Revisione critica dei risultati e nuovi algoritmi decisionali sulla chirurgia dell'OSAS
Creators: name: Pari, Milena <1966>
Publisher: name: Alma Mater Studiorum - Università di Bologna
Year: 2008
Subjects: MED/26 Neurologia

description: Obstructive sleep apnoea/hypopnoea syndrome (OSAHS) is the periodic reduction or cessation of
airflow during sleep. The syndrome is associated whit loud snoring, disrupted sleep and observed
apnoeas. Surgery aims to alleviate symptoms of daytime sleepiness, improve quality of life and
reduce the signs of sleep apnoea recordered by polysomnography.
Surgical intervention for snoring and OSAHS includes several procedures, each designed to
increase the patency of the upper airway.
Procedures addressing nasal obstruction include septoplasty, turbinectomy, and radiofrequency
ablation (RF) of the turbinates. Surgical procedures to reduce soft palate redundancy include
uvulopalatopharyngoplasty with or without tonsillectomy, uvulopalatal flap, laser-assisted
uvulopalatoplasty, and RF of the soft palate. More significant, however, particularly in cases of
severe OSA, is hypopharyngeal or retrolingual obstruction related to an enlarged tongue, or more
commonly due to maxillomandibular deficiency. Surgeries in these cases are aimed at reducing the
bulk of the tongue base or providing more space for the tongue in the oropharynx so as to limit
posterior collapse during sleep. These procedures include tongue-base suspension, genioglossal
advancement, hyoid suspension, lingualplasty, and maxillomandibular advancement.
We reviewed 269 patients undergoing to osas surgery at the ENT Department of Forlì Hospital in
the last decade.
Surgery was considered a success if the postoperative apnea/hypopnea index (AHI) was less than
20/h.
According to the results, we have developed surgical decisional algorithms with the aims to
optimize the success of these procedures by identifying proper candidates for surgery and the
most appropriate surgical techniques.
Although not without risks and not as predictable as positive airway pressure therapy, surgery
remains an important treatment option for patients with obstructive sleep apnea (OSA),
particularly for those who have failed or cannot tolerate positive airway pressure therapy.
Successful surgery depends on proper patient selection, proper procedure selection, and
experience of the surgeon.
The intended purpose of medical algorithms is to improve and standardize decisions made in the
delivery of medical care, assist in standardizing selection and application of treatment regimens,
to reduce potential introduction of errors.
Nasal Continuous Positive Airway Pressure (nCPAP) is the recommended therapy for patients with
moderate to severe OSAS. Unfortunately this treatment is not accepted by some patient, appears
to be poorly tolerated in a not neglible number of subjects, and the compliance may be critical,
especially in the long term if correctly evaluated with interview as well with CPAP smart cards
analysis. Among the alternative options in Literature, surgery is a long time honoured solution.
However until now no clear scientific evidence exists that surgery can be considered a really
effective option in OSAHS management.
We have design a randomized prospective study comparing MMA and a ventilatory device
(Autotitrating Positive Airways Pressure – APAP) in order to understand the real effectiveness of
surgery in the management of moderate to severe OSAS.
Fifty consecutive previously full informed patients suffering from severe OSAHS were enrolled and
randomised into a conservative (APAP) or surgical (MMA) arm. Demographic, biometric, PSG and
ESS profiles of the two group were statistically not significantly different. One year after surgery or
continuous APAP treatment both groups showed a remarkable improvement of mean AHI and
ESS; the degree of improvement was not statistically different. Provided the relatively small
sample of studied subjects and the relatively short time of follow up, MMA proved to be in our
adult and severe OSAHS patients group a valuable alternative therapeutical tool with a success
rate not inferior to APAP.