CLINICAL STUDY
Impact of Multilevel Surgical Treatment on Mean Platelet Volume in Patients With Obstructive Sleep Apnea Syndrome Emre Gu¨nbey, MD, Ismail Karabulut, MD,y Hayriye Karabulut, MD,z and Murat Zaim, MD§ Background and Objectives: Mean platelet volume (MPV) is a potential marker of platelet reactivity. Increased MPV levels are shown to be the predictor of cardiovascular diseases, hypertension, and stroke. Previous studies demonstrated increased MPV levels in patients with obstructive sleep apnea syndrome (OSAS). The aim of this study was to examine the impact of 1-stage multilevel surgical treatment on MPV levels in patients with OSAS. Methods: Preoperative and postoperative 6-month hematologic parameters as well as polysomnographic findings of 42 patients, who underwent 1-stage multilevel surgery for treatment of moderate or severe OSAS, were compared. Results: In the comparisons of preoperative and postoperative apneahypopnea index (AHI) and MPV values, statistically significant decreases were detected There was a significant positive correlation between the decrease in mean AHI and decrease in MPV levels. Conclusions: One-stage multilevel surgery targeting the obstruction at the retropalatal and tongue-base levels was found to be effective in decreasing AHI and MPV. Mean platelet volume may be a new index to indicate the success of OSAS surgery. Key Words: OSAS, MPV, uvuloplatopharyngoplasty, tongue-base surgery (J Craniofac Surg 2015;26: 1287–1289)
O
bstructive sleep apnea syndrome (OSAS) is a common disorder that predisposes to serious systemic problems if left untreated. The risk for cardiovascular diseases, such as congestive heart failure, arrhythmias, coronary artery disease, and myocardial infarction (MI), is increased in patients with OSAS.1 Platelet activation, thrombus formation, and thrombus rupture are key mechanisms for the development of cardiovascular morbidity. Increased platelet activation plays an important role in the development of atherosclerosis. A relationship between coronary and cerebrovascular disease as well as increased mean platelet From the Department of Otolaryngology, Ondokuz Mayis University Faculty of Medicine, Samsun; yDepartment of Physiology, Hacettepe University Faculty of Medicine; zDepartment of Otolaryngology, Gazi University Faculty of Medicine, Ankara; and §Department of Otolaryngology, Mus¸ Malazgirt State Hospital, Mus¸, Turkey. Received June 20, 2014. Accepted for publication January 12, 2015. Address correspondence and reprint requests to Emre Gu¨nbey, MD, Department of Otorhinolaryngology, School of Medicine, Ondokuz Mayis University, Kurupelit, Samsun, Turkey 55139. E-mail: [email protected] The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001556
The Journal of Craniofacial Surgery
volume (MPV) levels has been documented.1– 3 Previous studies demonstrated increased MPV levels in patients with severe OSAS.4 –7 However, the effect of surgical treatment on MPV in patients with OSAS has not been investigated. In this study, we examined the impact of 1-stage multilevel surgical treatment on MPV levels in patients with OSAS.
MATERIALS AND METHODS Forty-two patients underwent 1-stage multilevel surgery (modified uvulopalatopharyngoplasty with tongue-base coblation) for treatment of moderate or severe OSAS. The patients comprised those who refused or who did not agree to continuous positive airway pressure (CPAP) treatment. Exclusion criteria for the study were evidence of chronic heart failure, coronary artery disease, malignancy, diabetes mellitus, hepatic or renal dysfunction, hematologic disease, hypothyroidism or hyperthyroidism, and antithrombotic agent drug use. The modified uvulopalatopharyngoplasty procedure, defined by Friedman et al,8 and the tongue-base coblation procedure, defined by Maturo and Mair,9 were performed as the surgical techniques. Preoperative and postoperative 6-month hematologic parameters as well as polysomnographic findings were compared.
Sleep Study The diagnosis of the patients with OSAS was based on polysomnography (E-series system; Compumedics, Melbourne, Victoria, Australia). The system consisted of an electrocardiogram, a 4-channel electroencephalogram, electrogram, a bipolar electromyogram attached superficially to both the tibial muscle and the submental region, as well as a record device that sensed body position and movement. The breathing monitor consisted of a pulse oximetry, oral and nasal ammeters, a tracheal microphone, and a video recorder that recorded abdominal and thoracic movements. Apnea was defined as a complete cessation of airflow for at least 10 seconds, and hypopnea was defined as a decrease in airflow for at least 50% accompanied by 3% desaturation and a reduction in chest wall movement and/or arousal. The apnea-hypopnea index (AHI) was defined as the number of apneas and hypopneas per hour of sleep. Sleep staging and classification of the severity of OSAS were performed according to the standard criteria set by the American Academy of Sleep Medicine (mild OSAS: AHI, 5–15; moderate OSAS: AHI, 15–30; severe OSAS: AHI, >30).10
Laboratory Analyses Tripotassium EDTA-based anticoagulated blood samples were drawn from the antecubital vein in the morning after a fasting period of 12 hours. Analyses were performed immediately after sampling to prevent in vitro platelet activation. Coulter Gen-S device and Olsaton III diluent solution were used for the evaluation of preoperative and postoperative complete blood cell count. Complete blood cell count, hematocrit, mean corpuscular volume, mean
Volume 26, Number 4, June 2015
1287
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Gu¨nbey et al
corpuscular hemoglobin content, mean corpuscular hemoglobin concentration, MPV, as well as red blood cell count distribution width, platelet count, platelet distribution values of the patients were analyzed comparatively in terms of preoperative and postoperative values.
Statistical Analyses Data were analyzed using the SPSS statistical software package (SPSS, version 15.0 for Windows; SPSS Inc, Chicago, IL). The adequacy of all parameters to normal distribution was tested using the Kolmogorov-Smirnov test. In the comparisons of both hematologic analyses, paired-samples t-test was used to compare parameters with normal distribution, and the Wilcoxon signed rank test was used to compare parameters without normal distribution. In both cohort comparisons, the Mann-Whitney tests were used. The Chi-squared test was used to compare the categorical parameters between the groups for pairwise comparisons. Pearson correlation analysis was implemented for testing variables. A significance level of 0.05 was used.
RESULTS Forty-two patients (29 men, 13 women) were included in the study. The mean (SD) age was 47.1 years (14.5 y). Mean (SD) preoperative body mass index (BMI) was 32.6 (8.4), and mean (SD) postoperative BMI was 31.2 (9.1). There was no significant difference in terms of preoperative and postoperative BMI. There were no significant differences in terms of red blood cell, hemoglobin, hematocrit, mean corpuscular volume, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, white blood cell, platelet count, platelet crit, or platelet distribution width (PDW) (P > 0.05) when the preoperative and postoperative 6-month hematologic parameters were compared. However, in the comparisons of preoperative and postoperative MPV values, a statistically significant decrease was detected (mean [SD] preoperative MPV, 9.4 [0.7] fl; mean [SD] postoperative MPV, 8.5 [0.8] fl; Wilcoxon signed rank test, P ¼ 0.014) (Fig. 1).
Volume 26, Number 4, June 2015
TABLE 1. The Comparisons of Preoperative and Postoperative Hematologic and Polysomnographic Findings Preop. (n ¼ 42) Hematologic parameters RBC (106 cells/mL) Hb (g/dL) Htc (%) WBC (103 cells/mL) PLT (103 cells/mL) MPV (mm3) PDW (mm3) Polysomnographic parameters Sleep efficiency (%) AHI (event per hour) AHI-supine (event per hour) AHI-nonsupine (event per hour) AHI-REM (event per hour) AHI–non-REM (event per hour) Mean % arterial O2 desaturation Maximum % arterial O2 desaturation
Postop. (n ¼ 42)
P
4.32 13.6 42.1 7.12 256.65 9.4 15.6
(0.45) (2.2) (4.7) (2.04) (57) (0.7) (1.1)
4.13 12.7 41.3 7.37 247.88 8.5 15.2
(0.62) (3.1) (5.5) (2.75) (13) (0.8) (0.9)
0.091 0.125 0.242 0.063 0.024 0.014 0.026
80.4 35.8 42.4 27.8 39.1 22.5 7.7 11.6
(16.3) (12.1) (13.6) (7.5) (11.7) (8.3) (3.8) (4.8)
82.5 15.3 24.7 19.2 18.4 8.2 4.3 8.4
(13.6) (9.8) (14.5) (6.6) (9.9) (6.5) (2.9) (3.7)
0.127
Impact of Multilevel Surgical Treatment on Mean Platelet Volume in Patients With Obstructive Sleep Apnea Syndrome Emre Gu¨nbey, MD, Ismail Karabulut, MD,y Hayriye Karabulut, MD,z and Murat Zaim, MD§ Background and Objectives: Mean platelet volume (MPV) is a potential marker of platelet reactivity. Increased MPV levels are shown to be the predictor of cardiovascular diseases, hypertension, and stroke. Previous studies demonstrated increased MPV levels in patients with obstructive sleep apnea syndrome (OSAS). The aim of this study was to examine the impact of 1-stage multilevel surgical treatment on MPV levels in patients with OSAS. Methods: Preoperative and postoperative 6-month hematologic parameters as well as polysomnographic findings of 42 patients, who underwent 1-stage multilevel surgery for treatment of moderate or severe OSAS, were compared. Results: In the comparisons of preoperative and postoperative apneahypopnea index (AHI) and MPV values, statistically significant decreases were detected There was a significant positive correlation between the decrease in mean AHI and decrease in MPV levels. Conclusions: One-stage multilevel surgery targeting the obstruction at the retropalatal and tongue-base levels was found to be effective in decreasing AHI and MPV. Mean platelet volume may be a new index to indicate the success of OSAS surgery. Key Words: OSAS, MPV, uvuloplatopharyngoplasty, tongue-base surgery (J Craniofac Surg 2015;26: 1287–1289)
O
bstructive sleep apnea syndrome (OSAS) is a common disorder that predisposes to serious systemic problems if left untreated. The risk for cardiovascular diseases, such as congestive heart failure, arrhythmias, coronary artery disease, and myocardial infarction (MI), is increased in patients with OSAS.1 Platelet activation, thrombus formation, and thrombus rupture are key mechanisms for the development of cardiovascular morbidity. Increased platelet activation plays an important role in the development of atherosclerosis. A relationship between coronary and cerebrovascular disease as well as increased mean platelet From the Department of Otolaryngology, Ondokuz Mayis University Faculty of Medicine, Samsun; yDepartment of Physiology, Hacettepe University Faculty of Medicine; zDepartment of Otolaryngology, Gazi University Faculty of Medicine, Ankara; and §Department of Otolaryngology, Mus¸ Malazgirt State Hospital, Mus¸, Turkey. Received June 20, 2014. Accepted for publication January 12, 2015. Address correspondence and reprint requests to Emre Gu¨nbey, MD, Department of Otorhinolaryngology, School of Medicine, Ondokuz Mayis University, Kurupelit, Samsun, Turkey 55139. E-mail: [email protected] The authors report no conflicts of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001556
The Journal of Craniofacial Surgery
volume (MPV) levels has been documented.1– 3 Previous studies demonstrated increased MPV levels in patients with severe OSAS.4 –7 However, the effect of surgical treatment on MPV in patients with OSAS has not been investigated. In this study, we examined the impact of 1-stage multilevel surgical treatment on MPV levels in patients with OSAS.
MATERIALS AND METHODS Forty-two patients underwent 1-stage multilevel surgery (modified uvulopalatopharyngoplasty with tongue-base coblation) for treatment of moderate or severe OSAS. The patients comprised those who refused or who did not agree to continuous positive airway pressure (CPAP) treatment. Exclusion criteria for the study were evidence of chronic heart failure, coronary artery disease, malignancy, diabetes mellitus, hepatic or renal dysfunction, hematologic disease, hypothyroidism or hyperthyroidism, and antithrombotic agent drug use. The modified uvulopalatopharyngoplasty procedure, defined by Friedman et al,8 and the tongue-base coblation procedure, defined by Maturo and Mair,9 were performed as the surgical techniques. Preoperative and postoperative 6-month hematologic parameters as well as polysomnographic findings were compared.
Sleep Study The diagnosis of the patients with OSAS was based on polysomnography (E-series system; Compumedics, Melbourne, Victoria, Australia). The system consisted of an electrocardiogram, a 4-channel electroencephalogram, electrogram, a bipolar electromyogram attached superficially to both the tibial muscle and the submental region, as well as a record device that sensed body position and movement. The breathing monitor consisted of a pulse oximetry, oral and nasal ammeters, a tracheal microphone, and a video recorder that recorded abdominal and thoracic movements. Apnea was defined as a complete cessation of airflow for at least 10 seconds, and hypopnea was defined as a decrease in airflow for at least 50% accompanied by 3% desaturation and a reduction in chest wall movement and/or arousal. The apnea-hypopnea index (AHI) was defined as the number of apneas and hypopneas per hour of sleep. Sleep staging and classification of the severity of OSAS were performed according to the standard criteria set by the American Academy of Sleep Medicine (mild OSAS: AHI, 5–15; moderate OSAS: AHI, 15–30; severe OSAS: AHI, >30).10
Laboratory Analyses Tripotassium EDTA-based anticoagulated blood samples were drawn from the antecubital vein in the morning after a fasting period of 12 hours. Analyses were performed immediately after sampling to prevent in vitro platelet activation. Coulter Gen-S device and Olsaton III diluent solution were used for the evaluation of preoperative and postoperative complete blood cell count. Complete blood cell count, hematocrit, mean corpuscular volume, mean
Volume 26, Number 4, June 2015
1287
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Gu¨nbey et al
corpuscular hemoglobin content, mean corpuscular hemoglobin concentration, MPV, as well as red blood cell count distribution width, platelet count, platelet distribution values of the patients were analyzed comparatively in terms of preoperative and postoperative values.
Statistical Analyses Data were analyzed using the SPSS statistical software package (SPSS, version 15.0 for Windows; SPSS Inc, Chicago, IL). The adequacy of all parameters to normal distribution was tested using the Kolmogorov-Smirnov test. In the comparisons of both hematologic analyses, paired-samples t-test was used to compare parameters with normal distribution, and the Wilcoxon signed rank test was used to compare parameters without normal distribution. In both cohort comparisons, the Mann-Whitney tests were used. The Chi-squared test was used to compare the categorical parameters between the groups for pairwise comparisons. Pearson correlation analysis was implemented for testing variables. A significance level of 0.05 was used.
RESULTS Forty-two patients (29 men, 13 women) were included in the study. The mean (SD) age was 47.1 years (14.5 y). Mean (SD) preoperative body mass index (BMI) was 32.6 (8.4), and mean (SD) postoperative BMI was 31.2 (9.1). There was no significant difference in terms of preoperative and postoperative BMI. There were no significant differences in terms of red blood cell, hemoglobin, hematocrit, mean corpuscular volume, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, white blood cell, platelet count, platelet crit, or platelet distribution width (PDW) (P > 0.05) when the preoperative and postoperative 6-month hematologic parameters were compared. However, in the comparisons of preoperative and postoperative MPV values, a statistically significant decrease was detected (mean [SD] preoperative MPV, 9.4 [0.7] fl; mean [SD] postoperative MPV, 8.5 [0.8] fl; Wilcoxon signed rank test, P ¼ 0.014) (Fig. 1).
Volume 26, Number 4, June 2015
TABLE 1. The Comparisons of Preoperative and Postoperative Hematologic and Polysomnographic Findings Preop. (n ¼ 42) Hematologic parameters RBC (106 cells/mL) Hb (g/dL) Htc (%) WBC (103 cells/mL) PLT (103 cells/mL) MPV (mm3) PDW (mm3) Polysomnographic parameters Sleep efficiency (%) AHI (event per hour) AHI-supine (event per hour) AHI-nonsupine (event per hour) AHI-REM (event per hour) AHI–non-REM (event per hour) Mean % arterial O2 desaturation Maximum % arterial O2 desaturation
Postop. (n ¼ 42)
P
4.32 13.6 42.1 7.12 256.65 9.4 15.6
(0.45) (2.2) (4.7) (2.04) (57) (0.7) (1.1)
4.13 12.7 41.3 7.37 247.88 8.5 15.2
(0.62) (3.1) (5.5) (2.75) (13) (0.8) (0.9)
0.091 0.125 0.242 0.063 0.024 0.014 0.026
80.4 35.8 42.4 27.8 39.1 22.5 7.7 11.6
(16.3) (12.1) (13.6) (7.5) (11.7) (8.3) (3.8) (4.8)
82.5 15.3 24.7 19.2 18.4 8.2 4.3 8.4
(13.6) (9.8) (14.5) (6.6) (9.9) (6.5) (2.9) (3.7)
0.127
