B. Tucker Woodson

Laser midline glossectomy as a treatment for obstructive sleep apnea

Multiple site specific procedures have been proposed to treat obstructive sleep apnea syndrome (OSAS). Midline glossectomy (MLG) is a procedure that directly enlarges the hypopharyngeal airspace using the carbon dioxide laser. The initial experience of 12 patients is presented. Midline glossectomy as the sole procedure was performed on 11 patients who had failed uvulopalatopharyngoplasty (UPPP) and who were felt to have significant hypopharyngeal collapse on physical examination and Müllers maneuver. One patient with primary hypopharyngeal narrowing underwent MLG. Five (42%) were considered responders with Respiratory Disturbance Index (RDI) decreasing from 60.6 per hour to 14.5 per hour. In seven nonresponders, there was no significant change in the RDI (62.6 events per hour to 48.4 events per hour). Cephalometric analysis showed that responders tended to be more retrognathic (sella‐nasion‐supramentale (S‐N‐B = 74.4° )) than nonresponders (S‐N‐B = 79.3° ). Responders were significantly less obese (body mass index (BMI = 30.6)) than nonresponders (BMI = 37.9). There were five minor complications including minor bleeding (n = 3), prolonged odynophagia (n = 1), and minor change in taste (n = 1). There were no major complications, and no persistent difficulties with speech or swallowing. These results demonstrate that direct surgical modification of the tongue base and associated structures can significantly impact obstructive apnea. Midline glossectomy or similar procedures may be useful in a subset of patients with OSAS.

Clinical Experience with Lingualplasty as Part of the Treatment of Severe Obstructive Sleep Apnea

Because uvulopalatopharyngoplasty (UPPP) as the sole procedure for severe obstructive sleep apnea syndrome (OSAS) is often inadequate, multiple other procedures have been developed. These have been directed at other sites of potential collapse of the upper airway. Initial experience with midline glossectomy (MLG) has shown direct modification of the tongue base to be an effective procedure in a subset of patients with OSAS. Lingualplasty, a modification of MLG, is demonstrated to provide an improved response rate. Twenty-two consecutive patients with severe OSAS and Fujita type II airway classification (retropalatal, oropharyngeal, and hypopharyngeal compromise) underwent lingualplasty. Fourteen patients had previously undergone unsuccessful UPPP. Eight had synchronous lingualplasty and UPPP. All were selected for lingualplasty because of obstructive tongue base anatomy. Responders were defined as having a respiratory disturbance index (RDI) of less than 20 events/hour. For the entire group, 17 of 22 (77%) were classified as responders, with RDI decreasing from 58.8 ± 39.5 events/hour to 8.1 ± 6.2 events/hour. Lingualplasty, as an isolated procedure, resulted in a 79% responder rate, with RDI decreasing from 50.2 events/hour to 8.6 events/hour. There were no significant changes in the RDI of the nonresponder groups. No differences were identified that discriminated responders from nonresponders, including age, body mass index, or cephalometry. There were six complications (27%), including bleeding (3), tongue edema (1), prolonged odynophagia (1), and subcutaneous emphysema related to tracheotomy (1). All resolved with treatment. These results indicate that in appropriately selected patients who do not respond to UPPP, lingualplasty Is a significant improvement over MLG.

Carcinoma of the larynx in patients with gastroesophageal reflux

PURPOSE To study the relationship between gastroesophageal reflux disease (GERD) and the development of laryngeal cancer in patients who lack other accepted risk factors for the development of squamous cell carcinoma of the larynx. PATIENTS AND METHODS A retrospective review of patients either treated surgically or with radiation therapy for stage 1 or stage 2 laryngeal carcinoma with specific reference to smoking history and the presence of GERD. RESULTS We present 9 lifetime nonsmoking patients with stage 1 or 2 laryngeal carcinoma in whom GERD was clinically and/or radiographically shown. Also, 14 patients are identified who quit smoking more than 15 years before the development of laryngeal cancer and who also had evidence of GERD. CONCLUSION We propose that the development of laryngeal carcinoma in this cohort of patients who lack typical risk factors supports the notion that GERD plays a role in the etiology of carcinoma of the larynx. Because the accepted risk factors for laryngeal carcinoma such as smoking and alcohol use increase the likelihood of reflux, GERD may act as a cocarcinogen in smokers and drinkers. Of interest, the treatment of GERD can reverse the signs of chronic laryngitis and should be instituted in patients with laryngeal pathology who have GERD.

A randomized trial of temperature-controlled radiofrequency, continuous positive airway pressure, and placebo for obstructive sleep apnea syndrome

OBJECTIVE The study goal was to determine the effectiveness of (1) multilevel temperature-controlled radiofrequency tissue ablation (TCRFTA) or (2) continuous positive airway pressure (CPAP) for the treatment of mild to moderate obstructive sleep apnea syndrome (OSAS). STUDY DESIGN AND METHODS We conducted a randomized, placebo-controlled, 2-site trial, comparing TCRFTA (n = 30) and CPAP (n = 30) with sham-placebo (n = 30) using intention-to-treat analysis. RESULTS Compared with pretreatment baseline, TCRFTA improved reaction time, OSAS-specific quality of life (QOL), and subjective sleepiness (all P < 0.05). Compared with sham-placebo, TCRFTA improved QOL, airway volume, apnea index, and respiratory arousal index (all P < 0.05). TCRFTA side effects and complications were mild, temporary, and similar to sham-placebo. CPAP improved QOL and sleepiness compared with baseline and QOL when compared with sham-placebo (all P < 0.05). Significant differences were not seen between TCRFTA and CPAP outcomes. CONCLUSION TCRFTA and CPAP each improve QOL for mild-moderate OSAS patients. TCRFTA improvements may result from changes in airway volume, apnea index, and respiratory arousal index.

Implanted upper airway stimulation device for obstructive sleep apnea

Previous feasibility studies have shown that electrical stimulation of the hypoglossal nerve can improve obstructive sleep apnea (OSA). The current study examined the safety and preliminary effectiveness of a second generation device, the Upper Airway Stimulation (UAS) system, and identified baseline predictors for therapy success.

Expansion sphincter pharyngoplasty: A new technique for the treatment of obstructive sleep apnea

OBJECTIVE: In this study, we assessed the efficacy of a new method (expansion sphincter pharyngoplasty [ESP]) to treat obstructive sleep apnea. STUDY DESIGN: We conducted a prospective, randomized controlled trial. METHODS: Forty-five adults with small tonsils, body mass index less than 30 kg/m 2 , of Friedman stage II or III, of type I Fujita, and with lateral pharyngeal wall collapse were selected for the study. RESULTS: The mean body mass index was 28.7 kg/m 2 . The apnea-hypopnea index improved from 44.2 ± 10.2 to 12.0 ± 6.6 (P < 0.005) following ESP and from 38.1 ± 6.46 to 19.6 ± 7.9 in the uvulopalatopharyngoplasty group (P < 0.005). Lowest oxygen saturation improved from 78.4 ± 8.52% to 85.2 ± 5.1% in the ESP group (P = 0.003) and from 75.1 ± 5.9% to 86.6 ± 2.2% in the uvulopalatopharyngoplasty group (P < 0.005). Selecting a threshold of a 50% reduction in apnea-hypopnea index and apnea-hypopnea index less than 20, success was 82.6% in ESP compared with 68.1% in uvulopalatopharyngoplasty (P < 0.05). CONCLUSION/SIGNIFICANCE: The ESP may offer benefits in a selected group of OSA patients.

A Multi-Institutional Study of Radiofrequency Volumetric Tissue Reduction for OSAS

OBJECTIVES: Radiofrequency volume reduction (RFTVR) is a minor procedure directed at reducing the tongue base volume to treat obstructive sleep apnea. Subjective and objective treatment effectiveness was evaluated. STUDY DESIGN AND SETTING: Two separate prospective, matched, nonrandomized, open enrollment treatment groups (RFTVR, n = 73 and nasal continuous positive airway pressure (CPAP, n = 99) were concurrently enrolled in a multicenter study. RESULTS: Fifty-six (76.7%) RFTVR completed PSG with a mean 5.4 ± 1.8 treatments (13,394 ± 5459 joules). Perioperatively, acute pain was mild to moderate; edema, mucosal erosion, paresthesia, tinnitus were infrequent; and speech, swallowing taste, or throat irritation were unchanged. Self-reported outcomes did not differ between RFTVR and CPAP groups. Mean apnea/hypopnea index decreased (40.5 ± 21.5 to 32.8 ± 22.6 events/hr, P < 0.01). Electrolyte solution injected predicted results (r = 0.43, P < 0.001). The most severe complication was abscess (1.1%). CONCLUSION: RFTVR improves apnea/hypopnea index. Improvement may be related to solution injected with treatment. RFTVR and CPAP clinical outcomes improvement were similar. CLINICAL SIGNIFICANCE: In mild obstructive sleep apnea, treatment of symptomatic outcomes with RFTVR may be an alternative to CPAP.

Polysomnography indexes are discordant with quality of life, symptoms, and reaction times in sleep apnea patients.

OBJECTIVE: We tested whether polysomnography (PSG) indexes were associated with sleepiness, quality of life, or reaction times at baseline and as outcome measures following surgical or sham treatment for patients with obstructive sleep apnea syndrome (OSAS). STUDY DESIGN AND METHODS: Mild-moderate OSAS subjects were measured before and 8 weeks after surgical or sham treatment in this prospective longitudinal study. Measures included standard PSG indexes, sleepiness, quality of life, and reaction times. Associations were examined with Spearman correlations and multivariate linear regression. RESULTS: Correlations between baseline PSG and non-PSG measures ranged from −0.22 to 0.25 (n, 87 subjects; mean correlation, 0.00 ± 0.11), with one positive association significant of 56 tested (arousal index and SF36 Mental Component Summary, r, 0.25; P = 0.03). Correlations between change in PSG and non-PSG measures ranged from −0.37 to 0.35 (n, 54 subjects; mean correlation, −0.05 ± 0.19), with no significant positive association of 56 tested. Regression analyses confirmed these results. CONCLUSIONS: PSG indexes are not consistently associated with sleepiness, quality of life, or reaction time, both at baseline and as outcome measures in patients with mild-moderate OSAS. PSG indexes may not quantify some important aspects of OSAS disease burden or treatment outcome. Clinically important outcomes should be measured directly. EBM rating: A.

Prediction of uvulopalatopharyngoplasty response using cephalometric radiographs

PURPOSE To evaluate the relationship between facial cephalometric measures and response to uvulopalatopharyngoplasty (UPPP). PATIENTS AND METHODS Retrospective analysis of skeletal cephalometric measures obtained from a consecutive sample of 43 patients with obstructive sleep apnea syndrome (OSAS) who underwent body mass index (BMI) measures, UPPP, upright lateral cephalometric radiographs, and preoperative and postoperative polysomnography. Significant clinical effect by uvulopalatopharyngoplasty was arbitrarily defined as having a 50% reduction in the respiratory disturbance index (RDI). The cephalometric measurements used were based solely on skeletal landmarks. RESULTS No skeletal measurement predicted response to UPPP for the entire study population. When the patients were classified on the basis of retrognathia, 33 were identified without retrognathia. In that group, posterior airway length was the greatest predictor of response to UPPP (P < or = .05; odds ratio, 83.2). The distance between hyoid and mandible and the maxillary-mandibular relationship were also predictive of response (P < or = .05). CONCLUSION The skeletal anatomy supporting the airway directly impacts the response to UPPP. Prediction of response requires stratification by skeletal subtype.

Three-Year Outcomes of Cranial Nerve Stimulation for Obstructive Sleep Apnea The STAR Trial

Objective To describe the 36-month clinical and polysomnography (PSG) outcomes in an obstructive sleep apnea (OSA) cohort treated with hypoglossal cranial nerve upper airway stimulation (UAS). Study Design A multicenter prospective cohort study. Setting Industry-supported multicenter academic and clinical setting. Subjects Participants (n = 116) at 36 months from a cohort of 126 implanted participants. Methods Participants were enrolled in a prospective phase III trial evaluating the efficacy of UAS for moderated to severe OSA. Prospective outcomes included apnea-hypopnea index, oxygen desaturation index, other PSG measures, self-reported measures of sleepiness, sleep-related quality of life, and snoring. Results Of 126 enrolled participants, 116 (92%) completed 36-month follow-up evaluation per protocol; 98 participants additionally agreed to a voluntary 36-month PSG. Self-report daily device usage was 81%. In the PSG group, 74% met the a priori definition of success with the primary outcomes of apnea-hypopnea index, reduced from the median value of 28.2 events per hour at baseline to 8.7 and 6.2 at 12 and 36 months, respectively. Similarly, self-reported outcomes improved from baseline to 12 months and were maintained at 36 months. Soft or no snoring reported by bed partner increased from 17% at baseline to 80% at 36 months. Serious device-related adverse events were rare, with 1 elective device explantation from 12 to 36 months. Conclusion Long-term 3-year improvements in objective respiratory and subjective quality-of-life outcome measures are maintained. Adverse events are uncommon. UAS is a successful and appropriate long-term treatment for individuals with moderate to severe OSA.