Colin Huntley

Preoperative Drug Induced Sleep Endoscopy Improves the Surgical Approach to Treatment of Obstructive Sleep Apnea

Objective: Drug induced sleep endoscopy (DISE) allows for preoperative evaluation of the specific site and character of upper airway obstruction in obstructive sleep apnea (OSA). We aim to assess the impact DISE has on customizing the surgical plan and evaluate its role in surgical success. Methods: We retrospectively reviewed patients undergoing surgery for OSA. We compared those patients undergoing preoperative DISE to those that did not to assess procedures performed and surgical outcomes. Results: We found 87 patients undergoing surgery for OSA who had postoperative polysomnogram results. Of the group undergoing preoperative DISE, 8% had multilevel surgery. This compared to 59.5% in those not undergoing DISE (p = .0004). The success rate of patients who had preoperative DISE was 86% compared to 51.4% in those who did not have preoperative DISE (p < .001). We found no difference in age, gender, preoperative apnea-hypopnea index (AHI), oxygen nadir, Epworth sleepiness scale score (ESS), body mass index (BMI) and postoperative oxygen nadir, ESS, or BMI in the DISE and no DISE cohorts. Conclusion: The addition of DISE to our preoperative workup has contributed to a decreased rate of multilevel surgery and increased rate of surgical success through identification of the individual patient’s OSA architecture and customization of the surgical plan.

Upper Airway Stimulation for Treatment of Obstructive Sleep Apnea: An Evaluation and Comparison of Outcomes at Two Academic Centers

STUDY OBJECTIVES Data from patients at Thomas Jefferson University Hospital (TJUH) and University of Pittsburgh Medical Center (UPMC) undergoing upper airway stimulation (UAS) were analyzed. We hypothesize that treatment with UAS will improve both subjective and objective outcome measures and results will be reproducible between institutions. METHODS We reviewed patients undergoing UAS between May 2014 and August 2016. We recorded demographic data, Epworth Sleepiness Scale (ESS), and preoperative and postoperative polysomnographic information. We compared outcome data between institutions and subsequently combined the cohorts and compared baseline to posttreatment results. RESULTS The TJUH cohort consisted of 30 males and 18 females with a mean age of 60.88 years and body mass index of 29.29. The mean preoperative apnea-hypopnea index (AHI), O2 nadir, and ESS were 35.88, 80.96, and 11.09, respectively. The mean postoperative AHI, O2 nadir, and ESS were 6.34, 88.04, and 5.77, respectively. The UPMC cohort consisted of 30 males and 19 females with a mean age of 62.84 years and body mass index of 27.74. The mean preoperative AHI, O2 nadir, and ESS were 35.29, 79.58, and 10.94, respectively. The mean postoperative AHI, O2 nadir, and ESS were 6.28, 84.35, and 6.60, respectively. We found no difference in patients reaching a postoperative AHI less than 15, 10, and 5 when comparing the cohorts. After combining cohorts, we found a significant improvement in postoperative AHI, O2 nadir, and ESS compared to preoperative values. CONCLUSIONS UAS appears to provide a viable alternative to continuous positive airway pressure, producing improvement in both polysomnographic and quality-of-life measures. Results are reproducible at high-volume centers.

Upper Airway Stimulation for Obstructive Sleep Apnea: Results from the ADHERE Registry:

Objective Upper airway stimulation (UAS) is an alternative treatment option for patients unable to tolerate continuous positive airway pressure (CPAP) for the treatment of obstructive sleep apnea (OSA). Studies support the safety and efficacy of this therapy. The aim of this registry is to collect retrospective and prospective objective and subjective outcome measures across multiple institutions in the United States and Germany. To date, it represents the largest cohort of patients studied with this therapy. Study Design Retrospective and prospective registry study. Setting Ten tertiary care hospitals in the United States and Germany. Subjects and Methods Patients were included who had moderate to severe OSA, were intolerant to CPAP, and were undergoing UAS implantation. Baseline demographic and sleep study data were collected. Objective and subjective treatment outcomes, adverse events, and patient and physician satisfaction were reviewed. Results The registry enrolled 301 patients between October 2016 and September 2017. Mean ± SD AHI decreased from 35.6 ± 15.3 to 10.2 ± 12.9 events per hour (P < .0001), and Epworth Sleepiness Scale scores decreased from 11.9 ± 5.5 to 7.5 ± 4.7 (P < .0001) from baseline to the posttitration visit. Patients utilized therapy for 6.5 hours per night. There were low rates of procedure- and device-related complications. Clinical global impression scores demonstrated that the majority of physicians (94%) saw improvement in their patients’ symptoms with therapy. The majority of patients (90%) were more satisfied with UAS than CPAP. Conclusions Across a multi-institutional registry, UAS therapy demonstrates significant improvement in subjective and objective OSA outcomes, good therapy adherence, and high patient satisfaction.

Open vs. endoscopic cricopharyngeal myotomy; Is there a difference?

INTRODUCTION The upper esophageal sphincter (UES) is composed largely of the cricopharyngeus muscle (CP) and acts as the gatekeeper to the esophagus. There are multiple methods of treating UES dysfunction, but myotomy has been shown to be the most definitive means. We aim to evaluate the difference between open and endoscopic CP myotomy (CPM). METHODS A retrospective review of all patients undergoing endoscopic and open CPM was undertaken. We recorded demographic, clinical, operative, hospital, and postoperative data for both groups from January 2010-March 2015. The endoscopic and open CPM groups were directly compared. RESULTS Our cohort consisted of 38 open and 41 endoscopic CPM patients. There were 22 males and 16 females in the open group and 9 males and 32 females in the endoscopic group. The primary diagnosis for both groups was cricopharyngeal hyperfunction. We found a significant improvement in surgical time and symptomatic outcomes in the endoscopic group (p=0.008 and p=0.010). There was no difference in UES preop pressure, hospital stay, complication rate, time to oral intake, or length of follow-up between cohorts. CONCLUSION Endoscopic CPM is a safe and effective alternative to the open approach. Patients undergoing endoscopic CPM have shorter operative times and improved outcomes when compared to the open approach.

Perforation of a nasoseptal flap does not increase the rate of postoperative cerebrospinal fluid leak.

The nasoseptal flap (NSF) has been shown to be a valuable addition to the reconstructive armamentarium of the endoscopic skull‐base surgeon. We aimed to evaluate the rate of postoperative cerebrospinal fluid (CSF) leak after use of a NSF that had a small tear during harvest.

Upper Airway Stimulation in Patients Who Have Undergone Unsuccessful Prior Palate Surgery: An Initial Evaluation

Upper airway stimulation therapy (UAS) is a new option for treatment of obstructive sleep apnea (OSA) in patients unable to tolerate continuous positive airway pressure (CPAP). We set out to evaluate the effectiveness of UAS in patients who have undergone prior palate surgery. We designed a retrospective review and evaluated patients undergoing UAS at 2 academic centers. We recorded demographic and pre- and postoperative polysomnogram (PSG) data. We compared the cohort of patients who had undergone prior palate surgery, “prior surgery,” to the cohort who had not, “no prior surgery.” A total of 164 patients were included in the study: 23 in the prior surgery and 141 in the no prior surgery groups. The mean age was significantly higher in the no prior surgery group (P = .020). There were no other significant differences when comparing demographic, quality of life, or PSG variables between cohorts. UAS therapy is an option to treat OSA in patients having undergone unsuccessful prior palate surgery.

Comparing Upper Airway Stimulation to Transoral Robotic Base of Tongue Resection for Treatment of Obstructive Sleep Apnea: Upper Airway Stimulation Versus TORS

Transoral robotic surgery (TORS) and upper airway stimulation (UAS) are modalities for treating tongue base obstruction contributing to obstructive sleep apnea (OSA). We aim to compare patients with OSA undergoing TORS to those undergoing UAS.

Upper Airway Stimulation in Patients With Obstructive Sleep Apnea and an Elevated Body Mass Index: A Multi-institutional Review: Impact of BMI on Upper Airway Stimulation

An elevated body mass index (BMI) influences the severity of disease and treatment options utilized for obstructive sleep apnea (OSA). With this study, we aim to evaluate a cohort of patients undergoing upper airway stimulation (UAS) for treatment of OSA and assess the impact of BMI on surgical and quality of life outcomes.

Predicting Success of Oral Appliance Therapy in Treating Obstructive Sleep Apnea Using Drug-Induced Sleep Endoscopy

STUDY OBJECTIVES Oral appliance therapy (OAT) can be an effective treatment option for patients with obstructive sleep apnea unable to tolerate continuous positive airway pressure. We hypothesize that drug-induced sleep endoscopy (DISE) can be useful in identifying patients who will benefit from OAT. METHODS A retrospective review of all patients who underwent DISE (DISE group) between January 2014 and June 2016 was carried out. We included patients if they received OAT based on recommendations made by DISE findings. A control group was designed by selecting a sample of patients undergoing polysomnography (PSG) with an oral appliance in place who had not undergone prior DISE (no DISE group). The two cohorts were compared to evaluate the hypothesis. RESULTS A total of 20 patients fit inclusion criteria for the DISE group and 20 patients for the no DISE group. There was no difference between the DISE and no DISE cohorts with respect to mean age, sex, pre-OAT body mass index, post-OAT body mass index, or pre-OAT PSG characteristics including: apneahypopnea index (AHI), oxygen desaturation nadir, or Epworth Sleepiness Scale score. There was a significantly lower treatment AHI (P = .04) and increased number of patients reaching an AHI less than 5 events/h with OAT therapy (P = .04) in the DISE group. CONCLUSIONS Patients showing increased airway dimensions at the level of the velum and/or oropharynx with a jaw thrust may benefit the most from OAT. The use of DISE to identify this subset of patients is helpful in optimizing outcomes with OAT.

Comparing Upper Airway Stimulation to Expansion Sphincter Pharyngoplasty: A Single University Experience

Introduction: Expansion sphincter pharyngoplasty (ESP) is a surgical option for patients with obstructive sleep apnea (OSA). Upper airway stimulation (UAS) is an alternative that has shown success in initial outcomes studies. We compare outcomes of a cohort of patients undergoing UAS to ESP. Methods: We compared demographic and polysomnographic data of the UAS to ESP cohorts. We also calculated the proportion of patients achieving surgical success. Results: The ESP cohort consisted of 33 patients. The mean preoperative Apnea-Hypopnea Index (AHI), O2 nadir, Epworth Sleepiness Scale (ESS), and BMI were 36.47 ± 20.01, 82.63 ± 5.37, 10.69 ± 4.42, and 29.6 ± 4.49, which improved to 13.47 ± 18.74, 84.84 ± 5.48, 7.00 ± 5.81, and 29.92 ± 4.59 postoperatively. There was a 63.64% success rate. The UAS cohort consisted of 75 patients. The mean preoperative AHI, O2 nadir, ESS, and BMI were 36.76 ± 20.72, 80.24 ± 8.43, 11.18 ± 4.16, and 29.50 ± 3.96, which improved to 7.25 ± 11.19, 88.71 ± 3.25, 5.36 ± 3.35, and 29.36 ± 3.68 postoperatively. The success rate was 86.67%. We found a significant difference in gender, age, preoperative AHI, postoperative AHI, postoperative O2 nadir, surgical success, and patients reaching an AHI less than 10 and 5. Conclusion: Upper airway stimulation is a new surgical option for select patients with OSA showing comparable or improved outcomes to a cohort of patients undergoing ESP.