A surgical response to upper airway (UA) surgery for obstructive sleep apnea (OSA) depends on adequate correction of collapsible sites in the UA. This pilot study aimed to examine the surgical response to UA surgery directed by drug-induced sleep computed tomography (DI-SCT) for OSA.
Study Design
Prospective case series.
Setting
Tertiary referral center.
Subjects and Methods
This study recruited 29 OSA patients (median age, 41 years; median body mass index, 26.9 kg/m2) who underwent single-stage DI-SCT-directed UA surgery between October 2012 and September 2014. DI-SCT was performed with propofol for light sedation with a bispectral monitor before and after UA surgery. Nonresponders were defined as those with a reduction in apnea-hypopnea index <50% after 6 months following UA surgery.
Results
DI-SCT showed that 28 (97%) patients had collapses at multiple sites, all of whom underwent multilevel UA surgery accordingly. The apnea-hypopnea index decreased from 53.6 to 26.8 (P < .001). There were 18 (62%) nonresponders and 11 (38%) responders. Multiple-site collapses could not predict surgical response (P > .99). The nonresponders had significant improvements in velopharyngeal, oropharyngeal lateral wall, and tongue collapses (all P < .05), whereas the responders had significant improvements in velopharyngeal and oropharyngeal lateral wall collapses (both P ≤ .05).
Conclusion
Despite multilevel OSA surgery, residual UA obstruction in nonresponders likely occurs due to multiple mechanisms. DI-SCT may help to elucidate the reasons for a nonresponse.
KapurVKAuckleyDHChowdhuriSet al. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017;13:479-504.
2.
JennumPTonnesenPIbsenRet al. Obstructive sleep apnea: effect of comorbidities and positive airway pressure on all-cause mortality. Sleep Med. 2017;36:62-66.
3.
KushidaCALittnerMRHirshkowitzMet al. Practice parameters for the use of continuous and bilevel positive airway pressure devices to treat adult patients with sleep-related breathing disorders. Sleep. 2006;29:375-380.
4.
NishihataYTakataYUsuiYet al. Continuous positive airway pressure treatment improves cardiovascular outcomes in elderly patients with cardiovascular disease and obstructive sleep apnea. Heart Vessels. 2015;30:61-69.
5.
Campos-RodriguezFMartinez-GarciaMAdelaCruz-MoronIet al. Cardiovascular mortality in women with obstructive sleep apnea with or without continuous positive airway pressure treatment: a cohort study. Ann Intern Med. 2012;156:115-122.
6.
MarinJMCarrizoSJVicenteEet al. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005;365:1046-1053.
7.
AbuzaidASAl AshryHSElbadawiAet al. Meta-analysis of cardiovascular outcomes with continuous positive airway pressure therapy in patients with obstructive sleep apnea. Am J Cardiol. 2017;120:693-699.
8.
ChenSYCherngYGLeeFPet al. Risk of cerebrovascular diseases after uvulopalatopharyngoplasty in patients with obstructive sleep apnea: a nationwide cohort study. Medicine (Baltimore). 2015;94:e1791.
9.
KezirianEJGoldbergAN.Hypopharyngeal surgery in obstructive sleep apnea: an evidence-based medicine review. Arch Otolaryngol Head Neck Surg. 2006;132:206-213.
10.
LiHYLeeLAKezirianEJ.Efficacy of coblation endoscopic lingual lightening in multilevel surgery for obstructive sleep apnea. JAMA Otolaryngol Head Neck Surg. 2016;142:438-443.
11.
CaplesSMRowleyJAPrinsellJRet al. Surgical modifications of the upper airway for obstructive sleep apnea in adults: a systematic review and meta-analysis. Sleep. 2010;33:1396-1407.
12.
FriedmanMIbrahimHJosephNJ.Staging of obstructive sleep apnea/hypopnea syndrome: a guide to appropriate treatment. Laryngoscope. 2004;114:454-459.
13.
LiHYWangPCLeeLAet al. Prediction of uvulopalatopharyngoplasty outcome: anatomy-based staging system versus severity-based staging system. Sleep. 2006;29:1537-1541.
14.
ChenHCLeeLAHsinLJet al. Transverse retropalatal collapsibility is associated with obstructive sleep apnea severity and outcome of relocation pharyngoplasty. Otolaryngol Head Neck Surg. 2015;153:1056-1063.
15.
KimSJKimYSParkJHet al. Cephalometric predictors of therapeutic response to multilevel surgery in patients with obstructive sleep apnea. J Oral Maxillofac Surg. 2012;70:1404-1412.
16.
KimDKLeeWHLeeCHet al. Interrater reliability of sleep videofluoroscopy for airway obstruction in obstructive sleep apnea. Laryngoscope. 2014;124:1267-1271.
17.
LiHYLiKKChenNHet al. Three-dimensional computed tomography and polysomnography findings after extended uvulopalatal flap surgery for obstructive sleep apnea. Am J Otolaryngol. 2005;26:7-11.
18.
HuonLKLiuSYShihTTet al. Dynamic upper airway collapse observed from sleep MRI: BMI-matched severe and mild OSA patients. Eur Arch Otorhinolaryngol. 2016;273:4021-4026.
19.
De VitoACarrasco LlatasMVanniAet al. European position paper on drug-induced sedation endoscopy (DISE). Sleep Breath. 2014;18:453-465.
20.
LoYLNiYLWangTYet al. Bispectral index in evaluating effects of sedation depth on drug-induced sleep endoscopy. J Clin Sleep Med. 2015;11:1011-1020.
21.
LiHYLoYLWangCJet al. Dynamic drug-induced sleep computed tomography in adults with obstructive sleep apnea. Sci Rep. 2016;6:35849.
22.
BerryRBBudhirajaRGottliebDJet al. Rules for scoring respiratory events in sleep: update of the 2007 AASM manual for the scoring of sleep and associated events. Deliberations of the Sleep Apnea Definitions Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med. 2012;8:597-619.
23.
KezirianEJ. Nonresponders to pharyngeal surgery for obstructive sleep apnea: insights from drug-induced sleep endoscopy. Laryngoscope. 2011;121:1320-1326.
ZhangJLiYCaoXet al. The combination of anatomy and physiology in predicting the outcomes of velopharyngeal surgery. Laryngoscope. 2014;124:1718-1723.
26.
LiHYLeeLA. Relocation pharyngoplasty for obstructive sleep apnea. Laryngoscope. 2009;119:2472-2477.
27.
LeeLAHuangCGChenNHet al. Severity of obstructive sleep apnea syndrome and high-sensitivity C-reactive protein reduced after relocation pharyngoplasty. Otolaryngol Head Neck Surg. 2011;144:632-638.
28.
LiHYLeeLAWangPCet al. Can nasal surgery improve obstructive sleep apnea: subjective or objective?Am J Rhinol Allergy. 2009;23:e51-e55.
AmosJMDurrMLNardoneHCet al. Systematic review of drug-induced sleep endoscopy scoring systems. Otolaryngol Head Neck Surg. 2018;158:240-248.
31.
BlumenMBequignonEChabolleF. Drug-induced sleep endoscopy: a new gold standard for evaluating OSAS? Part II: results. Eur Ann Otorhinolaryngol Head Neck Dis. 2017;134:109-115.
32.
KotechaBDe VitoA. Drug induced sleep endoscopy: its role in evaluation of the upper airway obstruction and patient selection for surgical and non-surgical treatment. J Thorac Dis. 2018;10:S40-S47.
33.
LinHCFriedmanMChangHWet al. Z-palatopharyngoplasty combined with endoscopic coblator open tongue base resection for severe obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg. 2014;150:1078-1085.
34.
HandlerEHamansEGoldbergANet al. Tongue suspension: an evidence-based review and comparison to hypopharyngeal surgery for OSA. Laryngoscope. 2014;124:329-336.
35.
GillespieMBAyersCMNguyenSAet al. Outcomes of hyoid myotomy and suspension using a mandibular screw suspension system. Otolaryngol Head Neck Surg. 2011;144:225-229.
36.
StrolloPJJrSooseRJMaurerJTet al. Upper-airway stimulation for obstructive sleep apnea. N Engl J Med. 2014;370:139-149.
37.
GolzAGoldenbergDWestermanSTet al. Laser partial epiglottidectomy as a treatment for obstructive sleep apnea and laryngomalacia. Ann Oto Rhinol Laryngol. 2000;109:1140-1145.
38.
IwanagaKHasegawaKShibataNet al. Endoscopic examination of obstructive sleep apnea syndrome patients during drug-induced sleep. Acta Otolaryngol Suppl. 2003;(550):36-40.
39.
BerryRBMcNellisMIKouchiKet al. Upper airway anesthesia reduces phasic genioglossus activity during sleep apnea. Am J Respir Crit Care Med. 1997;156:127-132.
40.
KellnerPHerzogBPlosslSet al. Depth-dependent changes of obstruction patterns under increasing sedation during drug-induced sedation endoscopy: results of a German monocentric clinical trial. Sleep Breath. 2016;20:1035-1043.
41.
DahabaAAXueJXXuGXet al. Bilateral Bispectral Index (BIS)–Vista as a measure of physiologic sleep in sleep-deprived anesthesiologists. Minerva Anestesiol. 2011;77:388-393.
42.
HeiserCFthenakisPHapfelmeierAet al. Drug-induced sleep endoscopy with target-controlled infusion using propofol and monitored depth of sedation to determine treatment strategies in obstructive sleep apnea. Sleep Breath. 2017;21:737-744.
43.
GentaPRSandsSAButlerJPet al. Airflow shape is associated with the pharyngeal structure causing OSA. Chest. 2017;152:537-546.
44.
FullerJCBernsteinCHLevesquePAet al. Peak nasal inspiratory flow as an objective measure of nasal obstruction and functional septorhinoplasty outcomes. JAMA Facial Plast Surg. 2018;20:175-176.
45.
SoaresDSinaweHFolbeAJet al. Lateral oropharyngeal wall and supraglottic airway collapse associated with failure in sleep apnea surgery. Laryngoscope. 2012;122:473-479.
46.
GentaPRSchorrFEckertDJet al. Upper airway collapsibility is associated with obesity and hyoid position. Sleep. 2014;37:1673-1678.
47.
FriedmanMSchalchPJosephNJ. Palatal stiffening after failed uvulopalatopharyngoplasty with the Pillar Implant System. Laryngoscope. 2006;116:1956-1961.
48.
LiHYLiKKChenNHet al. Modified uvulopalatopharyngoplasty: the extended uvulopalatal flap. Am J Otolaryngol. 2003;24:311-316.
49.
PangKPWoodsonBT. Expansion sphincter pharyngoplasty: a new technique for the treatment of obstructive sleep apnea. Otolaryngol Head Neck Surg. 2007;137:110-114.
50.
ViciniCHendawyECampaniniAet al. Barbed reposition pharyngoplasty (BRP) for OSAHS: a feasibility, safety, efficacy and teachability pilot study. “We are on the giant’s shoulders.”Eur Arch Otorhinolaryngol. 2015;272:3065-3070.
