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Original Research Otolaryngology– Head and Neck Surgery 1–8 Comparative Effectiveness of the Ó American Academy of Otolaryngology—Head and Neck Different Treatment Modalities for Surgery Foundation 2015 Reprints and permission: sagepub.com/journalsPermissions.nav Snoring DOI: 10.1177/0194599815596166 http://otojournal.org

Stefanie Terryn, MD1,2, Joris De Medts, MD1,2, and Kathelijne Delsupehe, MD1

No sponsorships or competing interests have been disclosed for this article. Received February 16, 2015; revised June 8, 2015; accepted June 25, 2015. Abstract Objective. To evaluate what effects treatments of sleep- noring affects approximately 30% of middle-aged disordered breathing have on snoring and sleepiness: snoring men and 20% of middle-aged women.1,2 Although surgery including osteotomies, mandibular advancement device Sthe clinical significance of primary or nonapneic (MAD), and continuous positive airway pressure (CPAP). snoring remains equivocal, its psychosocial impact is con- 3,4 Study Design. Single-institution prospective comparative siderable. Snoring and obstructive sleep apnea (OSA) are 5 effectiveness trial. part of the spectrum of sleep-disordered breathing (SDB). Daytime sleepiness is the major contributor to the reduced Setting. University-affiliated secondary care teaching hospital. quality of life, mood disturbance, and decreased work per- Subjects and Methods. We prospectively studied 224 patients formance in SDB patients. Therefore, all patients presenting presenting with snoring at our department. All patients with snoring should undergo a polysomnography (PSG) to 5 underwent detailed evaluation, including symptom question- exclude sleep apnea. Additionally, we previously demon- naires, clinical examination, polysomnography, and drug- strated the added value of drug-induced sleep endoscopy 6 induced sleep endoscopy. Based on these results, a treat- (DISE) in the evaluation and treatment selection. In contrast ment was proposed after multidisciplinary consultation. to OSA, there is no golden standard treatment of primary 7 Treatment was evaluated through 4 questionnaires before snoring. Currently, a number of surgical and nonsurgical treatment and 6 weeks and 6 months after. Treatment suc- treatments are available for the management of nonapneic cess was defined as a global snoring visual analog scale score snoring. Studies reporting the outcome of the different treat- 3 at 6 months. ment modalities are of a low methodological quality with very few between-group comparisons being reported.7 The Results. A total of 195 patients complied with full workup and aim of this study was to provide rigorous evidence of the were proposed treatment. The mean age was 46 6 11 years; effectiveness on snoring and daytime sleepiness of the differ- the mean body mass index, 27 6 4; and the median apnea- ent treatment modalities for the whole spectrum of SDB in a hypopnea index, 10.0 (interquartile range, 4.7-20.1). After dis- real-world setting, including all patients irrespective of their cussion, 116 (59.5%) patients agreed to start treatment (46%, presentation or clinical findings. Hence, this is a comparative surgery; 26% MAD; 28% CPAP). All symptom scores, including effectiveness study. Unlike a randomized controlled trial, this Epworth Sleepiness Scale, decreased significantly for all treat- study should enable physicians to inform all patients on the ments at 6 weeks and 6 months. Treatment was successful in potential benefit of a specific treatment. 67% of the surgery patients, 67% of the MAD group, and 76% of the CPAP group. Only 6.7% reported an unchanged snoring Methods score in the surgery group, compared with 13.6% in the MAD Subjects groupand9.6%intheCPAPgroup. We included in this study a consecutive group of 224 patients Conclusion. Multidisciplinary agreed-on treatment of snoring who presented with snoring at our department from May is effective across the proposed treatments. 1ENT Department, AZ Delta, Roeselare, Belgium 2ENT Department, University Hospitals Leuven, Leuven, Belgium Keywords snoring treatments, sleep-disordered breathing, snoring sur- Corresponding Author: Kathelijne Delsupehe, MD, Department of Otolaryngology, AZ Delta, gery, mandibular advancement device, continuous positive Wilgenstraat 2, B 8800 Roeselare, Belgium. airway pressure Email: [email protected]

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2011 until November 2013. The study was approved by the was successful, we chose MAD as primary treatment. institutional review board (Medical Ethical Committee) of When it was not, we proposed multilevel surgery (a our institution and registered at http://www.clinicaltrials.be as palatal procedure with additional radiofrequency abla- trial B117201111290. All patients signed a written informed tion of the tongue base). consent prior to inclusion in the study. In case of troublesome nose obstruction with a significant septal deviation or hypertrophic conchae, Patient Initial Evaluation and Treatment Proposal nasal surgery was suggested exclusively or in com- At first presentation, a standardized clinical investigation bination with surgery at another level. was performed—including scoring of the Friedman tongue position, tonsil size, uvula and palatal webbing, evaluation of dental occlusion and chin position, skeletal class, nasal Surgical Techniques endoscopy, and laryngoscopy to evaluate the larynx, epi- All procedures were done under general anesthesia. The septo- glottis, tongue base, and tongue tonsil. Patients, with their plasty was performed by the traditional Cottle technique.8 bed partners, filled out a questionnaire that included the Partial inferior turbinectomy in combination with a septoplasty patients’ characteristics (body mass index, smoking, alcohol was performed by cold instruments (Foulon scissor) with addi- use, sleeping medication), sleep integrity of bed partner, and tional hemostasis via a suction-electrocauterization device. The the snoring scores (see Outcome Measures). Allergy skin UPPP procedure comprised a cold dissection tonsillectomy prick testing was performed, and nasal resistance was mea- and unipolar resection of the distal 1 cm of the uvula while sured with rhinomanometry. According to these results, the proximal uvular muscle was preserved. The mucosal mar- nasal patency was improved by conservative treatment if gins of the tonsil pillars and uvular base were sutured with applicable. A PSG and DISE were then planned in every Monocryl 4.0.9 For the radiofrequency procedures of the patient. Once all data were collected, a treatment was pro- palate and the tongue base, a radiofrequency generator posed after multidisciplinary consultation. (Boucart Medical, Brussels, Belgium) and RaVoR instruments If PSG showed an apnea-hypopnea index (AHI) of .20, (Sutter Medizintechnik, Freiburg, Germany) were used. In the patients were referred, according to reimbursement rules in somnoplasty group, a bipolar electrode was used for the sub- our country, for continuous positive airway pressure mucosal lesions. Five or 6 application sites were selected for (CPAP). If not, mandibular advancement device (MAD) or the radiofrequency application of the soft palate or the tongue surgery was considered. The choice between surgery and base with 10 or 12 W, respectively.10 When a bilateral partial MAD was based on the sleep endoscopy findings and body inferior turbinectomy was performed in combination with the mass index: In obese patients (body mass index .32), sur- somnoplasty procedures, it was also performed by radiofre- gery was not considered, and they were referred for MAD. quency technique using the nasal electrode with 10-W power When patients were referred for MAD treatment, the ortho- application on 3 insert sites over the length of the inferior dontist evaluated if the patient was a good candidate for nasal turbinate. In the RAUP group, additionally, hypertrophic osteotomies (eg, a young patient with a skeletal class 2 [ret- mucosa of the palatal webbing was resected, and uvulotomy rognathic profile]). If so, the patient was referred to the with transversal removal of the distal part of the uvula was maxillofacial surgeon for bimaxillary osteotomy. performed with the same radiofrequency generator and a In nonobese patients, the surgical options included septo- monopolar cutting device (type Arrowtip) at 12 W.10,11 The plasty, partial inferior turbinectomies, uvulopalatopharyngo- osteotomies were performed by 1 maxillofacial surgeon. In all plasty (UPPP), somnoplasty of the palate, radiofrequency- cases, a bimaxillary osteotomy was performed with advance- assisted uvuloplasty (RAUP), somnoplasty of the tongue ment of the maxilla and the mandible, aiming at an advance- base, or osteotomies. ment of 3 to 6 mm and 10 mm, respectively. In the same time, a chin advancement was performed of 4 to 6 mm. Most cases When there was a unilevel palatal collapse on concerned a skeletal class II. In skeletal class I, an overjet was DISE, we suggested a surgical procedure of the created preoperatively by premolar extractions in the mandible palate: palate somnoplasty for important palatal and orthodontic retraction of the lower front teeth. In all cases, webbing, RAUP when there was also a large uvula, simultaneous orthodontic treatment was performed to achieve and UPPP with tonsil size .3, a large palate, and a a stable occlusion. In most cases, bone grafting from the iliac large uvula. crest was used to enhance stability and bone healing.12 When there was a unilevel tongue base or epiglottis collapse on DISE, we suggested a MAD, especially Outcome Measures and Collection when the Esmarch maneuver (a careful maneuver The outcome measures consist of 4 symptom scores and advancing the mandibula only 0.5 to 0.6 cm) made treatment side effects. Patients filled out a questionnaire the snoring sound disappear. We also took into account regarding symptom scores before treatment and 6 weeks the Friedman tongue position, the amount of retro- and 6 months after treatment. Symptom scores include snor- gnathia, and if there was sufficient dentition. ing intensity from 0 (no snoring at all) to 10 (reason for bed When there was a multilevel collapse, we looked partner to sleep in another room), the severity of snoring again at the effect of the Esmarch maneuver. When it (frequency, duration, and loudness of snoring),13 the

Downloaded from oto.sagepub.com at University of Sydney on August 18, 2015 Terryn et al 3 sleepiness of the patient in 8 different circumstances 14 (Epworth Sleepiness Scale), and a global snoring score on 224 a visual analog scale (VAS). In accordance to other studies Patients included in the literature, treatment success was defined by a final snoring score on a VAS 3. This score was linked with bed partners’ satisfaction.2,9,11,15 Mild improvement was defined 29 as any decrease in snoring but with VAS .3. No effect was Lack of DISE and/or PSG defined as no change or an increase in final snoring score. In addition to snoring symptoms, the sleep integrity of the 195 bed partner of the patients was recorded. Bed partners were Patients were proposed divided into 2 groups: poor sleepers (partners with poor and treatment very poor sleep steadiness) and normal sleepers (partners with normal sleep and deep sleepers). Serious adverse 24 Surgery 61 31 MAD events requiring hospitalization were recorded. Other Refusal of treatment adverse events were collected with the posttreatment ques- 6 CPAP tionnaires at 6 weeks and 6 months. 18 Therapy not yet scheduled Statistics The data were analyzed with SPSS 21 (IBM, Chicago, Illinois). Paired t test was used to compare the first and final 116 Patients startedtreatment scores for each parameter in each group. Analysis of variance with repeated measures was used for comparisons of the mean scores between the groups. Chi-square test was used to look for correlations between 2 categorical variables. Statistical significance was inferred at the P \ .05 level. 53 30 33 Surgery MAD CPAP Results Figure 1. Patient enrolment in the trial. CPAP, continuous positive Patient Enrollment and Characteristics airway pressure; DISE, drug-induced sleep endoscopy; MAD, man- We included 224 consecutive patients presenting with snor- dibular advancement device; PSG, polysomnography. ing to our department. The patient flow is summarized in Figure 1. Twenty-nine patients were excluded because of missing test results (PSG and DISE). In sum, 195 patients However, 6 weeks after treatment, a smaller decrease was were proposed treatment after multidisciplinary discussion noted for CPAP (P = .07) vs surgery (P = .003) and the (surgery, n = 78, 40%; MAD, n = 76, 39%; CPAP, n = 41, MAD (P = .005; Figure 3). 21%). Sixty-one patients did not proceed with the proposed In terms of individual patients rather than a compilation treatment (surgery, n = 24; MAD, n = 31; CPAP, n = 6). Of of the mean symptom scores for the individual treatments, the 116 patients who effectively started treatment, 53 (46%) 66.7% of patients in the surgery and MAD groups had a had surgery; 30 (26%) started MAD therapy; and 33 (28%) successful treatment vs 76.2% for the CPAP group (Figure started CPAP. The baseline characteristics of the treated 4). There was no significant difference among the 3 treat- patients did not differ significantly among the treatment ment modalities. Only a minority of patients reported no groups, except for the AHI (Table 1). effect of therapy: 6.7% in the surgery group, 13.6% in the MAD group, and 9.6% in the CPAP group. The surgery Treatment Outcome group is too small to detect significant differences among Follow-up was available in 92 of 116 (79.3%) patients. The the types of surgery, but some trends can be identified. All symptom scores of the overall group decreased significantly patients in the UPPP group (n = 19) and in the osteotomy at 6 weeks and 6 months after treatment (P \ .001). There group (n = 9) reported successful treatment vs 43% in the were no significant differences between 6 weeks and 6 RAUP group (n = 7) and 33% in the palate somnoplasty months after treatment, indicating a durable effect of the group (n = 9). treatment (Figure 2). When the treatment modalities were compared, the mean snoring intensity and severity scores as Influence of Sleep Steadiness of the Bed Partner well as the overall snoring score decreased significantly 6 Data on the sleep steadiness of the bed partner was available weeks and 6 months for all treatments: for surgery (P \ in 78 of 116 (67%) patients. Treatment success (defined as .001), for MAD (P \ .001), and for CPAP (P \ .001) vs a VAS snoring score 3) was reported in 26 of 40 (65%) in the score preoperatively. The mean sleepiness score the group of partners with poor sleep steadiness vs 28 of 30 (Epworth Sleepiness Scale) also decreased significantly over (74%) in patients with partners reporting normal sleep stea- time for all 3 groups 6 months after treatment (P \ .04). diness (chi-square, P = .4).

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Table 1. Patient Characteristics.a Patients

Variable Included (N = 195) Treated (n = 116) Surgery (n = 53) MAD (n = 30) CPAP (n = 33)

Age, y 46.0 6 10.9 46.6 6 10.6 45.2 6 12.0 48.2 6 9.6 48.5 6 9.8 Body mass index, kg/m2 27.2 6 4.0 27.9 6 4.0 26.5 6 3.5 26.1 (3.6) 30.2 6 4.1 Male 77.9 83.6 88.7 73.6 87.8 Smokers 27.3 26.7 28.3 21.1 31.7 Allergy 35.3 40.7 45.8 28.7 42.5 Unilevel collapse on DISE 24.4 23.8 30.6 18.1 19.3 Sleep medication 11.5 7.9 9.8 12.0 10.0 Snoring Intensityb 7.8 6 1.9 7.9 6 1.8 7.8 6 1.8 7.7 6 2.1 8.3 6 1.7 Severityc 6.7 6 1.5 6.7 6 1.5 6.7 6 1.6 6.4 6 1.3 7.2 6 1.4 Score 7.6 6 1.6 7.7 6 1.5 7.7 6 1.4 7.3 6 1.7 8.0 6 1.5 Epworth Sleepiness Scaled 7.9 6 4.7 7.7 6 4.1 7.3 6 3.9 8.3 6 5.2 7.4 6 4.4 Apnea-hypopnea indexe 10.0 (4.7, 20.1) 13.2 (6.4, 26.3) 8.7 (3.6, 14.2) 9.7 (7.3, 13.2) 40.3 (25.0, 47.1)

Abbreviations: CPAP, continuous positive airway pressure; DISE, drug-induced sleep endoscopy; MAD, mandibular advancement device. aValues are presented in mean 6 SD or percentage, unless noted otherwise. bMeasured by visual analogue scale (scale, 0-10, where 0 means no snoring at all and 10 means reason for bed partner to sleep in another room) cSum of loudness, duration, and frequency of snoring (each scored from 0 to 3) dScale to measure daytime sleepiness, measured by a short questionnaire, with result \10 considered normal. eMedian (interquartile range: p25, p75).

Adverse Events months of follow-up. All symptom scores significantly One serious adverse event was noted. A patient in the sur- improved in all treatment groups. In total, about 70% of gery treatment group needed revision surgery for a postton- patients are satisfied with the treatment, and another 20% of sillectomy hemorrhage, requiring 1 night of hospitalization. patients improved. To the best of our knowledge, there are Follow-up questionnaires with recording of treatment side very few studies that actually compare the effectiveness of dif- effects were available in 82% of the patients. The following ferent treatment modalities for SDB, including primary snoring adverse events were reported in the surgery group at 6 and OSAS. We believe that our data can help to inform weeks and 6 months, respectively (percentage of total sur- patients on their postoperative results provided that the choice gery group): voice change (18%, 6%), difficulties with of treatment is carefully made after a detailed evaluation, swallowing (59%, 9%), speech difficulties (29%, 12%), including symptom severity, detailed clinical examinations, reduced taste (32%, 6%), and globus sensation (56%, 18%). PSG, DISE, and, thereafter, a multidisciplinary discussion. Side effects recorded at 6 months were respectively divided According to our algorithm (evidence based and per national among the surgery subgroups UPPP (n = 19), RAUP (n = reimbursement criteria), patients with an AHI .20 were 7), and palate somnoplasty (n = 9) as follows: change of referred for CPAP treatment. This, of course, explains a higher voice (n = 1, 0, 0), difficulties with swallowing (n = 2, 0, medianAHI(40.3)vsmedianAHIsof8.7inthesurgery 1), speech difficulties (n = 3, 0, 1), reduced taste (n = 1, 0, group and 9.7 in the MAD group (Table 1). For all other 1), and globus sensation (n = 2, 1, 3). In the osteotomy patients (with an AHI \20), DISE results were most determi- group (n = 9), facial hypoesthesia and difficulty with chew- nate. Our group previously reported on the important contribu- tion of DISE in establishing a treatment plan and a ing with need for a soft diet were recorded at 6 weeks after 6 treatment, with some facial hypoesthesia persisting after 6 multidisciplinary discussion. The results reported in this study are, generally speaking, comparable with reported individual months. The CPAP patients experienced the following side 2,7,9,11,16-22 effects at 6 weeks and 6 months, respectively: runny nose treatments results. However, here we compared all (33%, 0%), nose blockage (30%, 26%), discomfort in wear- treatment options both surgically and nonsurgically and report ing the mask (22%, 37%), intolerance of the CPAP device this as a real-world comparative effectiveness research study. (15%, 26%). Overall, a high percentage of treatment success and satisfaction is noted in the surgery group. When we compare the surgery subgroups, we see better results in the UPPP group Discussion as compared with the RAUP and the palate somnoplasty In this prospective longitudinal clinical trial, we demonstrated group. This is also confirmed by Hofmann et al.9 that a multidisciplinary agreed-on treatment of snoring is effec- In contrast to Balsevicˇius et al,10 we did not find a signif- tive and safe across the proposed treatments at 6 weeks and 6 icant difference in outcome between the RAUP group and

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Figure 2. Short-term (6 weeks) and long-term (6 months) effects of treatment on symptom scores for all treated patients. ESS, Epworth Sleepiness Scale. the palate somnoplasty group. Some studies warn for a pos- 1 in 4 CPAP patients could not tolerate the mask after 6 sible decrease of the effect of surgery over time.11,17,19 We months of treatment. This is comparable to or better than did not observe a decrease in treatment effect between 6 other reports concerning CPAP compliance.22,26 We reported weeks and 6 months after treatment. However, the absorp- the objective compliance rate to measure the so-called mean tion of scar tissue is a process that may last .1 year.17,23 disease alleviation (MDA). The MDA is a valuable tool to Studies with longer follow-up may be indicated to exclude a measure and improve the overall therapeutic effectiveness of long-term loss of treatment effect. However, longer-term a specific treatment. The MDA is the ratio of the therapeutic studies are difficult to perform, and it may be impossible to efficacy over the compliance rate. Since surgery has an control for changes in other factors, including weight gain, adherence of 100%, the success rate of surgery gives the alcohol or tobacco use, and loss of muscle tone that may amount of efficacy. In our study, the MDA of the surgery alter longer-term results. We report very good and lasting group is 63%. Vanderveken et al27 recently published an results of bimaxillary osteotomies. We speculate that this is MDA of 51% for MAD treatment. For CPAP, the therapeutic due to the strict selection, including DISE with Esmarch efficacy is high, but the compliance is low, resulting in an maneuver, multidisciplinary discussion, referral for initial MDA of 50%.28 In this study, we report a detailed standar- MAD treatment, and evaluation by the orthodontist. dized approach of the snoring patient to accomplish a stricter Particularly for young patients with a retrognathic profile, individual treatment selection and to allow a more accurate this is a very valuable solution. comparative therapeutic effectiveness. As for treatment side effects, the benefit in success rate in Our study has some limitations. We observed patient our UPPP group was not at the expense of more side dropout when we proposed further investigations, such as a effects.19 Some studies mention a significant percentage of PSG and DISE. Several studies have shown the pivotal role side effects after snoring surgery, especially after UPPP.24 and importance of detecting OSAS among snorers and With 9% to 18% of patients still experiencing side effects 6 determining the level of obstruction.5,6 Better information months after surgery, our results are comparable or even on the role of testing may increase compliance. Other tests better than other reports.2,9,17,19,24,25 In our population, about have been suggested to select OSAS patients, including the

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Figure 3. Short-term (6 weeks) and long-term (6 months) effects of the different treatments on symptom scores. CPAP, continuous positive airway pressure; ESS, Epworth Sleepiness Scale; MAD, mandibular advancement device. so-called STOP BANG, Stanford Sleepiness Scale, the manner in terms of their annoyance level.31 We could not Epworth and Berlin assessment. However, these have seri- confirm our hypothesis that the sleep steadiness of the bed ous limitations. In fact, there is insufficient evidence that partner of the patients influences treatment satisfaction or the Berlin and other questionnaires and clinical prediction reason for seeking medical advice. rules are able to accurately prescreen OSA patients.29,30 A significant proportion of patients (50% for MAD, 39% sur- Conclusion gery, and 10% CPAP) refused therapy after full workup for We report the results of different treatment modalities, sur- a variety of reasons. However, as shown in , the Table 1 gical and nonsurgical, for snoring individually selected after treated group did not differ from the total included group in standardized evaluation and multidisciplinary discussion. terms of their baseline characteristics. Therefore, it is Our results can assist physicians and patients to make unlikely that the high dropout rate has influenced the informed decisions. results. Compared with the other treatment modalities, only a few patients refused the proposed treatment in the CPAP Acknowledgments group. This may be due to the severity of the disease in We thank our colleagues Bernard Bouckaert, MD, from the moderate to severe OSAS with the accompanying more Department of Pulmonology, Marc Vanden Bulcke, MDS, DDS, validating symptoms. As observed in other studies and PhD, and Philippe Vuylsteke, MD, maxillofacial surgeon, for their despite having obtained written informed consent from all participation in the weekly multidisciplinary discussions and the patients, only 80% reported their outcomes. We cannot excellent care of the patients. exclude that this may have biased our results. In the literature, there is some discussion about the defi- Author Contributions nition of successful treatment for snoring. A recent elegantly Stefanie Terryn, consented patients, entered data, data analysis performed study showed good interrater reliability of the and statistics, first draft of the manuscript and several revisions; subjective assessments of snoring sounds using VAS scores. Joris De Medts, performed DISE patient recruitment, biweekly The authors concluded that using VAS scores for snoring patient discussion and selection, surgical therapy, revised manu- sounds can be assessed in a reproducible and comparable script; Kathelijne Delsupehe, study design, study analysis, final

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100% compared to standard clinical evaluation. Eur Arch 7% 13% 10% 90% Otorhinolaryngol. 2014;271:1311-1319. 14% 7. Main C, Liu Z, Welch K, Weiner G, Jones SQ, Stein K. Surgical 80% 27% 20% procedures and non-surgical devices for the management of non- 70% apnoeic snoring: a systematic review of clinical effects and asso- ciated treatment costs. Health Technol Assess. 2009;13(3):1-208. 60% 8. Huizing EH, de Groot JA. Functional Reconstructive Nasal 50% Surgery. Stuttgart, Germany: Thieme; 2003. 9. Hofmann T, Schwantzer G, Reckenzaun HK, Wolf G. 40% 76% Radiofrequency tissue volume reduction on the soft palate and 67% 67% 30% UPPP in the treatment of snoring. Eur Arch Otorhinolaryngol. 2006;263:164-170. 20% 10. Balsevicˇius T, Uloza V, Vaitkus S, et al. Controlled trial of 10% combined radiofrequency-assisted uvulopalatoplasty in the 0% treatment of snoring and mild to moderate OSAS (pilot study). Surgery MAD CPAP Sleep Breath. 2013;17:695-703. 11. Stuck A. Radiofrequency-assisted uvulopalatoplasty for snor- No change (VAS = or ↑) ing: long-term follow-up. Laryngoscope. 2009;119:1617-1620. Mild improvement (VAS ↓ but > 3) 12. Cisneros G, Triger N. Sleep apnea. In: Bell WH, ed. Modern Practice in Orthognathic and Reconstructive Succesful treatment (VAS ≤ 3) Surgery. Philadelphia, PA: WB Saunders; 1992;2021-2041. Figure 4. Percentage of success for the different treatments as 13. Morris LG, Kleinberger A, Lee KC, Liberatore LA, Burschtin measured by the global snoring score 6 months posttreatment. Surgery includes septoplasty, partial inferior turbinectomies, uvulo- O. Rapid risk stratification for obstructive sleep apnea, based palatopharyngoplasty, somnoplasty of the palate, radiofrequency- on snoring severity and body mass index. Otolaryngol Head assisted uvuloplasty, somnoplasty of the tongue base, and osteo- Neck Surg.2008;139:615-618. tomies. CPAP, continuous positive airway pressure; MAD, mandibu- 14. Johns MW. Daytime sleepiness, snoring, and obstructive sleep lar advancement device; VAS, visual analog score. apnea: the Epworth Sleepiness Scale. Chest. 1993;103:30-36. 15. Blumen MB, Dahan S, Fleury B, Hausser-Hauw C, Chabolle F. Radiofrequency ablation for the treatment of mild to moderate draft of the manuscript, performed DISE patient recruitment and obstructive sleep apnea. Laryngoscope. 2002;112:2086-2092. consent, biweekly patient discussion and selection, surgical therapy. 16. Certal V, Nishino N, Camacho M, et al. Reviewing the systematic reviews in OSA surgery. Otolaryngol Head Neck Surg. Disclosures 2013;149:817-830. Competing interests: None. 17. Ardestani SHS, Dadgarnia MH, Baradaranfar MH, et al. Sponsorships: None. Radiofrequency uvulopalatoplasty for primary snoring. Acta Funding source: None. Medica Iranica. 2013;51:530-536. References 18. Baisch A, Maurer JT, Ho¨rmann K, Stuck BA. Combined radiofrequency assisted uvulopalatoplasty in the treatment of snor- 1. Enright PL, Newman AB, Wahl PW, Manolio TA, Haponik ing. Eur Arch Otorhinolaryngol. 2009;266:125-130. EF, Boyle PJ. Prevalence and correlates of snoring and 19. Goh YH, Mark I, Fee WE. Quality of life 17 to 20 years after observed apneas in 5,201 older adults. Sleep. 1996;19:531- uvulopalatopharyngoplasty. Laryngoscope. 2007;117:503-506. 538. 20. Cistulli P, Gotsopoulos H, Marklund M, et al. Treatment of 2. Yoruk O, Akgun M, Sutbeyaz Y, et al. Treatment of primary snoring and obstructive sleep apnea with mandibular reposi- snoring using modified radiofrequency-assisted uvulopalato- tioning appliances. Sleep Med Rev. 2004;8:443-457. plasty. Eur Arch Otorhinolaryngol. 2009;266:1807-1814. 21. Hoffstein V. Review of oral appliances for treatment of sleep- 3. Stuck BA, Dreher A, Heiser C, et al. [S2K-guidelines ‘‘diag- disordered breathing. Sleep Breath. 2007;11:1-22. nosis and therapy of snoring in adults’’: compiled by the Sleep 22. Robinson S, Chia M, Carney AS, et al. Upper airway recon- Medicine Working Group of the German Society of structive surgery long-term quality-of-life outcomes compared Otorhinolaryngology, Head and Neck Surgery]. HNO. 2013; with CPAP for Adult obstructive sleep apnea. Otolaryngol 61:944-957. Head Neck Surg. 2009;141:257-263. 4. Galetke W. Primary snoring-harmless or not? Somnologie. 23. Ba¨ck LJ, Hyto¨nen ML, Roine RP, et al. Radiofrequency ablation 2014;18:75-79. treatment of soft palate for patients with snoring: a systematic 5. Usmani ZA, Chai-Coetzer CL, Antic NA, McEvoy RD. review of effectiveness and adverse effects. Laryngoscope. 2009; Obstructive sleep apnoea in adults. Postgrad Med J. 2013;89: 119:1241-1250. 148-156. 24. Franklin KA, Anttila H, Axelsson S, et al. Effects and side- 6. Pilaete K, De Medts J, Delsupehe KG. Drug-induced sleep effects of surgery for snoring and obstructive sleep apnea: a endoscopy changes snoring management plan very significantly systematic review. Sleep. 2009;32:27-36.

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