Article #78

The author, apparently an oral surgeon first trained in dentistry and later in medicine, describes 50 patients with obstructive sleep apnea in his own practice (in Marietta, Georgia), whom he treated with a modification of the maxillomandibular advancement (MMA) procedure pioneered by Drs. Riley and Powell at Stanford. See Article #32: "Long-term (2-year) follow-up of 15 patients who had surgical maxillomandibular osteotomy and advancement treatment for obstructive sleep apnea." This procedure, by first cutting through the maxillary and mandibular bones of the upper and lower jaw, then "advancing" them (outward from the face), pulls forward tissues connecting these bones to the upper airway, thereby enlarging the space inside the airway.      Dr. Prinsell describes his criteria for performing surgery as cases where "applicable conservative therapies are unsuccessful or not tolerated, and for patients with an underlying specific surgically correctable abnormality that is causing the OSAS [Obstructive Sleep Apnea Syndrome]." He states the important point that he did not limit this procedure to the most severely or intractably ill patients, but used it as his first line of surgical treatment for OSA.      Because it seems difficult enough to visualize the essential procedure without recourse to sketches and models, I will forego attempting to describe how the author attempted to match the procedure to the site of obstruction. Instead, I will focus on the variety of patients Dr. Prinsell treated and their results.      All patients had OSA diagnosed by all-night polysomnography, with either (1) an Apnea Hypopnea Index greater than 15, or (2) an Apnea Index greater than 5 plus a lowest arterial oxygen saturation less than 90%. All had the typical OSA symptom of excessive daytime sleepiness (EDS). All had previous "conservative" treatments (CPAP, weight control, reduction of sedatives or alcohol, dental appliances) which were "unsuccessful, not tolerated, or refused."      Of the 50 patients, 88% (44) were male. They averaged 43 years of age, ranging from 19 to 66 years. Preoperatively, they averaged an Apnea Hypopnea Index of 59 events/hour, with an average of 119 desaturation events per night, averaging a lowest oxygen saturation of 73%.      Besides the EDS present in all cases prior to surgery, all reported snoring, and a majority reported memory loss, impaired concentration, moodiness, and morning headaches. At follow-up averaging 5 months after surgery, all reported improvement in EDS, memory loss, and impaired concentration; most reported improvement of the other symptoms mentioned. Moreover, Body Mass Index and blood pressure improved "significantly" in all cases. Statistically significant improvement was found in Apnea Hypopnea Indices (from 59 to 5), Apnea Indices (34 to 1), number of desaturations (119 to 7), and lowest oxygen saturation (73% to 89%).      Dr. Prinsell refers to similarly impressive results reported by others using this type of procedures, with success rates in the range of 95-98%. He also notes the added safety factors of the MMA, which "not only preserves the functional integrity of the pharyngeal tissues but also minimizes the risk of worsened OSA in the immediate postoperative period because minimal edema occurs within the unoperated pharyngeal soft tissues." Furthermore, since the bone segments that are operated on do not move, there is no pain from swallowing, coughing, and talking, unlike the excruciating pain in the postoperative period after uvulopalatopharyngoplasty (UPPP).      With regard to the UPPP, the author succinctly states that it "has been one of the most commonly performed, yet one of the least effective, surgeries for OSAS." Combining 337 patients from 37 reports, the UPPP achieved only a modest degree of success (Apnea Hypopnea Index less than 20, Apnea Index less than 10, or 50% reduction of either), in a total of only 41%, a success rate perilously close to the 1/3 of patients usually responding to placebo medications or "sham" operations. Moreover, the UPPP can produce life-threatening postoperative swelling of the upper airway.

This remarkable article, all the more convincing in its critique of the UPPP by its author having a clear belief in the early use of surgery for OSA, shows how well information of value and importance to the medical consumer may remain inaccessible. The detailed diagrams and descriptions of different techniques taxes my ability to comprehend the article in its entirety, and would no doubt daunt most lay readers from making the attempt. Yet the article contains some clearly stated, crucial points.      One of these points is that people should stop risking their lives on the notoriously ineffective UPPP just because it is the only procedure most surgeons have the expertise to do for OSA, resembling as it does an overextended tonsillectomy. This article also helps demonstrate that the MMA procedure, which has shown impressive results, is no longer limited to a few research centers. If I were to consult a surgeon about help for my OSA nowadays, I would first make sure that he has a record of experience in performing the MMA.      Nevertheless, I am not sure I would agree with the author's apparent liberality in accepting for surgery those patients who have found CPAP "intolerable or unacceptable," at least without a clearer definition of what represents reasonable efforts to give CPAP a fair trial and try various strategies to overcome whatever problems its use presents for a given individual. In my view, too often people give up on CPAP almost at once, without even discussing with their doctor how to make it more tolerable. Excellent as the results of MMA appear, it still results in an essentially irreversible change, not at all easy to "readjust" if not entirely satisfactory, quite unlike CPAP in this respect.      At least, it seems unlikely that the MMA can be misrepresented to the patient as a "minor, routine" procedure, so supposedly trivial that it could be done in a brief outpatient visit. This misrepresentation probably plays a role in its widespread use--or misuse. As this author states, the "simple" UPPP can and has resulted in deaths. He also makes clear the extent of postoperative monitoring that he considers appropriate for the MMA even though this procedure does not carry the risk of acute exacerbation of OSA. Even with in-hospital conduct of the UPPP, postoperative monitoring after this supposedly insignificant procedure may prove lax to the point of negligence.

"The commonest sense is the sense of men asleep, which they express by snoring." Henry David Thoreau

This page hosted by Get your own Free Home Page