Ettinger Russell E, Oppenheimer Adam J, Lau Darryl, Hassan Fauziya, Newman M Haskell, Buchman Steven R, Kasten Steven J
Division of Plastic Surgery, University of Michigan Medical Center, 1500 E. Medical Center Drive, Ann Arbor, MI 48109, USA.
J Craniofac Surg. 2012 Nov;23(7 Suppl 1):1974-6. doi: 10.1097/SCS.0b013e31825b3ba9.
In patients who require additional surgery for velopharyngeal insufficiency (VPI), a higher incidence of obstructive sleep apnea (OSA) may be incurred. Although this phenomenon has been demonstrated with the posterior pharyngeal flap, the effect of dynamic sphincter pharyngoplasty (DSP) on OSA is less clear. The purposes of this case series were to (1) determine the incidence of OSA after DSP, (2) assess the changes in polysomnography after DSP, and (3) identify risk factors for the development of OSA after DSP. Our global hypothesis is that OSA and VPI exist on a continuum and that speech outcomes should not be considered in isolation.
For a 13-year period, 146 patients with idiopathic VPI, submucous cleft palate, cleft palate only, or cleft lip and palate underwent DSP for VPI. The diagnosis of OSA was defined as the prescription of continuous positive airway pressure therapy by a pediatric sleep medicine physician. The incidence of OSA preoperatively and postoperatively was compared using Fisher exact test. When available, preoperative and postoperative apnea-hypopnea indices (AHIs) were compared using the pairwise, 2-tailed, Student's t-test. Patient factors, such as obesity (body mass index ≥ 95th percentile), the presence of a craniofacial syndrome, surgical history, and a preexisting OSA diagnosis, were noted. A multiple logistic regression was performed to elucidate risk factors for the development of OSA.
The average age at surgery was 9.2 years (range, 4-40 y), and the mean follow-up time was 4.5 years (range, 1 mo to 12 y). The incidence of OSA increased after DSP, from 2 to 33 patients (1.4%-22%, respectively; P = 0.05). In 23 patients (16%), both preoperative and postoperative AHIs were available. There was a significant increase in AHI after DSP, from 3.1 to 8.4 episodes per hour of sleep (P = 0.001). Previous tonsillectomy/adenoidectomy was predictive of OSA after DSP (relative risk = 2.4; P = 0.04).
We report an increased incidence of OSA and higher-than-average AHIs postoperatively after DSP. Preoperative tonsillectomy/adenoidectomy predicted the development of OSA after DSP. A high index of suspicion for development of OSA must be maintained in patients who undergo secondary speech operations for VPI. Clinical screening for OSA should be used in this population, with a low threshold for polysomnographic evaluation. The surgeon must be wary that improvements in speech after DSP may change airway dynamics and increase the risk of OSA.
对于因腭咽闭合不全（VPI）而需要额外手术的患者，发生阻塞性睡眠呼吸暂停（OSA）的几率可能更高。虽然这种现象已在咽后壁瓣手术中得到证实，但动态括约肌咽成形术（DSP）对OSA的影响尚不清楚。本病例系列的目的是：（1）确定DSP术后OSA的发生率；（2）评估DSP术后多导睡眠图的变化；（3）确定DSP术后发生OSA的危险因素。我们的总体假设是，OSA和VPI处于连续统一体中，语音结果不应孤立地考虑。
在13年的时间里，146例患有特发性VPI、黏膜下腭裂、单纯腭裂或唇腭裂的患者接受了DSP治疗VPI。OSA的诊断定义为儿科睡眠医学医生开具持续气道正压通气治疗的处方。术前和术后OSA的发生率采用Fisher精确检验进行比较。如有可用数据，术前和术后的呼吸暂停低通气指数（AHIs）采用双尾配对Student t检验进行比较。记录患者因素，如肥胖（体重指数≥第95百分位数）、是否存在颅面综合征、手术史以及既往OSA诊断情况。进行多因素逻辑回归分析以阐明OSA发生的危险因素。
手术时的平均年龄为9.2岁（范围4 - 40岁），平均随访时间为4.5年（范围1个月至12年）。DSP术后OSA的发生率增加，从2例增至33例（分别为1.4% - 22%；P = 0.05）。23例患者（16%）术前和术后的AHIs数据均可用。DSP术后AHI显著增加，从每小时睡眠3.1次增至8.4次（P = 0.001）。既往扁桃体切除术/腺样体切除术是DSP术后OSA的预测因素（相对风险 = 2.4；P = 0.04）。
我们报告DSP术后OSA的发生率增加且术后AHIs高于平均水平。术前扁桃体切除术/腺样体切除术可预测DSP术后OSA的发生。对于接受VPI二期语音手术的患者，必须高度怀疑OSA的发生。该人群应进行OSA的临床筛查，多导睡眠图评估的阈值要低。外科医生必须警惕，DSP术后语音改善可能改变气道动力学并增加OSA的风险。
