Scott B. Boyd

Comparative Effectiveness of Maxillomandibular Advancement and Uvulopalatopharyngoplasty for the Treatment of Moderate to Severe Obstructive Sleep Apnea

PURPOSE To directly compare the clinical effectiveness of maxillomandibular advancement (MMA) and uvulopalatopharyngoplasty (UPPP)--performed alone and in combination--for the treatment of moderate to severe obstructive sleep apnea (OSA). PATIENTS AND METHODS The investigators designed and implemented a retrospective cohort study composed of patients with moderate to severe OSA (baseline AHI >15). The predictor variable was operative treatment and included MMA, UPPP, and UPPP followed by MMA (UPPP/MMA). The primary outcome variable was the apnea-hypopnea index (AHI) measured preoperatively and 3 months to 6 months postoperatively. Other variables were grouped into the following categories: demographic, respiratory, and sleep parameters. Descriptive and bivariate statistics were computed. RESULTS The sample was composed of 106 patients grouped as follows: MMA (n = 37), UPPP (n = 34), and UPPP/MMA (n = 35) for treatment of OSA. There were no significant differences between the 3 groups for the study variables at baseline, except for AHI. Surgical treatment resulted in a significant decrease in AHI in each group: MMA (baseline AHI, 56.3 ± 22.6 vs AHI after MMA, 11.4 ± 9.8; P < .0001), UPPP/MMA (baseline AHI, 55.7 ± 49.2 vs AHI after UPPP/MMA, 11.6 ± 10.7; P < .0001), and UPPP (baseline AHI, 41.8 ± 28.0 vs AHI after UPPP, 30.1 ± 27.5; P = .0057). After adjusting for differences in baseline AHI, the estimated mean change in AHI was significantly larger for MMA compared with UPPP (MMA AHI, -40.5 vs UPPP AHI, -19.4; P = < .0001). UPPP/MMA was no more effective than MMA (P = .684). CONCLUSION The results of this study suggest that MMA should be the surgical treatment option of choice for most patients with moderate to severe OSA who are unable to adequately adhere to CPAP.

Management of Obstructive Sleep Apnea by Maxillomandibular Advancement

Obstructive sleep apnea (OSA) is a common primary sleep disorder. It is characterized by repetitive partial or complete upper airway collapse during sleep. Maxillomandibular advancement (MMA) is an orthognathic surgical procedure that has been used to manage OSA. The main objective of this article is to provide practical guidelines for evaluating and managing OSA patients by MMA. The presentation will focus on MMA for adults, as this is the most common and clinically effective application of MMA to treat OSA.

Long-Term Effectiveness and Safety of Maxillomandibular Advancement for Treatment of Obstructive Sleep Apnea.

STUDY OBJECTIVE To determine the long-term clinical effectiveness and safety of maxillomandibular advancement (MMA) for the treatment of moderate to severe obstructive sleep apnea (OSA). METHODS A prospective two-center cohort study design was used to evaluate OSA patients who underwent MMA > 2 years ago. The primary outcome measure was the apnea-hypopnea index (AHI). Secondary outcome measures included blood pressure (BP), sleepiness (Epworth Sleepiness Scale [ESS]), and quality of life (Functional Outcomes of Sleep Questionnaire [FOSQ]). RESULTS 30 adult patients (80% men, age 50.5 ± 9.6 years [mean ± SD]) participated in the study. The AHI decreased from a mean of 49 to 10.9 events/h (p < 0.0001) at the time of long-term evaluation (6.6 ± 2.8 years after MMA), with 46.7% of patients obtaining an AHI < 5 and 83.4% of patients attaining an AHI ≤ 15 events/h. The mean diastolic BP decreased from 83.7 to 79.0 mm Hg (p < 0.05). ESS decreased from a mean of 12.1 to 6.0 (p < 0.01). FOSQ increased from a mean of 12.6 to 17.3 (p < 0.05). Few long-term treatment-related adverse events occurred, which had minimal impact on quality of life (QOL). CONCLUSIONS MMA is a clinically effective and safe long-term treatment for most patients with moderate-to-severe OSA as demonstrated by significant decreases in AHI, diastolic BP, and subjective sleepiness, with concomitant significant improvements in QOL. The results of this small cohort study suggest that MMA should be considered as the alternative treatment of choice for patients with severe OSA who cannot fully adhere to CPAP therapy.

Effectiveness of Treatment Apnea-Hypopnea Index: A Mathematical Estimate of the True Apnea-Hypopnea Index in the Home Setting

PURPOSE To present a new measurement instrument, the Effectiveness of Treatment Apnea-Hypopnea Index (ET-AHI), which the authors developed to determine an estimate of the therapeutic control of obstructive sleep apnea (OSA). MATERIALS AND METHODS The authors retrospectively evaluated a cohort of patients with OSA who initially attempted to use continuous positive airway pressure (CPAP) therapy and subsequently underwent maxillomandibular advancement (MMA) surgery. The ET-AHI calculations were performed to estimate the level of CPAP adherence that would be necessary to achieve equivalence with the MMA surgical result and to reach effective AHIs of 5 and 15. RESULTS The sample was composed of 37 adult patients (mean age, 44.2 ± 9.0 yr; 73% men) with moderate to severe OSA (baseline AHI, 56.3 ± 22.6). CPAP therapy was highly efficacious (CPAP titration AHI, 4.3 ± 5.9), but no patient could adequately adhere to treatment. MMA produced a significant decrease in OSA (AHI after MMA, 11.6 ± 7.4). The ET-AHI calculations predicted that an 86% adherence rate with CPAP would be necessary to achieve equivalence with MMA, whereas adherence rates of 99% and 79% may be required to achieve effective AHIs of 5 and 15, respectively. CONCLUSIONS The ET-AHI has the potential to significantly affect the care of patients with OSA because it may provide the treating clinician with a valuable tool to estimate the control of OSA for any therapeutic intervention. How closely the ET-AHI predicts the true effective AHI in the home setting requires further validation.

Controversies in Obstructive Sleep Apnea Surgery

Obstructive sleep apnea (OSA) is a common chronic disease characterized by repetitive pharyngeal collapse during sleep. OSA is associated with cardiovascular disease and increased mortality, among other issues. Continuous positive airway pressure (CPAP) is considered first line therapy for OSA, but is not always tolerated. Both non-surgical and surgical alternative management strategies are available for the CPAP intolerant patient. This article explores controversies surrounding airway evaluation, definition of successful treatment, and surgical management of the CPAP intolerant patient with moderate to severe OSA. Controversies specific to maxillomandibular advancement (MMA) are also discussed.