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Downloaded from Oto.Sagepub.Com at University of Sydney on August 18, 2015 2 Otolaryngology–Head and Neck Surgery 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] Downloaded from oto.sagepub.com at University of Sydney on August 18, 2015 2 Otolaryngology–Head and Neck Surgery 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 sig- nificant 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
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