Treatment of obstructive sleep apnea in high risk pregnancy: a multicenter randomized controlled trial.

BACKGROUND: Obstructive sleep apnea (OSA) during pregnancy is a risk factor for preeclampsia possibly through a link to placental physiology. This study evaluates the efficacy of continuous positive airway pressure (CPAP) on the modulation of blood pressure and the reduction in preeclampsia in women with high-risk pregnancy and OSA. METHODS: A multicenter open-label, randomized controlled trial comparing CPAP treatment versus usual antenatal care was conducted in three academic hospitals in Bangkok, Thailand. Participants included singleton pregnant women aged older than 18 years with any high-risk condition (i.e., chronic hypertension, obesity, history of preeclampsia or gestational diabetes in the previous pregnancy, or diabetes), and OSA (respiratory disturbance index 5-29.99 events/hour by polysomnography), who presented either in the first trimester (gestational age, GA 0-16 weeks) or subsequently developed OSA during the 2nd trimester (GA 24-28 weeks). The primary endpoint was blood pressure during antenatal care. Secondary endpoints included the incidence of preeclampsia. An intention-to-treat analysis was performed with additional per-protocol and counterfactual analyses for handling of nonadherence. RESULTS: Of 340 participants, 96.5% were recruited during the first trimester. Thirty participants were later excluded leaving 153 and 157 participants in the CPAP and usual-care groups for the modified-intention-to-treat analysis. CPAP adherence rate was 32.7% with average use of 2.5 h/night. Overall, CPAP treatment significantly lowered diastolic blood pressure (DBP) by - 2.2 mmHg [95% CI (- 3.9, - 0.4), p = 0.014], representing approximately - 0.5 mmHg per hour of CPAP use [95%CI (- 0.89, - 0.10), p = 0.013]. CPAP treatment also altered the blood pressure trajectory by continuously lowering DBP throughout pregnancy with mean differences (95% CI) of - 3.09 (- 5.34, - 0.93), - 3.49 (- 5.67, - 1.31) and - 3.03 (- 5.20, - 0.85) mmHg at GA 18-20, 24-28, and 32-34 weeks, respectively compared to 0-16 weeks. Preeclampsia rate was 13.1% (20/153 participants) in the CPAP and 22.3% (35/157 participants) in the usual-care group with a risk difference (95% CI) of - 9% (- 18%, - 1%, p-value = 0.032) and a number-needed-to-treat (95% CI) of 11 (1, 21). CONCLUSIONS: CPAP treatment in women with even mild-to-moderate OSA and high-risk pregnancy demonstrated reductions in both DBP and the incidence of preeclampsia. CPAP treatment also demonstrated a sustained reduction in DBP throughout gestation. Trial registration ClinicalTrial.GovNCT03356106, retrospectively registered November 29, 2017.

How does distraction osteogenesis maxillary expansion (DOME) reduce severity of obstructive sleep apnea?

OBJECTIVE: Distraction osteogenesis maxillary expansion (DOME) is a reliable method to expand the nasal floor and hard palatal vault in adults with obstructive sleep apnea (OSA). DOME results in a reduction in the apnea-hypopnea index (AHI) and subjective report of improved nasal breathing. Using rhinomanometry augmented computational fluid dynamic (CFD) modeling, we propose a mechanism of how DOME reduces upper airway pharyngeal collapse in adults with OSA. MATERIAL AND METHOD: A retrospective cohort with 20 subjects and mean age of 29.6 ± 8 years who completed DOME at Stanford University from September 2014 to April 2016. Subjects were included if polysomnography, airway morphology, and rhinomanometry were available for use. From the CBCT data, 3D nasal and pharyngeal airway model were generated. Numeric CFD simulation of the airway models were analyzed under the following conditions: (1) the volume of air was flowing at a velocity of 300 cm3/s, (2) the wall surface was not slippery, and (3) the simulations were repeated 1000 times to calculate mean values. Statistical analyses using SPSS v24 software included paired t tests, nonparametric Wilcoxon rank test, Friedman test with Bonferroni correction, and Spearman's correlation coefficients (p < 0.05). RESULTS: Mean AHI improved from 17.8 ± 17.6 to 7.8 ± 7.1 events per hour (p < 0.001). Mean lowest oxygen saturation improved from 88.2 ± 7.2 to 90.9 ± 4.2% (p < 0.05). Mean airflow velocity within the nasal airway decreased from 15.6 ± 7.3 to 7.4 ± 2.1 m/s (p < 0.001) after DOME. Mean negative pressure of the nasal airway, retropalatal airway, oropharyngeal airway, and hypopharyngeal airway is reduced from - 158.4 ± 115.3 to - 48.6 ± 28.7 Pa, from - 174.8 ± 119.9 to - 52.5 ± 31.3 Pa, from - 177.0 ± 118.4 to - 54.9 ± 31.8 Pa and from - 177.9 ± 117.9 to - 56.9 ± 32.1 Pa (p < 0.001), respectively. AHI positively correlated with nasal flow velocity (p < 0.05) and negatively correlated with pharyngeal airway pressure (p < 0.05). ODI was positively correlated with nasal velocity (p < 0.05) and negatively correlated with nasal airway pressure (p < 0.05), retropalatal airway pressure (p < 0.001), oropharyngeal airway pressure (p < 0.001), and hypopharyngeal airway pressure (p < 0.05). CONCLUSION: Anatomic expansion of the nasal floor with widening of the hard palatal vault from DOME is associated with reduction of nasal airflow velocity and downstream reduction of negative pressure in the pharyngeal airway. This dynamic interaction correlates with a reduction in the apnea-hypopnea index (AHI) and Oxygen Desaturation Index (ODI).

Changes in craniofacial and airway morphology as well as quality of life after passive myofunctional therapy in children with obstructive sleep apnea: a comparative cohort study.

PURPOSE: To examine the craniofacial and airway morphology as well as the quality of life before and after passive myofunctional therapy (PMFT) for 1 year in children with obstructive sleep apnea (OSA). METHODS: Forty children with OSA wearing an oral device nightly (treatment group) and seventeen without the device (control group) were followed up for 1 year. Lateral cephalometric radiography, polysomnography (without participants wearing the oral device), and quality of life survey (OSA-18) were performed before and after the study period. RESULTS: The apnea-hypopnea index (AHI) during sleep, REM AHI, hypopnea count, and desaturation count in the treatment group dropped significantly, compared with the control group. The craniofacial linear measurements increased significantly in both groups, while the length of mandible (Co-Gn) and anterior facial height (N-Me) became significantly larger in the treatment group. For the airway morphology, the intergroup comparison showed that OPha-Ophp (distance between anterior and posterior sides of oropharynx) increased significantly in the treatment group. For quality of life, the intergroup comparison found statistically significant improvements in the following in the treatment group, based on the OSA-18 survey: loud snoring, dysphagia, mood swings, discipline problems, difficulty awakening, total score for the emotional distress portion, and total survey score. CONCLUSIONS: Preliminary evidence is substantiated for the benefits of 1-year PMFT using an oral device with a built-in tongue bead, including improvements in nasal breathing during sleep, mandible linear growth (Co-Gn and N-Me), airway morphology (OPha-Ophp), and patients' quality of life.

A novel intermittent negative air pressure device ameliorates obstructive sleep apnea syndrome in adults.

PURPOSE: Patients with obstructive sleep apnea syndrome (OSAS) have difficulties in compliance with continuous positive airway pressure (CPAP) and the treatment outcome is heterogeneous. We proposed a proof-of-concept study of a novel intermittent negative air pressure (iNAP®) device for physicians to apply on patients who have failed or refused to use CPAP. METHODS: The iNAP® device retains the tongue and the soft palate in a forward position to decrease airway obstruction. A full nightly usage with the device was evaluated with polysomnography. Subgrouping by baseline apnea-hypopnea index (AHI) and body mass index (BMI) with different treatment response criteria was applied to characterize the responder group of this novel device. RESULTS: Thirty-five patients were enrolled: age 41.9 ± 12.2 years (mean ± standard deviation), BMI 26.6 ± 4.3 kg/m2, AHI 41.4 ± 24.3 events/h, and oxygen desaturation index (ODI) 40.9 ± 24.4 events/h at baseline. AHI and ODI were significantly decreased (p < 0.001) by the device. Patients with moderate OSAS, with baseline AHI between 15 to 30 events/h, achieved 64% response rate; and non-obese patients, with BMI below 25 kg/m2, achieved 57% response rate, with response rate defined as 50% reduction in AHI from baseline and treated AHI lower than 20. There were minimal side effects reported. CONCLUSIONS: In a proof-of-concept study, the device attained response to treatment as defined, in more than half of the moderate and non-obese OSAS patients, with minimal side effects.

Multiple sleep latency test in narcolepsy type 1 and narcolepsy type 2: A 5-year follow-up study.

Excessively sleepy teenagers and young adults without sleep-disordered breathing are diagnosed with either narcolepsy type 1 or narcolepsy type 2, or hypersomnia, based on the presence/absence of cataplexy and the results of a multiple sleep latency test. However, there is controversy surrounding this nomenclature. We will try to find the differences between different diagnoses of hypersomnia from the results of the long-term follow-up evaluation of a sleep study. We diagnosed teenagers who had developed excessive daytime sleepiness based on the criteria of the International Classification of Sleep Disorders, 3rd edition. Each individual received the same clinical neurophysiologic testing every year for 5 years after the initial diagnosis of narcolepsy type 1 (n = 111) or type 2 (n = 46). The follow-up evaluation demonstrated that narcolepsy type 1 (narcolepsy-cataplexy) is a well-defined clinical entity, with very reproducible clinical neurophysiologic findings over time, whereas patients with narcolepsy type 2 presented clear clinical and test variability. By the fifth year of the follow-up evaluation, 17.6% of subjects did not meet the diagnostic criteria of narcolepsy type 2, and 23.9% didn't show any two sleep-onset rapid eye movement periods in multiple sleep latency during the 5-year follow-up. Therefore narcolepsy type 1 (narcolepsy-cataplexy) is a well-defined syndrome, with the presentation clearly related to the known consequences of destruction of hypocretin/orexin neurons. Narcolepsy type 2 covers patients with clinical and test variability over time, thus bringing into question the usage of the term "narcolepsy" to label these patients.

Oropharyngeal and tongue exercises (myofunctional therapy) for snoring: a systematic review and meta-analysis.

PURPOSE: Oropharyngeal and tongue exercises (myofunctional therapy) have been shown to improve obstructive sleep apnea. However, to our knowledge, a systematic review has not been performed for snoring. The study objective is to perform a systematic review, with a meta-analysis, dedicated to snoring outcomes after myofunctional therapy. METHODS: PubMed/MEDLINE and three other databases were searched through November 25, 2017. Two authors independently searched the literature. Eligibility (1) patients: children or adults with snoring, (2) intervention: oropharyngeal and/or tongue exercises, (3) comparison: pre and post-treatment data for snoring, (4) outcomes: snoring frequency and snoring intensity, (5) study design: publications of all study designs. RESULTS: A total of 483 articles were screened, 56 were downloaded in their full text form, and nine studies reported outcomes related to snoring. There were a total of 211 patients (all adults) in these studies. The snoring intensity was reduced by 51% in 80 patients from pre-therapy to post-therapy visual analog scale values of 8.2 ± 2.1 (95% CI 7.7, 8.7) to 4.0 ± 3.7 (95% CI 3.2, 4.8). Berlin questionnaire snoring intensity reduced by 36% in 34 patients from 2.5 ± 1.0 (95% CI 2.2, 2.8) to 1.6 ± 0.8 (95% CI 1.3, 1.9). Finally, time spent snoring during sleep was reduced by 31% in 60 patients from 26.3 ± 18.7% (95% CI 21.6, 31.0) to 18.1 ± 20.5% (95% CI 12.9, 23.3) of total sleep time. CONCLUSIONS: This systematic review demonstrated that myofunctional therapy has reduced snoring in adults based on both subjective questionnaires and objective sleep studies.

Toward a functional definition of ankyloglossia: validating current grading scales for lingual frenulum length and tongue mobility in 1052 subjects.

PURPOSE: Alterations of the lingual frenulum may contribute to oromyofacial dysfunction, speech and swallowing impediments, underdevelopment of the maxillofacial skeleton, and even predispose to sleep breathing disorder. This study aims to assess the utility of existing instruments for evaluation of restricted tongue mobility, describe normal and abnormal ranges of tongue mobility, and provide evidence in support of a reliable and efficient measure of tongue mobility. METHODS: A prospective cohort study of 1052 consecutive patients was evaluated during a 3-month period. Age, gender, ethnicity, height, weight, BMI, maximal interincisal mouth opening (MIO), mouth opening with tongue tip to maxillary incisive papillae at roof of mouth (MOTTIP), Kotlow's free-tongue measurement, and presence of severe tongue-tie were recorded. Secondary outcome measures include tongue range of motion deficit (TRMD, difference between MIO and MOTTIP) and tongue range of motion ratio (TRMR, ratio of MOTTIP to MIO). RESULTS: Results indicate that MIO is dependent on age and height; MOTTIP and TRMD are dependent on MIO; Kotlow's free-tongue measurement is an independent measure of free-tongue length and tongue mobility. TRMR is the only independent measurement of tongue mobility that is directly associated with restrictions in tongue function. CONCLUSIONS: We propose the use of tongue range of motion ratio as an initial screening tool to assess for restrictions in tongue mobility. "Functional" ankyloglossia can thus be defined and treatment effects followed objectively by using the proposed grading scale: grade 1: tongue range of motion ratio is >80%, grade 2 50-80%, grade 3 < 50%, grade 4 < 25%.

Passive myofunctional therapy applied on children with obstructive sleep apnea: A 6-month follow-up.

BACKGROUND/PURPOSE: Myofunctional therapy is one of the recommended treatments for obstructive sleep apnea, but the level of compliance has often been low in children. This study aims to investigate the therapeutic effect of passive myofunctional therapy using an oral appliance during sleep in children suffering from obstructive sleep apnea. METHODS: Twenty-nine children who suffered from obstructive sleep apnea were divided into two groups: premature children and full-term children. All children wore an oral device to induce their tongue muscle activity during sleep for 6 months. Polysomnography during sleep was performed before and 1 week after the end of 6-month treatment. RESULTS: Both groups showed positive polysomnographic changes. Full-term children had a significant decrease in the apnea-hypopnea index, hypopnea index, and percentage of arousals. Prematurely born children had a significant decrease in the apnea-hypopnea index during rapid eye movement sleep and in the mean heart rate during sleep. CONCLUSION: Using a specialized oral device to perform myofunctional therapy during sleep may improve the breathing during sleep of children with obstructive sleep apnea.

Kleine-Levin Syndrome.

Kleine-Levin syndrome is a rare recurrent hypersomnia associated with symptoms of behavioral and cognitive impairment. This article reviews common presenting symptoms, differential diagnosis, diagnostic workup, and potential treatment options. Current updates on functional imaging studies and long-term neuropsychological studies are reviewed.

Missing teeth and pediatric obstructive sleep apnea.

BACKGROUND: Missing teeth in early childhood can result in abnormal facial morphology with narrow upper airway. The potential association between dental agenesis or early dental extractions and the presence of obstructive sleep apnea (OSA) was investigated. METHODS: We reviewed clinical data, results of polysomnographic sleep studies, and orthodontic imaging studies of children with dental agenesis (n = 32) or early extraction of permanent teeth (n = 11) seen during the past 5 years and compared their findings to those of age-, gender-, and body mass index-matched children with normal teeth development but tonsilloadenoid (T&A) hypertrophy and symptoms of OSA (n = 64). RESULTS: The 31 children with dental agenesis and 11 children with early dental extractions had at least 2 permanent teeth missing. All children with missing teeth (n = 43) had clinical complaints and signs evoking OSA. There was a significant difference in mean apnea-hypopnea indices (AHI) in the three dental agenesis, dental extraction, and T&A studied groups (p < 0.001), with mean abnormal AHI lowest in the pediatric dental agenesis group. In the children with missing teeth (n = 43), aging was associated with the presence of a higher AHI (R (2) = 0.71, p < 0.0001). CONCLUSION: Alveolar bone growth is dependent on the presence of the teeth that it supports. The dental agenesis in the studied children was not part of a syndrome and was an isolated finding. Our children with permanent teeth missing due to congenital agenesis or permanent teeth extraction had a smaller oral cavity, known to predispose to the collapse of the upper airway during sleep, and presented with OSA recognized at a later age. Due to the low-grade initial symptomatology, sleep-disordered breathing may be left untreated for a prolonged period with progressive worsening of symptoms over time.

The association between ophthalmologic diseases and obstructive sleep apnea: a systematic review and meta-analysis.

PURPOSE: The purpose of this study was to evaluate the association between obstructive sleep apnea (OSA) and ophthalmologic diseases, specifically glaucoma, nonarteritic anterior ischemic optic neuropathy (NAION), retinal vein occlusion (RVO), central serous chorioretinopathy (CSR), and floppy eyelid syndrome (FES), by performing a systematic review and meta-analysis of published studies. METHODS: PubMed, Embase, and Scopus databases were searched for observational studies on OSA and its association with select ophthalmologic diseases. Data was pooled for random-effects modeling. The association between OSA and ophthalmologic diseases was summarized using an estimated pooled odds ratio with a 95 % confidence interval. RESULTS: Relative to non-OSA subjects, OSA subjects have increased odds of diagnosis with glaucoma (pooled odds ratio (OR) = 1.242; P < 0.001) and floppy eyelids syndrome (pooled OR = 4.157; P < 0.001). In reverse, the overall pooled OR for OSA was 1.746 (P = 0.002) in the glaucoma group, 3.126 (P = 0.000) in the NAION group, and 2.019 (P = 0.028) in the CSR group. For RVO, one study with 5965 OSA patients and 29,669 controls demonstrated a 1.94-fold odds increase in OSA patients. CONCLUSIONS: Our results suggest significant associations between OSA and glaucoma, NAION, CSR, and FES. Screening for OSA should be considered in patients with glaucoma, NAION, CSR, or FES.

Emerging drugs for common conditions of sleepiness: obstructive sleep apnea and narcolepsy.

INTRODUCTION: Obstructive sleep apnea (OSA) and narcolepsy are sleep disorders associated with high prevalence and high symptomatic burden including prominent sleepiness, daytime dysfunction and poor nocturnal sleep. Both have elevated risk of poor health outcomes. Current therapies are often underutilized, cumbersome, costly or associated with residual symptoms. AREAS COVERED: This review covers current available therapies for OSA and narcolepsy as well as discusses areas for potential drug development, and agents in the therapeutic pipeline, including the cannabinoid dronabinol (OSA), the histamine inverse agonist/ antagonist pitolisant (narcolepsy), and stimulants with uncertain and/or multiple activities such as JZP-110 and JZP-386 (narcolepsy, possibly OSA). Finally it addresses new approaches and uses for therapies currently on the market such as the carbonic anhydrase inhibitor acetazolamide (OSA). EXPERT OPINION: Both OSA and narcolepsy are conditions of sleepiness for which lifelong treatments are likely to be required. In OSA, while continuous positive airway pressure will likely remain the gold standard therapy for the foreseeable future, there is plenty of room for integrating phenotypes and variants of OSA into therapeutic strategies to lead to better, more personalized disease modification. In narcolepsy, unlike OSA, drug therapy is the current mainstay of treatment. Advances using novel mechanisms to treat targeted symptoms such as sleepiness and/or novel agents that can treat more than one symptom of narcolepsy, hold promise. However, cost, convenience and side effects remain challenges.

Mouth breathing, "nasal disuse," and pediatric sleep-disordered breathing.

BACKGROUND: Adenotonsillectomy (T&A) may not completely eliminate sleep-disordered breathing (SDB), and residual SDB can result in progressive worsening of abnormal breathing during sleep. Persistence of mouth breathing post-T&As plays a role in progressive worsening through an increase of upper airway resistance during sleep with secondary impact on orofacial growth. METHODS: Retrospective study on non-overweight and non-syndromic prepubertal children with SDB treated by T&A with pre- and post-surgery clinical and polysomnographic (PSG) evaluations including systematic monitoring of mouth breathing (initial cohort). All children with mouth breathing were then referred for myofunctional treatment (MFT), with clinical follow-up 6 months later and PSG 1 year post-surgery. Only a limited subgroup followed the recommendations to undergo MFT with subsequent PSG (follow-up subgroup). RESULTS: Sixty-four prepubertal children meeting inclusion criteria for the initial cohort were investigated. There was significant symptomatic improvement in all children post-T&A, but 26 children had residual SDB with an AHI > 1.5 events/hour and 35 children (including the previous 26) had evidence of "mouth breathing" during sleep as defined [minimum of 44 % and a maximum of 100 % of total sleep time, mean 69 ± 11 % "mouth breather" subgroup and mean 4 ± 3.9 %, range 0 and 10.3 % "non-mouth breathers"]. Eighteen children (follow-up cohort), all in the "mouth breathing" group, were investigated at 1 year follow-up with only nine having undergone 6 months of MFT. The non- MFT subjects were significantly worse than the MFT-treated cohort. MFT led to normalization of clinical and PSG findings. CONCLUSION: Assessment of mouth breathing during sleep should be systematically performed post-T&A and the persistence of mouth breathing should be treated with MFT.

Sleep and breathing in premature infants at 6 months post-natal age.

BACKGROUND: Poor sleep contributes to the developmental problems seen in preterm infants. We evaluated sleep problems in preterm infants 6 months of post-gestational age using the subjective Brief Infant Sleep Questionnaire (BISQ) and objective sleep tests. We also compared the sleep of premature infants with that of full-term infants. METHODS: The study included 68 6-month-old full-term healthy infants and 191 premature infants born at <37 weeks gestation. All parents completed the BISQ-Chinese version and sleep diaries. At the same time, all premature infants were submitted to one night of polysomnography (PSG) in the sleep laboratory and also were set up with an actigraph kept for 7 days. Statistical analyses were performed using correlation coefficients and the t-test with SPSS version 18 to compare questionnaire responses with other subjective and objective measures of sleep. RESULTS: The sleep problems indicated in the subjective questionnaire for the premature infants, particularly: "the nocturnal sleep duration, number of night awakenings, daytime sleep duration, duration of time with mouth breathing, and loud-noisy breathing" had significant correlations with sleep diaries, actigraphy and PSG results. The BISQ showed that duration of infant's sleeping on one side, nocturnal sleep duration, being held to fall asleep, number of nighttime awakenings, daytime sleep duration, subjective consideration of sleep problems, loud-noisy breathing, and duration spent crying during the night were significantly different between the premature infants and the term infants. PSG confirmed the presence of a very high percentage (80.6%) of premature infants with AHI > 1 event/hour as indicated by the questionnaire. CONCLUSION: Premature infants have more sleep problems than full-term infants, including the known risk of abnormal breathing during sleep, which has been well demonstrated already with the BISQ-Chinese (CBISQ).

Accurate scoring of the apnea-hypopnea index using a simple non-contact breathing sensor.

Sleep apnea is a serious condition that afflicts many individuals and is associated with serious health complications. Polysomnography, the gold standard for assessing and diagnosing sleep apnea, uses breathing sensors that are intrusive and can disrupt the patient's sleep during the overnight testing. We investigated the use of breathing signals derived from non-contact force sensors (i.e. load cells) placed under the supports of the bed as an alternative to traditional polysomnography breathing sensors (e.g. nasal pressure, oral-nasal thermistor, chest belt and abdominal belt). The apnea-hypopnea index estimated using the load cells was not different than that estimated using standard polysomnography leads (t44  = 0.37, P = 0.71). Overnight polysomnography sleep studies scored using load cell breathing signals had an intra-class correlation coefficient of 0.97 for the apnea-hypopnea index and an intra-class correlation coefficient of 0.85 for the respiratory disturbance index when compared with scoring using traditional polysomnography breathing sensors following American Academy of Sleep Medicine guidelines. These results demonstrate the feasibility of using unobtrusive load cells installed under the bed to measure the apnea-hypopnea index.

The impact of sleep duration in obstructive sleep apnea patients.

PURPOSE: Obstructive sleep apnea (OSA) is a risk factor for cardiovascular disease. Strong associations have been reported among sleep duration, hypertension, obesity, and cardiovascular mortality. The authors hypothesize that sleep duration may play a role in OSA severity. The aim of this study is to analyze sleep duration in OSA patients. METHODS: Patients who underwent overnight polysomnography were consecutively selected from the Sleep Clinic of Universidade Federal de São Paulo database between March 2009 and December 2010. All subjects were asked to come to the Sleep Clinic at 8:00 a.m. for a clinical evaluation and actigraphy. Anthropometric parameters such as weight, height, hip circumference, abdominal circumference, and neck circumference were also measured. RESULTS: One hundred thirty-three patients were divided into four groups based on total sleep time, sleep efficiency, sleep latency, and wake after sleep onset: very short sleepers (n = 11), short sleepers (n = 21), intermediate sleepers (n = 56), and sufficient sleepers (n = 45). Apnea-hypopnea index (AHI) was higher in very short sleepers (50.18 ± 30.86 events/h) compared with intermediate sleepers (20.36 ± 14.68 events/h; p = 0.007) and sufficient sleepers (23.21 ± 20.45 events/h; p = 0.02). Minimal and mean arterial oxygen saturation and time spent below 90 % oxygen saturation exhibited worse values in very short sleepers. After adjustment for gender, age, AHI, and body mass index, mean oxygen saturation was significantly associated to total sleep time (p = 0.01). CONCLUSIONS: In conclusion, the present study suggests that sleep duration may be associated to low mean oxygen saturation in OSA patients.

Maxillomandibular Advancement for OSA: A 25-year perspective / Avancement maxillo-mandibulaire pour le traitement du SAOS : une perspective sur 25 ans

Objective: The aim of this study was to evaluate the result of maxillomandibular advancement (MMA) for the treatment of obstructive sleep apnea (OSA) by a single surgeon. Materials and Methods: Patients that underwent MMA for the treatment of OSA over a 25-year period were included in the study. Patients who initially presented for revision MMA surgery were excluded. Demographics (e.g., age, gender, pre- and post-MMA body mass index [BMI]), pre- and post-MMA cephalometrics (e.g., sella-nasion-point A angle [SNA], sella-nasion-point B angle [SNB], posterior airway space base of tongue [PAS]) and pre- and post-MMA sleep study metrics (e.g., respiratory disturbance index [RDI], lowest desaturation [SpO2-nadir], oxygen desaturation index [ODI], total sleep time [TST], % TST Stage N3 sleep, % TST rapid eye movement [REM] sleep) were abstracted. MMA surgical success was defined as a ≥ 50% reduction in RDI (or ODI) and post-MMA RDI (or ODI) < 20 events/hour. MMA surgical cure was defined as a post-MMA RDI (or ODI) < 5 events/hour. Results: A total of 1010 patients underwent MMA for the treatment of OSA. The mean age was 39.6 ± 14.3 years, and the majority were male (77%). Nine hundred forty-one patients with complete pre- and postoperative PSG data were analyzed. The mean ODI and RDI improved from 32.6 ± 27.4 to 7.7 ± 15.5 and 39.1 ± 24.2 to 13.6 ± 14.6 events per hour, respectively. The overall surgical success and surgical cure based on ODI was 79.4% and 71.9%, respectively. The overall surgical success and surgical cure based on RDI was 73.1% and 20.7%, respectively. Stratified by preoperative RDI showed older age, greater BMI were associated with greater preoperative RDI. Bivariate predictors of greater RDI reduction include younger age, female gender, lower preoperative BMI, higher preoperative RDI, greater BMI reduction postoperatively and greater change in SNA and PAS. Bivariate predictors of surgical cure based on RDI (RDI < 5) include younger age, female gender, lower preoperative RDI, and greater change in SNA and PAS. Bivariate predictor of RDI success (RDI < 20) include younger age, female gender, lower preoperative BMI, lower preoperative RDI, greater BMI reduction, greater increase in SNA, SNB and PAS postoperatively. Comparison of the first 500 patients and the later 510 patients demonstrate patients undergoing MMA have become younger, having lower RDI while achieving a better surgical outcome. Linear multivariate associations of greater percentage RDI reduction include younger age, greater percent change of SNA, greater preoperative SNA, lower preoperative BMI and higher preoperative RDI. Conclusions: MMA is an effective treatment to improve OSA, but the result can vary. Patient selection based on favorable prognostic factors and maximizing the advancement distance can improve outcomes.

Introduction: L'objectif de cette étude était d'évaluer les résultats obtenus avec le recours à des chirurgies d'avancement maxillo-mandibulaire (AMM) réalisées par le même chirurgien pour le traitement du syndrome d'apnée obstructive du sommeil (SAOS). Matériels et méthodes: Les patients qui ont subi une AMM pour le traitement de leur SAOS tout au long d'une période de 25 ans ont été inclus dans l'étude. Les patients qui se sont initialement présentés pour une révision d'une précédente AMM ont été exclus. Les données démographiques (par exemple l'âge, le sexe, l'indice de masse corporelle [IMC] avant et après l'AMM), les données céphalométriques avant et après l'AMM (par exemple, l'angle sella-nasion point A [SNA], l'angle sella-nasion point B [SNB], l'espace des voies aériennes postérieures à la base de la langue [EAP]) et les mesures de l'étude du sommeil avant et après l'AMM (par exemple, l'indice de perturbation respiratoire [IPR], la désaturation la plus faible [nadir-SpO2], l'indice de désaturation en oxygène [ODI], le temps total de sommeil [TTS], % de TTS de stade N3, % de TTS à mouvements oculaires rapides [REM]) ont été extraites. Le succès chirurgical de l'AMM a été défini comme une réduction ≥ 50 % de l'IPR (ou de l'ODI) et un IPR (ou un ODI) post-AMM < 20 événements/heure. La guérison chirurgicale de l'AMM a été définie comme un IPR (ou ODI) post-AMM < 5 événements/heure. Résultats: Un total de 1010 patients a subi une AMM pour le traitement du SAOS. L'âge moyen des patients était de 39,6 ± 14,3 ans et la majorité d'entre eux étaient des hommes (77 %). Les dossiers de neuf cent quarante et un patients, pour lesquels des données PSG complètes avant et après l'opération étaient disponibles, ont été analysés. L'ODI et l'IPR moyens se sont améliorés respectivement de 32,6 ± 27,4 à 7,7 ± 15,5 et de 39,1 ± 24,2 à 13,6 ± 14,6 événements par heure. Le succès chirurgical global et la guérison chirurgicale basés sur l'ODI étaient de 79,4 % et 71,9 %, respectivement. Le succès chirurgical global et la guérison chirurgicale basés sur l'IPR étaient de 73,1 % et 20,7 %, respectivement. La stratification en fonction de l'IPR préopératoire a montré qu'un âge et un IMC plus élevés étaient associés à un IPR préopératoire plus important. Les prédicteurs bivariés d'une plus grande réduction de l'IPR comprennent un âge moindre, le sexe féminin, un IMC préopératoire plus faible, un IPR préopératoire plus élevé, une plus grande réduction de l'IMC postopératoire et une plus grande modification de SNA et de l'EAP. Les prédicteurs bivariés de la guérison chirurgicale basée sur l'IPR (IPR < 5) comprennent un âge moindre, le sexe féminin, un IPR préopératoire plus faible et une plus grande variation de SNA et de l'EAP. Les prédicteurs bivariés du succès de l'IPR (IPR < 20) incluent un âge moindre, le sexe féminin, un IMC préopératoire plus faible, un IPR préopératoire plus faible, une plus grande réduction de l'IMC, une plus grande augmentation de SNA, de SNB et de l'EAP en postopératoire. La comparaison entre les 500 premiers patients opérés et les 510 derniers montre que le profil des patients subissant une AMM a évolué avec des patients d'âge moindre et un IPR plus faible et que cette évolution s'est accompagnée d'un meilleur résultat chirurgical. Les associations multivariées linéaires d'un pourcentage plus élevé de réduction de l'IPR comprennent un âge moindre, un pourcentage plus élevé de changement de SNA, un SNA préopératoire plus important, un IMC préopératoire plus faible et un IPR préopératoire plus élevé. Conclusions: L'AMM est un traitement efficace pour améliorer le SAOS, mais le résultat peut varier. La sélection des patients en fonction de facteurs pronostiques favorables et l'optimisation de la distance d'avancement peuvent améliorer les résultats.

Death, nasomaxillary complex, and sleep in young children.

This is an investigation of anatomical and sleep history risk factors that were associated with abrupt sleep-associated death in seven children with good pre-mortem history. Seven young children with abrupt deaths and information on health status, sleep history, death scene report, and autopsy performed in a specialized unit dedicated to investigation of abrupt death in young children were investigated Seven age and gender matched living children with obstructive-sleep-apnea (OSA) were compared to the findings obtained from the dead children. Two deaths results from accidents determined by the death scene and five were unexplained at the death scene. History revealed presence of chronic indicators of abnormal sleep in all cases prior death and history of an acute, often mild, rhinitis just preceding death in several. Four children, including three infants, were usually sleeping in a prone position. Autopsy demonstrated variable enlargement of upper airway soft tissues in all cases, and in all cases, there were features consistent with a narrow, small nasomaxillary complex, with or without mandibular retroposition. All children were concluded to have died of hypoxia during sleep. Our OSA children presented similar complaints and similar facial features. Anatomic risk factors for a narrow upper airway can be determined early in life, and these traits are often familial. Their presence should lead to greater attention to sleep-related complaints that may be present very early in life and indicate impairment of well been and presence of sleep disruption. Further investigation should be performed to understand the role of upper airway infection in the setting of anatomically small airway in apparently abrupt death of infants and toddlers.

Surgical and non-surgical maxillary expansion: expansion patterns, complications and failures

Objective: The focus of this report was to analyze the pattern of maxillary expansion and complications in patients following surgical and non-surgical maxillary expansion presented for evaluation and second opinion. Materials and Methods: During a 30-months period, 28 patients presented for second opinion following maxillary expansion performed elsewhere. The indication for treatment was obstructive sleep apnea (OSA). All patients reported a lack of symptomatic improvements and problems associated with the treatment. Clinical examination with pre- and post-expansion cone beam computed tomography (CBCT), and treatment photographs were analyzed. Results: Complete clinical records and CBCT were available in 22 patients for analysis. Six patients had undergone surgical expansion with distraction osteogenesis maxillary expansion (DOME), and 16 patients had undergone a variety of non-surgical expansion with different appliances. All the DOME patients had anterior nasal spine (ANS) separation without posterior nasal spine (PNS) separation. Diastema ranging between 10-16 mm was noted in the DOME patients, and the ratio of anterior diastema to ANS separation was between 2:1 to 3:1. Bone defects existed between the central incisors at 18 months or beyond following DOME in all the patients despite bone grafting attempts in four patients. Anterior gingival recession occurred in two patients and four incisor teeth required endodontic therapy with long-term guarded prognosis. Sixteen patients underwent non-surgical maxillary expansion with four different appliances, including anterior growth guidance appliance (AGGA), daytime-nighttime appliance (DNA), advanced lightwire functionals appliance (ALF), and mini-screw assisted rapid palatal expansion (MARPE). The midpalatal suture did not separate in any of the 16 patients, and the expansion pattern was purely dental and dentoalveolar in nature. Lateral dental tipping, thinning of the labial/ buccal alveolar bone with gingival recession were noted in 10 patients. Significant mobility of the maxillary anterior teeth due to vertical and horizontal bone loss was noted in the five patients that underwent AGGA treatment. Conclusions: Different maxillary expansion methods are currently being performed with varying outcomes. Critical analyses of these methods are needed to determine their impact and whether the desired outcomes are achieved.

Maxillomandibular Advancement for OSA: Serious Complications and Failures

Objective: The focus of this report was to analyze patients who presented for second opinion due to complications and failure following maxillomandibular advancement (MMA) performed elsewhere. Materials and Methods: During a five-year period, 16 patients presented with complications and/ or failure of MMA. The indication for treatment was obstructive sleep apnea (OSA). Analysis of treatment records including plane radiography and/or cone beam computed tomography (CBCT), progress photographs and clinical examination were performed. Results: Complete clinical and imaging records were available in all patients for analysis. Thirteen patients were surgical failures with advancement ranging from -4 to 5 mm. Five of the 13 patients had limited advancement at the initial surgery, and eight patients had hardware failure that required removal with resultant retrodisplacement of the mandible. Due to complications occurring in 11 patients, additional surgery ranging from two to six additional procedures after the initial operation was required. The complications included hardware failure (ten patients) that led to bone segment displacement (eight patients), non-union of the maxilla (two patients), non-union of the mandible (eight patients), chronic facial and/or joint pain (five patients), facial nerve injury (two patients), complete anesthesia of the lip/chin (five patients) and severe malocclusion (four patients). Conclusions: Although MMA is typically a predictable operation with excellent outcomes, failure of improvement and severe long-term sequelae from surgical complications are possible. Surgical precision with sufficient skeletal advancement for airway improvement and stable skeletal fixation is necessary to achieve a successful outcome.