Increase of the apnoea-hypopnoea index after uvulopalatopharyngoplasty: analysis of failure

From 70 patients who had uvulopalatopharyngoplasty (UPPP) operation and a pre- and postoperative sleep registration, we could retrospectively determine the failures and the correlation between variables such as age, gender, body mass index (BMI), earlier or concomitant tonsillectomy, unilevel (uvula-palate-tonsil) or multilevel (base of tongue as well) obstruction during sleep endoscopy and treatment outcome. From 70 patients, the preoperative sleep registration classified 15 social unacceptable snorers and 55 obstructive sleep apnoea syndrome (OSAS) patients. In this study we focused on the OSAS patients. From the 55 OSAS patients, 32 were classified as successful after UPPP, because they had a decreased apnoea-hypopnoea index (AHI) after surgery ( 0.56) as between the level of obstruction(s) (P > 0.24). For earlier or concomitant tonsillectomy we found a statistically difference (P > 0.039), but a very small number in the high failure group (n = 8). We conclude that although sleep endoscopy adds to better patient selection and better results, paradoxically, the finding of obstruction on palate-uvula level during sleep endoscopy can still give UPPP failures.     

Increase of the apnoea–hypopnoea index after uvulopalatopharyngoplasty: analysis of failure1

From 70 patients who had uvulopalatopharyngoplasty (UPPP) operation and a pre‐ and postoperative sleep registration, we could retrospectively determine the failures and the correlation between variables such as age, gender, body mass index (BMI), earlier or concomitant tonsillectomy, unilevel (uvula–palate–tonsil) or multilevel (base of tongue as well) obstruction during sleep endoscopy and treatment outcome. From 70 patients, the preoperative sleep registration classified 15 social unacceptable snorers and 55 obstructive sleep apnoea syndrome (OSAS) patients. In this study we focused on the OSAS patients. From the 55 OSAS patients, 32 were classified as successful after UPPP, because they had a decreased apnoea–hypopnoea index (AHI) after surgery (≤20). Eight patients had a decreased AHI, but more than 20 apnoeas/hypnoeas per hour. Fifteen patients were identified as UPPP failures with an equal or increased AHI and/or subjective deterioration of snoring. We were unable to find a statistically difference between the two groups with respect to variables such as age, BMI and AHI preoperative (P > 0.56) as between the level of obstruction(s) (P > 0.24). For earlier or concomitant tonsillectomy we found a statistically difference (P > 0.039), but a very small number in the high failure group (n = 8). We conclude that although sleep endoscopy adds to better patient selection and better results, paradoxically, the finding of obstruction on palate–uvula level during sleep endoscopy can still give UPPP failures.     

Diagnostic work-up of socially unacceptable snoring

Should all patients with socially unacceptable snoring (SUS) undergo polysomnography, or is history-taking sufficient to identify the presence of obstructive sleep apnoea syndrome (OSAS)? Three hundred and eighty consecutive patients with SUS who underwent sleep registration were evaluated retrospectively to determine the predictive value of a history of apnoea or excessive daytime somnolence (hypersomnia). Of the patients analysed, 54% had OSAS, defined as an apnoea / hypopnoea index (AHI) of >15. This is higher than previously reported in the literature (46.7%). (Incidental) apnoea was reported by 337 (89%) of the patients, with a sensitivity of 0.92 and a specificity of 0.13. The predictive value – as related to the gold standard, i.e. sleep registration, of a negative test and of a positive test for OSAS is low (0.56 and 0.59, respectively). Hypersomnia was reported by 280 (74%) of the patients, with a sensitivity of 0.29 and a specificity of 0.72. The predictive value of a negative test and a positive test for OSAS is also low, 0.45 and 0.56, respectively. These data confirm that apnoea and hypersomnia in the history do not have a reliable predictive value of an obstructive sleep apnoea syndrome. We conclude that sleep registration is indicated in all patients with SUS, to rule out or confirm the presence of OSAS.     

Tongue-base suspension in conjunction with uvulopalatopharyngoplasty for treatment of severe obstructive sleep apnea: long-term follow-up results

OBJECTIVES/HYPOTHESIS: To evaluate the usefulness of tongue-base suspension (TBS) in addition to uvulopalatopharyngoplasty (UPPP) in the treatment of obstructive sleep apnea syndrome (OSAS). STUDY DESIGN: Long-term prospective case series. SETTING: University tertiary care medical center. METHODS: Fifty-five consecutive patients with severe OSAS (apnea-hypopnea index [AHI] 52.8+/-14.9 events/hr) with multilevel upper airway obstruction who refused treatment with continuous positive airway pressure underwent UPPP plus TBS with the Repose system. All patients were evaluated before surgery by clinical history, Epworth Sleepiness Scale (ESS), fiberoptic nasopharyngoscopy with Müller maneuver, and nocturnal polysomnography (PSG). After 3 years of surgery, all patients were re-evaluated at the clinic and had ESS test and full PSG. Surgical success was defined when the ESS dropped bellow 11, and the AHI decreased below the threshold of 20 events per hour of sleep and at least 50% from the preoperative value RESULTS: There were 42 (78%) patients in which the AHI score decreased more than 50%, the AHI was lower than 20 events/hr in the PSG, and the ESS was lower than 11 after 3-years of follow-up (surgical success index). Logistic regression analysis demonstrated that body mass index at baseline was the only variable with significant statistical power to predict surgical success (odds ratio 0.85; 0.73-0.95, 95% confidence interval, P<.01) CONCLUSION: When associated with UPPP, the TBS technique performed with the Repose system demonstrates a surgical success of up to 78% for patients with severe OSA who refused nasal continuous positive airway pressure.     

UPPP治疗OSAS术后短期主客观疗效评价

对接受悬雍垂腭咽成形术的５２例阻塞性睡眠呼吸暂停综合征的患者术后随诊３－６个月并对其行术前术后主客观疗效评价。结果表明鼻声改善满意者３４例；白天嗜睡及晨起头痛改善者４６例。     

悬雍垂腭咽成形术后持续正压通气治疗

观察悬雍垂腭咽成形术（ｕｖｕｌｏｐｌａｔｏｐｈａｒｙｇｏｐｌａｓｔｙ,ＵＰＰＰ）后疗效不佳的阻塞性睡眠呼吸暂停综合征（ｏｂｓｔｒｕｃｔｉｖｅｓｌｅｅｐａｐｎｅａｓｙｎｄｒｏｍｅ,ＯＳＡＳ）患者为手术组行持续正压通气（ｃｏｎｔｎｕｏｕｓｐｏｓｉｔｉｖｅａｉｒｗａｙｐｒｅｓｓｕｒｅ,ＣＰＡＰ）治疗的效果。方法１５例ＵＰＰＰ术后呼吸暂停低通气指数（ａｐｎｏｅａ－ｈｙｐｏｎｏｅａｉｎｄｅｘ,ＡＨＩ）仍大于     

UPPP combined with radiofrequency thermotherapy of the tongue base for the treatment of obstructive sleep apnea syndrome

We investigated the outcome of uvulopalatopharyngoplasty (UPPP) combined with radiofrequency thermotherapy of the tongue base (RFTB) in patients with obstructive sleep apnea syndrome (OSAS) with both palatal and retroglossal obstruction, and we compared these results with the results of single level surgery (UPPP). A retrospective cohort study was performed in patients with mild to severe OSAS who underwent UPPP with or without RFTB. Seventy-five patients with both palatal and retroglossal obstruction underwent UPPP, 38 patients without RFTB (group 1) and 37 patients with RFTB (group 2). The outcome of the surgery was measured by both objective success (defined as a reduction of AHI >50% and AHI below 20) and subjective improvement. In group 1 the overall success rate was 42%, and in group 2 49%. Other polysomnographic values (AI, DI, mean SaO2) improved after surgery (not significant). No serious adverse events occurred. Surgical treatment of combined palatal and retroglossal obstruction remains a challenge. Adding RFTB to UPPP results in a mild improvement compared to UPPP alone. Although the addition of RFTB to UPPP seems to result in only a limited improvement, there is no major downside to it. RFTB is well tolerated and safe.     

Outcome comparison of two methods of pharyngeal cavity reconstruction in uvulopalatopharyngoplasty

Conclusions: The efficacy of uvulopalatopharyngoplasty (UPPP) can be achieved without application of an apposition suture of the palatopharyngeal arch and the palatoglossal arch. Objective: To compare the outcomes of two different methods of pharyngeal cavity reconstruction in UPPP. Methods: Forty-eight patients with obstructive sleep apnoea syndrome (OSAS) underwent UPPP (uvula-preserving). A classical pharyngeal cavity reconstruction was performed in 24 patients in group one, with plastic suture of the inferior nasopharynx and exposure of the tonsillar fossa in 24 patients in group two. The parameters evaluated were the subjective symptom score, the Epworth Sleepiness Scale (ESS), and polysomnography result. The mean operating times and complications of the post-operative pharyngeal cavity were investigated. Results: No significant difference was observed in surgical success (p?=?0.54), subjective syndromes (snoring, sleep apnoea, morning headache, daytime sleepiness) (p?=?0.16, 0.36, 0.79 and 0.52), ESS (p?=?0.41), apnoea-hypopnoea index (AHI) (p?=?0.32), and minimum SaO₂ (p?=?0.13) between the two groups. In group one, the mean operating time was 54.72?±?6.52?min, 11 suture dehiscence (45.8%), and five scar hypertrophy of the pharyngeal wall (20.8%) were observed post-operatively; while in group two was 38.78?±?5.75?min, no suture dehiscence resulting from suture cutting of tissue, three scar hypertrophy were observed (12.5%).     

OSAS患者咽腔阻塞定位预测UPPP疗效

目的：术前用纤维鼻咽镜判断阻塞性睡眠呼吸暂停综合征（OSAS）患者咽腔阻塞部位，提高悬雍垂腭咽成形术（UPPP）疗效。方法：28例OSAS患者术前分别做Muller检查和睡眠状态咽腔观察，根据阻塞部位的不同，将其分为口咽阻塞型、口咽如下咽阻塞型两种类型。通过术前、术后多导睡眠描记图变化比较两型患者的客观疗效。结果：（1）Muller检查方法：口咽阻塞型的AHI从52．7，最低血氧饱和度（SaO2)由63．1％升至80．0％（均P＜0．01）；口咽加下咽阻塞型的AHI从54．7降至38．6，最低SaO2由60．7％（均P＞0．05）。两型手术有效率分别为68．4％和22．2％（P＜0．01）。（2）睡眠咽腔观察法：口咽阻塞型的AHI从48．6降至18．7，最低SaO2由65％升至80％（均P＜0．01）；口咽加下咽阻塞型的AHI从5降至34（P＜0．01），最低SaO2由59％升至71％（P＜0．05）。两型手术有效率分别为73．3％和30．8％（P＜0．05）。结论：OSAS患者术前咽腔阻塞定位分析有助于改善UPPPP手术疗效。     

Faringoplastia de reposición modificada para el tratamiento del SAHS: cómo lo hacemos y nuestros resultados

Introduction and purposesThe relevance of the lateral pharyngeal walls in the collapse of the upper airway in obstructive sleep apnea patients has been revealed in the last 20 years. New surgical techniques that address this collapse have been published. The aim of this study is to show the technique that we are currently using to treat the collapse and its results.Materials and methodsThis is a retrospective study of surgically treated OSAS patients who did not tolerate conventional positive airway pressure (CPAP) or for whom it was not indicated. After a complete physical examination either awake or under drug-induced sleep endoscopy, tonsillectomy with reposition pharyngoplasty was performed using barbed bidirectional suture and removing the supratonsillar fat. Three to 6 months after surgery the subjective parameters were evaluated and a sleep study was performed.ResultsTwenty-six patients were enrolled with a significative decrease in the AHI and also significative improvement in all the rest parameters studied. In 65.4% of the patients the AHI decreased 50% and was lower than 20/h, in 42.3% postoperative AHI was lower than 10/h. The most frequent complication was the partial extrusion of the suture.ConclusionsThis surgical procedure obtains statistically significant results in objective and subjective parameters of sleep apnoea without major associated complications.     

Diagnostic work-up of socially unacceptable snoring

In the diagnostic work-up of socially unacceptable snoring (SUS) with or without a history suggestive of obstructive sleep apnoea syndrome (OSAS), information on the severity of the pathology as well as on local and general causative factors is needed. In part I of this study, we reported on the findings recorded in 380 patients by means of sleep registration. In this part, our emphasis is on analysis of the local contributing factors. In 340 of the 380 patients sleep endoscopy was performed to establish the level(s) of obstruction as accurately as possible. Sleep endoscopy was performed following artificial induction of sleep with midazolam and consisted in endoscopy and flexible nasopharyngoscopy and laryngoscopy. Although obstruction at the oropharyngeal level was often present, obstructions at lower levels or at multiple levels were also frequently found. In many cases sleep endoscopy showed obstruction at different level(s) than had been suspected on the grounds of ear nose and throat (ENT) investigation only. An obstruction at only one level was recorded in 35% of the patients (119), while 65% of patients (221) had multiple-level obstruction. The level(s) of obstruction could be well established by sleep endoscopy. We conclude that a diagnostic work-up involving a combination of sleep registration, sleep endoscopy, and analysis of general factors is worthwhile. Combining the results of these tests makes it possible to give individually tailored advice on treatment.     

One stage multilevel surgery (uvulopalatopharyngoplasty,hyoid suspension,radiofrequent ablation of the tongue base with/without genioglossus advancement), in obstructive sleep apnea syndrome

We evaluated the surgical results of a one tempo multilevel surgical approach of the upper airway to treat patients with obstructive sleep apnea syndrome (OSAS) in a prospective case series. Twenty-two patients with OSAS and obstruction at both palatinal and tongue base level, as assessed by sleep endoscopy, underwent UPPP, RFTB, HS with or without GA in one operative session. The mean apnea hypopnea index (AHI) decreased from 48.7 (range 17.4–100.9) to 28.8 (P < 0.0001). The success rate (AHI <20 and >50% reduction in AHI) was 45%, the response rate (reduction in AHI of 20–50%) was 27%. The overall response rate was 72%. The success rates of patients with an AHI <55 and >55 were 56 and 0%, respectively. The overall response rate of patients with an AHI <55 was 78% and >55 was 50%. Improvement of desaturation index was significant from 31.9 to 17.6 (P < 0.0001). Visual analogue scales for snoring and hypersomnolence and the Epworth Sleepiness Scores showed significant improvements too (all P < 0.0001). There was no difference in objective and subjective outcomes between the group with and without GA. This study demonstrates that one stage multilevel surgery, in which genioglossus advancement is not of additional value, is a valuable addition to the therapeutic armentarium and can be considered a viable alternative, objective as well as subjective, to NCPAP or as primary treatment in well selected patients with moderate to severe OSAS with an AHI <55.     

Clinical and functional analysis of long-term results of uvulopalatopharyngoplasty

In order to evaluate the clinical and functional effectiveness of uvulopalatopharyngoplasty (UPPP) in chronic roncopathy, we studied the subjective improvement of operated patients and compared to pulsioximetry findings before and after surgery. A follow-up was made on 72 patients entitled of chronic roncopathy--51 with obstructive sleep apnea syndrome (OSAS) and 21 with simple snoring-, for a mean period of time of 41 months. Preoperatory study included on ENT exploration, fibre optic endoscopy, Müller maneuver, pharyngeal CT, value of daytime sleepiness with Epworth's scale, espirometry and pulsioximetry, and the postoperatory study included of pulsioximetry and a health questionnaire over snoring and daytime sleepiness. Snoring improved or disappeared in 13 of 21 patients (61.8%), and daytime sleepiness did it in 26 of 39 (66.6%). Therapeutic failure in snoring was mainly due to an increase in the body mass index. After UPPP in OSAS, only 21 patients (41.1%) showed all positive response criteria (decrease into ODI > or = 50% or in absolute values < 6, CT 90% < 1%, and SaO2 Min > or = 85%). UPPP failed in long term evaluation in the rest of individuals. Patient selection is mandatory to optimize clinical response of UPPP for snoring, without OSAS success depends on body mass index, respiratory disturbances ratios and the eventual presence of another upper airways collapses below velopharyngeal segment.     

¿Es necesario repetir el estudio de sueño de control a todos los niños con SAHOS moderado-severo tras la cirugía?

Hypertrophy of adenotonsillar tissue is the most common cause of OSAS in otherwise healthy children, and therefore adenotonsillectomy is the first line treatment. Scientific societies recommend nocturnal follow-up PSG to assess for residual OSAS in children with preoperative evidence for moderate to severe OSAS, obesity, craniofacial anomalies that obstruct the upper airway and neurological disorders, based on the increasing trend of publications reporting residual OSAS after adenotonsillectomy. Follow-up PSG values in children with a pre-operative diagnosis of severe OSAS were analysed retrospectively, and compared to the parents’ impression after ENT surgery. The study population included 41 healthy children with severe OSAS and adenotonsillar surgery. The percentage of children with normal PSG parameters (AHI < 2/h) after adenotonsillectomy was 80.48%. A very good correlation was observed between the parents’ perception after treatment and the follow-up PSG parameters, specifically when the parents perceived that the patient had shown «complete resolution» (no snoring or apnoea), 90.62% of the children had an AHI < 2/h in the follow-up PSG, the maximum residual AHI being 2.6/h. In healthy children with no underlying pathology, the information provided by the parents on clinical progression after surgery could be useful and might enable the selection of those patients who require a follow-up study, avoiding overload in sleep units.     

快速眼动期睡眠相关氧减程度与改良悬雍 垂腭咽成形术疗效的相关分析

目的分析阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apnea hypopnea syndrome, OSAHS)患者快速眼动期（rapid eye movement, REM）睡眠相关氧减程度与保留悬雍垂的改良悬雍垂腭咽成形术(han uvulopalatopharyngoplasty, H UPPP)疗效相关情况。方法回顾性分析我院51例行H UPPP的OSAHS患者多导睡眠监测图(polysomnography, PSG)结果。所有患者均因上气道存在解剖狭窄,经评估后按治疗方案接受手术。术后6个月至1年随访PSG,按照指南［1］,分为有效组和无效组。用SPSS 13.0统计软件,比较分析患者术前REM睡眠和非快速眼动期(no rapid eye movement, NREM)睡眠最低动脉血氧饱和度(LSaO2)、呼吸暂停低通气指数(AHI)以及血氧低于90、85、65时间(CT90、CT85、CT65)分别所占总睡眠时间的比例等参数的差异。结果21例术后AHI较术前下降≥50%以上,有效率为41.2%。在REM期最低血氧高于NREM期的患者中,有效率是83.3%(15/18);而在REM期最低血氧低于或等于NREM期的患者中为18.2%（6/33）。结论AHI较低的患者易获得良好临床疗效。和NREM期相比,同一患者REM期的氧减时间延长、以及该期呼吸暂停继发氧减程度严重者,术后更加难获得治愈。     

睡眠呼吸暂停综合征术前经鼻正压通气的治疗

OBJECTIVE: Preoperative nasal continuous positive airway pressure(NCPAP) treatment was used as a substitute for protective tracheostomy before UPPP surgery in 42 patients with severe obstructive sleep apnea syndrome(OSAS) from 1994 to 1996. METHODS: Fifty-two patients operated on three years before this period served as control group. All cases were diagnosed as severe OSAS by polysomnography (PSC). RESULTS: There were no statistical difference in main parameters between two groups. Seven cases in the control group underwent protective tracheostomy whose apnea and hypopnea index(AHI) was 28.4-83.5 and lowest saturation oxygen (SaO2) were 7%-32%. One patient underwent emergency tracheostomy due to life-threatening situation during uvulopalatopharyngoplasty (UPPP). There were 9 similarly severe cases who did not undergo protective tracheostomy in NCPAP treatment group. All patients underwent preoperative 5-20 day NCPAP treatment in treatment group. The average positive pressure was 1.16 kPa(11.85 cmH2O). There were significant difference in main parameters between the two groups. The AHI, SaO2 and sleep structure were evidently improved. UPPP was safely performed without protective tracheostomy and any complications in all patients with NCPAP treatment. CONCLUSION: This result implys that NCPAP treatment could be used as a substitute for protective tracheostomy before UPPP in severe OSAS.     

Laser-assisted uvulopalatoplasty for the treatment of snoring and mild obstructive sleep apnea syndrome

OBJECTIVE: To determine the efficacy of the laser-assisted uvulopalatoplasty (LAUP) procedure on snoring and Apnea-Hypopnea-Index (AHI) improvement in patients with snoring and mild obstructive sleep apnea syndrome (OSAS). STUDY DESIGN: Prospective, nonrandomized, nonblinded assessment of outcomes after LAUP in patients suffering from benign habitual snoring and/or mild OSAS. METHODS: Fifty-nine patients with habitual snoring and 25 patients with mild OSAS underwent LAUP (6 of them underwent simultaneous classic tonsillectomy and 20 carbon-dioxide laser tonsillotomy). All patients and their bed partners completed pre- and post-treatment questionnaires ranking snoring, whereas the patients with mild OSAS underwent postoperative polysomnography (PSG). RESULTS: During a 6-month to 5-year follow-up (mean 40 months), 91.5% of the patients with habitual snoring reported significant short-term improvement based on post-treatment questionnaires, whereas 79.7% reported long-term subjective improvement. Nineteen of 25 patients (76%) with mild OSAS reported significant improvement of snoring based on posttreatment questionnaires. According to the postoperative PSG, only 2% showed a worse AHI, whereas 60% showed reduction of the AHI to < or = 5. Eight patients (32%) showed little or no improvement of AHI. CONCLUSIONS: LAUP, in combination with carbon-dioxide laser tonsillotomy in some cases, is a safe, cost-effective, outpatient procedure for the treatment of many cases of habitual snoring and mild OSAS when preceded by careful selection of the candidates.     

阻塞性睡眠呼吸暂停低通气综合征患者悬雍垂腭咽成形术后多导睡眠监测观察指标的比较

目的：探讨阻塞性睡眠呼吸暂停低通气综合征（0sAHs）患者悬雍垂腭咽成形术（UPPP）后PSG观察指标的改变。方法：对行UPPP手术的20例OSAHS患者于手术前后分别进行PSG监测。结果：①与术前比较，UPPP术后PSG监测观察指标中睡眠呼吸暂停低通气指数（AHI）（P〈0．01）、最低SaO2（P〈0．01）、平均SaO2（P〈0．01）、平均睡眠呼吸暂停低通气时间（P〈0．05），均有不同程度的改善；②UPPP手术后，PSG监测观察指标睡眠时相构成比的改变主要在与从S1期转入到S2期；③PSG监测观察指标中，AHI与最低SaO2、平均SaO2、平均最长睡眠呼吸暂停低通气时间之间均具有相关性，但是前两者之间的相关性更有统计学意义，且手术前后AHI的减小值与最低SaO2的升高值之间同样具有相关性。结论：对于患者病情轻重以及手术疗效的评价，SaO2是较睡眠呼吸暂停低通气时间更为敏感的指标，UPPP术后睡眠构成比的变化主要在于从S1期转入到S2期。     

改良悬雍垂腭咽成形术疗效的临床观察

目的:改进经典悬雍垂腭咽成形术(UPPP) 的手术方法，探讨保留悬雍垂的可行性和必要性。方法：全身麻醉下行保留悬雍垂的腭咽成形术，术中完整保留悬雍垂，切除腭帆间隙脂肪，提高软腭最高切点均在2.5?cm 以上。结果：完整保留的悬雍垂术后2周开始回缩，3个月后咽腔接近年轻状态，无腭咽关闭不全及再狭窄。主观问卷调查和PSG客观检测有效率为100%。结论：保留悬雍垂可提高软腭最高切点开大咽腔，扩大软腭鼻咽面和咽后壁间距并防止腭咽关闭不全，可明显提高UPPP手术疗效。     

Effects of uvulopalatopharyngoplasty in adult patients with obstructive sleep apnea syndrome

We performed uvulopalatopharyngoplasty (UPPP) in 51 adult patients with obstructive sleep apnea syndrome (OSAS). After UPPP, there were statistically significant improvements in apnea-hypopnea index (AHI), the lowest value of oxygen saturation during sleep and total time of apnic episodes. 28 patients (54.9%) were good responders who represented more than 50% improvements in their AHI. Poor responders tended to be more severe and older than good responders. After cephalometric analysis, poor responders were revealed to show significantly poor mandibular prognatism and also lower positioned hyoid bone than good responders.