Kenny P. Pang

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.

Severity of Obstructive Sleep Apnea: Correlation with Clinical Examination and Patient Perception

OBJECTIVE: To correlate clinical history, patient self-perception of obstructive sleep apnea, and physical examination with the severity of OSA. METHODS: One hundred and two consecutive patients were prospectively enrolled over a 6-month period. All patients underwent a comprehensive history and clinical examination, nasopharyngoscopy, and an overnight-attended polysomnogram. RESULTS: There were 65 males and 37 females with a mean age of 50.2 ± 11.3 years (range, 24 to 76 years). The mean apnea-hypopnea index (AHI) was 37.9 ± 27.7 (range, 0.7 to 111.2). There was a strong correlation between patient self-perception of OSA severity and AHI (r = 0.499, P < 0.0001), and the correlation with AI was 0.577 (P < 0.0001). OSA severity strongly correlated with Friedman Tongue Position grade, (r = 0.389, P < 0.0001), Friedman clinical staging, (r = 0.331, P = 0.0007). Of significance, only 6.9% of patients with mild OSA had a >50% collapse of the base of tongue region, as compared to 65.9% of patients with severe OSA. CONCLUSION: There is good correlation between clinical examination parameters and the severity of OSA. An algorithm for surgical treatment of OSA should acknowledge both the site of obstruction and the severity of disease.

Palatal implants: A new approach for the treatment of obstructive sleep apnea

OBJECTIVE: To evaluate the short-term safety and efficacy of palatal implants in patients with mild and moderate obstructive sleep apnea (OSA). STUDY DESIGN AND SETTING: A prospective, non-randomized study conducted at 5 clinical sites. Three polyester implants were placed in the soft palate under local anesthesia during a single-stage office procedure. Polysomnography was conducted at baseline and 90 days post-procedure. Subjective quality of life data were collected. RESULTS: Fifty-three patients were evaluated; the apnea hypopnea index (AHI) decreased from 25.0 ± 13.9 to 22.0 ± 14.8 events/hour (P = 0.05). The Epworth Sleepiness Scale (ESS) decreased from 11.0 ± 5.1 to 6.9 ± 4.5 (P < 0.001), and the snore score decreased from 7.9 ± 2.1 to 4.0 ± 3.0 (P < 0.001). No serious complications occurred during the study. CONCLUSION: Palatal implants can be an effective initial low morbidity treatment option for patients diagnosed with mild to moderate OSA.

Anterior palatoplasty for the treatment of OSA: three-year results.

OBJECTIVE: Review long-term results of the modified cautery-assisted palatoplasty (mod CAPSO)/anterior palatoplasty for the treatment of mild-moderate obstructive sleep apnea (OSA). STUDY DESIGN: Prospective series of 77 patients. All patients were >18 years old, type I Fujita, body mass index (BMI) < 33, Friedman clinical stage II, with apnea-hypopnea index (AHI) from 1.0 to 30.0. The mean follow-up time was 33.5 months. The procedure involved an anterior soft palatal advancement technique with or without removal of the tonsils. The procedure was done under general or local anesthesia. RESULTS: There were 69 men and eight women; the mean age was 39.3 years old; and mean BMI was 24.9 (range 20.7–26.8). There were 38 snorers and 39 OSA patients. The AHI improved in patients with OSA, 25.3 ± 12.6 to 11.0 ± 9.9 (P < 0.05). The overall success rate for this OSA group was 71.8 percent (at mean 33.5 months). The mean snore scores (visual analog score) improved from 8.4 to 2.5 (for all 77 patients). Lowest oxygen saturation also improved in all OSA patients. Subjectively, all patients felt less tired. CONCLUSION: This technique has been shown to be effective in the management of patients with snoring and mild-moderate OSA.

Pediatric tracheotomies in an Asian population: the Singapore experience.

Objective: Over the past 2 decades, tracheotomy in children and infants has evolved from a primarily emergent procedure for upper airway obstruction into a semielective procedure for airway access in assisted ventilation. We present a 12-year retrospective review of tracheotomies performed in the pediatric population in Singapore. Study Design and Setting: We reviewed all tracheotomies performed in children below the age of 16 years in 2 tertiary pediatric medical centers in Singapore from January 1991 to December 2003. Indications for surgery are reviewed, and outcomes in terms of morbidity rate, mortality rate, postoperative rehabilitation, and duration of decannulation process were analyzed. Results: Tracheotomies were performed in 48 children during the study period. The mean age of patients was 3.24 years, with ages ranging from 16 days to 14 years. Sixty-three percent of tracheotomies were done within the 1st year of life. The chief indication was airway access for assisted ventilation. The overall complication rate was 31%. There were 13 attempts at decannulation, with 9 successes. No tracheotomy-related deaths occurred. Conclusion: Tracheotomy is a relatively safe procedure in children and infants. Lower decannulation rates and the evolving role of tracheotomy for early access in assisted ventilation permits earlier discharge with tracheotomy in situ.

Modified cautery-assisted palatal stiffening operation: New method for treating snoring and mild obstructive sleep apnea

OBJECTIVE: To assess a new method (modified cautery-assisted palatal stiffening operation [CAPSO]) to treat snoring and mild obstructive sleep apnea (OSA). DESIGN: A prospective, nonrandomized trial. METHODS: Thirteen patients with simple snoring and mild OSA underwent the modified CAPSO under local anaesthesia. All patients had preoperative polysomnography and at 3 months postoperatively. RESULTS: All patients were Friedman stage II and III, with tonsil size 0, 1, or 2. All patients had improvement in their snoring. Eighty-four percent of the patients had improvement in the Epworth Sleepiness Scale, from 12.2 to 8.9. Objective success on the polysomnogram was noted in six out of the eight patients (75%) with mild OSA. The AHI improved from 12.3% to 5.2% (P < 0.05), and the LSAT improved from 88.3% to 92.5% (P < 0.05). CONCLUSION: The modified CAPSO is a simple, low-cost, and effective office-based method to treat snoring and mild obstructive sleep apnea.

Safety of Multilevel Surgery in Obstructive Sleep Apnea: A Review of 487 Cases

OBJECTIVE To review the safety of multilevel surgery in patients with obstructive sleep apnea (OSA). DESIGN Retrospective review. PATIENTS A total of 487 consecutive patients with OSA and 1698 surgical procedures from January 2007 to May 2010. INTERVENTIONS Multilevel OSA surgery comprising nasal surgery (endoscopic sinus surgery, septoplasty, and inferior turbinate reduction), palate surgery (traditional uvulopalatopharyngoplasty, expansion sphincter pharyngoplasty and anterior palatoplasty), and tongue surgery (hyoid suspension, radiofrequency tongue base, and tongue suspension suture). MAIN OUTCOME MEASURES Surgical complications. RESULTS The overall complication rate was 7.1%, with 1 patient having an upper airway obstruction. Complications were as follows: (1) 6 patients had postoperative oxygen desaturation within 3 hours after extubation (these patients had severe OSA [apnea-hypopnea index > 60 and lowest oxygen saturation level <80%]), (2) 15 patients had persistent hypertension (these patients had a history of hypertension), (3) 15 patients had secondary hemorrhage (7-12 days postoperatively), (4) there were 2 cases of negative pressure pulmonary edema, (5) 9 patients had tongue edema (following tongue surgery), and (6) 1 patient had upper airway obstruction requiring reintubation. Patients who had undergone tongue surgery were admitted routinely to the high-dependency unit (step-down care from the intensive care unit) overnight. CONCLUSIONS Routine postoperative admission to the intensive care unit for all patients with OSA is unnecessary. These patients should be closely monitored in the postanesthesia care unit area after surgery, and based on the outcome of this period, they can be observed overnight in either the high-dependency unit or the general ward.

Reconsidering first-line treatment for obstructive sleep apnea: a systematic review of the literature

BackgroundContinuous positive airway pressure (CPAP) is typically recommended as first line therapy for obstructive sleep apnea, but the adherence rate of CPAP is problematic. This study’s objective was to systematically review the literature relating to CPAP as first line therapy for OSA and compare it to surgical literature on the same topic.MethodsA systematic review was conducted according to PRISMA guidelines, examining Medline-Ovid, Embase, and Pubmed databases. The primary search objective was to identify all papers reporting the results of (1) randomized clinical trials (RCT) of CPAP for the treatment of adults with OSA; and (2) both randomized and non-randomized clinical trials and case series on the surgical treatment of OSA in adults. A PhD-level biostatistician first screened papers, and then those that met study criteria were retrieved and analyzed using standardized forms for each author. The primary outcomes were adherence rates of CPAP.ResultsA total of 82 controlled clinical trials for CPAP and 69 controlled and non-controlled surgery trials were identified for analysis. Variation in CPAP use within reported RCT trials were identified, and the majority of patients in the studies would eventually be considered non-adherent to CPAP.ConclusionsWhen considering the numerous patient-related factors that come into play when CPAP is prescribed, the concept of CPAP as gold-standard therapy for OSA should be reconsidered. In many cases surgery can provide a better overall outcome. This study’s results suggest that certain patients with OSA may be managed more effectively with surgery than CPAP, without confounding issues of treatment adherence.

The impact of sinus surgery on sleep outcomes

Background Functional endoscopic sinus surgery (FESS) is standard for patients who fail medical management of chronic sinusitis (CRS). The beneficial impact of surgery on CRS is well known. However, patients often note that their sleep is improved after FESS even without simultaneous correction of nasal obstruction. Sleep outcomes after FESS are significantly understudied. Hence in the current study we look to characterize patient sleep quality following sinus surgery. Methods Data was gathered from 2 sites (Western University [Canada] and the Asia Sleep Center [Singapore]). Patients meeting diagnostic criteria for CRS without nasal polyposis (CRSsNP) were included. Cases with polyposis and those who needed a septoplasty were excluded so as to purely analyze the impact of the sinus surgery on sleep. Sleep outcomes recorded at baseline just prior to surgery and 6 months after surgery were the Epworth Sleepiness Scale (EpSS) and the Pittsburgh Sleep Quality Index (PSQI). We also recorded 22-item Sino-Nasal Outcome Test (SNOT-22) scores and Nasal Obstruction Symptom Evaluation (NOSE) scores. Comparisons were made with paired t tests. Results Fifty-three patients met inclusion/exclusion criteria. Sleep outcomes showed a clinically and statistically significant improvement (EpSS before FESS = 14.7 ± 3.1, EpSS after FESS = 9.1 ± 1.1, p < 0.01; PSQI before FESS = 10.9 ± 2.8, PSQI after FESS = 5.3 ± 2.2, p < 0.01). CRS-specific outcomes were improved as well. Nasal obstruction scores did not change significantly. Conclusion FESS improved sleep outcomes for the patients in our study. This was independent of correction of nasal obstruction. Sinus surgery for CRSsNP has a beneficial impact on sleep; this novel information can be used during patient counseling and for justification to third-party payers.Functional endoscopic sinus surgery (FESS) is standard for patients who fail medical management of chronic sinusitis (CRS). The beneficial impact of surgery on CRS is well known. However, patients often note that their sleep is improved after FESS even without simultaneous correction of nasal obstruction. Sleep outcomes after FESS are significantly understudied. Hence in the current study we look to characterize patient sleep quality following sinus surgery.

A comparison of polysomnography and the SleepStrip in the diagnosis of OSA

Objective To investigate the role of a portable screening device (SleepStrip) in the diagnosis of obstructive sleep apnea (OSA). Methods and Materials Prospective, nonrandomized double-blinded single cohort study at an academic health center. Patients with suspected OSA scheduled for an attended overnight Level I polysomnogram (PSG) and who consented to participate in the study wore the SleepStrip device at home the night after the PSG. The apnea-hypopnea index (AHI) determined by PSG was compared with the results of the SleepStrip recording. Results Thirty-seven patients with a mean age of 52.1 ± 12.2 years and mean body mass index of 35.7 ± 5.2 participated in the study. The overall agreement between the AHI and the SleepStrip results using Cohens Kappa value was 0.139 (P = 0.19). The sensitivity and specificity of the SleepStrip for diagnosing severe OSA when the AHI was >40 were 33.3% and 95% (P = 0.05). When the AHI was >25, the SleepStrip sensitivity and specificity were 43.8% and 81.3% (P = 0.26). The sensitivity and specificity of the SleepStrip for diagnosing OSA in patients with an AHI >15 were 54.6% and 70%, respectively (P = 0.26). Conclusion The SleepStrip has a low correlation with the AHI as measured by PSG. Further studies are needed before this device can be recommended as a screening tool for the diagnosis of OSA. EBM rating: B-2b