Nelson B. Powell

Palatopharyngoplasty failure, cephalometric roentgenograms, and obstructive sleep apnea.

Nine patients with obstructive sleep apnea who underwent unsuccessful palatopharyngoplasty (PPP) as documented by polygraphic monitoring had abnormal cephalometric roentgenogram measurements. Findings indicated a small posterior airway space and inferiorly placed hyoid bone. Cephalometry performed with appropriate techniques to investigate soft tissue location should be obtained systematically in obstructive sleep apneic patients before any surgery is performed. The roentgenogram finding is a helpful guide in deciding whether PPP alone or PPP in combination with other surgical procedures would be more efficacious.

Sleepy Driving: Accidents and Injury

OBJECTIVE: The study goals were to evaluate the associated risks of driving and to assess predictors of accidents and injury due to sleepiness. STUDY DESIGN: A cross-sectional Internet-linked survey was designed to elicit data on driving habits, sleepiness, accidents, and injuries during the preceding 3 years. Statistical analysis included logistic models with covariate-adjusted P values of <0.01 (odds ratios and 95% confidence intervals or limits). Independent accident predictors were sought. RESULTS: Responses from 10,870 drivers were evaluated. The mean ± SD age was 36.9 ± 13 years; 61% were women and 85% were white. The Epworth Sleepiness Scale overall baseline score was 7.4 ± 4.2 (for drivers with no accidents) and ranged to 12.7 ± 7.2 (for drivers with ≥ 4 accidents) (P = < 0.0001). Twenty-three percent of all respondents experienced ≥ 1 accident. Among respondents who reported ≥ 4 accidents, a strong association existed for the most recent accident to include injury (P < 0.0001). Sleep disorders were reported by 22.5% of all respondents, with a significantly higher prevalence (35%, P = 0.002) for drivers who had been involved in ≥ 3 accidents. CONCLUSION: Factors of sleepiness were strongly associated with a greater risk of automobile accidents. Predictors were identified that may contribute to accidents and injury when associated with sleepiness and driving.

Surgical Treatment of Sleep-Related Breathing Disorders

Snoring, upper airway resistance syndrome (UARS), obstructive sleep apnea (OSA), and obstructive sleep apnea-hypopnea syndrome (OSAHS) are collectively referred to as sleeprelated breathing disorders (SRBD). These terms describe a partial or complete obstruction of the upper airway during sleep. Patency of the pharyngeal airway is maintained by two opposing forces: negative intraluminal pressure and the activity of the upper airway musculature. Anatomical or central neural abnormalities can disrupt this delicate balance and result in compromise of the upper airway. This reduction of airway caliber may cause sleep fragmentation and subsequent behavioral derangements, such as excessive daytime sleepiness (EDS) (1–3). The goal of medical and surgical therapy is to alleviate this obstruction and increase airway patency. The first therapeutic modality employed to treat SRBD was surgery. Kuhlo described placement of a tracheotomy tube in an attempt to bypass upper airway obstruction in Pickwickian patients (4). Although effective, tracheotomy does not address the specific sites of pharyngeal collapse and is not readily accepted by most patients. These sites include the nasal cavity/nasopharynx, oropharynx, and hypopharynx. Often, multilevel obstruction is present. Consequently, the surgical armamentarium has evolved to create techniques that correct the specific anatomical sites of obstruction. To eliminate SRBD, it is necessary to alleviate all levels of obstruction in an organized and safe protocol. The surgeon must counsel the patient regarding all surgical techniques, risks, complications, and alternative medical therapies prior to intervention. Medical management is often considered the primary treatment of SRBD; however, there are exceptions. Treatment may consist of weight loss, avoidance of alcohol and sedating medications, and manipulation of body position during sleep (5–9). Currently, continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BPAP) devices are the preferred methods of treatment and the standard to which other modalities are compared. The efficacy of CPAP has clearly been demonstrated, but a subset of patients struggle to comply with or accept CPAP therapy (10–13). Patients who are unwilling or unable to comply with medical treatment may be candidates for surgery.

Obstructive Sleep Apnea, Continuous Positive Airway Pressure, and Surgery

Patients with obstructive sleep apnea (OSA) who have undergone upper airway surgery could be expected to improve if surgery alleviated some or all of the anatomic obstructions, or continue to desaturate at preoperative levels if the surgery was not corrective. Factors such as morbid obesity, general anesthesia recovery, and operative edema can potentially cause desaturations below preoperative levels. Because of this risk, patients with severe OSA have been considered for protective tracheostomy. The findings of our study suggest that selected patients who would have been past candidates for protective tracheostomy while undergoing surgery for severe OSA can, as an alternative, be considered for immediate postoperative use of nasal continuous positive airway pressure (CPAP). Ten surgical patients with severe OSA who elected surgical treatment were successfully treated with CPAP immediately after extubation and postoperatively to assist with airway patency and hemoglobin saturation. Postoperative followup included monitoring of continuous pulse oximetry, cardiac activity, and intermittent arterial blood gases. Preoperatively, all ten patients had marked decrease in oxygen desaturation levels during sleep, with a mean nadir oxygen saturation (SaO2) to 51.5%. After surgery, all patients in this group maintained SaO2 levels to no lower than 90%, with a mean SaO2 level of 93% while using CPAP on room air (F10(2) 21%) only.