Lingual tonsillectomy using bipolar radiofrequency plasma excision.
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Catheter Ablation↗
Biomedical subjects
B Tucker Woodson
Publications and source records attributed to B Tucker Woodson.
Reduction of C-reactive protein with surgical treatment of obstructive sleep apnea hypopnea syndrome.
OBJECTIVES: To determine whether surgical treatment of obstructive sleep apnea/hypopnea syndrome (OSAHS) has an impact on C-reactive protein (CRP) level. STUDY DESIGN: Prospective study of 34 consecutive subjects undergoing surgical treatment for OSAHS. CRP levels were evaluated preoperatively and 2 months postoperatively. The most commonly performed procedure was uvulopalatopharyngoplasty (UPPP) combined with radiofrequency tongue base reduction. RESULTS: Seven patients were treated for mild OSAHS and 23 were treated for moderated/severe OSAHS; 18 of 23 patients with moderate/severe disease had relative elevation of preoperative CRP levels. Mean CRP level decreased from 0.33 mg/dL preoperatively to 0.16 mg/dL postoperatively (P=0.003). Even patients who did not achieve complete "cure" by classical polysomnography (PSG) criteria may benefit from lowered CRP levels. All patients, however did achieve reduction in apnea hypopnea index and improvement in clinical symptoms. CONCLUSIONS: Levels of CRP were elevated preoperatively but decreased after surgical treatment. Therefore, OSAHS surgical treatment may be useful in reduction of CRP levels in patients who will not or cannot accept nasal-CPAP therapy.
Adult↗
Polysomnography indexes are discordant with quality of life, symptoms, and reaction times in sleep apnea patients.
OBJECTIVE: We tested whether polysomnography (PSG) indexes were associated with sleepiness, quality of life, or reaction times at baseline and as outcome measures following surgical or sham treatment for patients with obstructive sleep apnea syndrome (OSAS). STUDY DESIGN AND METHODS: Mild-moderate OSAS subjects were measured before and 8 weeks after surgical or sham treatment in this prospective longitudinal study. Measures included standard PSG indexes, sleepiness, quality of life, and reaction times. Associations were examined with Spearman correlations and multivariate linear regression. RESULTS: Correlations between baseline PSG and non-PSG measures ranged from -0.22 to 0.25 (n, 87 subjects; mean correlation, 0.00 +/- 0.11), with one positive association significant of 56 tested (arousal index and SF36 Mental Component Summary, r, 0.25; P = 0.03). Correlations between change in PSG and non-PSG measures ranged from -0.37 to 0.35 (n, 54 subjects; mean correlation, -0.05 +/- 0.19), with no significant positive association of 56 tested. Regression analyses confirmed these results. CONCLUSIONS: PSG indexes are not consistently associated with sleepiness, quality of life, or reaction time, both at baseline and as outcome measures in patients with mild-moderate OSAS. PSG indexes may not quantify some important aspects of OSAS disease burden or treatment outcome. Clinically important outcomes should be measured directly. EBM RATING: A.
Adult↗
Multilevel temperature-controlled radiofrequency for obstructive sleep apnea: extended follow-up.
OBJECTIVE: To determine long-term effectiveness of multilevel (tongue and palate) temperature-controlled radiofrequency tissue ablation (TCRFTA) for patients with obstructive sleep apnea syndrome (OSAS). STUDY DESIGN AND SETTING: Prospective, 2-institution case series. Twenty-nine subjects with mild to moderate OSAS and who were at least 1 year from completion of multilevel TCRFTA were included, representing a subset of subjects who were enrolled in a previously published controlled trial. Exclusion criteria for this extended follow-up study included any additional treatment for OSAS after completion of TCRFTA. RESULTS: Median follow-up was 23 months. Daytime sleepiness and OSAS-related quality of life were significantly improved at extended follow-up (both P < 0.001). Median reaction time testing and apnea-hypopnea index (AHI) were also significantly improved at long-term follow-up (P = 0.03 and 0.01). Body mass index was unchanged (P = 0.94). CONCLUSIONS: Multilevel TCRFTA treatment of mild to moderate OSAS resulted in prolonged improvement in daytime somnolence, OSAS-related quality of life, psychomotor vigilance, and AHI in this group of subjects at extended follow-up.
Adult↗
Transpalatal advancement pharyngoplasty outcomes compared with uvulopalatopharygoplasty.
OBJECTIVE: Uvulopalatopharyngoplasty (UPPP) success rates in patients classified with Friedman stage 3 is reported as 8%. Surgical failure may result from persistent obstruction at the palate, which may be addressed by pharyngoplasty with palatal advancement (PA). The effectiveness of PA versus UPPP was evaluated by using polysomnographic outcomes in a retrospective cohort of patients classified with Friedman stage 3. METHODS: Surgical records were reviewed for PA (n = 47) and UPPP (n = 124). Clinical records were reviewed and reclassified by Friedman stage. Respiratory data were collected from overnight polysomnography. Statistical analysis was conducted of continuous variables (ANOVA), categorical variables (chi2), and adjusted odds ratios by using logistic regression. RESULTS: PA (n = 30) and UPPP (n = 44) did not differ in baseline apnea hypopnea index (AHI), age, or BMI. Both PA (48.3 +/- 24.6 to 19.8 +/- 16.8 events per hour, P < 0.000) and UPPP (47.9 +/- 30.0 to 30.9 +/- 24.2 events per hour, P < 0.000) improved with surgery. In the PA group, final AHI was lower (17.1 +/- 30.1 versus 28.5 +/- 25.6, P < 0.04) and postoperative change was greater (30.9 +/- 24.2 versus 19.8 +/- 16.8, P < 0.02). For patients with Friedman stage 3, odds ratio of having an AHI of <20 events per hour and a greater than 50% reduction with PA compared with UPPP was 3.80 (95% CI, 1.41-10.29, P < 0.013). Adjusted for age, body mass index, preoperative apnea severity, and tongue-base surgery, OR was 5.77 (95% CI of 1.80-17.98). CONCLUSIONS: Polysomnographic outcomes using AHI support the use of palatopharyngoplasty using palatal advancement as an effective treatment of obstructive sleep apnea. PA may offer benefit over UPPP alone in patients classified with Friedman stage 3.
Adult↗
Relationship of snoring and sleepiness as presenting symptoms in a sleep clinic population.
OBJECTIVES: Sleepiness has traditionally been considered medically the cardinal symptom of obstructive sleep apnea syndrome. Snoring is perceived as a social or cosmetic complaint. Without independent medical morbidity, snoring identification and treatment is not a major focus in sleep medicine. We speculate that snoring is a major independent symptom. To evaluate how patients rated snoring symptom severity, we compared the relative significance of a sleep clinic population's presenting symptoms of snoring and sleepiness. METHODS: We performed a retrospective analysis of 770 consecutive patients who completed sleep intake evaluation forms at the initial clinic visit, including standardized forms for both sleepiness and snoring using previously validated visual analog scales. Data on symptom magnitude (scale of 1 to 10), symptom importance (scale of 1 to 5), a combined symptom product score consisting of magnitude multiplied by importance (MIP; scale of 1 to 50), the Epworth Sleepiness Scale (ESS; n = 599), and the apnea-hypopnea index (AHI; n = 482; mean +/- SD, 35.6 +/- 31.9 events per hour) were collected. RESULTS: The mean snoring measures (magnitude, importance, and MIP) were greater than those for sleepiness (MIPsnoring of 32.7 +/- 14.8 versus MIPsleepiness of 22.4 +/- 14.2, p < .001). Snoring scored higher than sleepiness in 72% of individuals. To assess whether sleep apnea or sleepiness severity affected symptom scores, we stratified the subgroup with sleep studies into quartiles by AHI and ESS score. Snoring consistently scored higher than sleepiness in most AHI and ESS quartiles (p < .01). Only in the most severe ESS quartile did any sleepiness measure (importance) score higher than the snoring measure (p < .05). CONCLUSIONS: The presenting symptoms of snoring are larger in magnitude, importance, and severity than those of sleepiness in a broad population of patients with sleep disorders and sleep-disordered breathing irrespective of severity of sleep apnea or sleepiness. Symptoms of major significance are clinically relevant to identifying, diagnosing, and treating patients. Failure of medical providers to appreciate the impact of snoring on this population may affect attempts to identify, diagnose, and treat patients with sleep-disordered breathing.
Adult↗
A piece of the surgical puzzle.
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Humans↗
A comparison of radiofrequency treatment schemes for obstructive sleep apnea syndrome.
OBJECTIVES: We sought to determine whether increasing temperature-controlled radiofrequency tissue ablation (TCRFTA) treatments provide incremental improvement in outcomes of obstructive sleep apnea syndrome (OSAS). METHODS: Twenty-six subjects randomized to TCRFTA treatment for mild to moderate OSAS were studied at baseline, 1 month after 3 tongue treatments (interim), and then 2 months after 2 additional tongue and palate treatments (final). Outcomes included OSA-specific quality of life (Functional Outcomes of Sleep Questionnaire [FOSQ] and Symptoms of Nocturnal Obstruction and Related Events [SNORE25]), daytime sleepiness, and reaction times (slowest, median, and fastest). RESULTS: Interim outcomes were significantly better than baseline for FOSQ and SNORE25 (P < 0.05), with a trend toward improvement for sleepiness (P = 0.06). Final outcomes were significantly better than interim outcomes for FOSQ, sleepiness, slowest and median reaction time (all P < 0.05), and nonsignificantly improved for SNORE25 (P = 0.30) and fastest reaction time (P = 0.18). All final outcomes were improved from baseline (P < 0.05). CONCLUSIONS: Three TCRFTA tongue treatments significantly improved OSA-specific quality of life. An additional 2 TCRFTA tongue and palate treatment sessions further significantly improved quality of life and reaction times.
Adult↗
Association of autonomic dysfunction and mild obstructive sleep apnea.
BACKGROUND: Autonomic dysfunction (AD) has been independently associated with obstructive sleep apnea (OSA). Autonomic abnormalities are generally considered to be secondary to OSA. Autonomic dysfunction may also contribute to OSA. If AD contributes to OSA, we postulated that abnormalities may be present in mild OSA where the confounding causal effects of hypoxemia and sleep disruption are reduced. OBJECTIVE: We evaluated autonomic function tests and sleep studies in a cohort of subjects with no known diagnosis of OSA. METHODS: We prospectively enrolled a cohort without diagnosed OSA who were part of an ongoing study of vasomotor rhinitis (VMR) for testing. A battery of autonomic nervous system tests (sudomotor and cardiovagal), nonattended polysomnography, and three-site esophageal/pharyngeal pH monitoring were performed. RESULTS: Twenty of 22 patients completed the test battery and 12 (60%) met criteria for OSA (Apnea/Hypopnea Index "AHI" >5 events/hour). AHI correlated to mean tilt table blood pressure decrease (R = 0.58, P = 0.007) and the Valsalva-mediated phase 2 mean blood pressure decrease (R = 0.52, P = 0.017). OSA severity was related to sympathetic but not parasympathetic abnormalities. No differences in blood pressure responses were related to age, oxygen desaturation nadir, gastroesophageal reflux, VMR, or sleepiness. CONCLUSION: Autonomic abnormalities suggestive of decreased adrenergic tone are associated with mild OSA. These abnormalities may potentially be secondary but may also precede development of OSA.
Autonomic Nervous System↗
Upper airway physiology and obstructive sleep-disordered breathing.
Upper airway competence involves complex interactions between anatomy and physiology. The common final denominator of OSDB is a structurally small and abnormally collapsible upper airway. The mechanisms contributing are often an accumulation of many skeletal or soft tissue abnormalities and respiratory physiology that individually may or may not be pathologic. So far, simplistic models have hampered progress in this field. Successful medical and surgical treatment of OSDB continues to be elusive for too many patients. Great strides remain to be taken, but the possibility seems within reach.
Humans↗
A randomized trial of temperature-controlled radiofrequency, continuous positive airway pressure, and placebo for obstructive sleep apnea syndrome.
OBJECTIVE: The study goal was to determine the effectiveness of (1) multilevel temperature-controlled radiofrequency tissue ablation (TCRFTA) or (2) continuous positive airway pressure (CPAP) for the treatment of mild to moderate obstructive sleep apnea syndrome (OSAS). STUDY DESIGN AND METHODS: We conducted a randomized, placebo-controlled, 2-site trial, comparing TCRFTA (n = 30) and CPAP (n = 30) with sham-placebo (n = 30) using intention-to-treat analysis. RESULTS: Compared with pretreatment baseline, TCRFTA improved reaction time, OSAS-specific quality of life (QOL), and subjective sleepiness (all P < 0.05). Compared with sham-placebo, TCRFTA improved QOL, airway volume, apnea index, and respiratory arousal index (all P < 0.05). TCRFTA side effects and complications were mild, temporary, and similar to sham-placebo. CPAP improved QOL and sleepiness compared with baseline and QOL when compared with sham-placebo (all P < 0.05). Significant differences were not seen between TCRFTA and CPAP outcomes. CONCLUSION: TCRFTA and CPAP each improve QOL for mild-moderate OSAS patients. TCRFTA improvements may result from changes in airway volume, apnea index, and respiratory arousal index.
Adolescent↗
Sequential upper airway changes during mandibular distraction for obstructive sleep apnea.
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Airway Resistance↗
Nonattended home automated continuous positive airway pressure titration: comparison with polysomnography.
OBJECTIVE: Automatic adjusting nasal continuous positive airway pressure titration (APAP) has been introduced as an alternative method of establishing pressures for patients with sleep apnea. The performance and accuracy of APAP in nonattended home environment are controversial. This study assessed APAP polysomnographic outcomes and accuracy in a nonattended home environment. STUDY DESIGN AND SETTING: We conducted a retrospective consecutive case series of 24 consecutive patients who had nonattended APAP and simultaneous full polysomnography (PSG). RESULTS: APAP was tolerated and reduced obstructive Apnea-Hypopnea Index (AHI) to <10 events/h in all patients. Mean AHI decreased from 38.4 (21.2) to 5.9 (6.6) events/h. Central apneas worsened in one patient. A therapeutic pressure was determined in 91% of patients. Autoset accurately measured residual AHI compared with PSG (R = 0.77, P < 0.001). APAP overestimated the AHI by 1.4 events/h. CONCLUSIONS: Nonattended APAP is successful in many patients in determining a therapeutic positive pressure setting. Reported AHI via Autoset is similar to that of PSG. SIGNIFICANCE: APAP reduces AHI and is tolerated in a nonattended environment.
Adult↗
Practice parameters for using polysomnography to evaluate insomnia: an update.
Insomnia is a common and clinically important problem. It may arise directly from a sleep-wake regulatory dysfunction and/or indirectly result from comorbid psychiatric, behavioral, medical, or neurological conditions. As an important public-health problem, insomnia requires accurate diagnosis and effective treatment. Insomnia is primarily diagnosed clinically with a detailed medical, psychiatric, and sleep history. Polysomnography is indicated when a sleep-related breathing disorder or periodic limb movement disorder is suspected, initial diagnosis is uncertain, treatment fails, or precipitous arousals occur with violent or injurious behavior. However, polysomnography is not indicated for the routine evaluation of transient insomnia, chronic insomnia, or insomnia associated with psychiatric disorders.
Chronic Disease↗
Expiratory pharyngeal airway obstruction during sleep: a multiple element model.
OBJECTIVE/HYPOTHESIS: In patients with obstructive sleep apnea and snoring, airway obstruction during sleep is not limited to inspiration but may also occur with expiration. The aim of this study was to assess the segmental mechanics of expiratory obstruction. DESIGN: Experimental study of a convenience sample of 20 patients with snoring and mild obstructive sleep apnea. METHODS: During sedated sleep, airflow, airway pressure measurements (supraglottic, oropharyngeal, nasopharyngeal, and nasal mask), and either supraglottic/retroglossal or retropalatal areas were simultaneously measured. Nasal continuous positive airway pressures were experimentally adjusted during single breath tests (SBTs) to modify upper airway size. Airway mechanics were evaluated during pressure drops on expiration. RESULTS: The predominant level of expiratory obstruction was supraglottic/retroglossal level alone (65%) or combined supraglottic/retroglossal and retropalatal (17.6%). In nonobstructed SBTs, compliance curves derived from supraglottic/retroglossal and retropalatal pressures were similar but diverged in obstructed breaths. Compliance during expiration was greater in the supraglottic/retroglossal segment compared to the retropalatal segment. Retropalatal cross-sectional size was smaller during early and late expiration on obstructed than on nonobstructed breaths independent of airway pressure measures. The rate of expiratory collapse was increased at all time points measured (P <.005) in the retropalatal segment on obstructed as compared with nonobstructed breaths. CONCLUSIONS: During expiration, the supraglottic/retroglossal level is obstructed more frequently and has greater compliance than the retropalatal segment. Failure of upstream pressures to describe pharyngeal obstruction supports a multi-element model of collapse. Segments interact during expiration, with increased retropalatal collapse on obstructed as compared with nonobstructed breaths. Increased collapse on expiration provides a mechanism for increased obstruction on subsequent inspiratory breaths.
Airway Resistance↗
Practice parameters for the use of auto-titrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome. An American Academy of Sleep Medicine report.
Continuous positive airway pressure (CPAP) is used to treat patients with the obstructive sleep apnea syndrome (OSAS). The current standard is for an attendant technician to titrate CPAP during full polysomnography to obtain a fixed single pressure. The patient uses CPAP nightly at this fixed single pressure. Recently, devices using new technology that automatically titrate positive airway pressure (APAP) have become available. Such devices continually adjust pressure, as needed, to maintain airway patency (APAP titration). These adjustments can be made with or without attendant technician intervention. Data obtained during APAP titration can be used to provide a fixed single pressure for subsequent treatment. Alternatively, APAP devices can be used in self-adjusting mode for treatment (APAP treatment). A task force of the Standards of Practice Committee of the American Academy of Sleep Medicine reviewed the available literature. Based on this review, the Standards of Practice Committee developed these practice parameters as a guide to the appropriate use of APAP. Recommendations are as follows: 1) A diagnosis of OSAS must be established by an acceptable method. 2) APAP titration and APAP treatment are not currently recommended for patients with congestive heart failure, significant lung disease (e.g., chronic obstructive pulmonary disease), daytime hypoxemia and respiratory failure from any cause, or prominent nocturnal desaturation other than from OSA (e.g., obesity hypoventilation syndrome). In addition, patients who do not snore (either due to palate surgery or naturally) should not be titrated with an APAP device that relies on vibration or sound in the device's algorithm. 3) APAP devices are not currently recommended for split-night studies since none of the reviewed research studies examined this issue. 4) Certain APAP devices may be used during attended titration to identify by polysomnography a single pressure for use with standard CPAP for treatment of OSA. 5) Once an initial successful attended CPAP or APAP titration has been determined by polysomnography, certain APAP devices may be used in the self-adjusting mode for unattended treatment of patients with OSA. 6) Use of unattended APAP to either initially determine pressures for fixed CPAP or for self-adjusting APAP treatment in CPAP naïve patients is not currently established. 7) Patients being treated with fixed CPAP on the basis of APAP titration or being treated with APAP must be followed to determine treatment effectiveness and safety, and 8) a re-evaluation and, if necessary, a standard attended CPAP titration should be performed if symptoms do not resolve or the CPAP or APAP treatment otherwise appears to lack efficacy.
Equipment Design↗
Cephalometric and fiberoptic evaluation as a case-selection technique for obstructive sleep apnea syndrome (OSAS).
In order to obtain relatively simple and useful parameters to estimate the severity of obstructive sleep apnea syndrome (OSAS), cephalometric and fiberoptic studies were performed in 64 clinical cases previously diagnosed with either OSAS or snoring. Fourteen cephalometric parameters, 13 parameters derived from physical examination and 18 fiberoptic parameters were compared with the apnea index (AI), the apnea-hypopnea index and lowest SaO2 values. Statistically significant correlations were found between the Al and the shortest linear distance from the posterior line of the soft palate to the posterior pharyngeal wall measured along a line parallel to the supramentale-Gonion line (PAS-epipharynx distance), the distance from the mandibular plane to the most anterior and superior point on the body of the hyoid bone obtained from cephalometry (MP-H distance) and the degree of redundancy of mucosa in the arytenoid/aryepiglottic fold obtained from videoendoscopy. An increased Al was observed when the PAS-epipharynx distance was < 7 mm and there was 100% obstruction in Muller's maneuver at the palate level (supine), the MP-H distance was > 27.4 mm and the mucosa of the arytenoid/aryepiglottic fold was markedly redundant. As these three parameters are relatively easy to obtain on an outpatient basis, it is suggested that they could be used in an outpatient setting to provide a good prediction of the severity of OSAS.
Adult↗
Effects of prednisone and ibuprofen on radio frequency volume tissue reduction in a rabbit model.
This study investigates whether acute anti-inflammatory medications (prednisone and ibuprofen) alter muscle volumetric reduction following radio frequency tissue ablation (RFTA). We used a rabbit model to measure changes in leg muscle volume using serial magnetic resonance imaging in 3 groups: RFTA without medication (group 1), RFTA with prednisone and ibuprofen (group 2), and no RFTA or medication (group 3). The mean volumetric changes for groups I and 2 differed on days 1 and 7 (+0.5 cm3 versus -0.4 cm3, p < .0001; and -0.03 cm3 versus -0.7 cm3, p < .05), but not on day 28 (-0.8 cm3 versus -1.0 cm3, not significant). Group 3 had no change in volume. The volumetric reduction varied. Impaired volumetric reduction (<50% mean change) occurred in 30% of extremities and correlated to lower tissue impedance (p < .04). Combined steroidal and nonsteroidal anti-inflammatory medications did decrease acute edema, but not the final volumetric reduction, following RFTA. Volumetric changes are variable and may be altered by tissue impedance.
Animals↗