Positional therapy in patients with residual positional obstructive sleep apnea after upper airway surgery

Abstract

Purpose/background

A considerable portion of patients has residual positional obstructive sleep apnea (POSA) after upper airway surgery. Those patients could benefit from additional treatment with positional therapy (PT). The objective of this prospective study was to assess the additional effect of PT in patients with residual POSA after upper airway surgery for sleep apnea.

Methods

A polysomnography (PSG) was used to diagnose a patient with residual POSA after surgery. After informed consent, patients were treated with PT for 3 months and underwent a follow-up PSG while using the sleep position trainer (SPT). Changes in apnea-hypopnea index (AHI) and sleep position parameters were analyzed. Compliance rates and mean disease alleviation (MDA) were determined.

Results

Thirty-three patients with a median postoperative AHI of 18.3/h sleep were included. With the SPT median AHI dropped to 12.5/h sleep and the Epworth Sleepiness Scale (ESS) improved from 10.0 to 7.0. After 3 months, 37.5 % patients were considered responders of whom 31.3 % had treatment success. The compliance rate with SPT was 89.0 %. MDA was 44.7 % for SPT alone. With the combination of both surgery and SPT, MDA was 65.6 %.

Conclusions

The results of this study indicate that additional PT in a complex OSA patient population with residual POSA after surgery can increase overall therapeutic effectiveness by improving the median MDA from 39.5 % (effect of surgery alone) to 65.6 % (effect of combining surgery and PT).

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References

  1. 1.

    American Academy of. Sleep Medicine (2005) International classification of sleep disorders: diagnostic and coding manual, ed 2nd edn. American Academy of Sleep Medicine, Westchester IL

    Google Scholar 

  2. 2.

    Benoist LB, Morong S, van Maanen JP, Hilgevoord AA, de Vries N (2014) Evaluation of position dependency in non-apneic snorers. Eur Arch Otorhinolaryngol 271(1):189–194

    CAS  Article  PubMed  Google Scholar 

  3. 3.

    Ravesloot MJ, van Maanen JP, Dun L, de Vries N (2013) The undervalued potential of positional therapy in position-dependent snoring and obstructive sleep apnea—a review of the literature. Sleep Breath 17(1):39–49

    CAS  Article  PubMed  Google Scholar 

  4. 4.

    Cartwright RD (1984) Effect of sleep position on sleep apnea severity. Sleep 7(2):110–114

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    Richard W, Kox D, den Herder C, Laman M, van Tinteren H, de Vries N (2006) The role of sleep position in obstructive sleep apnea syndrome. Eur Arch Otorhinolaryngol 263(10):946–950

    Article  PubMed  Google Scholar 

  6. 6.

    Oksenberg A, Silverberg DS, Arons E, Radwan H (1997) Positional vs nonpositional obstructive sleep apnea patients: anthropomorphic, nocturnal polysomnographic, and multiple sleep latency test data. Chest 112(3):629–639

    CAS  Article  PubMed  Google Scholar 

  7. 7.

    van Maanen JP, Meester KA, Dun LN, Koutsourelakis I, Witte BI, Laman DM, Hilgevoord AA, de Vries N (2013) The sleep position trainer: a new treatment for positional obstructive sleep apnoea. Sleep Breath 17(2):771–779

    Article  PubMed  Google Scholar 

  8. 8.

    van Maanen JP, de Vries N (2014) Long-term effectiveness and compliance of positional therapy with the sleep position trainer in the treatment of positional obstructive sleep apnea syndrome. Sleep 37(7):1209–1215

    Article  PubMed  PubMed Central  Google Scholar 

  9. 9.

    Kribbs NB, Pack AI, Kline LR, Smith PL, Schwartz AR, Schubert NM, Redline S, Henry JN, Getsy JE, Dinges DF (1993) Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea. Am Rev Respir Dis 147(4):887–895

    CAS  Article  PubMed  Google Scholar 

  10. 10.

    Almeida FR, Bansback N (2013) Long-term effectiveness of oral appliance versus CPAP therapy and the emerging importance of understanding patient preferences. Sleep 36(9):1271–1272

    Article  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Sutherland K, Vanderveken OM, Tsuda H, Marklund M, Gagnadoux F, Kushida CA, Cistulli PA (2014) Oral appliance treatment for obstructive sleep apnea: an update. J Clin Sleep Med 10(2):215–227

    PubMed  PubMed Central  Google Scholar 

  12. 12.

    Dieltjens M, Vroegop AV, Verbruggen AE, Wouters K, Willemen M, De Backer WA, Verbraecken JA, Van de Heyning PH, Braem MJ, de Vries N, Vanderveken OM (2014) A promising concept of combination therapy for positional obstructive sleep apnea. Sleep Breath 19(2):637–644

    Article  PubMed  PubMed Central  Google Scholar 

  13. 13.

    Aurora RN, Casey KR, Kristo D, Auerbach S, Bista SR, Chowdhuri S, Karippot A, Lamm C, Ramar K, Zak R, Morgenthaler TI (2010) Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults. Sleep 33(10):1408–1413

    PubMed  PubMed Central  Google Scholar 

  14. 14.

    Caples SM, Rowley JA, Prinsell JR, Pallanch JF, Elamin MB, Katz SG, Harwick JD (2010) Surgical modifications of the upper airway for obstructive sleep apnea in adults: a systematic review and meta-analysis. Sleep 33(10):1396–1407

    PubMed  PubMed Central  Google Scholar 

  15. 15.

    Pang KP, Woodson BT (2007) Expansion sphincter pharyngoplasty: a new technique for the treatment of obstructive sleep apnea. Otolaryngol. Head Neck Surg 137(1):110–114

    Article  PubMed  Google Scholar 

  16. 16.

    den Herder C, van Tinteren H, de Vries N (2005) Hyoidthyroidpexia: a surgical treatment for sleep apnea syndrome. Laryngoscope 115(4):740–745

    Article  Google Scholar 

  17. 17.

    Richard W, Kox D, den Herder C, van Tinteren H, de Vries N (2007) One stage multilevel surgery (uvulopalatopharyngoplasty, hyoid suspension, radiofrequent ablation of the tongue base with/without genioglossus advancement), in obstructive sleep apnea syndrome. Eur Arch Otorhinolaryngol 264(4):439–444

    Article  PubMed  Google Scholar 

  18. 18.

    Strollo PJ Jr, Soose RJ, Maurer JT, de Vries N, Cornelius J, Froymovich O, Hanson RD, Padhya TA, Steward DL, Gillespie MB, Woodson BT, Van de Heyning PH, Goetting MG, Vanderveken OM, Feldman N, Knaack L, Strohl KP (2014) Upper-airway stimulation for obstructive sleep apnea. N Engl J Med 370(2):139–149

    CAS  Article  PubMed  Google Scholar 

  19. 19.

    Vicini C, Dallan I, Canzi P, Frassineti S, Nacci A, Seccia V, Panicucci E, Grazia La PM, Montevecchi F, Tschabitscher M (2012) Transoral robotic surgery of the tongue base in obstructive sleep apnea-hypopnea syndrome: anatomic considerations and clinical experience. Head Neck 34(1):15–22

    Article  PubMed  Google Scholar 

  20. 20.

    Hoekema A, de Lange J, Stegenga B, de Bont LG (2006) Oral appliances and maxillomandibular advancement surgery: an alternative treatment protocol for the obstructive sleep apnea-hypopnea syndrome. J Oral Maxillofac Surg 64(6):886–891

    Article  PubMed  Google Scholar 

  21. 21.

    Holty JE, Guilleminault C (2010) Maxillomandibular advancement for the treatment of obstructive sleep apnea: a systematic review and meta-analysis. Sleep Med Rev 14(5):287–297

    Article  PubMed  Google Scholar 

  22. 22.

    Zaghi S, Holty JE, Certal V, Abdullatif J, Guilleminault C, Powell NB, Riley RW, Camacho M (2016) Maxillomandibular advancement for treatment of obstructive sleep apnea: a meta-analysis. JAMA Otolaryngol. Head Neck Surg 142(1):58–66

    Google Scholar 

  23. 23.

    van Maanen JP, Witte BI, de Vries N (2014) Theoretical approach towards increasing effectiveness of palatal surgery in obstructive sleep apnea: role for concomitant positional therapy? Sleep Breath 18(2):341–349

    PubMed  Google Scholar 

  24. 24.

    Johns MW (1991) A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep 14(6):540–545

    CAS  Article  PubMed  Google Scholar 

  25. 25.

    Weaver TE, Laizner AM, Evans LK, Maislin G, Chugh DK, Lyon K, Smith PL, Schwartz AR, Redline S, Pack AI, Dinges DF (1997) An instrument to measure functional status outcomes for disorders of excessive sleepiness. Sleep 20(10):835–843

    CAS  PubMed  Google Scholar 

  26. 26.

    Vanderveken OM, Dieltjens M, Wouters K, De Backer WA, Van de Heyning PH, Braem MJ (2013) Objective measurement of compliance during oral appliance therapy for sleep-disordered breathing. Thorax 68(1):91–96

    Article  PubMed  Google Scholar 

  27. 27.

    Vroegop AV, Vanderveken OM, Boudewyns AN, Scholman J, Saldien V, Wouters K, Braem MJ, Van de Heyning PH, Hamans E (2014) Drug-induced sleep endoscopy in sleep-disordered breathing: report on 1, 249 cases. Laryngoscope 124(3):797–802

    Article  PubMed  Google Scholar 

  28. 28.

    Riley RW, Powell NB, Guilleminault C (1993) Obstructive sleep apnea syndrome: a surgical protocol for dynamic upper airway reconstruction. J oral Maxillofac. Surg 51(7):742–747

    CAS  Google Scholar 

  29. 29.

    Hendler BH, Costello BJ, Silverstein K, Yen D, Goldberg A (2001) A protocol for uvulopalatopharyngoplasty, mortised genioplasty, and maxillomandibular advancement in patients with obstructive sleep apnea: an analysis of 40 cases. J oral Maxillofac. Surg 59(8):892–897

    CAS  Google Scholar 

  30. 30.

    Neruntarat C (2003) Genioglossus advancement and hyoid myotomy: short-term and long-term results. J Laryngol Otol 117(6):482–486

    CAS  Article  PubMed  Google Scholar 

  31. 31.

    Miller FR, Watson D, Boseley M (2004) The role of the genial bone advancement trephine system in conjunction with uvulopalatopharyngoplasty in the multilevel management of obstructive sleep apnea. Otolaryngol Head Neck Surg 130(1):73–79

    Article  PubMed  Google Scholar 

  32. 32.

    Verse T, Baisch A, Hormann K (2004) Multi-level surgery for obstructive sleep apnea. Preliminary objective results. Laryngorhinootologie 83(8):516–522

    CAS  Article  PubMed  Google Scholar 

  33. 33.

    Katsantonis GP, Miyazaki S, Walsh JK (1990) Effects of uvulopalatopharyngoplasty on sleep architecture and patterns of obstructed breathing. Laryngoscope 100(10 Pt 1):1068–1072

    CAS  Article  PubMed  Google Scholar 

  34. 34.

    Lee CH, Shin HW, Han DH, Mo JH, Yoon IY, Chung S, Choi HG, Kim JW (2009) The implication of sleep position in the evaluation of surgical outcomes in obstructive sleep apnea. Otolaryngol Head Neck Surg 140(4):531–535

    Article  PubMed  Google Scholar 

  35. 35.

    Lee CH, Kim SW, Han K, Shin JM, Hong SL, Lee JE, Rhee CS, Kim JW (2011) Effect of uvulopalatopharyngoplasty on positional dependency in obstructive sleep apnea. Arch Otolaryngol. Head Neck Surg 137(7):675–679

    Google Scholar 

  36. 36.

    Ravesloot MJ, de Vries N (2011) Reliable calculation of the efficacy of non-surgical and surgical treatment of obstructive sleep apnea revisited. Sleep 34(1):105–110

    CAS  PubMed  PubMed Central  Google Scholar 

  37. 37.

    Ravesloot MJ, de Vries N, Stuck BA (2014) Treatment adherence should be taken into account when reporting treatment outcomes in obstructive sleep apnea. Laryngoscope 124(1):344–345

    Article  PubMed  Google Scholar 

  38. 38.

    Dieltjens M, Braem MJ, Vroegop AV, Wouters K, Verbraecken JA, De Backer WA, Van de Heyning PH, Vanderveken OM (2013) Objectively measured vs self-reported compliance during oral appliance therapy for sleep-disordered breathing. Chest 144(5):1495–1502

    Article  PubMed  Google Scholar 

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Acknowledgments

We would like to thank our colleagues from the Clinical Neurophysiology department of the OLVG West Hospital Amsterdam for their assistance with this research project. Special thanks also to Kristel Meesters for her additional support.

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Correspondence to L.B.L. Benoist.

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No funding was received for this research.

Conflict of interest

Drs. L.B.L. Benoist, M. Verhagen, B. Torensma and J.P. van Maanen certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria, educational grants, participation in speakers’ bureaus, membership, employment, consultancies, stock ownership or other equity interest, and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge, or beliefs) in the subject matter or materials discussed in this manuscript. Prof. dr. N. de Vries is a member of the Medical Advisory Board of NightBalance, consultant of Philips Healthcare and Olympus, researcher for Inspire Medical Systems, member of ReVent’s Medical Advisory Board, and has shares in NightBalance and ReVent.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

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Benoist, L., Verhagen, M., Torensma, B. et al. Positional therapy in patients with residual positional obstructive sleep apnea after upper airway surgery. Sleep Breath 21, 279–288 (2017). https://doi.org/10.1007/s11325-016-1397-x

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Keywords

  • Residual positional obstructive sleep apnea
  • Positional therapy
  • Upper airway surgery
  • Obstructive sleep apnea