Broadening Our Therapeutic Spectrum

The first issue of Sleep and Breathing in the new millennium focused on prevalence and clinical features of sleep-disordered breathing and simple diagnostic tools for its recognition in primary care medical practice. Continuing education of medical students and practitioners, and as a result improved availability of skilled people, will increase the number of patients sent to sleep specialists or sleep centers for advice. One of the most widespread sleep disorders is the obstructive sleep apnea syndrome (OSAS). The number of patients waiting and asking for treatment is increasing continuously. Thus, it is a logical consequence to tackle upcoming therapeutical challenges now.

For this issue we have put together a sample of articles dealing with diagnosis and treatment of hypopharyngeal and retroglossal obstruction. Several techniques have been developed and evaluated during the last year, offering new treatment options for our patients. But why are we always talking about new techniques? It is well-accepted that nasal continuous positive airway pressure (nCPAP) is the gold standard for the treatment of OSAS. It has been proved over the last 20 years that nCPAP can securely eliminate the breathing disorder in almost every patient. Compliance is increasing due to smaller and less noisy CPAP devices, more comfortable masks, and intensified support by the sleep centers.[1] However, McArdle and coworkers[2] have shown that only 68% of the patients still use their nCPAP device after 5 years. That means almost 30% of the patients treated originally will need alternative treatment. The aim of this issue is to give an actual overview about some of the most promising therapies for those patients, either because they have a very high efficacy or a very low morbidity.

Palatal surgery has been established with enthusiasm during the 1980s as a replacement for tracheotomy and nCPAP, which came into use as therapy the same year. Disillusionment when looking at the low efficacy[3] without patient selection and the morbidity of this procedure-sometimes even making nCPAP therapy absolutely impossible[4]-brought up conservative palatal procedures. The importance of the definition of the major site of obstruction prior to surgery was recognized. Still, responder rates of palatal surgery did not substantially pass 50%. Long-term success rates are still controversial. Treatment for patients with a primarily hypopharyngeal collapse was invented about 10 years ago by Riley et al[5] and targets the bony structures of the jaws. The concept of multilevel surgery takes into account the findings of a thorough upper airway evaluation. Upper airway evaluation has remained the subject of an ongoing discussion. We will contribute to that discussion by presenting some interesting cases of uncommon airway findings. It is always difficult to obtain long-term results from surgery. Yet, long-term data are absolutely necessary to compare surgery with nCPAP treatment, which is found to keep its efficacy even after decades. In this issue of Sleep and Breathing, the first long-term results of maxillomandibular advancement surgery (up to 12 years) are presented. Because these operations result in a higher morbidity than that seen with palatal surgery, less invasive techniques for the treatment of retroglosssal collapse have been developed during the last years.[6] Data on efficacy and morbidity with a more aggressive treatment protocol are shown here.

We have tried to present an interesting mixture of the current themes discussed in the field of surgery for sleep-disordered breathing. We hope that you enjoy reading the articles and that they give you some new ideas to think about when sitting in front of your next sleep apnea patient who cannot tolerate nCPAP.

REFERENCES

• 1 Hoy C J, Vennelle M, Kingshott R N, Engleman H M, Douglas N J. Can intensive support improve continuous positive airway pressure use in patients with the sleep apnea/hypopnea syndrome?.  Am J Respir Crit Care Med . 1999;  159 1096-1100
• 2 McArdle N, Devereux G, Heidarnejad H, Engleman H M, Mackay T W, Douglas N J. Long-term use of CPAP therapy for sleep apnea/hypopnea syndrome.  Am J Respir Crit Care Med . 1999;  159 1108-1114
• 3 Sher A E, Schechtman K B, Piccirillo J F. The efficacy of surgical modifications of the upper airway in adults with obstructive sleep apnea syndrome.  Sleep . 1996;  19 156-177
• 4 Mortimore I L, Bradley P A, Murray J A, Douglas N J. Uvulopalatopharyngoplasty may compromise nasal CPAP therapy in sleep apnea syndrome [see comments].  Am J Respir Crit Care Med . 1996;  154 1759-1762
• 5 Riley R W, Powell N B, Guilleminault C. Inferior mandibular osteotomy and hyoid myotomy suspension for obstructive sleep apnea: A review of 55 patients.  J Oral Maxillofac Surg . 1989;  47 159-164
• 6 Powell N B, Riley R W, Guilleminault C. Radiofrequency tongue base reduction in sleep-disordered breathing: A pilot study.  Otolaryngol Head Neck Surg . 1999;  120 656-664