Ir J Med Sci DOI 10.1007/s11845-014-1112-5
ORIGINAL ARTICLE
Efficacy of uvulopalatopharyngoplasty combined with oral appliance in treatment of obstructive sleep apnea–hypopnea syndrome D. Yang • H.-F. Zhou • Y. Xie
Received: 23 January 2014 / Accepted: 25 March 2014 Ó Royal Academy of Medicine in Ireland 2014
Abstract Objective This study aimed to investigate the efficacy of UPPP combined with an oral appliance (OA) in the treatment of obstructive sleep apnea–hypopnea syndrome (OSAHS). Methods Forty patients diagnosed with severe OSAHS were randomly divided into two groups: 20 patients in the pure surgery group treated by uvulopalatopharyngoplasty (UPPP) surgery and the remaining 20 patients in the combined treatment group for the combined application of UPPP and OA. Nocturnal PSG monitoring was performed in postoperative 0.5 and 3.0a. AHI, SaO2, and sleep structure improvement were calculated to compare the treatment efficiency of the two groups. Results The AHI of the combined treatment group in the postoperative 3 was lower than that of the pure surgery group, whereas the lowest SaO2 value was higher than that of the pure surgery group (P \ 0.05). The sleep structure improvement of the combined treatment group in the postoperative 3a was possibly more normal than that of the pure surgery group. Conclusion The long-term efficacy of the combined UPPP and OA for the treatment of OSAHS was higher than that of pure UPPP treatment. Keywords Obstructive sleep apnea–hypopnea syndrome Uvulopalatopharyngoplasty Oral appliance Treatment
D. Yang H.-F. Zhou (&) Y. Xie Department of Otorhinolaryngology, Tianjin Medical University General Hospital, No.154 Anshan Road, Tianjin 300052, China e-mail: [email protected]
Introduction Obstructive sleep apnea–hypopnea syndrome (OSAHS) refers to the apnea and hypoventilation induced by the repeated collapse and obstruction of the upper airway during sleep. OSAHS causes frequent blood oxygen desaturation and is accompanied by such symptoms as snoring, sleep structural disorder, and daytime sleepiness. OSAHS causes hypertension, night arrhythmia, pulmonary hypertension, and other serious complications, even death; thus, it is a potentially fatal disease [1–3]. With the continuous development of this industrialized society, the continuous improvement of living standards would make OSAHS increasingly common [4]. However, public health and medical professionals lack sufficient knowledge of OSAHS, and many patients with OSAHS cannot be diagnosed and treated [5]. The occurrence of OSAHS is affected by many factors; for instance, the anatomic stenosis of the upper respiratory tract is one of the most significant factors influencing OSAHS. Stenosis or obstruction in any part of the upper respiratory tract leads to the occurrence of OSAHS. To treat OSAHS, we apply uvulopalatopharyngoplasty (UPPP) as the main surgical method; however, the total efficiency of UPPP is approximately 50 % because of an unclear positioning diagnosis of stenosis or obstruction [6]. With moderate and severe OSAHS, the best treatment is the surgical method. The long-term effect of surgical treatment is unclear, but the oral appliance (OA) has better effect on pure snoring and mild OSAHS, whereas its efficacy toward severe OSAHS is not ideal [7, 8]. UPPP therapy was combined with OA in our hospital from January to December 2007 to investigate the long-term efficacy of the combination of UPPP and OA in the treatment of OSAHS.
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Ir J Med Sci
Subjects and methods
Statistical analysis
Clinical data
SPSS 11.5 statistical software was used. The normally distributed measured data were expressed as x ± s, and analysis of variance was performed; the non-normally distributed data were expressed as median; the counting data were subjected to v2 test, with P B 0.05 considered statistically significant.
Forty patients with OSAHS enrolled in the Department of Otorhinolaryngology of our hospital from January to December 2007 were selected, including 35 males and 5 females aged 35–58 years, with a mean age of 46.7 years. All of the patients exhibited symptoms, such as nocturnal snoring, breath holding, apnea, daytime sleepiness, fatigue, morning headaches, and poor memory. The body mass index was 29.1 ± 8.1. The patients were diagnosed with severe OSAHS using an EmblatteX10 nocturnal polysomnography (PSG) monitoring instrument (Embla Co., Ltd., USA). The apnea–hypopnea index (AHI) was 55.53 ± 5.61/h, and blood oxygen saturation (SaO2) was 89.33 ± 6.11 %. Oropharyngeal examination revealed that the pharynx was narrow and the tongue increased in thickness (which mainly appeared as tonsillar hypertrophy). The palate was long soft or collapsed, lateral pharyngeal band hypertrophy occurred, and the tongue increased in thickness and blocked the pharynx. The narrow plane was verified by oropharyngeal CT (GE, USA) examination. Intraoral examination revealed that one jaw had at least ten or more teeth, all articulation met angle classification II, and the temporomandibular joint showed no abnormalities. All of the patients were relieved from systemic diseases and nasal and nasopharyngeal anatomical abnormalities that may obstruct the upper airway. The patients with OSAHS were randomly divided into two groups, with 20 patients in the pure surgery group for the application of UPPP surgery and the other 20 in the combined treatment group for the combined application of UPPP and OA. This study was conducted in accordance with the declaration of Helsinki. This study was conducted with approval from the Ethics Committee of Tianjin Medical University General Hospital. Written informed consent was obtained from all participants. Treatment method and efficacy evaluation criteria All of the patients underwent UPPP under general anesthesia. The patients in the combined treatment group wore OA 1 month after UPPP surgery. All patients underwent overnight PSG monitoring on the postoperative 0.5 and 3a by the same physician, and the following data were recorded: AHI; SaO2; and sleep structure (sleep time of the rapid eye movement (REM) phase and non-REM (NREM) phase, and proportions of stages I, II, and III ? IV in NREM). AHI was used to evaluate the efficacy of OSAHS: AHI \10, cured; AHI \2 or decreased C50 %, markedly effective; AHI decreased C25 %, effective; AHI decreased \25 %, invalid [1].
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Results Efficacy comparison The patients of the two groups were subjected to re-examination 6 months and 3 years after the surgery. Nine cases in the pure UPPP group had recurrent snoring, apnea, daytime lethargy, and other symptoms, including three and six cases with recurrent symptoms in the postoperative 3 and 3 years, respectively. In the combined treatment group, three cases had recurrent snoring, apnea, daytime lethargy, and other symptoms; two cases experienced recurrence 2 years later, and one case experienced recurrence 3 years later (Table 1). Oropharyngeal CT observation CT observation revealed 28 cases of pure oropharyngeal significant stenosis. Among these cases, 12 also suffered from tissue hypertrophy in the lateral and posterior pharyngeal walls, a tongue that thickened and fell backwards, and a stricture plane in the upper respiratory tract (Fig. 1a, b) that significantly expanded after treatment (Fig. 2a–e). The patients with OSAHS also exhibited multi-plane oropharyngeal stenosis. The cross-sectional areas of the significant stenosis site in CT were compared before and after the treatment. After the combined treatment, the velopharyngeal cavity and tongue plane significantly expanded (P \ 0.05), the apnea of the patients significantly improved, and sleep quality improved (Table 2). Comparison of AHI, SaO2, and sleep structure The monitoring results of AHI and lowest SaO2 values and treatment efficacy of the two groups on the postoperative Table 1 Efficacy comparison of the two groups 3 years after the treatment Grouping
Cases
Effective
Invalid
Effectiveness rate
Pure UPPP group
20
11
9
55 %
Combined treatment group
20
17
3
85 %
x2 = 13.13, P \ 0.05
Ir J Med Sci Fig. 1 The postoperative superior oropharyngeal part significantly expanded, and the clinical symptoms significantly improved
6 months and 3 years of UPPP were observed. The postoperative 6-month AHI value in the combined treatment group was slightly lower than that of the pure UPPP surgery group, whereas the lowest SaO2 value was slightly higher, without difference (P [ 0.05); in particular, no significant difference was observed between the two groups in terms of mitigating breathing disorder frequency and increasing the minimum SaO2. The postoperative 3-year AHI value in the combined treatment group was significantly lower than that of the pure UPPP surgery group, whereas the lowest SaO2 value was significantly higher (P \ 0.05); in particular, the breathing disorder frequency in the combined treatment group significantly decreased, and low SaO2 significantly improved, indicating that OA application elicited long-term improvement effects on UPPP. The stage I sleep of the two groups after treatment was effective compared with that before treatment (P \ 0.05). No significant difference was observed in the sleep structure of the two groups 6 months after the treatment (P [ 0.05), and the sleep structure of the combined group was more effective than that of the pure surgery group 3 years after treatment (Table 3).
Discussion OSAHS is a sleep breathing-disordered disease characterized by repeated temporary obstruction in the upper airway during sleep. OSAHS poses risks, causing nocturnal hypoxia, pleural negative high pressure, and sleep structure disorder. The patients’ quality of life is severely reduced. OSAHS is also one of the causes of many seriously endangering human-health diseases, such as hypertension, coronary heart disease, cerebrovascular disease, diabetes, and Alzheimer’s disease [9]; OSAHS can also lead to
multiple-organ damage and sudden death. With the improvement of the national living standards and the social aging problem of Chinese, the prevalence of OSAHS has increased rapidly, and its early intervention has obtained common concern from many fields, such as otolaryngology, head and neck surgery, respiration, dentistry, cardiology, neurology, geriatric medicine, and anesthesiology. The quality of nocturnal sleep of patients with OSAHS is poor, and the sleep structure is disordered [10]; this behavior is mainly observed as significant shortening or even disappearing in stages III and IV and the REM stage. The light sleep of OSAHS patients was significantly increased compared with that of the simple snoring patients, but the deep sleep and REM sleep were significantly reduced; the sleep structure of OSAHS patients are significantly disordered [11]. The brain cannot experience sufficient rest during sleep; the intermittently increasing frequency of waking causes sleep discontinuity; furthermore, effective sleep is significantly reduced, thereby affecting the patient’s brain function and causing daytime sleepiness, fatigue, memory loss, and personality changes, even leading to cardiovascular and cerebrovascular disease in some severe situations [12, 13]. Patients with SAS are mainly divided into central, obstruction, and mixture types; among these types, obstruction is the most common. Patients with OSAHS exhibit anatomical abnormalities, such as mandibular retrusion and upper airway stenosis. Ryan [14] considered that the upper airway of most OSAHS patients during sleep is mainly obstructed in the posterior part of the soft palate. The upper airway is an irregular stereo-lumen. Understanding of the modality of such upper airway soft tissues as the uvula, soft palate, and tongue would help to determine the pharyngeal obstruction plane and show the width of the airway gap for the extent judgment of airway stenosis. In this research,
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Ir J Med Sci Fig. 2 Oropharyngeal narrow. a The palatopharyngeal part exhibited stenosis, it could be clearly seen that the soft palate and pharyngeal cavity were completely obstructed, only remaining a pin-hole-like gap, while the peri-pharyngeal soft tissue exhibited significant thickening and the bilateral tonsillar hypertrophy, and the cross-sectional area of pharyngeal cavity was extremely small. b The situation of the patient after sagittal reconstruction; stenosis could be seen in the palatopharyngeal cavity and pharynx oralis, and the tongue was thickened, c and d many parts of the patient’s oropharynx exhibited stenosis, the superior- and inferiororopharyngeal parts exhibited significant stenosis, the peripharyngeal soft tissue was thickened, and the crosssectional area of the pharyngeal cavity was decreased, e the inferior-oropharyngeal part and tongue of the patient fell backwards, and the tongue root plane exhibited stenosis
oropharyngeal CT scanning was performed to understand the situation of the upper airway of OSAHS patients. The patients presented significant upper airway stenosis; the velopharyngeal airway space, formed by the surrounding soft palate, uvula, and lateral and posterior pharyngeal walls, was narrow; the tongue thickened and fell backwards (Fig. 2, Table 2). Radiographic findings confirm that upper
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airway soft tissues are a reliable indicator for the diagnosis and narrow plane determination of patients with OSAHS. Among the various techniques used to treat OSAHS, not one therapy can completely cure OSAHS. Neither surgery nor non-surgical treatment can improve efficiency [15]. OSAHS treatment studies have all focused on how to choose the best surgery with little trauma and desired
Ir J Med Sci Table 2 Comparison of cross-sectional areas of stenosis site before and after the treatment (mm2, x ± s) Before treatment
Postoperative 0.5a
Postoperative 3a
Pure UPPP
108.12 ± 14.13
175.84 ± 15.48
172.43 ± 14.53
Combined treatment
108.21 ± 13.56
177.08 ± 17.62
178.39 ± 17.10
Comparison of the two groups before and after surgery, P \ 0.05
efficacy and how to resolve the recurrence of the case. The main treatment for OSAHS is general treatment, which includes improving lifestyle and drug therapy, continuous nocturnal positive pressure ventilation therapy, and bi-level positive pressure ventilation treatment. Surgical treatment mainly involves nasal surgery, pharyngeal surgery, and mandibular lingual root surgery; among these treatments, UPPP treatment has been an effective method for OSAHS. UPPP aims to increase the gap between the soft palate, tonsils, and posterior pharyngeal wall and reduce airway resistance. However, patients with OSAHS suffer not only from the thickened and falling-down uvula, prolonged soft palate, and shallowed palatal arch but also from stenosis or obstruction in one or several parts. Therefore, pure UPPP surgery cannot improve the upper airway stenosis caused by the backward falling of the jaw and tongue. The effective rate of pure UPPP surgery is only approximately 50 % [16]. Efficacy-affecting factors are related not only to the appropriate selection of indications but also to very small surgical resection [17]. Tuncel [18] considered that multi-plane surgical treatment is necessary for moderate and severe OSAHS. In practice, oropharyngeal CT scanning is performed to determine the stenosis plane, and traditional UPPP surgery is combined with OA therapy. OA application 1 month after UPPP produced the effects of
the anterior displacement of the jaw and tongue, reduced postoperative pharyngeal scar contracture, raised the soft palate, tractated the tongue to actively or passively move and incline forward, partially solved the effects of backward-falling mandible and tongue toward the airway, and increased the upper airway gap. The efficacy of OA ensures a long-term safe treatment of OSAHS [19]. Canadian physicians apply OA to snoring and the first-line treatment of mild/moderate OSAHS [20]. OA therapy has the advantages of unique safety, non-invasiveness, and reusability, although the single use of OA is ineffective for severe OSAHS. Thus, we combined UPPP surgery and OA therapy. We compared the AHI, lowest SaO2, and sleep structure of the preoperative and postoperative results after 6 months and 3 years between the two groups (Tables 1 and 3). The result indicates that the efficacy of the combined treatment group was superior to that of the pure surgery group. The recurrence rate was low, indicating that pure UPPP surgery can solve velopharyngeal airway stenosis and expand the velopharyngeal space. However, UPPP surgery cannot solve upper airway stenosis caused by the backward falling of the jaw and tongue. After OA was administered to the patients, the soft palate was effectively raised, the tongue and jaw were tractated to actively or passively shift forward, postoperative scar contracture was reduced, the upper airway space was increased, the stenosis caused by mandibular forward movement and tongue hypertrophy was improved, and postoperative scar contracture was reduced. Hence, the treatment ensures good outcome and improves the longterm cure rate. In long-term postoperative observation, the combination of UPPP surgery and OA therapy showed several advantages. Some of these advantages include small surgery range, low recurrence rate, and desired tolerability in solving upper airway stenosis.
Table 3 Comparison of AHI, lowest SaO2 and sleep structure of the two groups before and after treatment (x ± s) Group
AHI
SaO2
REM (%)
NREM (%) Stage I (%)
Stage II (%)
Stage III ? IV (%)
Pure UPPP Before
55.40 ± 5.56b
58.9 ± 6.13
10.5 ± 5.4
50.52 ± 8.95
33.48 ± 8.39
5.52 ± 2.20
0.5 year after
20.45 ± 4.52a
83.70 ± 3.48a
12.90 ± 4.35
29.52 ± 4.58b
43.24 ± 4.09b
13.48 ± 2.61
3 years after
50.80 ± 3.14a
80.4 ± 4.84c
12.19 ± 2.68
30.43 ± 2.96c
43.33 ± 5.46c
13.57 ± 2.77
Combined treatment group Before
55.65 ± 5.79b
59.10 ± 6.75
10.43 ± 5.15
49.71 ± 8.74
33.62 ± 7.92
6.14 ± 2.10
0.5 year after
19.75 ± 4.79a
85.75 ± 3.96a
12.14 ± 3.31
30.67 ± 3.58b
42.76 ± 3.51b
14.43 ± 4.18
3 years after
19.16 ± 2.91c
89.35 ± 10.86c
11.67 ± 1.77
21.8 ± 3.71c
47.7 ± 4.01c
19.3 ± 4.79
Compared with the same preoperative group a b c
P \ 0.05; comparison of the two groups 6 months after treatment, P [ 0.05 Comparison of the two groups before and after treatment P \ 0.05 Comparison of the two groups 3 years after treatment, P \ 0.05
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Ir J Med Sci
In-depth fundamental studies of airway obstruction involving complex diseases, such as OSAHS, should be performed. The obstruction site should also be accurately determined. Pure UPPP surgery cannot treat obstructive symptoms, which easily relapse. By comparison, the combination of UPPP surgery and OA therapy can further improve upper airway ventilation on the basis of OSAHS surgery, remitting airway obstruction symptoms, significantly reducing the recurrence rate, and improving the patient quality of life. Preoperative CT scan is an important method to diagnose the positioning of OSAHS. This technique can provide a scientific basis for the determination of the treatment plan. Surgical indications should be strictly mastered and comprehensive treatment programs should be applied to improve the long-term efficacy of OSAHS treatment. Acknowledgments This study was supported by Research Project Foundation of Tianjin Health Bureau (09kz114). Conflict of interest
None.
References 1. American Academy of Sleep Medicine (2005) The international classification of sleep disorders: diagnostic and coding manual, 2nd edn. American Academy of Sleep Medicine, Westchester 2. Young T, Skatrud J, Peppard PE (2004) Risk factors for obstructive sleep apnea in adults. J Am Med Assoc 291:2013– 2016 3. Guilleminault C, Tilkian A, Dement WC (1976) The sleep apnea syndromes. Ann Rev Med 27:465–484 4. Punjabi NM (2008) The epidemiology of adult obstructive sleep apnea. Proc Am Thorac Soc 5:136–143. doi:10.1513/pats. 200709-155MG 5. Davey MJ (2003) Understanding obstructive sleep apnoea. Nurs Times 99:26–27 6. Isono S, Remmers JE (1994) Anatomy and physiology of upper airway obstruction. In: kryger HH (ed) Principles and practice of sleep medicine, vol 2. Saunders, Philadelphia, pp 642–656
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7. Farmer WC, Giudici SC (2000) Site of airway collapse in obstructive after uvulopalatopharyngoplasty. Ann Oto Rhinol Laryngol 109:581–584 8. Randerath WJ, Heise M, Hinz R et al (2002) An individually adjustable or appliance vs. continuous positive air way pressure in mild-to-moderate obstructive sleep apnea syndrome. Chest 122:569–575 9. Epstein LJ, Kristo D, Strollo PJ Jr et al (2009) Clinical guideline for the evaluation, management and longterm care of obstructive sleep apnea in adults. J Clin Sleep Med 5:263–276 10. Bixleb EO, Vgonizas AN, Lin HM et al (2009) Sleep disordered breathing in children in a general population sample: prevalence and risk factors. Sleep 32:731–736 11. Li ZP, Zhong Y, Huang JQ et al (2008) The Association of apnea–hypopnea indices with body mass index in patients with OSAS. J Clin Pulm Med 13:971–972 12. Foucher A (2007) Cardiovascular consequences of sleep apnea. Nephrol Ther 3:463–473 Epub 2007 Jul 31 13. Komiya H, Masubuchi Y, Mori Y et al (2008) The validity of body mass index criteria in obese school-aged children. Tohoku J Exp Med 214:27–37 14. Ryan CF, Love LL, Peat D et al (1999) Mandibular advancement oral appliance therapy for obstructive sleep apnea: effect on awake calibre of the velopharynx. Thorax 54:972–977 15. Winslow DH, Bowden CH, DiDonato KP et al (2012) A randomized, double-blind, placebo-controlled study of an oral, extended-release formulation of phentermine/topiramate for the treatment of obstructive sleep apnea in obese adults. Sleep 35:1529–1539. doi:10.5665/sleep.2204 16. Fujita S (1984) UPPP for sleep apnea and snoring. Ear Nose Throat J 63:224–235 17. Kimmelman CP, Levine SB, Shore ET et al (1985) Uvulopalatopharyngoplasty: a comparison of two techniques. Laryngoscope 95:1488–1490 18. Tunc¸el U, Inanc¸l HM, Ku¨rkc¸u¨og˘lu SS et al (2012) A comparison of unilevel and multilevel surgery in obstructive sleep apnea syndrome. Ear Nose Throat J 91:13–18 19. Gong X, Zhang J, Zhao Y et al (2013) Long-term therapeutic efficacy of oral appliances in treatment of obstructive sleep apnea–hypopnea syndrome. J Angle Orthod 83:653–658. doi:10. 2319/060412-463.1 (Epub 2012 Dec 27) 20. Gauthier L, Almeida F, Arcache JP (2012) Position paper by Canadian dental sleep medicine professionals on the role of different health care professionals in managing obstructive sleep apnea and snoring with oral appliances. Can Respir J 19:307–309
ORIGINAL ARTICLE
Efficacy of uvulopalatopharyngoplasty combined with oral appliance in treatment of obstructive sleep apnea–hypopnea syndrome D. Yang • H.-F. Zhou • Y. Xie
Received: 23 January 2014 / Accepted: 25 March 2014 Ó Royal Academy of Medicine in Ireland 2014
Abstract Objective This study aimed to investigate the efficacy of UPPP combined with an oral appliance (OA) in the treatment of obstructive sleep apnea–hypopnea syndrome (OSAHS). Methods Forty patients diagnosed with severe OSAHS were randomly divided into two groups: 20 patients in the pure surgery group treated by uvulopalatopharyngoplasty (UPPP) surgery and the remaining 20 patients in the combined treatment group for the combined application of UPPP and OA. Nocturnal PSG monitoring was performed in postoperative 0.5 and 3.0a. AHI, SaO2, and sleep structure improvement were calculated to compare the treatment efficiency of the two groups. Results The AHI of the combined treatment group in the postoperative 3 was lower than that of the pure surgery group, whereas the lowest SaO2 value was higher than that of the pure surgery group (P \ 0.05). The sleep structure improvement of the combined treatment group in the postoperative 3a was possibly more normal than that of the pure surgery group. Conclusion The long-term efficacy of the combined UPPP and OA for the treatment of OSAHS was higher than that of pure UPPP treatment. Keywords Obstructive sleep apnea–hypopnea syndrome Uvulopalatopharyngoplasty Oral appliance Treatment
D. Yang H.-F. Zhou (&) Y. Xie Department of Otorhinolaryngology, Tianjin Medical University General Hospital, No.154 Anshan Road, Tianjin 300052, China e-mail: [email protected]
Introduction Obstructive sleep apnea–hypopnea syndrome (OSAHS) refers to the apnea and hypoventilation induced by the repeated collapse and obstruction of the upper airway during sleep. OSAHS causes frequent blood oxygen desaturation and is accompanied by such symptoms as snoring, sleep structural disorder, and daytime sleepiness. OSAHS causes hypertension, night arrhythmia, pulmonary hypertension, and other serious complications, even death; thus, it is a potentially fatal disease [1–3]. With the continuous development of this industrialized society, the continuous improvement of living standards would make OSAHS increasingly common [4]. However, public health and medical professionals lack sufficient knowledge of OSAHS, and many patients with OSAHS cannot be diagnosed and treated [5]. The occurrence of OSAHS is affected by many factors; for instance, the anatomic stenosis of the upper respiratory tract is one of the most significant factors influencing OSAHS. Stenosis or obstruction in any part of the upper respiratory tract leads to the occurrence of OSAHS. To treat OSAHS, we apply uvulopalatopharyngoplasty (UPPP) as the main surgical method; however, the total efficiency of UPPP is approximately 50 % because of an unclear positioning diagnosis of stenosis or obstruction [6]. With moderate and severe OSAHS, the best treatment is the surgical method. The long-term effect of surgical treatment is unclear, but the oral appliance (OA) has better effect on pure snoring and mild OSAHS, whereas its efficacy toward severe OSAHS is not ideal [7, 8]. UPPP therapy was combined with OA in our hospital from January to December 2007 to investigate the long-term efficacy of the combination of UPPP and OA in the treatment of OSAHS.
123
Ir J Med Sci
Subjects and methods
Statistical analysis
Clinical data
SPSS 11.5 statistical software was used. The normally distributed measured data were expressed as x ± s, and analysis of variance was performed; the non-normally distributed data were expressed as median; the counting data were subjected to v2 test, with P B 0.05 considered statistically significant.
Forty patients with OSAHS enrolled in the Department of Otorhinolaryngology of our hospital from January to December 2007 were selected, including 35 males and 5 females aged 35–58 years, with a mean age of 46.7 years. All of the patients exhibited symptoms, such as nocturnal snoring, breath holding, apnea, daytime sleepiness, fatigue, morning headaches, and poor memory. The body mass index was 29.1 ± 8.1. The patients were diagnosed with severe OSAHS using an EmblatteX10 nocturnal polysomnography (PSG) monitoring instrument (Embla Co., Ltd., USA). The apnea–hypopnea index (AHI) was 55.53 ± 5.61/h, and blood oxygen saturation (SaO2) was 89.33 ± 6.11 %. Oropharyngeal examination revealed that the pharynx was narrow and the tongue increased in thickness (which mainly appeared as tonsillar hypertrophy). The palate was long soft or collapsed, lateral pharyngeal band hypertrophy occurred, and the tongue increased in thickness and blocked the pharynx. The narrow plane was verified by oropharyngeal CT (GE, USA) examination. Intraoral examination revealed that one jaw had at least ten or more teeth, all articulation met angle classification II, and the temporomandibular joint showed no abnormalities. All of the patients were relieved from systemic diseases and nasal and nasopharyngeal anatomical abnormalities that may obstruct the upper airway. The patients with OSAHS were randomly divided into two groups, with 20 patients in the pure surgery group for the application of UPPP surgery and the other 20 in the combined treatment group for the combined application of UPPP and OA. This study was conducted in accordance with the declaration of Helsinki. This study was conducted with approval from the Ethics Committee of Tianjin Medical University General Hospital. Written informed consent was obtained from all participants. Treatment method and efficacy evaluation criteria All of the patients underwent UPPP under general anesthesia. The patients in the combined treatment group wore OA 1 month after UPPP surgery. All patients underwent overnight PSG monitoring on the postoperative 0.5 and 3a by the same physician, and the following data were recorded: AHI; SaO2; and sleep structure (sleep time of the rapid eye movement (REM) phase and non-REM (NREM) phase, and proportions of stages I, II, and III ? IV in NREM). AHI was used to evaluate the efficacy of OSAHS: AHI \10, cured; AHI \2 or decreased C50 %, markedly effective; AHI decreased C25 %, effective; AHI decreased \25 %, invalid [1].
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Results Efficacy comparison The patients of the two groups were subjected to re-examination 6 months and 3 years after the surgery. Nine cases in the pure UPPP group had recurrent snoring, apnea, daytime lethargy, and other symptoms, including three and six cases with recurrent symptoms in the postoperative 3 and 3 years, respectively. In the combined treatment group, three cases had recurrent snoring, apnea, daytime lethargy, and other symptoms; two cases experienced recurrence 2 years later, and one case experienced recurrence 3 years later (Table 1). Oropharyngeal CT observation CT observation revealed 28 cases of pure oropharyngeal significant stenosis. Among these cases, 12 also suffered from tissue hypertrophy in the lateral and posterior pharyngeal walls, a tongue that thickened and fell backwards, and a stricture plane in the upper respiratory tract (Fig. 1a, b) that significantly expanded after treatment (Fig. 2a–e). The patients with OSAHS also exhibited multi-plane oropharyngeal stenosis. The cross-sectional areas of the significant stenosis site in CT were compared before and after the treatment. After the combined treatment, the velopharyngeal cavity and tongue plane significantly expanded (P \ 0.05), the apnea of the patients significantly improved, and sleep quality improved (Table 2). Comparison of AHI, SaO2, and sleep structure The monitoring results of AHI and lowest SaO2 values and treatment efficacy of the two groups on the postoperative Table 1 Efficacy comparison of the two groups 3 years after the treatment Grouping
Cases
Effective
Invalid
Effectiveness rate
Pure UPPP group
20
11
9
55 %
Combined treatment group
20
17
3
85 %
x2 = 13.13, P \ 0.05
Ir J Med Sci Fig. 1 The postoperative superior oropharyngeal part significantly expanded, and the clinical symptoms significantly improved
6 months and 3 years of UPPP were observed. The postoperative 6-month AHI value in the combined treatment group was slightly lower than that of the pure UPPP surgery group, whereas the lowest SaO2 value was slightly higher, without difference (P [ 0.05); in particular, no significant difference was observed between the two groups in terms of mitigating breathing disorder frequency and increasing the minimum SaO2. The postoperative 3-year AHI value in the combined treatment group was significantly lower than that of the pure UPPP surgery group, whereas the lowest SaO2 value was significantly higher (P \ 0.05); in particular, the breathing disorder frequency in the combined treatment group significantly decreased, and low SaO2 significantly improved, indicating that OA application elicited long-term improvement effects on UPPP. The stage I sleep of the two groups after treatment was effective compared with that before treatment (P \ 0.05). No significant difference was observed in the sleep structure of the two groups 6 months after the treatment (P [ 0.05), and the sleep structure of the combined group was more effective than that of the pure surgery group 3 years after treatment (Table 3).
Discussion OSAHS is a sleep breathing-disordered disease characterized by repeated temporary obstruction in the upper airway during sleep. OSAHS poses risks, causing nocturnal hypoxia, pleural negative high pressure, and sleep structure disorder. The patients’ quality of life is severely reduced. OSAHS is also one of the causes of many seriously endangering human-health diseases, such as hypertension, coronary heart disease, cerebrovascular disease, diabetes, and Alzheimer’s disease [9]; OSAHS can also lead to
multiple-organ damage and sudden death. With the improvement of the national living standards and the social aging problem of Chinese, the prevalence of OSAHS has increased rapidly, and its early intervention has obtained common concern from many fields, such as otolaryngology, head and neck surgery, respiration, dentistry, cardiology, neurology, geriatric medicine, and anesthesiology. The quality of nocturnal sleep of patients with OSAHS is poor, and the sleep structure is disordered [10]; this behavior is mainly observed as significant shortening or even disappearing in stages III and IV and the REM stage. The light sleep of OSAHS patients was significantly increased compared with that of the simple snoring patients, but the deep sleep and REM sleep were significantly reduced; the sleep structure of OSAHS patients are significantly disordered [11]. The brain cannot experience sufficient rest during sleep; the intermittently increasing frequency of waking causes sleep discontinuity; furthermore, effective sleep is significantly reduced, thereby affecting the patient’s brain function and causing daytime sleepiness, fatigue, memory loss, and personality changes, even leading to cardiovascular and cerebrovascular disease in some severe situations [12, 13]. Patients with SAS are mainly divided into central, obstruction, and mixture types; among these types, obstruction is the most common. Patients with OSAHS exhibit anatomical abnormalities, such as mandibular retrusion and upper airway stenosis. Ryan [14] considered that the upper airway of most OSAHS patients during sleep is mainly obstructed in the posterior part of the soft palate. The upper airway is an irregular stereo-lumen. Understanding of the modality of such upper airway soft tissues as the uvula, soft palate, and tongue would help to determine the pharyngeal obstruction plane and show the width of the airway gap for the extent judgment of airway stenosis. In this research,
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Ir J Med Sci Fig. 2 Oropharyngeal narrow. a The palatopharyngeal part exhibited stenosis, it could be clearly seen that the soft palate and pharyngeal cavity were completely obstructed, only remaining a pin-hole-like gap, while the peri-pharyngeal soft tissue exhibited significant thickening and the bilateral tonsillar hypertrophy, and the cross-sectional area of pharyngeal cavity was extremely small. b The situation of the patient after sagittal reconstruction; stenosis could be seen in the palatopharyngeal cavity and pharynx oralis, and the tongue was thickened, c and d many parts of the patient’s oropharynx exhibited stenosis, the superior- and inferiororopharyngeal parts exhibited significant stenosis, the peripharyngeal soft tissue was thickened, and the crosssectional area of the pharyngeal cavity was decreased, e the inferior-oropharyngeal part and tongue of the patient fell backwards, and the tongue root plane exhibited stenosis
oropharyngeal CT scanning was performed to understand the situation of the upper airway of OSAHS patients. The patients presented significant upper airway stenosis; the velopharyngeal airway space, formed by the surrounding soft palate, uvula, and lateral and posterior pharyngeal walls, was narrow; the tongue thickened and fell backwards (Fig. 2, Table 2). Radiographic findings confirm that upper
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airway soft tissues are a reliable indicator for the diagnosis and narrow plane determination of patients with OSAHS. Among the various techniques used to treat OSAHS, not one therapy can completely cure OSAHS. Neither surgery nor non-surgical treatment can improve efficiency [15]. OSAHS treatment studies have all focused on how to choose the best surgery with little trauma and desired
Ir J Med Sci Table 2 Comparison of cross-sectional areas of stenosis site before and after the treatment (mm2, x ± s) Before treatment
Postoperative 0.5a
Postoperative 3a
Pure UPPP
108.12 ± 14.13
175.84 ± 15.48
172.43 ± 14.53
Combined treatment
108.21 ± 13.56
177.08 ± 17.62
178.39 ± 17.10
Comparison of the two groups before and after surgery, P \ 0.05
efficacy and how to resolve the recurrence of the case. The main treatment for OSAHS is general treatment, which includes improving lifestyle and drug therapy, continuous nocturnal positive pressure ventilation therapy, and bi-level positive pressure ventilation treatment. Surgical treatment mainly involves nasal surgery, pharyngeal surgery, and mandibular lingual root surgery; among these treatments, UPPP treatment has been an effective method for OSAHS. UPPP aims to increase the gap between the soft palate, tonsils, and posterior pharyngeal wall and reduce airway resistance. However, patients with OSAHS suffer not only from the thickened and falling-down uvula, prolonged soft palate, and shallowed palatal arch but also from stenosis or obstruction in one or several parts. Therefore, pure UPPP surgery cannot improve the upper airway stenosis caused by the backward falling of the jaw and tongue. The effective rate of pure UPPP surgery is only approximately 50 % [16]. Efficacy-affecting factors are related not only to the appropriate selection of indications but also to very small surgical resection [17]. Tuncel [18] considered that multi-plane surgical treatment is necessary for moderate and severe OSAHS. In practice, oropharyngeal CT scanning is performed to determine the stenosis plane, and traditional UPPP surgery is combined with OA therapy. OA application 1 month after UPPP produced the effects of
the anterior displacement of the jaw and tongue, reduced postoperative pharyngeal scar contracture, raised the soft palate, tractated the tongue to actively or passively move and incline forward, partially solved the effects of backward-falling mandible and tongue toward the airway, and increased the upper airway gap. The efficacy of OA ensures a long-term safe treatment of OSAHS [19]. Canadian physicians apply OA to snoring and the first-line treatment of mild/moderate OSAHS [20]. OA therapy has the advantages of unique safety, non-invasiveness, and reusability, although the single use of OA is ineffective for severe OSAHS. Thus, we combined UPPP surgery and OA therapy. We compared the AHI, lowest SaO2, and sleep structure of the preoperative and postoperative results after 6 months and 3 years between the two groups (Tables 1 and 3). The result indicates that the efficacy of the combined treatment group was superior to that of the pure surgery group. The recurrence rate was low, indicating that pure UPPP surgery can solve velopharyngeal airway stenosis and expand the velopharyngeal space. However, UPPP surgery cannot solve upper airway stenosis caused by the backward falling of the jaw and tongue. After OA was administered to the patients, the soft palate was effectively raised, the tongue and jaw were tractated to actively or passively shift forward, postoperative scar contracture was reduced, the upper airway space was increased, the stenosis caused by mandibular forward movement and tongue hypertrophy was improved, and postoperative scar contracture was reduced. Hence, the treatment ensures good outcome and improves the longterm cure rate. In long-term postoperative observation, the combination of UPPP surgery and OA therapy showed several advantages. Some of these advantages include small surgery range, low recurrence rate, and desired tolerability in solving upper airway stenosis.
Table 3 Comparison of AHI, lowest SaO2 and sleep structure of the two groups before and after treatment (x ± s) Group
AHI
SaO2
REM (%)
NREM (%) Stage I (%)
Stage II (%)
Stage III ? IV (%)
Pure UPPP Before
55.40 ± 5.56b
58.9 ± 6.13
10.5 ± 5.4
50.52 ± 8.95
33.48 ± 8.39
5.52 ± 2.20
0.5 year after
20.45 ± 4.52a
83.70 ± 3.48a
12.90 ± 4.35
29.52 ± 4.58b
43.24 ± 4.09b
13.48 ± 2.61
3 years after
50.80 ± 3.14a
80.4 ± 4.84c
12.19 ± 2.68
30.43 ± 2.96c
43.33 ± 5.46c
13.57 ± 2.77
Combined treatment group Before
55.65 ± 5.79b
59.10 ± 6.75
10.43 ± 5.15
49.71 ± 8.74
33.62 ± 7.92
6.14 ± 2.10
0.5 year after
19.75 ± 4.79a
85.75 ± 3.96a
12.14 ± 3.31
30.67 ± 3.58b
42.76 ± 3.51b
14.43 ± 4.18
3 years after
19.16 ± 2.91c
89.35 ± 10.86c
11.67 ± 1.77
21.8 ± 3.71c
47.7 ± 4.01c
19.3 ± 4.79
Compared with the same preoperative group a b c
P \ 0.05; comparison of the two groups 6 months after treatment, P [ 0.05 Comparison of the two groups before and after treatment P \ 0.05 Comparison of the two groups 3 years after treatment, P \ 0.05
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Ir J Med Sci
In-depth fundamental studies of airway obstruction involving complex diseases, such as OSAHS, should be performed. The obstruction site should also be accurately determined. Pure UPPP surgery cannot treat obstructive symptoms, which easily relapse. By comparison, the combination of UPPP surgery and OA therapy can further improve upper airway ventilation on the basis of OSAHS surgery, remitting airway obstruction symptoms, significantly reducing the recurrence rate, and improving the patient quality of life. Preoperative CT scan is an important method to diagnose the positioning of OSAHS. This technique can provide a scientific basis for the determination of the treatment plan. Surgical indications should be strictly mastered and comprehensive treatment programs should be applied to improve the long-term efficacy of OSAHS treatment. Acknowledgments This study was supported by Research Project Foundation of Tianjin Health Bureau (09kz114). Conflict of interest
None.
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