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Pattern of airway collapse on drug-induced sleep endoscopy of a 37-year-old man after maxillomandibular advancement. A, Velum: no collapse. B, Oropharynx: no collapse. 

Pattern of airway collapse on drug-induced sleep endoscopy of a 37-year-old man after maxillomandibular advancement. A, Velum: no collapse. B, Oropharynx: no collapse. 

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Objectives To use drug-induced sedation endoscopy (DISE) and computational fluid dynamics (CFD) modeling to study dynamic airway and airflow changes after maxillomandibular advancement (MMA), and how the changes correlate with surgical success based on polysomnography parameters. Study Design Retrospective cohort study. Setting University medical...

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Objective To describe the patterns of upper airway obstruction in patients with sleep-disordered breathing with apnea-hypopnea index (AHI) <5 using drug-induced sleep endoscopy (DISE). Study Design Retrospective study. Setting Tertiary care center. Subjects and Methods Inclusion of patients with sleep-disordered breathing with AHI <5 on polysomn...

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... A more retrusive profile with a smaller mandible should contribute to a smaller airway leading to tongue obstruction 47 . In our study, this facial feature has had a tendency not only with the tongue base obstruction but also with the obstruction at the oropharyngeal lateral wall, a piece of data another study had already found 48 . ...
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Objectives: To organize an assessment instrument with questionnaires and myofunctional orofacial/oropharyngeal assessment for OSA patients and correlate it with the upper airway obstructive site detected during drug-induced sleep endoscopy (DISE). Material and Methods: 29 OSA patients aged 22-65 years with an indication to undergo DISE to evaluate an alternative treatment to PAP and signed the consent form. Patients over 65 years old with maxillofacial deficiency and BMI>30 were excluded. The subjects answered the Pittsburgh, Berlin (snore), and Epworth questionnaires. The myofunctional orofacial/oropharyngeal assessment comprised soft palate, palatine pillars, and uvula (structure and mobility), tonsils (size), mandible (bony bases), hard palate (depth and width), tongue (posture, volume, width, and height), floor of mouth (mylohyoid), tongue suction and sustaining (mobility), “lowering of the back of the tongue” (stimulus), which were scored by three speech-language pathologists with expertise. DISE was scored according to VOTE classification. The statistical analysis (t-test) compared groups without and with obstruction in VOTE with questionnaires and myofunctional orofacial/oropharyngeal assessment. Results: The following were significantly different: snoring frequency (p=0.03) with VOTE/velopharynx; intensity (p=0.02) and frequency of snoring (p=0.03) with VOTE/lateral wall of oropharynx; suction the tongue and sustain (p=0.02) with VOTE/velopharynx; hard palate depth (p=0.02) and width (p=0.05) with obstruction VOTE/epiglottis; tonsils volume (p=0.05) with VOTE/epiglottis; tongue posture (p=0.00) with obstruction VOTE/epiglottis; floor of the mouth (p=0.02) with VOTE/epiglottis. Conclusion: Higher snoring frequency and intensity was observed in patients with obstruction at the velopharynx and oropharyngeal lateral wall. Obstruction at the velopharynx was associated with poor tongue ability to suck the tongue against the hard palate. Obstruction at the epiglottis had structural and functional associations, including the oropharyngeal lateral wall, affected by the palatine tonsils size, depth and width of the hard palate, tongue position, and flaccidity of the floor of mouth. Considering that this is a preliminary study, the data should be carefully verified and not generalized.
... It is not suitable to represent the total surgery group. Fifth, in addition to UPPP, there are several alternative options for upper airway surgery for OSA, such as maxillomandibular advancement surgery (MMA) (35), selective neurostimulation of the hypoglossal nerve (36) and lateral pharyngoplasty (37, 38), which have higher success rates and lower long-term complications than UPPP (39)(40)(41). Besides, lateral pharyngoplasty has effects on blood pressure improvement in patients with obstructive sleep apnea (42). ...
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Purpose To determine whether treatment with uvulopalatopharyngoplasty (UPPP) or continuous positive airway pressure (CPAP) in patients with obstructive sleep apnea (OSA) prevents hypertension, compared to those not receiving any treatment. Methods A retrospective cohort study was conducted among 413 patients with OSA (age ≥ 35 years) at the Shuang Ho Hospital between 2009 and 2016. The patients were divided into three groups: UPPP, CPAP, and non-treatment groups. Data about the personal characteristics, history of comorbidities, and polysomnography (PSG) reports were collected at baseline. A Cox model with inverse probability of treatment weighting was used to adjust for confounders and baseline diversity. Results After multivariate adjustment and weighting for incident hypertension, patients in both the CPAP and UPPP groups showed a significant preventive effect on hypertension than in the non-treatment group. Moreover, patients in the CPAP group had lower event rates than those in the UPPP group. Conclusion UPPP can prevent the development of new-onset hypertension in patients with OSA. CPAP had a better preventive effect than UPPP. UPPP might be a good alternative for reducing the risk of the onset of hypertension when compliance to CPAP is poor.
... Dichos niveles anatómicos de colapso no sólo se afectan por problemas de los tejidos blandos de la VAS en sí mismos, sino que podemos verlos afectados también por los otros factores contribuyentes a alteraciones anatómicas: -Alteraciones dentomaxilofaciales: • Del maxilar superior: este hueso, al rodear las fosas nasales y tener inserciones del paladar blando, teóricamente puede generar a su vez estrechez en los niveles nasal-nasofaríngeo y orofaríngeo retropalatal 9 . • De la mandíbula: este hueso, al tener inserciones de la musculatura suprahioídea y de los músculos constrictores faríngeos superior y medio, teóricamente puede generar estrechez en niveles orofaríngeo retropalatal y orofaríngeo retrolingual-hipofaríngeo 10 . ...
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Resumen Los trastornos respiratorios del sueño (ronquido primario y síndrome de apnea-hipopnea obstructiva del sueño) han sido tratados mediante múltiples modalidades a lo largo de la historia. Sin embargo, la cirugía de la vía aérea superior siempre ha estado presente, dando cabida a la aparición de múltiples técnicas para este fin. El estudio adecuado de los sitios anatómicos de estrechez o colapso de la vía aérea superior y sus contribuyentes (bajo el concepto de topodiagnóstico) y el mejor entendimiento de los mecanismos de acción de los diferentes procedimientos descritos, ha permitido el nacimiento de una nueva disciplina, dedicada al manejo quirúrgico planificado de este grupo de patologías: la cirugía del sueño. Palabras clave: Trastornos respiratorios del sueño, topodiagnóstico, cirugía multinivel, cirugía del sueño. Abstract Sleep-related breathing disorders (primary snoring and obstructive sleep apnea-hypopnea syndrome) have been treated with multiple modalities throughout history. However, upper airway surgery has always been present, giving appearance of multiple techniques for this purpose. The adequate study of the anatomical sites of upper airway narrowness or collapse and its contributors (under the concept of topodiagnosis) and a better understanding of the different procedures, has allowed the birth of a new discipline, dedicated to a planned surgical management for this group of pathologies: sleep surgery.
... With the development of the biomechanical technique and on the basis of studies on the air ow characteristics in normal airway, there are more and more researches on the internal ow eld of upper airway in OSA patients. In order to meet the needs of clinical diagnosis and treatment, scholars have carried out a lot of CFD studies on the biomechanical model of upper airway in OSA patients, from simulating various virtual surgeries [9] to evaluating the real surgical effects [10][11][12]. Based on the previous studies, CFD has been considered to have high reliability and accuracy, can be used to evaluate the changes of air ow in the upper airway caused by stenosis in OSA patients, also can be used to quantitatively analyze the in uence of the changes caused by surgical treatments on air ow characteristics, which are helpful to objectively evaluate the curative effects after surgical treatment. ...
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Background: Current researches about hemifacial microsomia (HFM) patients after distraction osteogenesis (DO) most emphasize the morphologic changes. This case report shows the outcome of DO on the upper airway of a HFM patient with obstructive sleep apnea (OSA) based on the use of computational fluid dynamics (CFD). Case presentation: A boy of 11-year-old was diagnosed as HFM with OSA, and underwent unilateral DO. Polysomnography and CT scans were performed before and six months after treatment. After DO, lowest blood oxygen saturation increased from 81% to 95% and apnea and hypopnea index decreased from 6.4 events/hour to 1.2 events/hour. The oropharynx and nasopharynx were obviously expanded. We observed apparently increased average pressure, decreased average velocity and pressure drop in all cross-sections, and largely decreased airflow resistance and maximum velocity entirely in the airway. Conclusions: The results suggest that DO might be effective for the treament of OSA by expanding the upper airway and reducing the resistance of inspiration.
... With the development of the biomechanical technique and on the basis of studies on the air ow characteristics in normal airway, there are more and more researches on the internal ow eld of upper airway in OSA patients. In order to meet the needs of clinical diagnosis and treatment, scholars have carried out a lot of CFD studies on the biomechanical model of upper airway in OSA patients, from simulating various virtual surgeries [9] to evaluating the real surgical effects [10][11][12]. Based on the previous studies, CFD has been considered to have high reliability and accuracy, can be used to evaluate the changes of air ow in the upper airway caused by stenosis in OSA patients, also can be used to quantitatively analyze the in uence of the changes caused by surgical treatments on air ow characteristics, which are helpful to objectively evaluate the curative effects after surgical treatment. ...
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Background: Current researches about hemifacial microsomia (HFM) patients after distraction osteogenesis (DO) most emphasize the morphologic changes. This case report shows the outcome of DO on the upper airway of a HFM patient with obstructive sleep apnea (OSA) based on the use of computational fluid dynamics (CFD). Case presentation: A boy of 11-year-old was diagnosed as HFM with OSA, and underwent unilateral DO. Polysomnography and CT scans were performed before and six months after treatment. After DO, lowest blood oxygen saturation increased from 81% to 95% and apnea and hypopnea index decreased from 6.4 events/hour to 1.2 events/hour. The oropharynx and nasopharynx were obviously expanded. We observed apparently increased average pressure, decreased average velocity and pressure drop in all cross-sections, and largely decreased airflow resistance and maximum velocity entirely in the airway. Conclusions: The results suggest that DO might be effective for the treament of OSA by expanding the upper airway and reducing the resistance of inspiration.
... Lateral pharyngeal wall collapse, for instance, is a notoriously difficult area to address with soft tissue surgery. Maxillomandibular advancement advances the bony framework of the upper and lower jaws, is highly successful at reducing upper airway collapsibility especially at the lateral walls, and produces excellent outcomes [48,49]. Advocating this arguably more major surgery as the primary procedure is justifiable in cases where DISE reveals significant lateral pharyngeal collapse. ...
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Obstructive sleep apnea is a prevalent sleep disorder characterized by partial or complete obstruction of the upper airway. Continuous positive airway pressure is the first-line therapy for most patients, but compliance is often poor. Alternative treatment options such as mandibular advancement devices, positional therapy and surgical interventions including upper airway stimulation target different levels and patterns of obstruction with varying degrees of success. Drug-induced sleep endoscopy enables visualization of upper airway obstruction under conditions mimicking sleep. In an era of precision medicine, this additional information may facilitate better decision-making when prescribing alternative treatment modalities, with the hope of achieving better compliance and/or success rates. This review discusses the current knowledge and evidence on the role of drug-induced sleep endoscopy in the non-positive airway pressure management of obstructive sleep apnea.
... But as we have said, for patients already suffering the stress that accompanies this epidemic through sleep disruption (of which the worst is obstructive sleep apnea), symptomatic treatments include oral appliances, the use of CPAP (continuous positive airway pressure) machines, and surgery (Liu et al. 2016(Liu et al. , 2019. ...
Article
Contemporary humans are living very different lives from those of their ancestors, and some of the changes have had serious consequences for health. Multiple chronic "diseases of civilization," such as cardiovascular problems, cancers, ADHD, and dementias are prevalent, increasing morbidity rates. Stress, including the disruption of traditional sleep patterns by modern lifestyles, plays a prominent role in the etiology of these diseases, including obstructive sleep apnea. Surprisingly, jaw shrinkage since the agricultural revolution, leading to an epidemic of crooked teeth, a lack of adequate space for the last molars (wisdom teeth), and constricted airways, is a major cause of sleep-related stress. Despite claims that the cause of this jaw epidemic is somehow genetic, the speed with which human jaws have changed, especially in the last few centuries, is much too fast to be evolutionary. Correlation in time and space strongly suggests the symptoms are phenotypic responses to a vast natural experiment-rapid and dramatic modifications of human physical and cultural environments. The agricultural and industrial revolutions have produced smaller jaws and less-toned muscles of the face and oropharynx, which contribute to the serious health problems mentioned above. The mechanism of change, research and clinical trials suggest, lies in orofacial posture, the way people now hold their jaws when not voluntarily moving them in speaking or eating and especially when sleeping. The critical resting oral posture has been disrupted in societies no longer hunting and gathering. Virtually all aspects of how modern people function and rest are radically different from those of our ancestors. We also briefly discuss treatment of jaw symptoms and possible clinical cures for individuals, as well as changes in society that might lead to better care and, ultimately, prevention.
... Here, the focus is on how drug-induced sedation (or sleep) endoscopy (DISE) has been used within the context of extrapharyngeal surgery. DISE has been added to the comprehensive decision-making process for sleep surgery in general [12], and for MMA in particular [13][14][15]. MMA reverses lateral pharyngeal wall collapse and complete concentric collapse (CCC) of the velum under DISE. As lateral pharyngeal wall collapse is difficult to resolve with intrapharyngeal operations [16][17][18], MMA can be considered in OSA patients with this airway collapse pattern, regardless of their maxillofacial phenotype [19][20][21]. ...
... Previously, it was thought that the MMA effectively reduces the apnea-hypopnea index (AHI) by expanding the skeletal frame and allowing more room for the tongue. More recent dynamic examinations have shown that in fact, stability of the velum and lateral pharyngeal wall is most consistently associated with the success of MMA [14,15]. Hence, the contribution of MMA to AHI reduction derives both from the stability of upper airway dilator muscles and from the increased intraoral volume for the tongue. ...
... Other indications include inadequate response to Riley-Powell phase 1 surgery (intrapharyngeal surgery with or without genioglossus advancement) [11,19,21]. Concentric and lateral pharyngeal wall collapse observed on DISE also favor MMA [14,15]. While there is not a strict body mass index (BMI) cutoff, the efficacy of upper airway surgery decreases with increasing BMI. ...
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There are many ways to categorize surgery for obstructive sleep apnea (OSA), one of which is to distinguish between intrapharyngeal and extrapharyngeal procedures. While the general otolaryngologist treating OSA is familiar with intrapharyngeal procedures, such as uvulopalatopharyngoplasty and tongue base reduction, extrapharyngeal sleep operations such as maxillomandibular advancement (MMA) and upper airway stimulation (UAS) have evolved rapidly in the recent decade and deserve a dedicated review. MMA and UAS have both shown predictable high success rates with low morbidity. Each approach has unique strengths and limitations, and for the most complex of OSA patients, the two in combination complement each other. Extrapharyngeal airway operations are critical for achieving favorable outcomes for sleep surgeons.
... The patterns of complete concentric collapse (CCC), multilevel collapse, and tongue base collapse are associated with higher AHI [41,42]. CCC has been associated with poor surgical outcomes in multilevel surgery and upper airway stimulation (UAS) [43,44], but is well-addressed by MMA [45]. ...
... MMA involves osteotomies of the maxilla and mandible, followed by their advancement that is frequently accompanied with counterclockwise rotation (Fig. 5) [102,103]. The net effect includes greater volume for intraoral soft tissue structures and stability of the upper airway dilator muscles [7,45,104,105]. Generally, indications for MMA are : (1) moderate to severe OSA with our without history of phase 1 surgery, (2) OSA of all severity if there is comorbid dentofacial deformity, and (3) concentric and lateral pharyngeal wall collapse seen with DISE [6,7,103]. Age of patient and severity of OSA have not been shown to impact the technical aspects of MMA in a high volume center [106]. ...
... Beyond the AHI, MMA has shown normalization of sleep architecture (increase in REM sleep and decrease in wakefulness after sleep onset when compared to age-matched healthy controls [45]. It has also shown improvements in multiple health-related and functional outcomes [111]. ...
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Sleep surgery is part of a continuum of care for OSA that involves medical, pharmacologic, and behavioral therapy. Upper airway surgery for OSA can significantly improve stability by way of modulating the critical negative closing pressure. This is the same mechanism of action as PAP or oral appliance therapy (OAT). The updated surgical algorithm in this review adds precision in 3 areas: 1) patient selection, 2) identification of previously unaddressed anatomic phenotypes with associated treatment modality, and 3) improved techniques of previously established procedures. While the original Riley and Powell Phase 1 and 2 approach to sleep surgery has focused on individual surgical success rate, this algorithm strives for an overall treatment success with multi-modal and patient-centric treatments.
... 13,14,16 In the case of complete concentric collapse at the velum, this pattern tends to be refractory to soft tissue surgical intervention, 12,17,18 although it has been reported to respond to skeletal surgery such as maxillomandibular advancement. 21,22 Furthermore, complete concentric velum collapse disqualifies patients from candidacy for hypoglossal nerve stimulation, an otherwise very promising PAP-alternative treatment for OSA. 17 It may be that obesity mediates the development of OSA by affecting the velopharynx and oropharynx preferentially, and by induction of 2C obstruction in particular, because this was the pattern seen to be driving statistical significance of velopharynx findings with increased BMI. ...
Article
Objectives We describe drug‐induced sleep endoscopy (DISE) obstruction patterns in adults with obstructive sleep apnea (OSA) based on body mass index (BMI). We also evaluate subgroups of patients with clinically significant obstruction patterns at the velopharynx and oropharynx. Study Design Retrospective chart review. Methods Single‐institution, retrospective chart review of adults with OSA who underwent DISE with dexmedetomidine sedation from 2016 to 2018. Endoscopic findings were graded using VOTE (Velum, Oropharynx, Tongue base, Epiglottis) classification. Oropharyngeal obstruction was additionally graded with the modifier T when due to palatine tonsil tissue. Findings in patients who had BMI < 25, 25 ≤ BMI < 30, and BMI ≥ 30 were compared. Results One hundred and eleven patients (1 underweight, 23 normal weight, 56 overweight, and 31 obese) were reviewed. Patients with lower BMI were more likely to have more severe obstruction at the level of the tongue base (χ2 = 11.52, P = .021) and epiglottis (χ ² = 10.56, P = .032). Conversely, patients with higher BMI were more likely to have complete concentric (grade 2C) velum obstruction (χ ² = 16.04, P < .001) and more severe oropharyngeal obstruction (χ ²= 9.65, P = .046). Patients with grade 2 oropharyngeal obstruction without tonsil obstruction had more severe concurrent velum obstruction compared to subjects with grade 2 T oropharyngeal obstruction (P = .009). Conclusion In adults with OSA, BMI categories have significantly distinct obstruction patterns at all airway levels on DISE, and there appear to be distinct subgroups associated with certain velum and oropharynx collapse patterns. These findings may have important implications for positive airway pressure–alternative treatment. Level of Evidence 3 Laryngoscope , 2020