Kenji Kawakatsu

Endoscopic examination of obstructive sleep apnea syndrome patients during drug-induced sleep.

Sixty patients diagnosed with obstructive sleep apnea syndrome (OSAS) underwent uvulopalatopharyngoplasty (UPPP). The effects of surgery were studied based on endoscopic findings during drug-induced sleep and determination of the apnea-hypopnea index (AHI) before and after the operation. Changes in the form of the airway during sleep in the recumbent position were observed, and the role of upper airway endoscopy in the diagnosis and surgical treatment of OSAS was determined. The site of airway obstruction during sleep induced by i.v. injection of 10 mg of diazepam was classified into five types, and changes in AHI and the site of airway obstruction were compared before and after surgery. Changes in airway morphology during sleep in the supine and recumbent positions were also compared before surgery. The postoperative improvement rate was 74.4% for the soft palatal type of obstruction, 76.2% for the tonsillar type, 53.3% for the circumferential palatal type and 34.0% for the mixed type. Treatment produced excellent or good effects for the soft palatal and tonsillar types of obstruction. However, many patients with the circumferential palatal and mixed types of obstruction showed only some improvement or no change. Good airway morphology was maintained in the recumbent position by patients with the soft palatal type of obstruction. With the circumferential palatal and mixed types of obstruction, improvement can be expected from operations which include surgical treatment of the posterior pharyngeal wall or lateral funiculus, or with midline laser glossectomy. A good operative outcome can be predicted in patients showing improvement of apnea in the recumbent position preoperatively.

Posture of patients with sleep apnea during sleep

The relationship between sleep apnea syndrome (SAS) and posture during sleep has been noted and the beneficial effect of an optimal posture on sleep apnea has been empirically indicated. We investigated this effect in a group of subjects that included obese patients and found that the apnea-hypopnea index (AHI) may be normalized in the lateral position, even among patients severely affected with apnea. Among those with intermediate or lower AHI values, sleeping in a lateral position markedly improved the symptoms, with AHI even approaching the normal range in many patients. A tendency was noted for AHI to rise regardless of posture but in proportion to the increase in body mass index (BMI). In other words, the improvement due to changes in posture became increasingly insignificant with increase in BMI.

Laser midline glossectomy and lingual tonsillectomy as treatments for sleep apnea syndrome.

Preservation treatments for sleep respiratory disorders, such as the use of a dental device and the technique of nasal continuous positive air pressure, cause discomfort to the patient and are not radical treatments. Therefore, we performed operative therapy instead. Laser midline glossectomy was performed to treat constriction at the root of the tongue in 16 patients diagnosed with sleep apnea syndrome. We also tried lingual tonsil excision using the Harmonic Scalpel in three patients with stenosis at the base of the tongue.

Application of lingual tonsillectomy to sleep apnea syndrome involving lingual tonsils.

In sleep apnea syndrome, surgical treatment is applied in obstructive-type cases and some mixed-type cases. If the obstructive part is in the root of the tongue, forward transfer of the tongue, lingual tonsillectomy and laser midline glossectomy are applied. In this study, we demonstrate the surgical technique of lingual tonsillectomy using an ultrasonic coagulating dissector (SonoSurg) with a blade tip shape developed in our department. We conclude that lingual tonsillectomy using SonoSurg, which we have frequently used, should be the first choice of treatment for snoring and sleep apnea caused by hypertrophy of the lingual tonsils from the viewpoints of effectiveness, prevention of hemorrhage, safety and handling.

Comparison of surgery and nasal continuous positive airway pressure treatment for obstructive sleep apnea syndrome.

Uvulopalatopharyngoplasty (UPPP) and nasal continuous positive airway pressure (n-CPAP) are used for the treatment of obstructive sleep apnea syndrome (OSAS). Although OSAS results from an abnormality of the pharynx, very little research has been carried out regarding the selection of UPPP or n-CPAP according to the type of abnormality. We performed n-CPAP titration before and after surgery, compared the treatment methods and evaluated the effect of the medical therapy. A sleep polygraph was recorded on the first night of admission and patients diagnosed with OSAS underwent n-CPAP titration on the second night. The blocked region was identified by means of endoscopic examination. A couple of months after surgery, polysomnography was repeated to determine the effect of surgery and the pressure level during n-CPAP forpatients who showed < 50% improvement in the apnea-hypopnea index. The results of surgery were poor in cases revealed by endoscopy to have the circumferential type of obstruction, but good for the soft palate and tonsil types. When endoscopic examinations were performed in conjunction with n-CPAP, the treatment was observed to act on the pharynx and to expand the airway in all cases Combined medical treatments were effective in cases where n-CPAP alone was ineffective due to high pressure.

Long-term surgical follow-up of sleep apnea syndrome.

During a 10-year period, 845 patients suspected of having sleep apnea syndrome underwent overnight monitoring at our institution. We report herein the results of a study of 204 surgical patients who responded to a questionnaire survey. Of these 204 cases, 86 (42%) showed a > or = 75% postoperative improvement in the apnea-hypopnea index (AHI) (or AHI < 10) and 48 (24%) showed an improvement of > or = 50%. Based on the data obtained from the questionnaire survey we studied the long-term postoperative improvement as well as the long-term prognosis in terms of the postoperative improvements in AHI and body weight.

Development of new blades of ultrasonic surgical system (SonoSurgR) for tonsillectomy and nasal conchotomy

Abstract In the otolaryngological field, SonoSurg R (Ultrasonic Surgical System, developed by Olympus Corporation in Japan) has never been used because the shape of the tips is too large for ENT-Head and Neck Surgery use. SonoSurg R is an ultrasonic surgical device with 47000 Hz vibration and 75 μm amplitude. An ultrasonic vibration at the tip of the SonoSurg R blade can cut the tissue continuously with low tissue damage. SonoSurg R has hemostasis and coagulation performance by frictional heat on the side of the blade. Coagulation will finish with a low temperature, less than 80 °C, and causes few lateral tissue damages. In this paper, we presented the advantages and disadvantages of a SonoSurg R knife blade and a spatula blade that we newly developed for tonsillectomy and nasal conchotomy. SonoSurg R needs no protective glasses, has strong stop-bleeding and high-coagulation ability, has few lateral tissue damage, and has no muscle twitch. Fine SonoSurg R blades with 3.8 mm diameter as newly developed by us are more useful for our ENT-Head and Neck Surgical field surgery. SonoSurg R has a few disadvantages in that the blades are somewhat costly and the sheath heats up with continuous use.

Two Cases of Sleep Apnea Syndrome Caused by Primary Hypothyoidism.

Two cases of obstructive sleep apnea (OSAS) caused by primary hypothyroidism are reported.The first patient was a 66-year-old man who complained of sleep apnea with an apnea/hypopnea index (AHI) of 50.8 per night as assessed by all night monitoring. Hypothyroidism was subsegently suspected when he showed delayed recovery from general anesthesia following surgery involving UPPP (uvulo-palato-pharyngoplasty). Hypothyroidism was diagnosed on the basis of blood tests. His snoring and apnea improved after 2 months of levothyroxine sodium administration and the AuI changed from 50.8 to 13.0.The second patient was a 73-year-old man with an AHI of 41.3 per night as assessed by all night monitoring. Hypothyroidism was diagnosed on the basis of blood tests and was suspected because of his slow speech. He was similarly treated with levothyroxine sodium. The AHI did not decrease after treatment for 4 months. His desaturation time (the rate of O2 saturation less than 90%) improved however, from 56.6 to 31.9, and the symptoms of hypothyroidism also recovered markedly. In both patients, elevated creatine phosphokinase (CPK), dull facial expression, peripheral edema, and slow speech were recognized and these were suggestive of hypothyroidism. The type of sleep apnea was mainly obstructive in both patients.

A Questionnaire-Based Survey of Patients after Obstructive Sleep Apnea Syndrome Surgery. Comparison with Improvement in Apnea-Hypopnea Index.

The following six parameters were studied in 119 patients who responded to a questionnairebased long-term survey of 208 adults who had undergone surgery for obstructive sleep apnea syndrome in the previous 8 years: 1) snoring, 2) sleep apnea, 3) daytime sleepiness, 4) nocturnal arousal, 5) malaise, and 6) quality of sleep.The patients were divided into a markedly or moderately improved group (group A) and a slightly improved or unchanged group (group B) based on improvement of the apnea-hypopnea index (AHI) after surgery.In group A, improvement of snoring, sleep apnea, daytime sleepiness, and quality of sleep tended to decrease over the long term.In group B, improvement of these four symptoms was more marked than improvement of the AHI in the early postoperative period (1 year after surgery), with a significant difference between the two. The same pattern was also apparent in the long-term results.There was no major difference between the improvement of nocturnal awakening or malaise and improvement of the AHI over either the short or long term in groups A or B.