This paper, which has been reviewed and approved by the Board of Directors of the American Sleep Disorders Association, provides the background for the Standards of Practice Committee's parameters for the practice of sleep medicine in North America. The intent of this paper is to provide an overview of the surgical treatment of obstructive sleep apnea syndrome, to provide the basis for the American Sleep Disorders Association's practice parameters on this subject and to share our findings of metanalysis of previously published studies regarding uvulopalatopharyngoplasty. We searched MEDLINE from January 1966 through April 1993, with an update in February 1995, to provide a review of the application of surgical modifications of the upper airway to treat adults with obstructive sleep apnea syndrome. Operations to treat obstructive sleep apnea syndrome include nasal septal reconstruction; uvulopalatopharyngoplasty; uvulopalatopharyngoglossoplasty; laser midline glossectomy; lingualplasty; inferior sagittal mandibular osteotomy and genioglossal advancement, with hyoid myotomy and suspension (the entire process is referred to as GAHM); maxillomandibular osteotomy and advancement, and tracheotomy. Papers included in metanalysis provided preoperative and postoperative polysomnographic data on at least nine patients treated with uvulopalatopharyngoplasty for their obstructive sleep apnea. Analysis of the uvulopalatopharyngoplasty papers revealed that this procedure is, at best, effective in treating less than 50% of patients with obstructive sleep apnea syndrome. The site of pharyngeal narrowing or collapse, although identified by different and unvalidated methods, has a marked effect on the probability of success of uvulopalatopharyngoplasty. Patients who achieve a favorable response with uvulopalatopharyngoplasty tend to have less severe obstructive sleep apnea than those who do not. For patients who demonstrate retrolingual narrowing or collapse, other surgical modifications have been described, such as lingualplasty, GAHM, and maxillomandibular osteotomy and advancement. The studies to support the use of the surgical treatment of obstructive sleep apnea syndrome contain biases related to small sample size, limited follow-up and patient selection.

The Efficacy of Surgical Modifications of the Upper Airway in Adults With Obstructive Sleep Apnea Syndrome

Spinal hematoma has been described in autopsies since 1682 and as a clinical diagnosis since 1867. It is a rare and usually severe neurological disorder that, without adequate treatment, often leads to death or permanent neurological deficit. Epidural as well as subdural and subarachnoid hematomas have been investigated. Some cases of subarachnoid spinal hematoma may present with symptoms similar to those of cerebral hemorrhage. The literature offers no reliable estimates of the incidence of spinal hematoma, perhaps due to the rarity of this disorder. In the present work, 613 case studies published between 1826 and 1996 have been evaluated, which represents the largest review on this topic to date. Most cases of spinal hematoma have a multifactorial etiology whose individual components are not all understood in detail. In up to a third of cases (29.7%) of spinal hematoma, no etiological factor can be identified as the cause of the bleeding. Following idiopathic spinal hematoma, cases related to anticoagulant therapy and vascular malformations represent the second and third most common categories. Spinal and epidural anesthetic procedures in combination with anticoagulant therapy represent the fifth most common etiological group and spinal and epidural anesthetic procedures alone represent the tenth most common cause of spinal hematoma. Anticoagulant therapy alone probably does not trigger spinal hemorrhage. It is likely that there must additionally be a "locus minoris resistentiae" together with increased pressure in the interior vertebral venous plexus in order to cause spinal hemorrhage. The latter two factors are thought to be sufficient to cause spontaneous spinal hematoma. Physicians should require strict indications for the use of spinal anesthetic procedures in patients receiving anticoagulant therapy, even if the incidence of spinal hematoma following this combination is low. If spinal anesthetic procedures are performed before, during, or after anticoagulant treatment, close monitoring of the neurological status of the patient is warranted. Time limits regarding the use of anticoagulant therapy before or after spinal anesthetic procedures have been proposed and are thought to be safe for patients. Investigation of the coagulation status alone does not necessarily provide an accurate estimate of the risk of hemorrhage. The most important measure for recognizing patients at high risk is a thorough clinical history. Most spinal hematomas are localized dorsally to the spinal cord at the level of the cervicothoracic and thoracolumbar regions. Subarachnoid hematomas can extend along the entire length of the subarachnoid space. Epidural and subdural spinal hematoma present with intense, knife-like pain at the location of the hemorrhage ("coup de poignard") that may be followed in some cases by a pain-free interval of minutes to days, after which there is progressive paralysis below the affected spinal level. Subarachnoid hematoma can be associated with meningitis symptoms, disturbances of consciousness, and epileptic seizures and is often misdiagnosed as cerebral hemorrhage based on these symptoms. Most patients are between 55 and 70 years old. Of all patients with spinal hemorrhage, 63.9% are men. The examination of first choice is magnetic resonance imaging. The treatment of choice is surgical decompression. Of the patients investigated in the present work, 39.6% experienced complete recovery. The less severe the preoperative symptoms are and the more quickly surgical decompression can be performed, the better are the chances for complete recovery. It is therefore essential to recognize the relatively typical clinical presentation of spinal hematoma in a timely manner to allow correct diagnostic and therapeutic measures to be taken to maximize the patient's chance of complete recovery.

Spinal hematoma: a literature survey with meta-analysis of 613 patients

Pulmonary Complications of Obesity

Although there is increasing interest in the use of oral appliances to treat obstructive sleep apnea (OSA), the evidence base for this is weak. Furthermore, the precise mechanisms of action are uncertain. We aimed to systematically investigate the efficacy of a novel mandibular advancement splint (MAS) in patients with OSA. The sample consisted of 28 patients with proven OSA. A randomized, controlled three-period (ABB/BAA) crossover study design was used. After an acclimatization period, patients underwent three polysomnographs with either a control oral plate, which did not advance the mandible (A), or MAS (B), 1 wk apart, in either the ABB or BAA sequence. Complete response (CR) was defined as a resolution of symptoms and a reduction in Apnea/Hypopnea Index (AHI) to or = 50% reduction in AHI, but remaining > or = 5/h. Twenty-four patients (19 men, 5 women) completed the protocol. Subjective improvements with the MAS were reported by the majority of patients (96%). There were significant improvements in AHI (30 +/- 2/h versus 14 +/- 2/h, p < 0.0001), MinSa(O(2)) (87 +/- 1% versus 91 +/- 1%, p < 0.0001), and arousal index (41 +/- 2/h versus 27 +/- 2/h, p < 0.0001) with MAS, compared with the control. The control plate had no significant effect on AHI and MinSa(O(2)). CR (n = 9) or PR (n = 6) was achieved in 62.5% of patients. The MAS is an effective treatment in some patients with OSA, including those patients with moderate or severe OSA.

https://www.atsjournals.org/doi/pdf/10.1164/ajrccm.163.6.2004213

A Randomized, Controlled Study of a Mandibular Advancement Splint for Obstructive Sleep Apnea

A Randomized Crossover Study of an Oral Appliance vs Nasal-Continuous Positive Airway Pressure in the Treatment of Mild-Moderate Obstructive Sleep Apnea

This paper, which has been reviewed and approved by the Board of Directors of the American Sleep Disorders Association, provides the background for the Standards of Practice Committee's parameters for the practice of sleep medicine in North America. The 21 publications selected for this review describe 320 patients treated with oral appliances for snoring and obstructive sleep apnea. The appliances modify the upper airway by changing the posture of the mandible and tongue. Despite considerable variation in the design of these appliances, the clinical effects are remarkably consistent. Snoring is improved and often eliminated in almost all patients who use oral appliances. Obstructive sleep apnea improves in the majority of patients; the mean apnea-hypopnea index (AHI) in this group of patients was reduced from 47 to 19. Approximately half of treated patients achieved an AHI of < 10; however, as many as 40% of those treated were left with significantly elevated AHIs. Improvement in sleep quality and sleepiness reflects the effect on breathing. Limited follow-up data indicate that oral discomfort is a common but tolerable side effect, that dental and mandibular complications appear to be uncommon and that long-term compliance varies from 50% to 100% of patients. Comparison of the risk and benefit of oral appliance therapy with the other available treatments suggests that oral appliances present a useful alternative to continuous positive airway pressure (CPAP), especially for patients with simple snoring and patients with obstructive sleep apnea who cannot tolerate CPAP therapy.

/pdf/oral-appliances-for-the-treatment-of-snoring-and-obstructive-2vb2nmej8w.pdf

Francisco Perez-Guerra

Papers

Oral appliances for the treatment of snoring and obstructive sleep apnea: a review.

Epidural Hematoma as a Cause of Postpneumonectomy Paraplegia

Hypercapnia during latrogenically Induced Metabolic Alkalosis

IgG4 Related Disease Emerging