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Easy, inexpensive tools for assessment of OSA patients.
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Murat Enoz, Department of Otolaryngology, Head&Neck Surgery Istanbul University, School of Medicine, Turkey
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muratenoz{at}yahoo.com Murat Enoz
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Dear Editor Obstructive sleep apnea (OSA) is characterized by periodic complete or partial upper airway obstruction during sleep, causing intermittent cessations of breathing (apneas) or reductions in airflow (hypopneas) despite ongoing respiratory effort. This disorder has been described for decades, but its recognition has remained a problem. Surgical approaches are likely more effective for patients with OSA with discrete craniofacial abnormalities than for simply obese patients. A wide variety of procedures are available, many of which are directed at the site of obstruction. Surgery can be carried out in at least 2 separate phases (Table). Phase I surgery can include combinations of all the listed procedures, with the exception of maxillomandibular advancement. The reported short- term response rate to these procedures in combination is approximately 60%. If the patient does not respond, Phase II surgery can be considered, which consists of maxillomandibular advancement. These surgeries are best conducted in tertiary centers by experienced surgeons. In selected patients the success rate from combined Phase I and II surgery can be as high as 90%. The success rate is likely lower if the patient is obese with severe OSA and oxygen desaturation to less than 70% (1). Table: Surgical approaches to OSA PhaseI *Nasalseptoplasty *Turbinate reduction *Tonsillectomy and adenoid resection *Laser-assisted uvulopalatoplasty *Uvulopalatopharyngoplasty *Mandibular osteotomy with *Genioglossus advancement *Hyoid myotomy-suspension Phase II *Maxillomandibular Advancement The use of a surgical approach to OSA that uses careful history and examination to identify levels of obstruction followed by systematic surgical intervention at each site is effective for the majority of patients. Observed failure of surgical procedures aimed at limited loci within the pharynx is assumed to result from residual or secondary airway compromise at a remote locus not addressed. A model considers the pharynx as consisting of two loci: (a) retropalatal: located posterior to the soft palate; and b) retrolingual: located posterior to the vertical portion of the tongue. The pharynx is preoperatively classified as follows: (a) Type I: only the retropalatal region is compromised; (b) Type II: both retropalatal and retrolingual regions are compromised; and (c) Type III: only the retrolingual region is compromised (2). UPPP was first described by Ikematsu in 1964 for treatment of habitual snoring (3). Uvulopalatopharyngoplasty (UPPP) that consists of removal of the palatine tonsil, uvula, a portion of the soft palate, and the lateral pharyngeal wall is the most common surgical procedure for the treatment of OSA (4). The reason UPPP can fail is that the procedure addresses the obstruction at the soft palate area only, without improving the airway at the base of the tongue (hypopharyngeal area). Many studies have studied the craniofacial anatomy in OSA using various imaging techniques. Although conventional cephalometry can be done in supine position (5), computed tomographic technique carries significant advantages over plain roentgenographic imaging as it allows beter delineation of soft tissue and air, hence more accurate measurements for upper airway morphology. Using CT to assess the upper airway and cephalometry in the same subject also provide a unique opportunity to evaluate the relationship between these two groups of parameters. However, in a recent study, CT of the upper airway did not show any difference in upper airway volume between OSA subjects and snorers (6). We are doing indirect laryngoscopy, fibrooptic endoscopy, and cephalometry as easy, inexpensive tools for assessment of the retroglossal region in the pre-surgical evaluation of OSA patients. It is also suggested that a three-dimensional imaging modality might be more informative, and would probably detect a narrow lateral pharyngeal wall that is not detected by plain cephalometry. Sincerely Dr. Murat Enoz References 1- Riley RW, Powell NB, Guilleminault C. Obstructive sleep apnea syndrome: a review of 306 consecutively treated surgical patients. Otolaryngol Head Neck Surg 1993;108:117-25. 2- Fujita S. Midline laser glossectomy with lingualplasty: A treatment of sleep apnea syndrome. Op Tech Otolaryngol HNS 1991; 2: 127- 131. 3- Ikematsu T. Study of snoring, 4th report: therapy. Journal of Japanese Otorhinolaryngology 1964;64:434-435. 4- Shepard JW, Olsen KD: Uvulopalatopharyngoplasty for the treatment of obstructive sleep apnea. Mayo Clin Proc 1990; 65:1260-1267. 5- Liu Y, Park YC, Lowe AA, Fleetham JA. Supine cephalometric analyses of adjustable oral appliance used in the treatment of obstructive sleep apnea. Sleep Breath 2000;4:59–66. 6- Chen NH, Li KK, Li SY, et al. Airway assessment by volumetric computed tomography in snorers and subjects with obstructive sleep apnea in a Far-East Asian population (Chinese). Laryngoscopy 2002;112:721–6. |
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