Regina Conradt

Long-term follow-up after surgical treatment of obstructive sleep apnoea by maxillomandibular advancement

Obstructive sleep apnoea (OSA) is a common disorder with potentially serious consequences. If maxillary and mandibular deficiency, often in combination with a narrow posterior airway space is present, therapy of OSA by maxillomandibular osteotomy is possible. However, long-term follow-up of patients undergoing these procedures is lacking. We present the results of 15 OSA patients (1 female and 14 males), who underwent maxillomandibular advancement surgery with a follow-up of at least 2 yrs. Polysomnography was performed before surgery, after 6-12 weeks, and 1 and 2 yrs postoperatively. Mean apnoea/hypopnoea index (AHI) decreased from 51.4 events.h-1 before therapy to 5.0 events.h-1 6 weeks postoperatively, and was 8.5 events.h-1 after 2 yrs. Oxygen saturation significantly increased following surgery. After 2 yrs, the AHI was < 10 events.h-1 in 12 out of 15 subjects. No significant changes were found comparing the 6-12 weeks versus the 2 year follow-up data. The significant increase in stage 3/4 non-rapid eye movement (NREM) sleep and decrease in stage 1 NREM sleep, indicative of the restoration of normal physiological sleep structure, persisted in 14 of the 15 subjects 2 yrs postoperatively. Three patients, however, did not show satisfactory improvement 2 yrs postoperatively; two showed obstructive and one central respiratory events. This study demonstrates that maxillomandibular advancement is successful in a high percentage of patients carefully selected by cephalometric and polysomnographic investigation. Postoperative success has proved to be stable over a period of 2 yrs. Further preoperative evaluation seems necessary in patients with predominantly mixed or central apnoeas.

Sleep fragmentation and daytime vigilance in patients with OSA treated by surgical maxillomandibular advancement compared to CPAP therapy

Impaired vigilance is a frequent daytime complaint of patients with obstructive sleep apnoea (OSA). To date, continuous positive airway pressure (CPAP) is a well established therapy for OSA. Nevertheless, in patients with certain craniofacial characteristics, maxillomandibular advancement osteotomy (MMO) is a promising surgical treatment. Twenty‐four male patients with OSA (pretreatment respiratory disturbance index (RDI) 59.3 SD±24.1 events/h) participated in this investigation. The mean age was 42.7±10.7 years and the mean body mass index was 26.7±2.9 kg/m2. According to cephalometric evaluation, all patients had a narrow posterior airway space, more or less due to severe maxillary and mandibular retrognathia. All patients except two were treated first with CPAP for at least 3 months and afterwards by MMO. Two patients only tolerated a CPAP trial for 2 nights. Polysomnographic investigation and daytime vigilance were assessed before therapy, with CPAP therapy and 3 months after surgical treatment. Patients’ reports of impaired daytime performance were confirmed by a pretreatment vigilance test using a 90‐min, four‐choice reaction‐time test. The test was repeated with effective CPAP therapy and postoperatively. Daytime vigilance was increased with CPAP and after surgical treatment in a similar manner. Respiratory and polysomnographic patterns clearly improved, both with CPAP and after surgery, and showed significant changes compared to the pretreatment investigation. The RDI decreased significantly, both with CPAP (5.3±6.0) and postoperatively (5.6±9.6 events/h). The percentages of non‐rapid eye movement Stage 1 (NREM 1) sleep showed a marked decrease (with CPAP 8.2±3.6% and after MMO 8.2±4.4% vs. 13.3±7.4% before treatment), whereas percentages of slow wave sleep increased significantly from 8.0±6.1% before therapy to 18.2±12.8 with CPAP and 14.4±7.3% after MMO. The number of awakenings per hour time in bed (TIB) was significantly reduced after surgery (2.8±1.3), compared to both preoperative investigation (baseline 4.2±2.0 and CPAP 3.4±1.5). Brief arousals per hour TIB were reduced to half with CPAP (19.3±20.0) and after MMO (19.7±13.6), compared to baseline (54.3±20.0). We conclude that the treatment of OSA by MMO in carefully selected cases has positive effects on sleep, respiration and daytime vigilance, which are comparable to CPAP therapy.