Position-dependent obstructive sleep apnea and its influence on treatment success of mandibular advancement devices

© 2021, The Author(s), under exclusive licence to Springer Nature Switzerland AG.Purpose: Depending on the severity of pre-treatment obstructive sleep apnea (OSA) and the criteria used to define treatment success, the efficacy of mandibular advancement devices (MADs) ranges from 30 to 69%. Identifying suitable candidates is the key to increasing the efficacy of a MAD. Positive predictors include a low body mass index, a low apnea–hypopnea index (AHI), and low age. Another consideration is whether or not a patient’s OSA is position dependent. To evaluate the effect of such dependency on MAD treatment success, we studied the following: treatment success across the patient’s total AHI and in the supine and non-supine sleeping positions; the influence of pre-treatment position dependency on MAD treatment success; and the effect of MAD treatment on post-treatment shifts in position dependency. Methods: This is a single-center retrospective study of patients with OSA. Patients were diagnosed through an overnight polysomnography and treated with a MAD between February 2015 and January 2018. They were defined as being positional if the AHI in supine sleeping position was at least twice as high as in the non-supine position. Results: Complete treatment success was achieved in 32% of study population (n = 96) and partial success in 54%. Complete treatment success was significantly higher (p = 0.004) when a patient was sleeping in the non-supine position. Treatment success did not differ significantly between patients who were position dependent and those who were not. When treated with a MAD, patients did not spend significantly more time in supine position. Neither did we find any post-treatment shifts in position dependency. Conclusion: A MAD is an effective treatment modality that may significantly reduce the total AHI, supine, and non-supine AHI. Since position dependency has no impact on MAD treatment success, it does not determine whether or not a patient is a suitable candidate for MAD treatment

Daytime polysomnography to perform titration for upper airway stimulation in patients with obstructive sleep apnea

PURPOSE: Upper airway stimulation (UAS) is an innovative treatment for patients with obstructive sleep apnea (OSA). UAS titrations are performed 3 months after activation of the device to optimize its effectiveness. In general, these titrations are performed during an in-laboratory overnight polysomnography (PSG). However, overnight titrations are expensive and can be logistically challenging because they are labor-intensive which causes shortage of sleep technicians available for night shifts. In addition, recently, overnight PSGs were postponed and canceled due to the COVID-19 pandemic. We aimed to assess the feasibility of a daytime PSG to perform titration of UAS therapy as an alternative for a conventional overnight PSG. METHODS: We performed a prospective single-center observational cohort study. Patients were included when planned for UAS titration; this was approximately 6 months after UAS activation. Data on sleep architecture, patient experience, and respiratory outcomes were collected to evaluate the feasibility. An overnight follow-up PSG 12 months after implantation was used to compare sleep architecture and therapy response. RESULTS: Of 23 patients, four were excluded from analysis because of technical issues during PSG. Even though patients slept significantly shorter during the daytime PSG, this was enough time to complete the titration successfully with 30-min sleep in final therapeutic settings in 84% of the patients. Patients (94%) had a positive experience with the daytime titration. Respiratory outcomes were significantly reduced during titration and were maintained at the 12-month follow-up. CONCLUSION: Daytime titrations are a valuable alternative for conventional overnight titrations. Our findings suggest the implementation of daytime titrations as standard of care. This will contribute to easier logistics and better work circumstances for sleep technicians without jeopardizing titration quality

The Role of Isolated Nasal Surgery in Obstructive Sleep Apnea Therapy—A Systematic Review

Nasal obstruction is believed to play a significant role in the pathophysiology and management of obstructive sleep apnea (OSA). However, controversy remains about the ability of isolated nasal surgery to improve OSA. The objective of this systematic review is to give an updated overview of the literature on whether isolated nasal surgery can improve OSA subjectively (Epworth Sleepiness Scale (ESS)) and/or objectively (polysomnography (PSG)). Methods: A systematic review was performed searching the electronic databases PubMed, Embase.com (accessed on 20 June 2022) Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials (CENTRAL) up to 20 June 2022. Eligible studies were reviewed for methodological quality using the NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Results: Twenty-one studies met the inclusion criteria. The majority of the included studies reported no significant reduction in the apnea–hypopnea index (AHI) after isolated nasal surgery in patients with OSA. The meta-analysis suggests that the AHI slightly decreases after nasal surgery. The ESS was significantly lower after nasal surgery in eighteen studies. Conclusion: Based on the present analysis of objective outcomes, isolated nasal surgery did not improve the AHI significantly in the majority of the studies. The meta-analysis suggests a slight decrease in AHI after nasal surgery, but this reduction is not clinically relevant in terms of treatment success. Isolated nasal surgery should therefore not be recommended as a first-line treatment for OSA. Because of high study heterogeneity, these results should be interpreted with caution. Isolated nasal surgery can possibly improve OSA subjectively. Perhaps only OSA patients with complaints of nasal obstruction or OSA patients experiencing difficulty with continuous positive airway pressure (CPAP) compliance would benefit from isolated nasal surgery

The role of isolated nasal surgery in obstructive sleep apnea therapy : a systematic review

Purpose: Nasal obstruction is believed to play a significant role in the pathophysiology and management of obstructive sleep apnea (OSA). However, controversy remains about the ability of isolated nasal surgery to improve OSA. The objective of this systematic review is to give an updated overview of the literature on whether isolated nasal surgery can improve OSA subjectively (Epworth Sleepiness Scale (ESS)) and/or objectively (polysomnography (PSG)). Methods: A systematic review was performed searching the electronic databases PubMed, Embase.com (accessed on 20 June 2022) Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials (CENTRAL) up to 20 June 2022. Eligible studies were reviewed for methodological quality using the NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Results: Twenty-one studies met the inclusion criteria. The majority of the included studies reported no significant reduction in the apnea–hypopnea index (AHI) after isolated nasal surgery in patients with OSA. The meta-analysis suggests that the AHI slightly decreases after nasal surgery. The ESS was significantly lower after nasal surgery in eighteen studies. Conclusion: Based on the present analysis of objective outcomes, isolated nasal surgery did not improve the AHI significantly in the majority of the studies. The meta-analysis suggests a slight decrease in AHI after nasal surgery, but this reduction is not clinically relevant in terms of treatment success. Isolated nasal surgery should therefore not be recommended as a first-line treatment for OSA. Because of high study heterogeneity, these results should be interpreted with caution. Isolated nasal surgery can possibly improve OSA subjectively. Perhaps only OSA patients with complaints of nasal obstruction or OSA patients experiencing difficulty with continuous positive airway pressure (CPAP) compliance would benefit from isolated nasal surgery

Bilateral vs Unilateral Hypoglossal Nerve Stimulation in Patients With Obstructive Sleep Apnea

Objective: Unilateral hypoglossal nerve stimulation (uniHNS) is an effective treatment for obstructive sleep apnea. Bilateral hypoglossal nerve stimulation (biHNS) is a novel therapeutic option and a different approach to hypoglossal nerve stimulation. The aim of this study was to analyze the clinical outcome of the first 10 biHNS cases vs the first 10 uniHNS cases ever implanted. Study Design: Prospective data analysis. Setting: International multicenter comparative clinical trial. Methods: The first 10 patients in 2020 who received a biHNS device (Genio System; Nyxoah) and the first 10 patients in 2014 who received a uniHNS system (Inspire II; Inspire Medical Systems) were included. Treatment outcome was evaluated at 3 months after surgery. Data collection included demographics, apnea hypopnea index (AHI), oxygen saturation and desaturation index, Epworth Sleepiness Scale, and adverse events. Results: The mean ± SD age was 52.1 ± 9.6 years (biHNS) and 58.3 ± 8.6 years (uniHNS). The mean body mass index was 26.4 ± 5.6 kg/m2 (biHNS) and 26.2 ± 2.2 kg/m2 (uniHNS). The mean preimplantation AHI (biHNS, 39.9 ± 14.8/h; uniHNS, 32.2 ± 11.0/h) decreased in both groups after 3 months (biHNS, 19.2 ± 14.0/h, P =.008; uniHNS, 13.1 ± 16.8/h, P =.037) with no significant difference between groups (P =.720). The mean preimplantation Epworth Sleepiness Scale (biHNS, 11.8 ± 6.2; uniHNS, 11.1 ± 4.9) decreased as well after 3 months (biHNS, 9.4 ± 6.3; uniHNS, 6.0 ± 5.0). Conclusion: Preliminary postmarket data suggest that biHNS may be as safe and effective as uniHNS. Long-term follow-up in a larger sample size is required to assess the stability of biHNS

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

Bilateral vs unilateral hypoglossal nerve stimulation in patients with obstructive sleep apnea

OBJECTIVE: Unilateral hypoglossal nerve stimulation (uniHNS) is an effective treatment for obstructive sleep apnea. Bilateral hypoglossal nerve stimulation (biHNS) is a novel therapeutic option and a different approach to hypoglossal nerve stimulation. The aim of this study was to analyze the clinical outcome of the first 10 biHNS cases vs the first 10 uniHNS cases ever implanted. STUDY DESIGN: Prospective data analysis. SETTING: International multicenter comparative clinical trial. METHODS: The first 10 patients in 2020 who received a biHNS device (Genio System; Nyxoah) and the first 10 patients in 2014 who received a uniHNS system (Inspire II; Inspire Medical Systems) were included. Treatment outcome was evaluated at 3 months after surgery. Data collection included demographics, apnea hypopnea index (AHI), oxygen saturation and desaturation index, Epworth Sleepiness Scale, and adverse events. RESULTS: The mean ± SD age was 52.1 ± 9.6 years (biHNS) and 58.3 ± 8.6 years (uniHNS). The mean body mass index was 26.4 ± 5.6 kg/m(2) (biHNS) and 26.2 ± 2.2 kg/m(2) (uniHNS). The mean preimplantation AHI (biHNS, 39.9 ± 14.8/h; uniHNS, 32.2 ± 11.0/h) decreased in both groups after 3 months (biHNS, 19.2 ± 14.0/h, P = .008; uniHNS, 13.1 ± 16.8/h, P = .037) with no significant difference between groups (P = .720). The mean preimplantation Epworth Sleepiness Scale (biHNS, 11.8 ± 6.2; uniHNS, 11.1 ± 4.9) decreased as well after 3 months (biHNS, 9.4 ± 6.3; uniHNS, 6.0 ± 5.0). CONCLUSION: Preliminary postmarket data suggest that biHNS may be as safe and effective as uniHNS. Long-term follow-up in a larger sample size is required to assess the stability of biHNS

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. CITATION: Zhou N, Ho J-PTF, de Vries N, Bosschieter PFN, Ravesloot MJL, de Lange J. Evaluation of drug-induced sleep endoscopy as a tool for selecting patients with obstructive sleep apnea for maxillomandibular advancement. J Clin Sleep Med. 2022;18(4):1073-1081