Brazilian
Journal
of
OTORHINOLARYNGOLOGY
www.bjorl.org
ORIGINAL
ARTICLE
New
clinical
staging
for
pharyngeal
surgery
in
obstructive
sleep
apnea
patients
夽
,
夽夽
Tatiana
Aguiar
Vidigal
a,
Fernanda
Louise
Martinho
Haddad
a,b,∗,
Rafael
Ferreira
Pacheco
Cabral
c,
Maria
Claudia
Soares
Oliveira
a,
Ricardo
Rodrigues
Cavalcante
d,
Lia
Rita
Azeredo
Bittencourt
a,b,
Sergio
Tufik
a,b,
Luis
Carlos
Gregório
aaDepartmentofOtorhinolaryngology,UniversidadeFederaldeSãoPaulo(UNIFESP),SãoPaulo,SP,Brazil bDepartmentofPsychobiology,UniversidadeFederaldeSãoPaulo(UNIFESP),SãoPaulo,SP,Brazil cInstitutodoRoncoeApneiadeMaringá,Maringá,PR,Brazil
dClínicaOpus,SãoJosédosCampos,SP,Brazil
Received1July2013;accepted1August2014 Availableonline16September2014
KEYWORDS Sleepapnea, obstructive; Tonsillectomy; Classification
Abstract
Introduction:Thesuccessofpharyngealsurgeryinthetreatmentofobstructivesleepapnea syndromedependsontheappropriateselectionofpatients.
Objective:Toproposeanewstagingforindicationofpharyngealsurgeryinobstructivesleep apneasyndrome.
Methods:A total of 54 patients undergoing extended tonsillectomy were retrospectively included,dividedintosixstages.StageI: patientswithpalatinetonsilsgrade3/4and mod-ifiedMallampatiindex1/2;stageII:palatinetonsils3/4andmodifiedMallampatiindex3/4; stageIII:palatinetonsils1/2andmodifiedMallampatiindex1/2;stageIV:palatinetonsils1/2 andmodifiedMallampatiindex3/4;stageV:bodymassindex≥40kg/m2withpalatinetonsils
3/4andmodifiedMallampatiindex1,2,3,or4.StageVI:bodymassindex≥40withpalatine tonsils1/2andmodifiedMallampatiindex1,2,3,or4.
夽 Pleasecitethisarticleas:VidigalTA,HaddadFL,CabralRF,OliveiraMC,CavalcanteRR,BittencourtLR,etal.Newclinicalstagingfor
pharyngealsurgeryinobstructivesleepapneapatients.BrazJOtorhinolaryngol.2014;80:490---6.
夽夽
Institution:UniversidadeFederaldeSãoPaulo(UNIFESP),SãoPaulo,SP,Brazil. ∗Correspondingauthor.
E-mail:femartinho@uol.com.br(F.L.M.Haddad).
http://dx.doi.org/10.1016/j.bjorl.2014.09.003
Results:Thesurgicalsuccessrateswere88.9%,75.0%,35.7%,38.5%,and100.0%instagesI---V.
Conclusion: Thepresenceofhypertrophicpalatinetonsilswastheanatomicalfactorin com-moninthemostsuccessfulstages(I,II,andV),regardlessofbodymassindex.Althoughthe modifiedMallampatiindexclasses3and4reducedthesuccessrateofsurgeryinpatientswith hypertrophictonsils(stageII),thepresenceofmodifiedMallampatiindexclasses1and2did notfavorsurgicalsuccessinpatientswithnormaltonsils(stageIII).
© 2014Associac¸ãoBrasileira de Otorrinolaringologiae CirurgiaCérvico-Facial. Publishedby ElsevierEditoraLtda.Allrightsreserved.
PALAVRAS-CHAVE Apneiaobstrutivado sono;
Tonsilectomia; Classificac¸ão
Novomodelodeestadiamentoparaindicac¸ãodecirurgiafaríngeaempacientescom apneiaobstrutivadosono
Resumo
Introduc¸ão: Osucessodacirurgiafaríngeanotratamentodasíndromedaapnéiaobstrutivado sono(SAOS)dependedaadequadaselec¸ãodepacientes.
Objetivo: Proporumnovoestadiamentoparaindicac¸ãodecirurgiafaríngeanaSAOS.
Método: Estudoretrospectivo,ondeforaminclusos,54pacientessubmetidosaamigdalectomia ampliada,divididosem6estádios.EstádioI:pacientescomtonsilaspalatinasgraus3/4eíndice deMallampatimodificado(IMM)1/2;EstádioII:tonsilaspalatinas3/4eIMM3/4;EstádioIII: tonsilaspalatinas1/2eIMM1/2;EstádioIV:tonsilaspalatinas1/2eIMM3/4;EstádioV:IMC (índicedemassacorpórea)≥comtonsilaspalatinas3/4eIMM1,2,3ou4.EstádioVI:IMC≥ kg/m2comtonsilaspalatinas1ou2eIMM1,2,3,ou4.
Resultados: Astaxasdesucessocirúrgicoforamde88,9%;75,0%;35,7%;38,5%e100,0%nos estádiosIaV.
Conclusão:Apresenc¸adetonsilaspalatinashipertróficasfoiofatoranatômicoemcomumnos estádiosdemaiorsucesso(I,IIeV),independentedoIMC.ApesardoIMMclasseIIIeIVdiminuir ataxadesucessodacirurgiaempacientescomtonsilashipertróficas(estádioII),apresenc¸a deIMMclasseIeIInãofavoreceuosucessocirúrgicoempacientescomtonsilasnormotróficas (estádioIII).
©2014Associac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial.Publicado por ElsevierEditoraLtda.Todososdireitosreservados.
Introduction
Obstructivesleepapneasyndrome(OSAS)isahighly preva-lentdisease that affects32.9% ofthe adult populationof the city of São Paulo, Brazil1 and compromises the qual-ity of life of patients as a result of excessive daytime sleepiness,cognitivefunctionimpairmentandincreasedrisk for cardiovasculardisease.2,3Ventilationwithpositive air-waypressure,especiallycontinuouspositiveairwaypressure (CPAP)isthetreatmentofchoiceforpatientswith moder-atetosevereOSAS4;however,manypatientshavedifficulty adaptingtothislong-termtreatment.3,5---7
Uvulopalatopharyngoplasty was the most often per-formed pharyngeal surgical procedure to treat OSAS; however, the success rate, when the surgery is indis-criminately indicated, was approximately 40%.6 Several factorswereconsideredunfavorable,suchasdisease sever-ity, age, the presence of multiple sites of obstruction, obesity, and anatomical abnormalities of the maxilla and mandible.8
Several pharyngealsurgerytechniques aredescribedin theliterature,andaccording toameta-analysis,9 the iso-lateduvulopalatopharyngoplastyprocedure,withorwithout tonsillectomy, interferes with the apnea---hypopnea index
(AHI), but maintains residual OSAS,9,10 mainly in patients withmoderatetosevereOSAS.
In an attempt to improve the selection criteria for uvulopalatopharyngoplasty, Friedman et al.11 proposed a clinicalstagingbasedonanthropometricand otorhinolaryn-gologicalphysicalexaminationforpatientswithOSAS,that isusedtilldate.Thisstagingisbasedonthreeclinical crite-ria:modified Mallampati index(MMI),palatine tonsilsize, andbodymassindex(BMI).MMIclasses3and4showan unfa-vorablerelationshipamongthesoftpalate,thetongue,and theoropharynx;palatinetonsilsgrade3and4areconsidered hypertrophic.
Thus, he divided patients into four groups. Group I: patientswithMMI1or2associatedwithpalatinetonsilgrade 3or4andBMI<40kg/m2;groupII:patientswithMMI3or
4associatedwithpalatinetonsilgrade3or4orMMI1or2 withpalatinetonsilsgrade1or2andBMI<40kg/m2;group
III:patients withMMI 3or 4associated withpalatine ton-sil1 or2 withBMI<40kg/m2;andgroup IV:patients with
BMI>40kg/m2or significantskull-facialalteration,
regard-lessoftheMMIandtonsilsize.
8.1%,respectively.Theauthorsfeltthattheprocedurewas contraindicated in group IV, stating that the presence of MMIclasses3and4couldpreventafavorablesurgical out-come,eveninpatientswithhypertrophicpalatine tonsils, andthatthepresenceofevidentskull-facialalterationsand obesityclassIII wouldbe factorstorenderthe procedure contraindicated.
However,Martinhoetal.,13inaseriesofcaseswithseven obesepatientswithOSAS,MMIclasses 3and4,and hyper-trophy of thepalatine tonsilsgrades 3 and 4,observed a significant reduction in the AHI (preoperative: 81±26/h; postoperative: 23±18/h; p<0.05) and minimum oxyhe-moglobinsaturationimprovement(preoperative:69±14%; postoperative:83±3%;p<0.05),afterextended tonsillec-tomy. Despite the small number of patients, this study suggestedthattonsillarhypertrophymaybethemain fac-torassociated withpharyngealsurgery success,regardless oftheMMIorthepresenceofobesity.
Therefore, it is evident that the clinical and anatomi-calassessmentofpatientswithOSASiscrucialinchoosing the best treatment modality. However, to date, there is no ideal staging model for the indication of pharyngeal surgery in the treatment of OSAS, especially for patients with BMI>40kg/m2 or with significant skull-facial
alter-ation,regardlessoftheMMIandsizeofpalatinetonsils. Therefore, this study aimed to develop a new staging model for the indication of pharyngeal surgery in adult patientswith OSAS,aswell asto describethe useof the extendedtonsillectomytechniquetotreatthesepatients.
Methods
Theresearchprojectwasapprovedbytheethicscommittee (CEP:0268/11).
A retrospective study was conducted by reviewing the medicalchartsofpatientstreatedfromJanuaryof2003to Decemberof2007inaRespiratorySleepDisorderOutpatient ClinicoftheDepartmentofOtorhinolaryngology andHead andNeckSurgery.
Inclusion criteria were patients aged between 18 and 65years,of bothgenders,withmoderate tosevereOSAS, submittedtoextendedtonsillectomywithpre-and postop-erativepolysomnographyassessment.
Patientsreferredforotherclinicalorsurgicaltreatments ofOSASotherthanextendedtonsillectomy;thosewithother types of sleep disorder than OSAS; those whoused seda-tives,consumedalcohol,orhadaclinicallydecompensated diseasewereexcludedfromthestudy.
Assessmentprotocol
In thisoutpatient clinic, patients areroutinely submitted totheassessmentprotocol,thatconsistsof otorhinolaryn-gological evaluation, visual analog scale (VAS), Epworth sleepinessscale,14 andbaselinepolysomnography,whichis repeatedthreemonthsafterthesurgicalprocedure.
On the VAS, patients were asked about the presence of snoring and witnessed pauses, which were considered ‘‘usual’’when they occurred everynight or almost every night. The Epworth sleepiness scale14 suggests excessive daytimesleepinesswhenthescoresare>9.These criteria
wereusedincombinationwiththepolysomnographyfindings forthediagnosisofOSAS,accordingtotheII International ClassificationofSleepDisorders(ICSD-2)15andtheAmerican AcademyofSleepMedicine(AASM)2005criteria.16
Otorhinolaryngologicalassessment
The otorhinolaryngological assessment consisted of the facial skeleton inspection through oroscopy and anterior rhinoscopy.Forthepurposeofthestudy,wedescribeonly thecriteriatobeusedintheproposedstagingmethod.They arethepalatinetonsilclassification(PTC),theMMI,andthe BMI,calculatedusingtheformula:weight(kg)/height2(m2).
The MMI was performed as suggested by Friedman etal.,17 withthepatientinthesittingposition,with max-imummouthopeningandrelaxedtonguepositionedwithin the oral cavity. Patientswere classified into four grades: grade1(theentireoropharynxiswellvisualized,including thesoftpalate,thetonsillarpillars,thepalatinetonsils,and theuvula);grade2(theupperpoleofthepalatinetonsils andtheuvulaarevisualized);grade3(partofthesoftpalate andtheuvulainsertionisvisualized);andgrade4(onlythe hardpalateisvisualized).
As proposed by Friedman et al.17 and Zonato et al.,18 the palatine tonsils were classified asgrade 1 (occupying upto25%oftheoropharynx),grade2(50%ofthe orophar-ynx),grade3(75%oftheoropharynx),andgrade4(>75% oforopharynx).Grades3and4wereconsideredascasesof obstructivehypertrophyofthepalatinetonsils.
Basalpolysomnography
PolysomnographywasperformedinanEMBLAcomputerized system (EMBLA® S7000; EMBLA Systems, Inc. ---
Broom-field, CO, United States). An overnight recording was performed in a dark, quiet room, specially designed for this procedure, while monitoring was performed through electroencephalogram, electrooculogram, submental and tibialelectromyogram,electrocardiogram,airflowbynasal cannula connected to a pressure transducer and an oral thermistor, respiratory movements by inductance plethy-smography with thoracoabdominal belts, oxyhemoglobin saturation(SpO2)bypulseoximetry,andsnoringsoundswere
recordedbyamicrophoneandbodypositionsensor. The stagingof sleepfollowed the criteriaproposed by Rechtschaffen and Kales,19 and awakenings followed the 1992 criteria of the AmericanSleep Disorders Association (ASDA).20 The staging of respiratory events followed the 1999criteriaoftheAASM.16
The diagnosis of OSAS followed the 2005 clinical and polysomnographiccriteriaoftheICSD-2.15Amildincreasein AHIwasconsideredwhenpatientshadindexvaluesbetween 5 and 15 events per hour of sleep; moderate increase, between15and30;andmarkedincrease,>30.
Surgicaltechnique---extendedtonsillectomy
The surgical techniqueusedin patients withhypertrophic tonsils is conservative, as the main objective is the lateral amplification of the pharynx, while preserving and repositioning the pillars, addressing mainly the lat-eral oropharyngeal wall, sparing the soft palate and the uvularegion(midline).Therefore,thistechnique iscalled extendedtonsillectomy.
Initially,abilateraltonsillectomyisperformed,withan ellipticalperitonsillar incisionin themucosaoverlyingthe palatopharyngeal and palatoglossus muscles after medial tractionofthemucosa,aimingatitsmaximumpreservation in this region. This is followed by tonsil removal through dissection along the tonsil capsule, while preserving the underlying musculature and subsequent hemostasis using bipolar cauteryand simple stitcheswith vicrylrapid 3.0®
suture thread.The muscle layer of the tonsillar regionis closed with single stitches in the craniocaudal direction, usingvicrylrapid3.0®suturethread.Afterclosingthe
mus-clelayer,thepalate‘‘web’’(membraneformedbythelow insertion of theposterior pillar of theuvula) is removed, whenpresent,usingelectricscalpelorscissors,andthisis theupperlimitofthemidlineresection.Then,themucosa isclosedwithvicrylrapid3.0® suturethread,usingsimple
stitches,inthecraniocaudaldirection.Iftheuvulais consid-eredlong,apartialuvulectomyisperformed,corresponding tothedistalthirdoftheuvula.Theaimofthistechniqueis thelateralenlargementofthepharynxandanteriorization ofthesoftpalate.
The procedure is performed under general anesthesia without pre-anesthetic sedative medication, as recom-mended in patients with OSAS. Patients remain in the hospital for 24hours and receive antibiotics (amoxicillin at adose of50mg/kg/dayforseven days)and non-opioid analgesics (paracetamol and dipyrone) at discharge. The follow-upconsultationsareperformedafterone,three,12, 18,and24weeks.
Newproposedstaging
In our proposed staging (Table 1), we decided to divide stageIIofFriedmanetal.17(Table2)intotwoseparate sub-groupsandtoaddagroupforpatientswithclassIIIobesity (BMI>40kg/m2) withpalatine tonsilsgrade 3 and 4
asso-ciatedwithanyclassofMMI,asanewstageV.Wedidnot
Table1 Newclinicalstagingforpharyngealsurgery indi-cationinpatientswithobstructivesleepapnea.
Stage MMI PTC BMI
StageI 1or2 3or4 <40kg/m2
StageII 3or4 3or4 <40kg/m2
StageIII 1or2 1or2 <40kg/m2
StageIV 3or4 1or2 <40kg/m2
StageV 1,2,3,or4 3or4 >40kg/m2
StageVI 1,2,3,or4 1or2 >40kg/m2
MMI,modifiedMallampatiindex;PTC,palatinetonsil classifica-tion;BMI,bodymassindex.
performsurgeryforpatientswithobesityclassIIIandtonsils grade1and2,regardlessofMMI.
Thus,thepatientsweredividedintosixgroups:stageI, patientswithgrade3or4palatine tonsilsandMMIclass1 or2;stageII,patientswithgrade3or4palatinetonsilsand MMIclass3or4;stageIII,patientssubmittedto tonsillec-tomy(0)grade1or2palatinetonsilsandMMIclass1or2; stageIV,patients submitted totonsillectomy (0), grade1 or2palatinetonsils,andMMIclass3or4;stageV,patients withBMI>40kg/m2withgrade3or4palatinetonsilsandMMI
class1,2,3,or4;andstageVI,patientswithBMI>40kg/m2
withgrade1or2palatinetonsilsandMMIclass1,2,3,or 4.Thislattergroupcomprisedthepatientsnotreferredfor surgeryduetohighmorbidity.
Within each stage, patients were also divided accord-ing to AHI, as follows: group I, patients with mild OSAS (between5and15eventsperhourofsleepandassociated clinicalcomplaints);groupII,patientswithmoderateOSAS (between 15 and 30); and group III, patients with severe OSAS(>30).
Results
Ofthe622reviewedmedicalrecordsofpatienttreated dur-ingthe study period,129 patients receivedindication for extendedtonsillectomy;54patientsmettheinclusion crite-riaandwerethusincludedinthestudy.
Ofthe54patients,35(64.8%)weremalesand19(35.1%) were females, aged 18---61 years, with a mean age of 38.9±7.5years. Afterstaging, thepatients were divided as follows: stage I: nine patients (16.6%); stage II: eight patients(14.8%);stageIII:14patients(25.9%);stageIV:13 patients (24%);and stage V: 10 patients (18.5%). Surgical
Table2 Friedman’sstagingforindicationofuvulopalatopharyngoplastyinpatientswithobstructivesleepapneasyndrome.17
MMI Sizeofpalatinetonsils BMI
FriedmanI 1or2 3or4 <40kg/m2
FriedmanII 1or23or4 0,1or2
3or4
<40kg/m2
FriedmanIII 3or4 0,1or2 <40kg/m2
FriedmanIV 1,2,3,or4 0,1,2,3,or4
Evidentcraniofacial alteration
>40kg/m2
Table3 Comparisonofsuccessandfailureratesaccordingtothenewstagingforpatientsundergoingextendedtonsillectomy forthetreatmentofobstructivesleepapneasyndrome(OSAS).
Success Failure Total p
n % n % n
StageI 8 88.9 1 11.1 9 0.07
StageII 6 75.0 2 25.0 8 0.44
StageIII 5 35.7 9 64.3 14 0.02
StageIV 5 38.5 8 61.5 13 0.03
StageV 10 100.0 0 0.0 10 <0.01
StageVI Nosurgicalindication
Significancevalue:p<0.05,chi-squaretest.
successrateswere88.9%,75.0%,35.7%,38.5%and100.0%, respectively.
Dataforeachgroupandthesuccessandfailureratesare showninTable3.Therewasastatisticallysignificant differ-enceinstagesIII,IV,andV(p=0.02,p=0.03,andp<0.01, respectively).StagesIIIandIVpresentedthehighestfailure rates(p=0.02 andp=0.03, respectively),andthe highest successrateswereobservedinstageV(p<0.01).
RegardingtheAHI,24patients(44.4%)hadmildincrease inAHI;20patients(37.0%)hadamoderateincrease,andten patients(18.6%)achievedamarkedincrease(Table4).The failureratewassignificantlyhigherinthegroupwithmild increaseinAHI(p<0.01),andthehighestsuccessratewas foundinthegroupwithamarkedincreaseinAHI(p=0.01). Withineach proposed stage,thepatients weredivided accordingtoAHI increase, andtherewerenostatistically significantdifferences(Table5).
When we staged the patients according tothe criteria byFriedmanetal.,21thefollowingresultswereobtained:in FriedmangroupI,ninepatientswereincludedwithasurgical successrateof89%;inFriedmangroupII,22patientswere includedwith50%surgicalsuccess;inFriedmaningroupIII, 13patientswereincludedwithsurgicalsuccessrateof38%; lastly,FriedmangroupIVincludedtenpatientswithsurgical successrateof100% (Table6).Statisticallysignificant dif-ferenceswereobservedinFriedmanstagesIII andIV,with thehighestfailurerateinFriedmangroupIII(p=0.03)and thehighestsuccessinFriedmangroupIV(p<0.01).
Discussion
Ourproposedstagingdemonstratedthattheextended ton-sillectomysurgeryforthetreatmentofOSAShasthehighest
successratesinpatientswithhypertrophictonsils(stagesI, II,andV)andthatMMIclasses3and4(stageII)decreased thesuccessrateinthesepatients.Nonetheless,thesuccess ratewashigherthaninthosepatientswithnormal-sized ton-sils(stagesIIIandIV),eveninpatientswithfavorableMMI (stageIII) andthosewithclassIII obesity (stageV).Thus, our division of Friedman etal.’s17 stage II and the inclu-sionof patientswhohave classIIIobesity associatedwith hypertrophictonsilscanimprovetheindicationcriteriafor pharyngealsurgeryinthetreatmentofOSAS.
CPAPis consideredthe goldstandard for treating mod-eratetosevereOSAS,buthasthedisadvantagethatmany patients have difficulties in adapting to it, especially in the long term, making surgical treatment a therapeutic option.22
When performed ina systematic way,the success rate ofuvulopalatopharyngoplastyis40.7%,6butifpatientsare selectedaccordingtothepresenceofanatomicalchangesin theoropharynx, suchastonsillar hypertrophy,medianized pillars,redundantpalate,andelongateduvula,thesuccess rateishigher.11,12,21
Somestudiesintheliteraturehavedemonstratedhigher successrateswhenthesurgerywasperformedonpatients with mild to moderate OSAS.23,24 In the present study, patientswithmarkedincreaseinAHIwerethosewho ben-efitedthemostfromthesurgicaltreatment,probablydue tothecriterionselectedforsuccess.Inpatientswithmild increaseinAHI,areduction<50%wasconsideredasfailure, whenitisknownthat,forthesepatients,thecontrolof clin-icalsymptomsisamoreimportantoutcomethanAHI,since presenceofOSASisonlyconsideredinpatientswithAHI<15 perhourwhenassociatedwithaclinicalcomplaint.
AnotherfactthatleadstobelievethatOSASseverityis not adeterminant factor for theindication of pharyngeal
Table4 Comparisonofsuccessandfailureratesaccordingtotheincreaseofapnea---hypopneaindex.
Success Failure Total p
n % n %
AHI5---15 9 37.5 15 62.5 24 <0.01
AHI15---30 16 80 4 20 20 0.08
AHI>30 10 100 0 0 10 0.01
Table5 Comparisonofsuccessandfailureratesaccordingtothenewstagingandapnea---hypopneaindexforpatients under-goingextendedtonsillectomyforthetreatmentofobstructivesleepapneasyndrome(OSAS).
OSAS Success Failure Total p
n % n %
StageI
Mild 0 0 1 100.0 1 0.11
Moderate 6 100.0 0 0.0 6 0.33
Marked 2 100.0 0 0.0 2 0.77
StageII
Mild 2 66.6 1 33.3 3 0.64
Moderate 2 66.6 1 33.3 3 0.64
Marked 2 100.0 0 0.0 2 0.53
StageIII
Mild 4 40 6 60.0 10 0.54
Moderate 1 25 3 75.0 4 0.54
Marked 0 0 0 0.0 0
---StageIV
Mild 2 22.2 7 77.8 9 0.11
Moderate 2 66.6 1 33.3 3 0.31
Marked 1 100 0 0.0 1 0.38
StagesV
Mild 1 100 0 0.0 1
---Moderate 5 100 0 0.0 5
---Marked 4 100 0 0.0 4
---StagesVI
Nosurgicalindication
surgeriesforthetreatmentofOSASisthat,whenthedegree ofAHIincreaseiscomparedamongthestages,nosignificant differenceswerefoundinrelationtosuccess.Similar find-ingsweredescribedbyFriedmanetal.,12whoalsofoundno associationbetween OSASseverityandpharyngeal surgery success.
In 2002, Friedman et al.11 proposed a staging system basedonupperairwayalterations(sizeofpalatine tonsils andMMI)andBMI,andreportedasurgical successrateof 80.6%inpatientswithBMI<40kg/m2,withhypertrophic
ton-sils(grades3and4)andfavorableMMI(1and2),regardless ofOSASseverity;thesuccessratedecreasedsignificantlyas theseparametersvariedintheotherstages.
Since Martin et al.13 found significant improvement in polysomnographic respiratory parameters in a case series ofobesepatientswithMMIclasses3and4andhypertrophic palatinetonsils(patientswithFriedman’sstagesIIandIV),
we considered that a refinement of Friedman’s17 staging systemmightimprovetheindicationofpharyngeal surger-ies,as this stagingmixed patients with normal-sized and hypertrophictonsilsinstageIIandcontraindicatedsurgery in patients withclass III obesity,even in the presence of hypertrophictonsils(stageIV).
Confirming the findings of Martin et al.13 and Fried-man et al.,21 our study demonstrated that patients who hadhypertrophic palatine tonsilsachieved higher success rateswiththeprocedure,independentofAHI13,21orclassIII obesity,13 andthatthepresenceofMMI3and4decreased thesuccess rate in such patients. However,the presence of MMI 1 and 2 in patients with normotrophic tonsilsdid notcorrelatewithsurgicalsuccess.Thus,weconcludethat anunfavorableMMIdecreasesthechancesof success,but afavorableMMI does notimprovethe chancesof surgical successunlessthepatientsalsohadhypertrophictonsils.
Table6 ComparisonbetweensuccessandfailureratesaccordingtoFriedman’sstaging.
Success Failure Total p
n % n % n
StageI 8 89.9 1 11.1 9 0.13
StageII 11 50.0 11 50.0 22 0.07
StageIII 5 38.5 8 61.5 13 0.03
Conclusions
Despitethelimitations of thisstudy,mainlyits retrospec-tive nature and a small sample size, we conclude that ourproposed new stagingmethod can improve the surgi-calindicationsandresultsofextendedtonsillectomyinthe treatmentofpatientswithOSAS.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
1.Tufik S,Santos-SilvaR, Taddei JA,Bittencourt LRA. Obstruc-tivesleepapneasyndromeintheSaoPauloepidemiologicsleep study.SleepMed.2010;11:441---6.
2.BittencourtLRA,TogeiroSMGP,BagnatoMC.Diagnósticoda sín-dromedaapnéiaehipopnéiaobstrutivadosono.RevBrasMed. 2001;58:584---93.
3.Li HY, Wang PC, Lee LA, Chen NH, Fang TJ. Predic-tion of uvulopalatopharyngoplasty outcome: anatomy-based staging system versus severity-based staging system. Sleep. 2006;29:1537---41.
4.Kushida CA,Littner MR, Hirshkowitz M. Practiceparameters fortheuseofcontinuousandbilevelpositiveairwaypressure devicestotreatadultpatientswithsleep-relatedbreathing dis-orders.AnAmericanAcademyofSleepMedicineReport.Sleep. 2006;29:375---80.
5.Bittencourt LRA. Diagnóstico e tratamento da síndrome da apnéiadosono:guiaprático.SãoPaulo:LivrariaMédicaPaulista Editora;2008.
6.SherAE,SchechtmanKB,PiccirilloJF.Theefficacyofsurgical modifications of theupperairway in adultswithobstructive sleepapneasyndrome.Sleep.1996;19:156---77.
7.Senior BA, Rosenthal L, Lumley A. Efficacy of uvu-lopalatopharyngoplasty in unselected patients with mild obstructive sleep apnea. Otolaryngol Head Neck Surg. 2000;123:179---82.
8.BrodskyL.Modernassessmentoftonsilsandadenoids.Pediatr ClinNorthAm.1989;36:1551---69.
9.CaplesS,RowleyJA,PrinsellJR,PallanchJF,ElaminMB,Katz SG,etal.Surgicalmodificationsoftheupperairwayforsleep apnea:asystematicreview.Sleep.2010;33:1396---407. 10.AuroraRN,CaseyKR,KristoD,AuerbachS,BistaSR,Chowdhuri
S,etal.Practiceparametersforthesurgicalmodificationsof
theupperairwayforobstructivesleepapneainadults.Sleep. 2010;33:1408---13.
11.FriedmanM,IbrahimH,BassL.Clinicalstagingforsleep disor-deredbreathing.OtolaryngolHeadNeckSurg.2002;127:13---21. 12.FriedmanM,IbrahimH,JosephJN.Stagingofobstructivesleep apnea/hypopneasyndrome:aguidetoappropriatetreatment. Laryngoscope.2004;114:454---9.
13.MartinhoFL,TangerinaRP,MouraSMGT,GregórioLC,TufikS, BittencourtLRA.Systematicheadandneckphysical examina-tionasapredictorofobstructivesleepapneainclassIIIobese patients.BrazJMedBiolRes.2008;41:1093---7.
14.JohnsMW.Sleepinessindifferentsituationsmeasuredbythe EpworthSleepinessScale.Sleep.1994;17:703---10.
15.AmericanAcademy ofSleepMedicine.ICSD-2---International ClassificationofSleepDisorders.Diagnosticandcodingmanual. AmericanAcademyofSleepMedicine;2005.
16.AmericanAcademyofSleepMedicine.Sleep-relatedbreathing disordersinadults:recommendationsfor syndromedefinition and measurement techniques in clinical research. American AcademyofSleepMedicineTaskForce.Sleep.1999;22:667---89. 17.FriedmanM,TanyeriH,LaRosaM,LandsbergR,Vaidyanathan K,PieriS,etal.Clinicalpredictorsofobstructivesleepapnea. Laryngoscope.1999;109:1901---7.
18.ZonatoAL,BittencourtLRA,MartinhoFL,SantosJrJF,Gregorio LC,TufikS.Associationofsystematicheadandneckphysical examinationwithseverityofobstructivesleepapnea---hypopnea syndrome.Laryngoscope.2003;113:973---80.
19.RechtschaffenA, KalesA, editors.Amanual ofstandardized terminology,techniquesandscoringsystemforsleepstagesof humansubjects.Washington,DC:USPublicHealthService,US GovernmentPrintingOffice;1968.
20.AmericanSleepDisordersAssociation(ASDA)EEGarousals: sco-ringrulesandexamples:a preliminaryreportfromtheSleep DisordersAtlasTaskForce.Sleep.1992;2:173---84.
21.Friedman M, Vidyasagar R, Bliznikas D, Joseph N. Does severity of obstructive sleep apnea/hypopnea syndrome predict uvulopalatopharyngoplasty outcome? Laryngoscope. 2005;115:2109---13.
22.SinD,MayersI,ManG,PawlukL.Longtermcomplianceratesto continuouspositiveairwaypressureinobstructivesleepapnea. Chest.2002;121:430---5.
23.Janson C, Gislason T, Bengtsson H. Long term follow-up of patients with obstructive sleep apnea treated with uvu-lopalatopharyngoplasty. Arch Otolaryngol Head Neck Surg. 1997;123:257---62.
