%), epiglottis (10.0%), or obstruction intrinsic to the larynx (10.0%) were significantly less frequently identified as contributors to OSA when compared to the adenoid (P < .001). The majority of patients had multilevel obstruction (25 patients, 62.5%). Adenoidectomy (27 patients, 67.5%) was the most commonly performed procedure, followed by tonsillectomy (10 patients, 25.0%, P < .001) and tongue base surgery (9 patient 22.5%, P < .001). CONCLUSION: In this group, small palatine tonsils were infrequently identified as a contributor to airway obstruction and tonsillectomy was avoided in most cases. This study illustrates the utility of DISE as a tool to personalize the surgical management of pediatric patients with OSA and small tonsils on physical exam.

Reliability of a pediatric sleep endoscopy scoring system.

INTRODUCTION: The surgical management of Obstructive Sleep Apnea (OSA) may be guided by Drug Induced Sleep Endoscopy (DISE), but there is no universally accepted scoring system for DISE in children. The purpose of this study is to compare a novel system to the more commonly used VOTE (Velum, Oropharynx, Tongue base, Epiglottis) system. METHODS: A total of thirty pediatric DISE videos were reviewed and scored twice by 5 raters with a range of experience levels. The videos were scored using both the VOTE and the new scoring systems. The raters were also asked to recommend surgical intervention based on the DISE exam alone. Intra-rater test-retest analysis of the responses was conducted using weighted kappa (WK) statistic and percentage agreement (PA), respectively. Inter-rater reliability analysis of responses was evaluated using Krippendorff's alpha reliability coefficient (KA). Using a proportional odds model, a comparison of the weighted kappa statistic for the VOTE and the novel scoring systems was conducted. RESULTS: For the novel scoring system, the intra-rater test-retest WK coefficient was 0.62 and 0.87 and the PA was 64% and 82% at the 25th and 75th percentiles, respectively. For the VOTE system, the intra-rater test-retest WK coefficient was 0.50 and 1.00 and PA was 75% and 100% at the 25th and 75th percentiles, respectively. KA was 0.36 and 0.77 at the 25th and 75th percentiles. In addition, responses to the surgical intervention survey analysis yielded a test-retest WK coefficient of 0.40 and 1.00 and a PA 71%-100% at the 25th and 75th percentiles, respectively. KA was 0.40 and 0.61 at the 25th and 75th percentiles, respectively. There was no significant difference between the 2 scoring systems on the WK statistic (p = .15), but significant difference on PA (p = .01). CONCLUSION: Our novel scoring system demonstrated intra-rater test-retest and inter-rater reliability similar to the VOTE system, includes more sites of potential airway obstruction, and has potential for widespread use.

Pediatric Drug-Induced Sleep Endoscopy: Technique and Scoring System.

Drug-induced sleep endoscopy (DISE) is an invaluable tool for identifying sites of obstruction for patients with obstructive sleep apnea (OSA). During DISE, the patient is in a state of drug-induced sleep, and a flexible laryngoscope is passed through the nose into the upper airway. Sites of obstruction are visualized and scored to guide surgical management. Currently, there is no universally accepted method of DISE analysis and scoring. This limitation in comparability impedes large-scale analysis between clinicians, institutions, and studies. In this report, we propose a standardized method of scoring and performing DISE in children with OSA. Our DISE scoring system is internally developed, consistent through the study, and addresses all levels of potential upper airway obstruction.

Sleep endoscopy findings in children with persistent obstructive sleep apnea after adenotonsillectomy.

OBJECTIVES: Describe the patterns of obstruction in persistent pediatric OSA and their relationship with patient weight. STUDY DESIGN: Retrospective review. METHODS: All pediatric DISE procedures performed at a tertiary care hospital between October 2010 and October 2015 were reviewed. Patients had polysomnography after adenotonsillectomy that confirmed persistent obstructive sleep apnea (OSA). Variables included age, gender, co-morbidities, and AHI. DISE findings focused on inferior turbinates, adenoid, tongue base, epiglottis, aryepiglottic (AE) folds, arytenoids, lingual tonsil and their contributions to obstruction. RESULTS: 34 patients were included with mean age of 7.85 (2-16) years, mean BMI of 23.15 (13.6-44.8) and mean AHI of 6.34 (1.5-25.2) events per hour. Obstruction occurred at the level of the epiglottis in 97%, with retropositioning by tongue base (73.6%) or lingual tonsil enlargement (70.5%). Obstruction occurred at the inferior turbinates in 76.5%, the adenoid in 64.7% and the palate in 58.8%. Shortened AE folds were less often identified (15%). Multiple sites of partial or complete obstruction were found in 97% of patients. Overweight or obese patients had a mean of 3 sites of complete obstruction and 4.69 sites of partial or complete obstruction as compared to 2.33 and 4.52 in underweight or normal weight children. Overweight or obese children were more likely to have obstruction at the lingual tonsil or adenoid than normal/underweight children. CONCLUSION: Multiple sites of obstruction in persistent pediatric OSA were found. Children with higher BMIs had slightly different findings, suggesting that attention to adenoid regrowth and lingual tonsil hypertrophy is important.

Adenoid size by drug induced sleep endoscopy compared to nasopharyngeal mirror exam.

OBJECTIVE: To establish how assessment of adenoid size is correlated between drug-induced sleep endoscopy (DISE) with indirect mirror nasopharyngoscopy (IMN). STUDY DESIGN: Retrospective chart review. SETTING: Tertiary care academic hospital. METHODS: Over a 6-year period, 154 pediatric patients underwent DISE for obstructive sleep apnea and had IMN. DISE videos were assessed by one reviewer, blinded to results of mirror exams. IMN findings were taken from operative notes recorded by one attending physician. Demographic data, co-morbidities, and sleep study results were also recorded. RESULTS: Ninety-three (58.5%) males and 66 (41.5%) females were included. Mean age at DISE was 7.34 ± 3.99 years, with an average of 29 days after DISE until nasopharyngeal mirror examination. The mean initial adenoid size based on DISE assessment was 2.62 + 0.99, and on nasopharyngeal mirror assessment was 2.56 + 0.97. DISE and IMN assessment of adenoid size correlated well (Spearman's Rho = 0.82, P < 0.00001; Kendal tau = 0.764, P < 0.00001). CONCLUSIONS: DISE has proven to be an excellent tool to assess adenoid size prior to adenoidectomy in children with OSA.