Australasian Sleep Association position statement on consensus and evidence based treatment for primary snoring.

Primary snoring impacts a significant portion of the adult population and has the potential to significantly impair quality of life. The purpose of these guidelines is to provide evidence-based recommendations to assist Australasian practitioners in the management of adult patients who present with primary snoring without significant obstructive sleep apnoea. The Timetable, Methodology and Standards by which this Position Statement has been established is outlined in the Appendix S1. The main recommendations are: Weight loss, and reduced alcohol consumption should be recommended, where appropriate If clinical judgement dictates, benzodiazepine and opioid reduction or avoidance may be advised Positional therapy should be considered in supine dominant snorers In dentate patients, Mandibular advancement devices (MAD) should be recommended as a first line treatment following assessment by both an appropriate Dentist and Sleep physician Continuous positive airway pressure (CPAP) devices may be recommended in patients with primary snoring in those already committed to their use or willing to try Surgical treatment of primary snoring by an appropriately credentialled surgeon may be advised and includes nasal (adjunctive), palatal and other interventions This position statement has been designed based on the best available current evidence and our combined expert clinical experience to facilitate the management of patients who present with primary snoring. It provides clinicians with a series of both non-surgical and surgical options with the aim of achieving optimal symptom control and patient outcomes. This is the first such set of recommendations to be established within Australasia and has also been reviewed and endorsed by the Australasian Sleep Association.

Incidence of allergen-specific and total immunoglobulin E positivity in children undergoing adenotonsillectomy.

AIM: To conduct a prospective, consecutive cohort study to evaluate the incidence of allergen-specific and total immunoglobulin E (IgE) in a paediatric population undergoing adenotonsillectomy for sleep-disordered breathing. METHODS: A total of 64 consecutive patients presenting for adenotonsillectomy at a single centre were recruited over a period of 3 months. All patients underwent adenotonsillectomy and had allergen-specific and total IgE serum testing at the time of anaesthesia induction. Pre-operative history and examination were conducted to determine clinical allergy. Caregivers completed the Sleep-Related Breathing Disorder scale of the Paediatric Sleep Questionnaire and the Mini Rhinoconjunctivitis Quality of Life Questionnaire at baseline and at 6 weeks post-operatively. RESULTS: A total of 37 (57.8%) patients had either allergen-specific or total IgE positivity. House dust mite was the most prevalent allergen-specific IgE finding, being present in moderate to high levels in 14 (21.9%) patients. A total of 17 (26.6%) patients had a history of atopy, while 34 (53.1%) had examination findings suggestive of allergy. Neither serum IgE testing nor clinical history and examination were independently associated with residual symptoms post adenotonsillectomy. Patients with concomitant serum IgE positivity and clinical allergy had higher residual symptom scores compared to those who did not using both Sleep-Related Breathing Disorder scale of the Paediatric Sleep Questionnaire (P = 0.035) and Mini Rhinoconjunctivitis Quality of Life Questionnaire (P = 0.02) questionnaires. CONCLUSIONS: Our prospective, consecutive cohort of patients reflect a greater incidence of serum IgE positivity compared to historical figures. When utilised with clinical findings on history and examination, serum IgE is a useful adjunct that is associated with greater residual symptoms post-adenotonsillectomy.

Bilateral hypoglossal nerve stimulation for treatment of adult obstructive sleep apnoea.

BACKGROUND AND AIM: Hypoglossal nerve stimulation (HNS) decreases obstructive sleep apnoea (OSA) severity via genioglossus muscle activation and decreased upper airway collapsibility. This study assessed the safety and effectiveness at 6 months post-implantation of a novel device delivering bilateral HNS via a small implanted electrode activated by a unit worn externally, to treat OSA: the Genio™ system. METHODS: This prospective, open-label, non-randomised, single-arm treatment study was conducted at eight centres in three countries (Australia, France and the UK). Primary outcomes were incidence of device-related serious adverse events and change in the apnoea-hypopnoea index (AHI). The secondary outcome was the change in the 4% oxygen desaturation index (ODI). Additional outcomes included measures of sleepiness, quality of life, snoring and device use. This trial was registered with ClinicalTrials.gov, number NCT03048604. RESULTS: 22 out of 27 implanted participants (63% male, aged 55.9±12.0 years, body mass index (BMI) 27.4±3.0 kg·m-2) completed the protocol. At 6 months BMI was unchanged (p=0.85); AHI decreased from 23.7±12.2 to 12.9±10.1 events·h-1, a mean change of 10.8 events·h-1 (p<0.001); and ODI decreased from 19.1±11.2 to 9.8±6.9 events·h-1, a mean change of 9.3 events·h-1 (p<0.001). Daytime sleepiness (Epworth Sleepiness Scale; p=0.01) and sleep-related quality of life (Functional Outcomes of Sleep Questionnaire-10; p=0.02) both improved significantly. The number of bed partners reporting loud, very intense snoring, or leaving the bedroom due to participant snoring decreased from 96% to 35%. 91% of participants reported device use >5 days per week, and 77% reported use for >5 h per night. No device-related serious adverse events occurred during the 6-month post-implantation period. CONCLUSIONS: Bilateral HNS using the Genio™ system reduces OSA severity and improves quality of life without device-related complications. The results are comparable with previously published HNS systems despite minimal implanted components and a simple stimulation algorithm.

Surgical management of obstructive sleep apnoea: A position statement of the Australasian Sleep Association.

Surgery for adult obstructive sleep apnoea (OSA) plays a key role in contemporary management paradigms, most frequently as either a second-line treatment or in a facilitatory capacity. This committee, comprising two sleep surgeons and three sleep physicians, was established to give clarity to that role and expand upon its appropriate use in Australasia. This position statement has been reviewed and approved by the Australasian Sleep Association (ASA) Clinical Committee.

Effect of Multilevel Upper Airway Surgery vs Medical Management on the Apnea-Hypopnea Index and Patient-Reported Daytime Sleepiness Among Patients With Moderate or Severe Obstructive Sleep Apnea: The SAMS Randomized Clinical Trial.

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.

Advances in Pharyngeal Surgery Over the Past 10 Years: New Techniques and Technology.

This article is a review of advances in pharyngeal surgery over the past 10 years regarding literature, surgical technique, assessment, collaboration, and future direction in the management of adult and pediatric obstructive sleep apnea.

A virtual reality environment for supporting mental wellbeing of students on remote clinical placement: A multi-methods evaluation.

BACKGROUND: Nursing and Allied Health Profession (NAHP) students undertake clinical placements as part of their pre-registration training. The remote nature of some placement sites, shiftwork and the emotionally challenging nature of the workload has led to mental wellbeing issues in many students. AIM: This project aimed to evaluate a novel 3D immersive virtual reality environment that supports mental wellbeing for NAHP students on clinical placement. It comprises a calming 3D tropical beach environment where students and tutors can meet for reflection and mutual support. DESIGN: A multi-methods design gathered quantitative impact data with validated measurement tools and qualitative output related to the lived experience of students. SETTINGS AND PARTICIPANTS: All 600 pre-registration NAHP students within the institution undertaking clinical placements were invited to participate, irrespective of mental wellbeing status. Students were randomly assigned to either a VR or Conventional cohort; all participants received the control support mechanism in a subsequent placement. METHODS: All participants completed an initial demographic and Readiness for Therapy survey followed by weekly Beck Anxiety and Depression Inventories during placement. All participants were invited to a semi-structured interview. RESULTS: Overall, 32 participants engaged with the application; although the VR cohort demonstrated improved scores on both Beck inventories, these were not statistically significant. This is probably due to the low response rate for the control cohort. A total of 15 interviews were conducted and several themes emerged from the data in relation. to both experiential outcomes (escapism, anonymity and sense of community) and instrumental outcomes (calming, mindfulness and combatting loneliness). CONCLUSIONS: User feedback indicates that a VR environment can provide a calming escape from the pressures and anxiety arising from clinical placement for healthcare students. The relaxing beach environment facilitated mindfulness meditation and the additional opportunities for pseudo-anonymous interactions with peers and tutors were wellreceived by students.

Sleep apnea multi-level surgery trial: long-term observational outcomes.

STUDY OBJECTIVES: The sleep apnea multi-level surgery (SAMS) randomized clinical trial showed surgery improved outcomes at 6 months compared to ongoing medical management in patients with moderate or severe obstructive sleep apnea (OSA) who failed continuous positive airway pressure therapy. This study reports the long-term outcomes of the multi-level surgery as a case series. METHODS: Surgical participants were reassessed >2 years postoperatively with the same outcomes reported in the main SAMS trial. Primary outcomes were apnea-hypopnea index (AHI) and Epworth sleepiness scale (ESS), with secondary outcomes including other polysomnography measures, symptoms, quality of life, and adverse events. Long-term effectiveness (baseline to long-term follow-up [LTFU]) and interval changes (6 month to LTFU) were assessed using mixed effects regression models. Control participants were also reassessed for rate of subsequent surgery and outcomes. RESULTS: 36/48 (75%) of surgical participants were reevaluated (mean (standard deviation)) 3.5 (1.0) years following surgery, with 29 undergoing polysomnography. AHI was 41/h (23) at preoperative baseline and 21/h (18) at follow-up, representing persistent improvement of -24/h (95% CI -32, -17; p < 0.001). ESS was 12.3 (3.5) at baseline and 5.5 (3.9) at follow-up, representing persistent improvement of -6.8 (95% CI -8.3, -5.4; p < 0.001). Secondary outcomes were improved long term, and adverse events were minor. Interval change analysis suggests stability of outcomes. 36/43 (84%) of the control participants were reevaluated, with 25 (69%) reporting subsequent surgery, with symptom and quality of life improvements. CONCLUSION: Multi-level upper airway surgery improves OSA burden with long-term maintenance of treatment effect in adults with moderate or severe OSA in whom conventional therapy failed. CLINICAL TRIAL: Multi-level airway surgery in patients with moderate-severe obstructive sleep apnea (OSA) who have failed medical management to assess change in OSA events and daytime sleepiness; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366019&isReview=true; ACTRN12614000338662.

Surgery for adult obstructive sleep apnoea.

Surgery rarely cures OSA, but the lack of cure should not be judged as failure. New higher-level evidence shows excellent clinical outcomes with surgery, in long-term health, short-term symptoms and quality of life, even when complete cure is not achieved. It is unrealistic and inappropriate to expect that surgery must result in a cure to be considered worthwhile. Evaluating surgical treatments is complicated because placebo control is usually not feasible with invasive therapies, randomisation to or away from invasive therapy may limit patient enrolment and generalisability, and surgery is a heterogeneous array of procedures and combinations of procedures. Despite these testing challenges, well controlled studies are showing important benefits of surgery and, moreover, of combinations of surgical procedures.

Combination CPAP and bilateral hypoglossal nerve stimulation for obstructive sleep apnea in Treacher Collins syndrome: first case report.

We report the first case of bilateral hypoglossal nerve stimulator implantation in a patient with Treacher Collins syndrome and very severe obstructive sleep apnea, who was initially intolerant of continuous positive airway pressure (CPAP) treatment. Novel bilateral hypoglossal nerve stimulation in combination with CPAP allowed near obliteration of snoring, improved sleep quality, and ability to maintain the CPAP mask in position in the setting of craniofacial changes associated with this condition. CITATION: Wong ACL, Jones A, Stone A, MacKay SG. Combination CPAP and bilateral hypoglossal nerve stimulation for obstructive sleep apnea in Treacher Collins syndrome: first case report. J Clin Sleep Med. 2023;19(1):197-199.

Mean disease alleviation between surgery and continuous positive airway pressure in matched adults with obstructive sleep apnea.

STUDY OBJECTIVES: Polysomnography parameters measure treatment efficacy for obstructive sleep apnea (OSA), such as reduction in apnea-hypopnea index (AHI). However, for continuous positive airway pressure (CPAP) therapy, polysomnography measures do not factor in adherence and thus do not measure effectiveness. Mean disease alleviation (MDA) corrects polysomnography measures for CPAP adherence and was used to compare treatment effectiveness between CPAP and multilevel upper airway surgery. METHODS: This retrospective cohort study consisted of a consecutive sample of 331 patients with OSA managed with multilevel airway surgery as second-line treatment (N = 97) or CPAP (N = 234). Therapeutic effectiveness (MDA as % change or as corrected change in AHI) was calculated as the product of therapeutic efficacy (% or absolute change in AHI) and adherence (% time on CPAP of average nightly sleep). Cardinality and propensity score matching was utilized to manage confounding variables. RESULTS: Surgery patients achieved greater MDA % than CPAP users (67 ± 30% vs. 60 ± 28%, p = 0.04, difference 7 ± 3%, 95% confidence interval 4% to 14%) in an unmatched comparison, despite a lower therapeutic efficacy seen with surgery. Cardinality matching demonstrated comparable MDA % in surgery (64%) and CPAP (57%) groups (p = 0.14, difference 8 ± 5%, 95% confidence interval -18% to 3%). MDA measured as corrected change in AHI showed similar results. CONCLUSIONS: In adult patients with OSA, multilevel upper airway surgery and CPAP provide comparable therapeutic effectiveness on polysomnography. For patients with inadequate CPAP use, surgery should be considered.

Precision Medicine in Adult Obstructive Sleep Apnea and Home Diagnostic Testing: Caution in Interpretation of Home Studies Without Clinician Input Is Necessary.

Purpose: To assess the validity of home sleep apnea test directed diagnosis and treatment of obstructive sleep apnea (OSA) in a real-life clinical setting and establish the extent to which clinical evaluation alters diagnosis and therapeutic intervention, in the context of the evolving realm of precision medicine. Methods: Retrospective consecutive cohort study of 505 patients referred to a single center between 15th September 2015 to 14th September 2016, multidisciplinary specialist sleep clinic presenting with a home sleep apnea test prior to referral. We evaluated the effect of sleep medicine practitioner (SMP) and ear, nose, and throat surgeon (ENTS) review on patient diagnoses, disease severity, and management options in OSA. Results: Hundred and fifteen patients were included. Repeat evaluation with in-lab polysomnogram (PSG) was required in 46/115 (40.0%) of patients, of which 20/46 (43.5%) had OSA severity changed. Sleep medicine practitioner review decreased the need for repeat testing with formal in-lab PSG (p < 0.05) and increased patient acceptance of continuous positive airway pressure (CPAP) as a long-term management option for OSA. Sleep medicine practitioner/ENTS review resulted in discovery of a non-OSA related sleep disorder or change in OSA severity in 47.8% (55/115). Ear, nose, and throat surgeon review resulted in additional or changed diagnosis in 75.7% (87/115) of patients. Conclusion: In the clinical assessment and diagnosis of OSA, patients should be reviewed by medical practitioners with an interest in sleep disorders to better navigate the complexities of assessment, as well as the identification of co-morbid conditions.

Meteorological data rescue: Citizen science lessons learned from Southern Weather Discovery.

Daily weather reconstructions (called "reanalyses") can help improve our understanding of meteorology and long-term climate changes. Adding undigitized historical weather observations to the datasets that underpin reanalyses is desirable; however, time requirements to capture those data from a range of archives is usually limited. Southern Weather Discovery is a citizen science data rescue project that recovered tabulated handwritten meteorological observations from ship log books and land-based stations spanning New Zealand, the Southern Ocean, and Antarctica. We describe the Zooniverse-hosted Southern Weather Discovery campaign, highlight promotion tactics, and replicate keying levels needed to obtain 100% complete transcribed datasets with minimal type 1 and type 2 transcription errors. Rescued weather observations can augment optical character recognition (OCR) text recognition libraries. Closer links between citizen science data rescue and OCR-based scientific data capture will accelerate weather reconstruction improvements, which can be harnessed to mitigate impacts on communities and infrastructure from weather extremes.

Low morbidity high anterior neck approach for removal of a deep intraglossal foreign body: A case report.

INTRODUCTION AND IMPORTANCE: In the era of both new bilateral hypoglossal nerve stimulator and long-standing experience with Sistrunk's procedures, it is notable that the literature scarcely describes high anterior neck approaches, tending to focus on transoral removal of intra-glossal foreign bodies. Herein we describe a case of a low morbidity anterior approach for access to an intra-glossal foreign body and discuss the implications. CASE PRESENTATION: A morbidly obese 73 year old lady presented acutely after inadvertent ingestion of a sewing needle. Initial assessment demonstrated an intraglossal foreign body which subsequently migrated into the deep substance of the tongue. Endoscopic retrieval was attempted but was unsuccessful. A midline transcervical anterior neck incision was made, exposure and midline separation of mylohyoid, and midline dissection of geniohyoid muscles was performed to expose genioglossi muscles and the foreign body removed. The patient recovered well without complication. CLINICAL DISCUSSION: This approach carries low morbidity compared to transoral approaches despite traditional dogma mandating avoidance of open neck approaches. Such approaches have recently been developed for implantation of bilateral hypoglossal nerve stimulators. CONCLUSION: Otolaryngologists should consider midline transcervical approach to retrieve deep intra-glossal foreign bodies, particularly in scenarios where other options may not provide adequate access or may enhance intra-oral morbidity.

Hypocalcaemia in pharyngolaryngectomy: Preservation or autotransplantation of parathyroid glands.

OBJECTIVE: To describe transient and permanent hypocalcaemia following partial and total pharyngolaryngectomy with parathyroid gland preservation or autotransplantation. METHODS: Thirty patients underwent partial or total pharyngolaryngectomy by a single surgeon during the period 2009-2020. Intraoperative parathyroid gland preservation or autotransplantation (where the gland appeared devascularized) was routinely performed. Calcium levels performed on day 1, 3 months, and at 12 months postoperatively were collected. Rates of transient and permanent hypocalcaemia were calculated. RESULTS: A total of 13% of patients had transient hypocalcaemia, and 10% permanent hypocalcaemia. Rates of transient and permanent hypocalcaemia in total pharyngolaryngectomy were 14% and 14%, respectively. Partial pharyngectomy hypocalcaemia rates were 13% for transient and 0% for permanent. The majority of patients underwent salvage surgery for oncological resection, often following radiotherapy (63%). Ipsilateral hemithyroidectomy was preferred to total (57% vs 7%), with high rates of concurrent neck dissection (67%) and reconstruction (87%). CONCLUSION: This data supports preservation or autotransplantation of parathyroid glands as a means of reducing permanent postoperative hypocalcaemia. LEVEL OF EVIDENCE: Level IV, case series, retrospective.

Smart polymer implants as an emerging technology for treating airway collapse in obstructive sleep apnea: a pilot (proof of concept) study.

STUDY OBJECTIVES: To assess the use of a novel magnetic polymer implant in reversing airway collapse and identify potential anatomical targets for airway implant surgery in an in vivo porcine model. METHODS: Target sites of airway collapse were genioglossus muscle, hyoid bone, and middle constrictor muscle. Magnetic polymer implants were sutured to these sites, and external magnetic forces, through magnets with pull forces rated at 102 kg and 294 kg, were applied at the skin. The resultant airway movement was assessed via nasendoscopy. Pharyngeal plexus branches to the middle constrictor muscle were stimulated at 0.5 mA, 1.0 mA, and 2.0 mA and airway movement assessed via nasendoscopy. RESULTS: At the genioglossus muscles, large magnetic forces were required to produce airway movement. At the hyoid bone, anterior movement of the airway was noted when using a 294 kg rated magnet. At the middle constrictor muscle, an anterolateral (or rotatory) pattern of airway movement was noted when using the same magnet. Stimulation of pharyngeal plexus branches to the middle constrictor revealed contraction and increasing rigidity of the lateral walls of the airway as stimulation amplitude increased. The resultant effect was prevention of collapse as opposed to typical airway dilation, a previously unidentified pattern of airway movement. CONCLUSIONS: Surgically implanted smart polymers are an emerging technology showing promise in the treatment of airway collapse in obstructive sleep apnea. Future research should investigate their biomechanical role as an adjunct to treatment of airway collapse through nerve stimulation.