Jaw thrust versus the use of a boil-and-bite mandibular advancement device as a screening tool during drug-induced sleep endoscopy

STUDY OBJECTIVES: The objectives of this study were to analyze agreement in degree of obstruction and configuration of the upper airway between jaw thrust and an oral device in situ during drug-induced sleep endoscopy and to evaluate clinical decision making using jaw thrust or a boil-and-bite mandibular advancement device (MAD; the MyTAP). METHODS: This was a single-center prospective cohort study in patients with obstructive sleep apnea who underwent drug-induced sleep endoscopy between January and July 2019. RESULTS: Sixty-three patients were included. Agreement among observations in the supine position for degree of obstruction was 60% (n = 36, κ = 0.41) at the level of the velum, 68.3% (n = 41, κ = 0.35) for oropharynx, 58.3% (n = 35, κ = 0.28) for tongue base, and 56.7% (n = 34, κ = 0.14) for epiglottis; agreement among observations in the lateral position were 81.7% (n = 49, κ = 0.32), 71.7% (n = 43, κ = 0.36), 90.0% (n = 54, κ = 0.23), and 96.7% (n = 58, κ = could not be determined), respectively. In the supine position, agreement for configuration of obstruction at the level of the velum was found in 20 of 29 patients (69.0%, κ = 0.41) and in the lateral position was 100%. Thirty patients would have been prescribed a MAD using jaw thrust and 34 using the boil-and-bite MAD as a screening instrument. The main reason for being labeled as nonsuitable was complete residual retropalatal collapse during jaw thrust. Using the boil-and-bite MAD, this was caused by complete retropalatal or hypopharyngeal collapse. CONCLUSIONS: There is only slight to moderate agreement in degree of obstruction for jaw thrust and a new-generation boil-and-bite MAD during drug-induced sleep endoscopy. Greater improvement of upper airway patency at the hypopharyngeal level was observed during jaw thrust, but this maneuver was less effective in improving upper airway obstruction at the retropalatal level. CITATION: Vonk PE, Uniken Venema JAM, Hoekema A, Ravesloot MJL, van de Velde–Muusers JA, de Vries N. Jaw thrust versus the use of a boil-and-bite mandibular advancement device as a screening tool during drug-induced sleep endoscopy. J Clin Sleep Med. 2020;16(7):1021–1027

Uvulopalatopharyngoplasty with or without tonsillectomy in the treatment of adult obstructive sleep apnea – A systematic review

Background: The most commonly performed surgical procedure for obstructive sleep apnea (OSA) is uvulopalatopharyngoplasty with or without tonsillectomy (UPPP ± TE). However, there is currently no review solely focusing on clinically relevant effects of standard UPPP technique with or without tonsillectomy as a monotherapy in patients with OSA. Methods: A systematic review and meta-analysis were performed to assess the effects of isolated UPPP ± TE in patients with OSA. Studies of any design referring to adult patients with obstructive sleep apnea diagnosed via polysomnography or comparable objective measures were considered, in which isolated “standard” UPPP ± TE was performed. Results: Forty-eight studies were included for the qualitative analysis. All but one study demonstrated a reduction in the frequency of respiratory events and success/response rates ranged from 35 to 95.2%. In the six studies that reported pre- and postoperative mean scores of the Epworth Sleepiness Scale (ESS), a reduction in sleepiness scores was demonstrated. Data addressing the effect of UPPP ± TE in comparison to no treatment or control were available from two randomized controlled trials (RCT). When pooling the data, UPPP ± TE was significantly more effective in reducing the apnea-hypopnea index (AHI) and Epworth Sleepiness Scale (ESS) (large effect): an AHI mean difference (MD) of −18.59 (95% CI −34.14, −3.04) and an ESS MD of −5.37 (95% CI −7,03, −3.72). Data addressing effect of UPPP ± TE in comparison to baseline was available from three RCT. When pooling the data, the AHI was reduced from a mean 35.4 to 17.9 (49.5% reduction); a MD of −20.41, 95% CI −32.78, −8.04 (−1.80, −1.15) (large effect). Various additional beneficial effects of UPPP ± TE were demonstrated including improvement in sexual function, ventricular function, sleep stages, serum lipid, depressive disorder and driving performance. Conclusion: UPPP ± TE reduces respiratory events and daytime sleepiness in adult patients with OSA and UPPP ± TE is superior to non-treated controls in this regard. Further research is needed to establish the long-term benefit, the impact on cardiovascular morbidity and the role of UPPP ± TE in the variety of available treatment options for OSA

The Annoying Nature of Snoring Sounds Is Not Only about Intensity: A Pilot Study on Exposed Test Subjects

This study aims to assess (i) which acoustic characteristics of snoring sounds are associated with the annoying nature of snoring sounds; (ii) whether listeners’ heart rates correlate with their perceived annoyance; and (iii) whether perceived annoyance is different between listeners with different experiences with their bedpartners’ snoring sounds. Six snoring epochs with distinct acoustic characteristics (viz., reference, high pitch, high intensity, short interval, irregular intensity, and irregular intervals) were collected from snoring patients. Twenty physicians and technicians were involved in the healthcare of snoring patients, and were divided into three groups based on personal experience with their bedpartners’ snoring sounds (viz., non-snoring, snoring but not annoying, and snoring and annoying). The test subjects listened to each epoch and rated its level of annoyance. Listeners’ heart rates were also recorded during the test using a finger plethysmograph. Within the limitations of this study, it was found that, compared with other snoring sounds, snoring sounds with high intensity and irregularity were associated with higher perceived annoyance. However, higher perceived annoyance of snoring sound was not reflected in heart rate-related parameters. In addition, listeners’ personal experiences do not seem to affect their perceived annoyance

Evaluation of body position in upper airway stimulation for obstructive sleep apnea—is continuous voltage sufficient enough?

Purpose: The definition of positional obstructive sleep apnea (POSA) is widely accepted as a difference of 50% or more in AHI between supine and non-supine position. Upper airway stimulation (UAS) is an effective treatment for OSA but the implant delivers a single voltage over sleep period without consideration of body position. Clinical practice suggests different outcomes for OSA in supine position under UAS treatment. Methods: Outcomes of 44 patients were analyzed 12 months after implantation in a two-center, prospective consecutive trial in a university hospital setting. Total night and supine AHI were evaluated and the ratio of time spent in supine was considered. Correlation between the classic and the modified definition of POSA and treatment response were evaluated. Results: The time ratio spent in supine position did not differ before implantation and after 12 months. Total and supine AHI were reduced with the use of UAS therapy (p < 0.001) but both the baseline and final supine AHI were higher than total night AHI. Considering POSA definition as a ratio of supine to non-supine AHI, there was no clear cutoff for defining responders neither with nor without the additional component of time in supine position. Conclusions: The OSA reduction is strong for the total AHI and supine AHI. Nonetheless, here, there is no cutoff for defining POSA as critical for UAS therapy response. Therefore, there is no evidence for excluding POSA patients from UAS in general. Future technology improvement should take body position and adaptive voltage into account

The influence of position dependency on surgical success in patients with obstructive sleep apnea undergoing maxillomandibular advancement

STUDY OBJECTIVES: (1) To evaluate surgical success in patients with obstructive sleep apnea undergoing maxillomandibular advancement (MMA) stratifying for the reduction of both the total apnea-hypopnea index (AHI) and the AHI in the supine and nonsupine position; (2) to evaluate the influence of position dependency on surgical outcome; and (3) to analyze the prevalence of residual position-dependent obstructive sleep apnea (OSA) in nonresponders after MMA. METHODS: A single-center retrospective study including a consecutive series of patients with OSA undergoing MMA between August 2011 and February 2019. RESULTS: In total, 57 patients were included. The overall surgical success was 52.6%. No significant difference in surgical success between nonpositional patients (NPP) and positional patients (PP) with OSA was found. Surgical success of the supine AHI was not significantly different between NPP and PP, but surgical success of the nonsupine AHI was significantly greater in NPP than in PP. Of the 17 preoperative NPP, 13 of them moved to being PP with less severe OSA postoperatively. In total, 21 out of 27 nonresponders (77.8%) were PP postoperatively. CONCLUSIONS: No significant difference in surgical success between NPP and PP undergoing MMA was found. However, the improvement of total and nonsupine AHI in NPP was significantly greater compared to PP. In nonresponders, a postoperative shift from severe OSA in NPP to less severe OSA in PP was found, caused by a greater reduction of the nonsupine AHI than the supine AHI postoperatively. In patients with residual OSA in the supine position after MMA, additional treatment with positional therapy can be indicated

The influence of position dependency on surgical success in patients with obstructive sleep apnea undergoing maxillomandibular advancement

STUDY OBJECTIVES: (1) To evaluate surgical success in patients with obstructive sleep apnea undergoing maxillomandibular advancement (MMA) stratifying for the reduction of both the total apnea-hypopnea index (AHI) and the AHI in the supine and nonsupine position; (2) to evaluate the influence of position dependency on surgical outcome; and (3) to analyze the prevalence of residual position-dependent obstructive sleep apnea (OSA) in nonresponders after MMA. METHODS: A single-center retrospective study including a consecutive series of patients with OSA undergoing MMA between August 2011 and February 2019. RESULTS: In total, 57 patients were included. The overall surgical success was 52.6%. No significant difference in surgical success between nonpositional patients (NPP) and positional patients (PP) with OSA was found. Surgical success of the supine AHI was not significantly different between NPP and PP, but surgical success of the nonsupine AHI was significantly greater in NPP than in PP. Of the 17 preoperative NPP, 13 of them moved to being PP with less severe OSA postoperatively. In total, 21 out of 27 nonresponders (77.8%) were PP postoperatively. CONCLUSIONS: No significant difference in surgical success between NPP and PP undergoing MMA was found. However, the improvement of total and nonsupine AHI in NPP was significantly greater compared to PP. In nonresponders, a postoperative shift from severe OSA in NPP to less severe OSA in PP was found, caused by a greater reduction of the nonsupine AHI than the supine AHI postoperatively. In patients with residual OSA in the supine position after MMA, additional treatment with positional therapy can be indicated

Evaluation of drug-induced sleep endoscopy as a tool for selecting patients with obstructive sleep apnea for maxillomandibular advancement

Study Objectives: (1) To investigate if drug-induced sleep endoscopy (DISE) findings are predictive of surgical response for patients undergoing maxillomandibular advancement (MMA) for obstructive sleep apnea (OSA) and (2) to investigate the predictive value of the jaw thrust maneuver during DISE in terms of surgical response to MMA. Methods: A retrospective cohort study was conducted in patients with OSA who underwent a baseline polysomnography (PSG) and DISE followed by MMA and a 3- to 6-month follow-up PSG between September 1, 2011, and September 30, 2020. Results: Sixty-four patients with OSA (50 males [78.1%]; mean ± SD age = 51.7 ± 9.5 years; mean ± SD apnea-hypopnea index = 49.0 ± 20.8 events/h) were included. Thirty-nine patients were responders, and 25 were nonresponders. Adjusting for baseline characteristics and surgical characteristics (eg, age, baseline apnea-hypopnea index, degree of maxillary advancement), patients with complete anteroposterior epiglottic collapse had 0.239 times lower odds for response to MMA (95% confidence interval, 0.059–0.979; P = .047). No significant relationship was found between complete concentric velum collapse and MMA response. There was no statistically significant association between effect of jaw thrust maneuver during DISE on upper airway patency and treatment outcome of MMA. Conclusions: This study indicates that DISE is a promising tool to identify patients who will or will not respond to MMA for treating OSA. Patients with complete anteroposterior epiglottic collapse may be less suitable candidates for MMA

Evaluation of a new simple treatment for positional sleep apnoea patients

Obstructive sleep apnoea syndrome is a common clinical problem. Positional sleep apnoea syndrome, defined as having a supine apnoeahypopnoea index of twice or more compared to the apnoeahypopnoea index in the other positions, occurs in 56% of obstructive sleep apnoea patients. A limited number of studies focus on decreasing the severity of sleep apnoea by influencing sleep position. In these studies an object was strapped to the back (tennis balls, squash balls, special vests), preventing patients from sleeping in the supine position. Frequently, this was not successful due to arousals while turning from one lateral position to the other, thereby disturbing sleep architecture and sleep quality. We developed a new neck-worn device which influences sleep position by offering a vibration when in supine position, without significantly reducing total sleep time. Thirty patients with positional sleep apnoea were included in this study. No side effects were reported. The mean apnoeahypopnoea index dropped from 27.7 +/- 2.4 to 12.8 +/- 2.2. Seven patients developed an overall apnoeahypopnoea index below 5 when using the device in ON modus. We expect that positional therapy with such a device can be applied as a single treatment in many patients with mild to moderate position-dependent obstructive sleep apnoea, while in patients with a more severe obstructive sleep apnoea such a device could be used in combination with other treatment modalitie

Development and Internal Validation of a Prediction Model for Surgical Success of Maxillomandibular Advancement for the Treatment of Moderate to Severe Obstructive Sleep Apnea

Background: Maxillomandibular advancement (MMA) has been shown to be the most effective surgical therapy for obstructive sleep apnea (OSA). Despite high success rates, there are patients who are considered as non-responders to MMA. In order to triage and inform these patients on their expected prognosis of MMA before the surgery, this study aimed to develop, internally validate, and calibrate a prediction model for the presence of surgical success for MMA in patients with OSA. Methods: A retrospective cohort study was conducted that included patients that had undergone MMA for moderate to severe OSA. Baseline clinical, polysomnographic, cephalometric, and drug-induced sleep endoscopy findings were recorded as potential predictors. Presence or absence of surgical success was recorded as outcome. Binary logistic regression analyses were conducted to develop the model. Performance and clinical values of the model were analyzed. Results: One hundred patients were included, of which sixty-seven (67%) patients reached surgical success. Anterior lower face height (ALFH) (OR: 0.93 [0.87–1.00], p = 0.05), superior posterior airway space (SPAS) (OR: 0.76 [0.62–0.92], p p = 0.13), and a central apnea index (CAI) p p = 0.20). The model showed acceptable discrimination with a shrunken area under the curve of 0.74, and acceptable calibration. The added predictive values for ruling in and out of surgical success were 0.21 and 0.32, respectively. Conclusions: Lower age at surgery, CAI < 5 events/hour, lower ALFH, and smaller SPAS were significant predictors for the surgical success of MMA. The discrimination, calibration, and clinical added values of the model were acceptable