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LETTERS: D Whinney, P Williamson, and P Bicknell Snoring and sleep apnoea BMJ 1994; 309: 477a [Full text]

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Uvulopalatopharyngoplasty and OSA

Murat Enoz   (19 March 2005)

CPAP therapy

Murat Enoz   (1 April 2005)

Uvulopalatopharyngoplasty and OSA 19 March 2005
Murat Enoz, instructor in Department of Otolaryngology, Head&Neck Surgery Istanbul University, School of Medicine Turkey Send response to journal: Re: Uvulopalatopharyngoplasty and OSA	Dear Editor Obstructive sleep apnea syndrome (OSAS) is an important public health problem [1, 2]. The typical symptoms during sleep are apnea, snoring, dyspnea, and choking episodes. Once apnea or hypopnea develops, recurrent arousal causes excessive sleepiness and cognitive decreases during the daytime. The combination of acute and chronic haemondynamic effects in obstructive sleep apnea have been associated with increased risk of myocardial infarction, cerebrovascular accidents, hypertension, and congestive heart failure. It is necessary to provide appropriate treatment for Obstructive sleep apnea syndrome(OSAS). Although there is no universally accepted definition of Obstructive Sleep Apnea Syndrome, it is usually defined as an apneic index (AI). Obstructive sleep apnea is divided has been divided into three severity of levels based on the RDI. The apneic index is the number of apneic episodes during 1 h of sleep. Individuals with an respiratory disturbance index (RDI) greater than 5 were defined as having OSA. An RDI of 5每20 indicated mild OSA, 21每40 moderate OSA and over 40 severe OSA. Most health care providers offer nasal continuous positive airway pressure (CPAP) or oropharyngeal surgery for these patients, but neither approach has proved to be a panacea. Although the use of nasal CPAP after pressure titration in the sleep laboratory offers effective reversal of the obstructive apneas, the short- and long-term compliance becomes an issue in more than 50% of patients [3]. Because it is relatively noninvasive, most practitioners offer CPAP as the first line of treatment. Oropharyngeal surgery is a commonly performed alternative to nasal CPAP for OSA. The most widely performed procedure, uvulopalatopharyngoplasty (UPPP), has a limited cure rate, particularly for patients who have had prior tonsillectomy or those with severe sleep apnea. In addition, cure rates tend to drop as duration from surgery increases[4]. Historically, the focus of surgery has been on the oropharyngeal level, but recently, the hypopharyngeal space has been found to be another important area of obstruction. Traditionally, maxillary mandibular advancement has been used to expand this level of airway obstruction. Given the morbidity of such a procedure, other operations have been proposed, including genioglossus advancement, hyoid advancement, and base of tongue reduction using radiofrequency energy, to increase cure rates [5-8]. Although nasal surgery clearly improves the efficacy of nasal CPAP, its role in the etiology of OSA remains unclear. Verse et al. [9] reported that patients with OSA and nasal obstruction are ※cured§ in only about 16% of cases after nasal surgery alone, concluding that nasal obstruction is not a major contributor to OSA. The multiplicity of surgical modalities described for OSA suggests that no clear surgical approach has been widely accepted for the management of this disease. Most of the studies on various surgical approaches to OSA focus on a single surgical modality. Although this concept is helpful in reporting a procedure＊s efficacy, most studies assume that the patients with OSA are a homogeneous group with the same type of pathology. We believe that OSA is a multilevel, multifactorial disease process creating a very heterogeneous patient population. To improve the surgical cure rates for OSA, the entire upper airway must be brought under inspection, and each level of obstruction identified needs to be addressed. The treatment plan should potentially include nasal, oropharyngeal/palatal, and hypopharyngeal measures to improve the airway. The main sites of obstruction are the nose, the retropalatal and the retroglossal regions. The airway is a collapsible tube. Changes in the physical characteristics in one area of the tube may generate altered airflow velocities, transmural pressure, and intramural pressure that may cause anatomical collapse in an area that is initially structurally sound [10]. Consequently, uvulopalatopharyngoplasty (UPPP) that consists of removal of the palatine tonsil, uvula, a portion of the soft palate, and the lateral pharyngeal wall is the most common surgical procedure for the treatment of OSA [11]. Although subjective improvement of symptoms including excessive daytime sleepiness and snoring have been acceptable[12], the response rate on objective assessment based on polysomnographic (PSG) results has been no greater than 50% [13] . To improve the response rate, many modifications have been attempted; however, the results have been mixed [14, 15, 16, 17, 18]. UPPP was first described by Ikematsu in 1964 for treatment of habitual snoring [19]. Fujita et al modified the technique to increase the oropharyngeal airway space by excising the uvula and 8 to 15 mm of the posterior aspect of the soft palate, as well as the redundant lateral pharyngeal wall mucosa [20]. Although UPPP has resulted in symptomatic improvement from habitual snoring in up to 90% of cases, only 41% to 66% of patients see improvement or elimination of OSA and results may worsen over time [22, 23, 24, 25]. The reason UPPP can fail is that the procedure addresses the obstruction at the soft palate area only, without improving the airway at the base of the tongue (hypopharyngeal area) or nasal cavity. In addition, scar contracture at the posterior border of the soft palate can create a ※curtain§ effect, pulling the soft palate downward against the tongue and causing significant transverse narrowing between the posterior faucial pillars, further contributing to OSA. Complications from UPPP include nasal regurgitation, velopharyngeal incompetence, hypernasal speech, palatal stenosis, and residual OSA. The use of a surgical approach to OSA that uses careful history and examination to identify levels of obstruction followed by systematic surgical intervention at each site is effective for the majority of patients. We are using the UPPP for succesfully treatment of the mild OSA patients. We are using indirect laryngoscopy, fibro-optic endoscopy, and cephalometry〞as easy, inexpensive tools〞for assessment of the retroglossal region in the pre-surgical evaluation of OSA patients. If the patients have an obstruction site beside of retropalatal or palatal region we planned the other surgical technics or CPAP therapy. Sincerely Dr. Murat Enoz References 1- C. Guilleminault, A. Tilkian, W.C. Dement, The sleep apnea syndrome, Annu. Rev. Med. 27 (1976) 465每 484. 2- T. Young, P.E. Peppard, D.J. Gottieb, Epidemology of obstructive sleep apnea: a population health perspective, Am. J. Respir. Crit. Care Med. 165 (2002) 1217每 1239. 3- Practice parameters for the treatment of obstructive sleep apnea in adults:the efficacy of surgical modifications of the upper airway. An American Sleep Disorders Association report. Sleep 1996;19:152每5. 4- Sher AE, Schechtman KB, Piccirillo JF. The efficacy of surgical modifications of upper airway in adults with obstructive sleep apnea syndrome. Sleep 1996;19:156- 77. 5- Riley RW, Powell NB, Li KK, et al. Surgery and obstructive sleep apnea: long-term clinical outcomes. Otolaryngol Head Neck Surg 2000;122:415-21. 6- Vilaseca I, Morello A, Montserrat JM, et al. Usefulness of uvulopalatopharyngoplasty with genioglossus and hyoid advancement in the treatment of obstructive sleep apnea. Arch Otolaryngol Head Neck Surg 2002;128:435- 40. 7- Finkelstein Y, Stein G, Ophir D, et al. Laser-assisted uvulopalatoplasty for the management of obstructive sleep apnea. Arch Otolaryngol Head Neck Surg 2002; 128:429-34. 8- Powell NB, Zonato AI, Weaver EM, et al. Radiofrequency treatment of turbinate hypertrophy in subjects using continuous airway pressure: a randomized, doubleblind, placebo-controlled clinical pilot trial. Laryngoscope 2001;111:1783-90. 9- Verse T, Maurer JT, Pirsig W. Effect of nasal surgery on sleep- related breathing disorders. Laryngoscope 2002; 112:64-8. 10- R.J. Troell, R.W. Riley, N.B. Powell, et al., Surgical management of the hypopharyngeal airway in sleep disorder breathing, in: J. Coleman (Ed.), Sleep Apnea Pt 1, Otolaryngol. Clin. North Am., vol. 31(6), Saunders, Philadelphia, 1998, pp. 979每 1012. 11- Shepard JW Jr, Olsen KD. Uvulopalatopharyngoplasty for treatment of obstructive sleep apnea. Mayo Clin Proc. 1990 Sep;65(9):1260-7. 12- Friberg D, Carlsson-Nordlander B, Larsson H, Svanborg E. UPPP for habitual snoring: a 5-year follow-up with respiratory sleep recordings. Laryngoscope. 1995 May;105(5 Pt 1):519-22. 13- Sher AE, Schechtman KB, Piccirillo JF. The efficacy of surgical modifications of the upper airway in adults with obstructive sleep apnea syndrome. Sleep. 1996 Feb;19(2):156-77. 14- O'Leary MJ, Millman RP. Technical modifications of uvulopalatopharyngoplasty: the role of the palatopharyngeus. Laryngoscope. 1991 Dec;101(12 Pt 1):1332-5. 15- Zohar Y, Finkelstein Y, Strauss M, Shvilli Y. Surgical treatment of obstructive sleep apnea. Technical variations. Arch Otolaryngol Head Neck Surg. 1993 Sep;119(9):1023-9. 16- Myatt HM, Croft CB, Kotecha BT, Ruddock J, Mackay IS, Simonds AK. A three-centre prospective pilot study to elucidate the effect of uvulopalatopharyngoplasty on patients with mild obstructive sleep apnoea due to velopharyngeal obstruction. Clin Otolaryngol. 1999 Apr;24(2):95- 103. 17- Fairbanks DN. Operative techniques of uvulopalatopharyngoplasty. Ear Nose Throat J. 1999 Nov;78(11):846-50. 18- Bresalier HJ, Brandes W. Uvulopalatopharyngoplasty: prevention of complications with the imbrication technique. Ear Nose Throat J. 1999 Dec;78(12):920-2. 19- Ikematsu T. Study of snoring, 4th report: therapy. Journal of Japanese Otorhinolaryngology 1964;64:434-435. 20- Fujita S, Conway W, Zorick F, Roth T. Surgical correction of anatomic abnormalities in obstructive sleep apnea syndrome: uvulopalatopharyngoplasty. Otolaryngol Head Neck Surg 1981;89:923-934. 21- Simmons FB, Guilleminault C, Silvestri R. Snoring, and some obstructive sleep apnea, can be cured by oropharyngeal surgery. Arch Otolaryngol 1983;109:503-507. 22- Simmons FB, Guilleminault C, Miles LE. The palatopharyngoplasty operation for snoring and sleep apnea: an interim report. Otolaryngol Head Neck Surg 1984;92:375-380. 23- Katsantonis GP, Schweitzer PK, Branham GH, Chambers G, Walsh JK. Management of obstructive sleep apnea: comparison of various treatment modalities. Laryngoscope 1988;98:304-309 24- Guilleminault C, Hayes B, Smith L, Simmons FB. Palatopharyngoplasty and obstructive sleep apnea syndrome. Bull Eur Physiopathol Res 1983;19:595-599. 25- Ryan CF, Love LL. Unpredictable results after laser assisted uvuloplasty in the treatment of obstructive sleep apnea. Thorax 2000;55:399-404. Competing interests: Uvulopalatopharyngoplasty is useful treatment method for selected patient with OSA
CPAP therapy 1 April 2005
Murat Enoz, Department of Otolaryngology, Head&Neck Surgery Istanbul University, School of Medicine Turkey Send response to journal: Re: CPAP therapy	Dear Editor, Nasal CPAP therapy for OSA was first reported in 1981[1]. It treats apneas-hypopneas by providing air under positive pressure through a nasal or facial mask, thus creating a pneumatic splint in the pharynx, which prevents collapse of the pharyngeal airway. In one early study covert compliance monitoring revealed acceptable compliance rates to be as low as 46%[2]. Compliance rates of 65% to 90% have been reported in more recent literature. Compliance is likely higher if a patient has significant daytime somnolence before initiation of therapy and perceives subsequent improvement with CPAP therapy. Aggressive patient education and support from health care providers also improve compliance with treatment. Pepin et al.[3] recently reported a compliance rate of 80% in response to augmented support for CPAP-treated patients with OSA. Side effects of CPAP Common side effects of CPAP include rhinorrhea, nasal congestion and dryness, mask discomfort, conjunctivitis from air leak, skin abrasions, claustrophobia, irritation from device noise, difficulty exhaling, aerophagy, chest discomfort, and bed-partner intolerance. Nasal symptoms reported by Pepin et al[4] in association with CPAP therapy included nasal congestion (25%), rhinorrhea-sneezing (35%), and nasal dryness (65%). Similar symptoms were reported by Brander et al [5] and Hoffstein and Szali.[6] The addition of heated humidification to CPAP and the administration of nasal steroids are commonly used to combat these symptoms. Rakotonanahary et al.[7] demonstrated that the addition of humidification to CPAP increased compliance and device use. Patients who cannot tolerate CPAP because of discomfort from exhaling against high pressure can be treated with the addition of a pressure "ramp" or the use of bilevel positive-pressure therapy. Autotitrating CPAP was also introduced in the last decade with the premise that by continuously adjusting pressure to meet the patient's variable needs, the overall mean airway pressure will be reduced. Improvements in CPAP technology have addressed patient complaints about the machine and mask, but the level of compliance with CPAP is still a clinically significant problem. Compliance appears to depend on the severity of the disease as well as on the initial inpatient management session. The first few weeks are critical to compliance[8-10]. Sincerely Murat Enoz Competing interests: CPAP remains the treatment of choice for Obstructive Sleep Apnea Syndrome (OSAS), but compliance with CPAP is poor.