Macario Camacho

Myofunctional Therapy to Treat Obstructive Sleep Apnea: A Systematic Review and Meta-analysis

OBJECTIVE To systematically review the literature for articles evaluating myofunctional therapy (MT) as treatment for obstructive sleep apnea (OSA) in children and adults and to perform a meta-analysis on the polysomnographic, snoring, and sleepiness data. DATA SOURCES Web of Science, Scopus, MEDLINE, and The Cochrane Library. REVIEW METHODS The searches were performed through June 18, 2014. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement was followed. RESULTS Nine adult studies (120 patients) reported polysomnography, snoring, and/or sleepiness outcomes. The pre- and post-MT apneahypopnea indices (AHI) decreased from a mean ± standard deviation (M ± SD) of 24.5 ± 14.3/h to 12.3 ± 11.8/h, mean difference (MD) -14.26 [95% confidence interval (CI) -20.98, -7.54], P < 0.0001. Lowest oxygen saturations improved from 83.9 ± 6.0% to 86.6 ± 7.3%, MD 4.19 (95% CI 1.85, 6.54), P = 0.0005. Polysomnography snoring decreased from 14.05 ± 4.89% to 3.87 ± 4.12% of total sleep time, P < 0.001, and snoring decreased in all three studies reporting subjective outcomes. Epworth Sleepiness Scale decreased from 14.8 ± 3.5 to 8.2 ± 4.1. Two pediatric studies (25 patients) reported outcomes. In the first study of 14 children, the AHI decreased from 4.87 ± 3.0/h to 1.84 ± 3.2/h, P = 0.004. The second study evaluated children who were cured of OSA after adenotonsillectomy and palatal expansion, and found that 11 patients who continued MT remained cured (AHI 0.5 ± 0.4/h), whereas 13 controls had recurrent OSA (AHI 5.3 ± 1.5/h) after 4 y. CONCLUSION Current literature demonstrates that myofunctional therapy decreases apnea-hypopnea index by approximately 50% in adults and 62% in children. Lowest oxygen saturations, snoring, and sleepiness outcomes improve in adults. Myofunctional therapy could serve as an adjunct to other obstructive sleep apnea treatments.

Maxillomandibular Advancement for Treatment of Obstructive Sleep Apnea: A Meta-analysis.

IMPORTANCE Maxillomandibular advancement (MMA) is an invasive yet effective surgical option for obstructive sleep apnea (OSA) that achieves enlargement of the upper airway by physically expanding the facial skeletal framework. OBJECTIVE To identify criteria associated with surgical outcomes of MMA using aggregated individual patient data from multiple studies. DATA SOURCES The Cochrane Library, Scopus, Web of Science, and MEDLINE from June 1, 2014, to March 16, 2015, using the Medical Subject Heading keywords maxillomandibular advancement, orthognathic surgery, maxillary osteotomy, mandibular advancement, sleep apnea, surgical, surgery, sleep apnea syndrome, and obstructive sleep apnea. STUDY SELECTION Inclusion criteria consisted of studies in all languages of (1) adult patients who underwent MMA as treatment for OSA; (2) report of preoperative and postoperative quantitative outcomes for the apnea-hypopnea index (AHI) and/or respiratory disturbance index (RDI); and (3) report of individual patient data. Studies of patients who underwent adjunctive procedures at the time of MMA (including tonsillectomy, uvulopalatopharyngoplasty, and partial glossectomy) were excluded. DATA EXTRACTION Three coauthors systematically reviewed the articles and updated the review through March 16, 2015. The PRISMA statement was followed. Data were pooled using a random-effects model and analyzed from July 1, 2014, to September 23, 2015. MAIN OUTCOMES AND MEASURES The primary outcomes were changes in the AHI and RDI after MMA for each patient. Secondary outcomes included surgical success, defined as the percentage of patients with more than 50% reduction of the AHI to fewer than 20 events/h, and OSA cure, defined as a post-MMA AHI of fewer than 5 events/h. RESULTS Forty-five studies with individual data from 518 unique patients/interventions were included. Among patients for whom data were available, 197 of 268 (73.5%) had undergone prior surgery for OSA. Mean (SD) postoperative changes in the AHI and RDI after MMA were -47.8 (25.0) and -44.4 (33.0), respectively; mean (SE) reductions of AHI and RDI outcomes were 80.1% (1.8%) and 64.6% (4.0%), respectively; and 512 of 518 patients (98.8%) showed improvement. Significant improvements were also seen in the mean (SD) postoperative oxygen saturation nadir (70.1% [15.6%] to 87.0% [5.2%]; P < .001) and Epworth Sleepiness Scale score (13.5 [5.2] to 3.2 [3.2]; P < .001). Rates of surgical success and cure were 389 (85.5%) and 175 (38.5%), respectively, among 455 patients with AHI data and 44 (64.7%) and 13 (19.1%), respectively, among 68 patients with RDI data. Preoperative AHI of fewer than 60 events/h was the factor most strongly associated with the highest incidence of surgical cure. Nevertheless, patients with a preoperative AHI of more than 60 events/h experienced large and substantial net improvements despite modest surgical cure rates. CONCLUSIONS AND RELEVANCE Maxillomandibular advancement is an effective treatment for OSA. Most patients with high residual AHI and RDI after other unsuccessful surgical procedures for OSA are likely to benefit from MMA.

Tracheostomy as treatment for adult obstructive sleep apnea: a systematic review and meta-analysis.

To systematically review outcomes for polysomnography, sleepiness, and mortality in patients who undergo tracheostomy for the treatment of adult obstructive sleep apnea (OSA).

Hypoglossal nerve stimulation in the treatment of obstructive sleep apnea: A systematic review and meta-analysis.

Poor adherence to continuous positive airway pressure treatment in obstructive sleep apnea (OSA) adversely affects the effectiveness of this therapy. This study aimed to systematically review the evidence regarding the efficacy and safety of hypoglossal nerve stimulation as an alternative therapy in the treatment of OSA.

The Effect of Nasal Surgery on Continuous Positive Airway Pressure Device Use and Therapeutic Treatment Pressures: A Systematic Review and Meta-Analysis

BACKGROUND The relationship between nasal surgery and its effect on continuous positive airway pressure (CPAP) device therapeutic treatment pressures and CPAP device use has not been previously systematically examined. STUDY OBJECTIVES To conduct a systematic review and meta-analysis evaluating the effect of isolated nasal surgery on therapeutic CPAP device pressures and use in adults with obstructive sleep apnea (OSA). METHODS MEDLINE, Scopus, Web of Science, and The Cochrane Library were searched through July 15, 2014. The MOOSE consensus statement and PRISMA statement were followed. RESULTS Eighteen studies (279 patients) reported CPAP data after isolated nasal surgery. Seven studies (82 patients) reported preoperative and postoperative mean therapeutic CPAP device pressures and standard deviations (SD), which reduced from 11.6 ± 2.2 to 9.5 ± 2.0 centimeters of water pressure (cwp) after nasal surgery. Pooled random effects analysis demonstrated a statistically significant pressure reduction, with a mean difference (MD) of -2.66 cwp (95% confidence interval (CI), -3.65 to -1.67); P < 0.00001. Eleven studies (153 patients) reported subjective, self-reported data for CPAP use; and a subgroup analysis demonstrated that 89.1% (57 of 64 patients) who were not using CPAP prior to nasal surgery subsequently accepted, adhered to, or tolerated it after nasal surgery. Objective, device meter-based hours of use increased in 33 patients from 3.0 ± 3.1 to 5.5 ± 2.0 h in the short term (<6 mo of follow-up). CONCLUSION Isolated nasal surgery in patients with OSA and nasal obstruction reduces therapeutic CPAP device pressures and the currently published literatures objective and subjective data consistently suggest that it also increases CPAP use in select patients.

Inferior turbinate classification system, grades 1 to 4: development and validation study.

To develop a validated inferior turbinate grading scale.

Airway changes in obstructive sleep apnoea patients associated with a supine versus an upright position examined using cone beam computed tomography

OBJECTIVE This study aimed to describe total volume and cross-sectional area measurement changes in obstructive sleep apnoea patients associated with a supine versus an upright position. METHOD A retrospective chart review of patients who underwent cone beam computed tomography in upright and supine positions was performed, and the images were analysed. RESULTS Five obstructive sleep apnoea patients (all male) underwent both upright and supine cone beam computed tomography imaging. Mean age was 35.0 ± 9.3 years, mean body mass index was 28.1 ± 2.7 kg/m2 and mean apnoea-hypopnoea index was 39.3 ± 23.0 per hour. The airway was smaller when patients were in a supine compared with an upright position, as reflected by decreases in the following airway measurements: total volume; posterior nasal spine, uvula tip, retrolingual and tongue base (not significant) cross-sectional areas; and site of the minimum cross-sectional area (of the overall airway). Total airway volume decreased by 32.6 per cent and cross-sectional area measurements decreased between 32.3 and 75.9 per cent when patients were in a supine position. CONCLUSION In this case series, the airway of obstructive sleep apnoea patients was significantly smaller when patients were in a supine compared with an upright position.

Epiglottis collapse in adult obstructive sleep apnea: A systematic review.

To systematically review the international literature evaluating the role of the epiglottis in snoring and obstructive sleep apnea and to explore possible treatment options available.

Awake examination versus DISE for surgical decision making in patients with OSA: A systematic review.

Traditionally, upper airway examination is performed while the patient is awake. However, in the past two decades, drug‐induced sleep endoscopy (DISE) has been used as a method of tridimensional evaluation of the upper airway during pharmacologically induced sleep. This study aimed to systematically review the evidence regarding the usefulness of DISE compared with that of traditional awake examination for surgical decision making in patients with obstructive sleep apnea (OSA).

Comprehensive review of surgeries for obstructive sleep apnea syndrome.

UNLABELLED There are several surgical treatment modalities utilized for obstructive sleep apnea syndrome (OSAS). OSAS can cause excessive daytime sleepiness as well as cardiovascular morbidity and mortality. Patients who fail medical management often seek surgical treatment. OBJECTIVE This paper reviews surgical treatment options for obstructive sleep apnea syndrome to include original descriptions as well as outcomes for snoring, apnea-hypopnea indices, and mortality benefits. METHOD A literature review was performed for OSAS surgical treatment options for soft tissue and skeletal surgeries. Articles with the original descriptions and surgical reviews are included for each procedure. RESULTS A total of twenty-eight surgical treatment modalities for OSAS were identified. Original article authors and year of description were obtained and presented. Polysomnographic data for apnea indices, apnea-hypopnea indices and mortality are presented. CONCLUSION There is a large amount of variability in outcomes for sleep surgeries, however, in order to maximize success and cure rates, multiple procedures are most often necessary. Sleep surgeons must get familiar with modern surgical concepts and techniques, and participate in multi-disciplinary care in order to maximize treatment outcomes.