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PubMed1997

Surgical maxillofacial treatment of obstructive sleep apnea.

Obstructive sleep apnea is the most common sleep-related breathing disorder, with a surprisingly high prevalence. The treatment of choice is nasal continuous positive airway pressure (CPAP) ventilation during sleep, which has to be applied throughout the patient's whole life. Because of various underlying pathomechanisms in patients with certain craniofacial disorders--narrow posterior airway space and maxillary-mandibular deficiency--surgical therapy by craniofacial osteotomies seems possible. A series of 38 consecutive patients were treated by 10-mm maxillomandibular advancement by retromolar sagittal split osteotomy and Le Fort I osteotomy, respectively. Obstructive sleep apnea syndrome was improved considerably in all patients; there was no significant difference compared to the results under nasal CPAP. In 37 of 38 patients, the postoperative apnea-hypopnea index was reduced clearly to under 10 per hour, oxygen saturation rose, and sleep quality improved. This was achieved by maxillomandibular advancement of 10 mm without secondary refinements in all but 2 patients. In one patient, the apnea-hypopnea index could only be reduced to 20 per hour, probably because of insufficient maxillary advancement. These results indicate that successful surgical treatment is possible in a high percentage of selected patients with certain craniofacial characteristics. In addition to cardiorespiratory polysomnography, there should be routine cephalometric evaluation of all patients. Maxillomandibular advancement should be offered as an alternative therapy to all patients with maxillary and/or mandibular deficiency or dolichofacial type in combination with narrow posterior airway space.

Adult↗
PubMed2004

[Quality of life in patients with obstructive sleep apnea].

Obstructive sleep apnea syndrome (OSA) is a condition affecting up to 5% of the population, in which episodes of upper airway obstruction lead to temporary cessation of airflow, disturbed sleep architecture and daily somnolence. The health consequences of OSA also include psychological and cognitive deficits, an increased risk of systemic and pulmonary hypertension, coronary disease, bradyarrhythmias and motor vehicle accidents. Symptoms and complications of OSA lead to a significant decrease of health-related quality of life (HRQOL) of affected patients. We review the current literature on HRQOL effects of OSA and its treatment. There is good evidence of beneficial effect of the continuous positive airway pressure (CPAP) therapy on the quality of life of patients with OSA. Improvements in HRQOL are most appreciable in patients with moderate to severe OSA, although they also seem to be present in selected patients with mild OSA. The effects of dental devices and surgical procedures on HRQOL of patients with OSA have not been studied in randomized, placebo-controlled trials. Health-related quality of life has become one of the major outcome measures in patients with sleep apnea. Assessment of HRQOL has become a crucial part of any clinical study involving patients with OSA.

Continuous Positive Airway Pressure↗
PubMed1996

Sleep fragmentation in obstructive sleep apnea.

Obstructive sleep apnea is associated with fragmentation of sleep due to the repeated occurrence of end-apneic arousal throughout the night. Arousals are provoked by stimuli generated during upper airway obstruction. Mechanoreceptor stimuli produced during obstructed inspiratory efforts appear to play a major role in mediating the end-apneic arousal response. The sleep disruption resulting from repeated arousals plays a major role in the pathogenesis of most of the consequences of OSA (i.e. neuropsychiatric, respiratory, and cardiovascular) and may contribute to the progression of OSA severity. However, the relative contribution of sleep fragmentation versus hypoxia in producing these complications and the precise mechanisms require further studies to be elucidated. A recently developed animal model of long-term repeated airway occlusion during sleep and a modification of the model to produce isolated sleep fragmentation should provide important new insights in this field. Treatment of the sleep disruption owing to OSA is achieved by minimizing the occurrence of arousal-promoting stimuli. This is obtained by maintaining upper airway patency during sleep.

Airway Obstruction↗
PubMedDate not supplied

Pathogenesis of obstructive sleep apnea.

Obstructive sleep apnea is a fairly common disorder with significant adverse health consequences. However, the pathogenetic mechanisms remain incompletely understood. Upper airway (UA) patency is determined by several neuromuscular and nonneuromuscular factors including (1) UA dilating muscle activity, (2) the collapsing transmural pressure generated during inspiration, (3) changes in caudal traction, (4) vasomotor tone, and (5) mucosal adhesive forces. This review addresses the effect of sleep on UA function and how these factors conspire to cause UA obstruction.

Humans↗
PubMed2004

Obstructive Sleep Apnea.

Obstructive sleep apnea (OSA) is a major public health problem in the US that afflicts at least 2% to 4% of middle-aged Americans and incurs an estimated annual cost of 3.4 billion dollars. At Stanford, we utilize a multispecialty team approach combining the expertise of sleep medicine specialists (adult and pediatric), maxillofacial and ear, nose, and throat surgeons, and orthodontists to determine the most appropriate therapy for complicated OSA patients. The major treatment modality for children with OSA is tonsillectomy and adenoidectomy with or without radiofrequency treatment of the nasal inferior turbinate. Children with craniofacial anomalies resulting in maxillary or mandibular insufficiency may benefit from palatal expansion or more invasive maxillary/mandibular surgery. Continuous positive airway pressure (PAP) therapy is used in children with OSA who are not surgical candidates or have failed surgery. As a last resort, tracheotomy may be used in patients with persistent or severe OSA who do not respond to other measures. The cornerstone of treatment in adults utilizes PAP: continuous PAP, bilevel PAP, or auto PAP. Treatment of nasal obstruction, appropriate titration, attention to mask-fit issues, desensitization for claustrophobia, use of heated humidification for nasal dryness and nasal pain with continuous PAP, patient education, regular follow-up, use of compliance software (in selected individuals), and referral to support groups (AWAKE) are measures that can improve patient compliance. Adjunctive treatment modalities include lifestyle/behavioral/pharmacologic measures. Oral appliances can be used in patients with symptomatic mild sleep apnea or upper airway resistance syndrome. Patients who are unwilling or unable to tolerate continuous PAP or who have obvious upper airway obstruction may benefit from surgery. Surgical success depends on appropriate patient selection, the procedure performed, and the experience of the surgeon. Phase I surgeries have a success rate of 50% to 60%, whereas phase II surgeries have a success rate greater than 90%.

Journal Article↗
PubMedDate not supplied

Clinical features as diagnostic guides in obstructive sleep apnea.

Obstructive sleep apnea (OSA) may induce psychiatric problems, but clinical risk factors do not reliably predict laboratory-verified OSA. Therefore, OSA diagnosis requires laboratory sleep monitoring. To find additional clinical features that would sharpen indications for sleep monitoring, we applied univariate analyses to clinical data for 137 OSA patients seen in a psychiatry sleep clinic. A symptomatology questionnaire was obtained from 101 of these patients: 71 had morning and 86 had afternoon vigilance tests, and all had upper-airway evaluation and polysomnography. Cigarette consumption but no other clinical features differed among OSA severity groups and total sleep period groups; upper-airway findings differed among vigilance groups. Multidiscriminant clinical predictor terms categorized several patients with severe OSA into less severe OSA categories. Clinical features did not accurately predict OSA. OSA will continue to be identified primarily by sleep laboratory testing. A two-phase laboratory routine, reserving full laboratory testing for patients with negative results on initial, less expensive screening tests, might conserve resources.

Adult↗
PubMed1996

Effects of electrical stimulation to the soft palate on snoring and obstructive sleep apnea.

Obstructive sleep apnea (OSA) is a disorder and has been associated with social and physical problems. Many treatments of OSA have been proposed with various levels of success. Seven patients with histories of snoring and OSA participated in this pilot study to evaluate the effects of electrical stimulation to the soft palate. Each patient slept with a palatal appliance that delivered a weak electrical stimulus to the soft palate on activation. A 3 milliampere stimulus in the range of 9 to 10 volts was found to be effective in terminating snoring without causing patient arousal. The effects of the stimulus on OSA were variable. The results of this study indicated that electrical stimulation of the soft palate may be effective as a treatment for snoring and OSA and warrants further investigation.

Adult↗
PubMed2003

Molecular and physiologic basis of obstructive sleep apnea.

Obstructive sleep apnea-hypopnea syndrome occurs because of various combinations of anatomic, mechanical, and neurologic anomalies that jeopardize ventilation only when normal state-dependent reductions in drive to upper airway respiratory muscles and pump muscles occur. A well thought out and carefully described infrastructure of the normal and abnormal physiology in persons with OSAHS has been developed over the past few decades, which enables the development of innovative and largely effective therapies. The most recent data complement the infrastructure with the neurochemical changes underlying the state-dependent respiratory disorder and observations that the disease process itself can impair muscles, neural inputs, and soft tissue in a manner that has the potential to worsen disease. Oxidative and nitrosative stress from the repeated oxyhemoglobin desaturations and re-oxygenations is implicated in the injury to these tissues. An improved understanding of the mechanisms through which OSAHS progresses may lead to alternative therapies and aid in the identification of persons at risk for disease progression.

Animals↗
PubMed2004

Neuropsychological effects of pediatric obstructive sleep apnea.

Obstructive sleep apnea (OSA) is a fairly common nocturnal breathing disorder, affecting 2-4% of individuals. Although OSA is associated with medical morbidity, its most functionally disruptive effects in adults appear to be neuropsychological in nature. Research on the neuropsychological effects of pediatric OSA has been limited. This study compared the neuropsychological functioning of school-aged children with OSA to that of healthy children. The primary goal was to clarify the presence and pattern of neuropsychological morbidity associated with pediatric OSA. Sleep was assessed with parent-report questionnaires and laboratory sleep studies. Neuropsychological functioning was assessed by formal tests and parent- and teacher-report questionnaires. Data indicated OSA-related cognitive and behavioral impairment that was particularly marked on measures of behavior regulation and some aspects of attention and executive functioning. Minimal effects were observed on measures of intelligence, verbal memory, or processing speed. Exploratory analyses failed to indicate any clear relationship between neuropsychological functioning and objective indexes of hypoxia or sleep disruption, though the sample was small. These data add to a growing literature which suggests that significant neuropsychological deficits are associated with pediatric OSA. Findings suggest a pattern of neuropsychological morbidity that is similar but not identical to that seen in adult OSA.

Attention↗
PubMedDate not supplied

Surgical management of obstructive sleep apnea.

Obstructive sleep apnea syndrome (OSAS) is most commonly the result of unfavorable anatomic configuration of the pharyngeal airway. Although tracheostomy bypasses the pharyngeal airway, other surgical approaches to OSAS modify the pharyngeal airway by extirpation of soft tissue or modification of the underlying craniofacial skeleton. Frequently more than one anatomic alteration is required for effective therapy. The techniques applied are determined by radiological and endoscopic assessment. Multiple techniques may be required and may be applied either in one surgical session or in sequential sessions.

Humans↗
PubMed2000

Surgical management of obstructive sleep apnea.

Obstructive sleep apnea (OSA) syndrome is a common disorder that has recently received much attention by the medical community due to its potentially serious physiological consequences. The clinical significance of OSA results from hypoxemia and sleep fragmentation caused by collapse of the airway, which leads to apnea or hypopnea during sleep. This paper reviews common surgical techniques used for clinical management of OSA patients, with emphasis on jaw advancement surgical procedures.

Journal Article↗
PubMed1995

Automatic control of airway pressure for treatment of obstructive sleep apnea.

Obstructive sleep apnea (OSA) occurs when airflow ceases because of pharyngeal wall collapse in sleep. Repeated apneic events results in the development of a pathological condition called OSA syndrome. We describe the methodology and design of a prosthetic device, named automatic positive airway pressure (APAP), for treatment of this syndrome. APAP applies a stream of air via a nasal mask at an initial pressure selected by the patient. By sensing specific pressure characteristics of air flow immediately preceding pharyngeal wall collapse, the APAP device automatically raises the applied pressure to maintain a patent upper airway and thus prevent apnea. Conversely, when such conditions are absent, pressure is lowered step wise until a preselected minimum pressure is reached. Performance evaluation of the APAP system in five OSA patients and five normal (asymptomatic for sleep apnea) subjects revealed that it effectively treated OSA syndrome. It lowered the apnea-hypopnea index without disturbing sleep and resulted in a lower mean airway pressure compared to the traditional continuous positive airway pressure (CPAP) therapy. The results also show that the pressure needed to prevent OSA varied significantly throughout the night. For OSA syndrome patients, this pressure ranged from 3 to 18 cm H2O. The mean airway pressure for these patients had a sample average of 6.80 cm H2O and a standard deviation of 3.17 cm H2O. In normal subjects, the device did not raise pressure except in response to Pharyngeal Wall Vibration events.

Adult↗
PubMed1998

Association of hypothyroidism and obstructive sleep apnea.

Obstructive sleep apnea (OSA) and hypothyroidism are relatively common disorders that have similar clinical features and are thought to be causally linked. We sought to determine the prevalence of previously unrecognized hypothyroidism in a series of patients evaluated for OSA and whether an association between hypothyroidism and OSA was present. Chart review was used to obtain information on thyroid function status, polysomnography results, levothyroxine use, and clinical signs and symptoms in 336 consecutive adult patients who underwent polysomnography for suspected OSA. In addition, levothyroxine use was determined in age- and sex-matched control subjects for the purposes of a case-control study. Among the patients without prior history of hypothyroidism who underwent polysomnography and thyroid function testing, four new cases or 1. 41% (95% CI 0.04-2.78) were found to have subclinical hypothyroidism. Our findings do not support routine thyroid screening by specialists in patients referred for polysomnography. The odds ratio of the association of prior history of hypothyroidism to OSA was 1. 47 (95% CI 0.8-2.8). Limitations in study design may have limited our ability to detect a statistically significant association between OSA and hypothyroidism.

Adult↗
PubMed2000

Reduced alpha- and beta(2)-adrenergic vascular response in patients with obstructive sleep apnea.

Obstructive sleep apnea (OSA) has been associated with increased sympathetic activity. This study tested the hypothesis that the alpha- and beta(2)-receptor-mediated vascular response is altered in patients with OSA. Forearm vascular resistance was evaluated by venous occlusion plethysmography in 10 normotensive OSA patients and 10 normotensive controls (apnea/hypopnea index [mean +/- SD] 29.4 +/- 2.3 and 1.6 +/- 0.3 per hour, respectively) roughly matched for body mass index (BMI) and age. Forearm vascular resistance was measured after intraarterial infusion of norepinephrine (NE) (7.4, 31, 120, 472 and 1421 pmol/100 ml forearm volume [FAV]/min), before and after phentolamine infusion (2 microgram/100 ml FAV/min), and isoproterenol (ISO) (1, 2, 6, and 15 ng/100 ml FAV/min). NE-induced vasoconstriction was significantly attenuated in OSA patients compared with controls (65.0 +/- 36.6% versus 129.4 +/- 81.8%, p = 0.049). The reduction of vascular resistance after phentolamine was similar in patients and control subjects (-50.8 +/- 16.7% versus -43.4 +/- 20.0%, p = 0.38). During ongoing phentolamine infusion NE increased resistance to a similar extent in both groups (0.5 +/- 4.9% versus -0.9 +/- 10.1%, p = 0.96). Vasodilation following ISO was significantly attenuated in OSA patients compared with control subjects (-53.3 +/- 9.0% versus -64.7 +/- 10.3%, p = 0.049). Moreover, the vascular response to NE in OSA patients was negatively correlated with plasma NE concentration (r = -0.76, p < 0.05). The reduced vascular response to alpha- and beta-receptor stimulation suggests a functional downregulation of vascular sympathoadrenergic receptors in patients with sleep apnea.

Adult↗
PubMed1986

Sleep parameters after surgery for obstructive sleep apnea.

Obstructive sleep apnea (OSA) is a disorder that is frequently treated surgically. Few reports in the literature give objective reports of the effect of such treatment on polysomnographic parameters before and after treatment, although symptomatic improvement is common. This article reviews total sleep time (TST) spent in apnea, number of apneic episodes per hour or sleep apnea index (SAI), and oxygen desaturations in such patients treated with tracheostomy, uvulopalatopharyngoplasty (UPP), and combinations of these. Although improvement is noted in these parameters after UPP, this is not as impressive as some reports in the literature indicate. Our suggested indications for this type of surgery are discussed.

Humans↗
PubMed1989

Dental appliances for the treatment of obstructive sleep apnea.

Obstructive sleep apnea (OSA) is a syndrome in which the airflow created from breathing ceases through the upper airway although diaphragm movement continues. Resulting complications include severe daytime sleepiness, morning headaches, loud snoring, and disturbed nighttime sleep. Patients affected with OSA are frequently hypertensive and can have dangerous cardiac arrhythmias. The diagnosis of OSA requires an all-night polysomnographic recording; neither snoring nor other subjective complaints constitute adequate criteria for treatment. The treatment objective for OSA is to maintain airway patency. A potential treatment discussed here is temporary advancement of the mandible or tongue during sleep with the use of dental appliances.

Equipment Design↗
PubMed1993

Managing obstructive sleep apnea.

Obstructive sleep apnea, cessation of breathing during sleep, is potentially life threatening and requires prompt intervention. A prosthesis can reposition the mandible during sleep and minimize or prevent the tongue from collapsing against the pharynx. Two case reports discuss the effectiveness of prosthetic devices.

Aged↗