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Surgery for Snoring and Obstructive Sleep Apnea Syndrome

edited by: M. Fabiani

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Publication details: Book. 2003. xiii and 624 pages. Publication date: 2003-01-09. 277 figures, of which 25 in full color, and 50 tables. Hardbound. 16x24 cm (6.3x9.4 in).

ISBN: 978-90-6299-182-2 (ISBN 10: 90-6299-182-3; Kugler Publications)

Also available as ebook



'Bocca della Verità' or 'Mouth of Truth' is the logo of the Unit for the Study and Therapy of Sleep Respiratory Disorders at the University of Rome 'La Sapienza'. It was chosen because its round shape with surprised expression, small nose and open mouth mirrors the typical face of a patient with OSAS (pre-therapy). The stone (diameter 1.75 m) in fact represents the face of a screaming faun and was originally found in the Mercury Temple area. According to popular legend, anyone putting his hand in the mouth will have it cut off if he has told a lie.

When I first became involved in the field of OSAS about ten years ago, I had no idea that this activity would become foremost in both my professional and my academic life.

My curiosity was aroused when a patient of mine, an extremely fat patient, whom I had been following for a long time regarding a hearing problem, asked me for a prescription for CPAP. He had read in a newspaper that this device could solve his nocturnal respiration and diurnal hypersomnolence problems. Suddenly, I was confronted with documentation on snoring, OSAS, polysomnography, upper airway surgery, and positive pressure devices. 

I was then, and still am now, a Professor of Audiology. Audiology was and still is the object of my love, but it is mainly a speculative discipline. It involves physics, electronics, psychology, rehabilitation, and great possibilities for basic research. However, only rarely does an audiological patient obtain full satisfaction clinically. Patients with neurosensorially-based deafness can be rehabilitated, but with difficulty; conductive hearing loss is light and recovers automatically in most cases; in a few cases, the patient can be packed up and delivered to the ear surgeon or audioprosthetic technician. 

Vertigo is dramatic, but recovers spontaneously or after long-term rehabilitation, or it is categorized as a neurological symptom. Tinnitus is frustrating and the audiologist centers most of his time and energy on trying to convince the patient to forget it. In fact, it is very rare to see a patient affected by an audiological disease recover after intervention by an audiologist. Furthermore, most patients are either very old or very young.

With OSAS patients, things are very different. The patient is usually at the peak of his life; he has serious disturbances in his social, familial, and working spheres; he is sedentary and is often a manager with a disordered of lifestyle (does not partake in any sport; smokes and drinks too much), he has become irritable, apathetic, and is starting to worry about dying during the night or suffocating. He has been followed for years for his arterial hypertension and latent arrhythmia. He, or often she, is a snorer and, after complaints from their partner, sleeps in a separate room. His sex life is affected, and he often gets up during the night convinced that he has prostatic problems too. 

Unfortunately, for many years, no-one thought that these kinds of patients should consider consulting an otolaryngologist, and, at the same time, otolaryngologists never thought of taking care of this pathology.

As soon I started to see the first cases and was able to solve their obstruction, the number of patients being referred grew dramatically, as did my skill in this field. It was a really rewarding job. After years of hyperspecialistic practice, I returned to patient care in its entirety. Sometimes, a simple intervention such as nasal septoplasy or tonsillectomy, i.e., one of those interventions so often underestimated by more expert colleagues, was able to solve some of the serious problems of life. In the meantime, specific new techniques came into being: radiofrequencies, oral appliances, diode lasers, tongue suspension devices, while, at the same time, diagnostic instrumentation such as polysomnography became more flexible and could more easy to be applied to obstructive disorders. 

By 1997, my department was in an uproar about OSAS since I had got most of my colleagues interested in becoming involved, and the first sponsor was my former chief, Roberto Filipo, who gave me his approval, space to work in, and encouragement to overcome all the problems. My other colleagues, and I would like to mention all of them here: Giorgio Bandiera, Maurizio Barbara, Gian Antonio Bertoli, Ferdinando D'Ambrosio, Elio De Seta, Simonetta Masieri, Antonio Minni, Simonetta Monini, Virgilio Pizzichetta, Mario Patrizi, Maurizio Saponara, and Antonino Sciuto, either directly or indirectly, also offered to put their experience into writing various sections for this book. A specific section was also organized at the Institute, and I was able to coordinate some of our residents who have recently taken on the task of apostles, spreading the knowledge they acquired on OSAS during their time with us to other hospitals in the region. I must mention them too, since very often they did most of the work, and in OSAS, that is a lot of work: Francesca Auriti, Angelo Clarici, Fulvio Di Fulvio, Arianna Mattioni, Angela Mollica, Maria Laura Panatta, Barbara Pichi, Raniero Pucci, Mario Rinaldi, Rocco Roma, Anna Sambito, Ilenia Schettino, Rocco Schettino, Emanuela Sitzia, Artur Zajmi, and others. 

The diagnosis and treatment of, and scientific research into, OSAS is a multidisciplinary task, and I succeeded in involving many professors from related disciplines at the hospital of the University 'La Sapienza': Carlo Cannella for Alimentation and Human Nutrition, Eugenio Gaudio for Anatomy, Giuseppe Calcagnini for Cardiology, Vincenzo Bonifacio and Debora Giannini for Endocrinology, Adolfo Francesco Attili for Gastroenterology, Franco Angelico for Internal Medicine, Giorgio Iannetti for Maxillo-Facial Surgery, Giuseppe Amabile for Neurology, Maria Pia Villa for Pediatrics, Alessandro Perrone and Ilio Cammarella for Pneumology, and Carlo De Dominicis for Urology. They used their experience in treating these patients and present their results in their contributions to this book.

During the same period, the diagnosis and therapy of OSAS was spreading fast to all otolaryngological units at universities and hospitals throughout Italy. It was easy for me to share my enthusiasm, and thus we built up a network of close cooperation. Any otolaryngologist will know these contributors so well that it would be easy for him to find their papers in this book, but still I want to mention those who were closest in advising and helping me: Marco Fusetti from L'Aquila, Luigi D'Angelo and Vieri Galli from Naples, Pietro Ferrara, Riccardo Speciale and Salvatore Restivo from Palermo, Oskar Schindler from Turin, and Maurizio Maurizi and Vittorio Pierro from Rome.

The time was now ripe to confront the world nomenclature on OSAS. The dream to share a rendezvous with all (or most of) the prominent people from all the disciplines involved in both the clinical and scientific research on OSAS was realized in 1997 at the 'ROMA OSAS - First International Conference on the Diagnosis and Therapy of Snoring and OSAS', which was followed by a second meeting in the year 2000, and a third in 2002. I only have to mention the names of the presidents of these conferences to testify to the high quality that was achieved: Giovanni Bonsignore, Gisle Djupesland, Roberto Filipo,
Christian Guilleminault, Meir Kryger, Elio Lugaresi. It would be inappropriate to mention here only some of those who also took part, and there are too many to mention them all, since they are all equally important. I was very honored to ask them for and to receive papers for this book. Some of the abstracts presented at these conferences are also included in this book as highlights on various subjects, due to their particular relevance. 

And so, finally, you now know how this book was born. It is the collection of an enthusiastic beginner who persuaded his friends and/or colleagues from his department, his university, his country, and the entire scientific community, to submit papers on the basics and state-of-the-art of relevant topics regarding snoring and OSAS, which, hopefully, in its turn will help those other enthusiastic beginners who wish to improve their knowledge on the care of apneic patients. Also, even though many of the chapters are written by participants at the ROMA OSAS Conferences, this book is not an abstract volume of those meetings. It does, however, represent the scientific development unearthed on those occasions. For this reason, I think it would also be a valid textbook on OSAS from an otolaryngological point of view.

After the many thanks due to the contributors, my final thanks must go to the person who had the patience to cooperate with me on the editorial work: Peter Bakker of Kugler Publications. My confrontations with him were often thorny, but we both had the same goal in mind: to offer you the best possible product. We hope that you will agree with us that this book will be a useful addition, both to your practice and to your continuing education.

Mario Fabiani

Table of Contents

Table of Contents

Introduction, M. Fabiani

Anatomo-Physiology of the Upper Airways, Gaudio, E. and A. Vetuschi
Soft Palate and Voicing, Schindler, O. and A. Schindler
Obstructive Sleep Apnea. A Historical Survey, Bassiri, A. and C. Guilleminault
Classification of Heavy Snorers Disease. From Snoring to Sleep Apnea Syndrome, Lombardi, C., F. Provini, R. Vetrugno and E. Lugaresi
Epidemiology, Provini, F., C. Lombardi, R. Vetrugno and E. Lugaresi

Neurological correlation in neurological breathing disorders, Amabile, G., F. Pauri and F. Fattapposta
Pathophysiology of Obstructive Sleep Apnea Syndrome, Kryger, M.H.
Obstructive Sleep Apnea and Cardiovascular Disease, Calcagnini, G. and F. De Pasquale
Nasal Obstruction and Obstructive Sleep Apnea Syndrome, Filipo, R., A. Minni and G.A. Bertoli

Obesity and Obstructive Sleep Apnea Syndrome
Weight Management Strategies for Obesity in Patients with Obstructive Sleep Apnea Syndrome, Giannini, D., M. Saponara, L. Bruno, M. Fabiani and V. Bonifacio
Obesity in Obstructive Sleep Apnea Syndrome. Dietary Therapy and Pharmacotherapy, Pinto, A., V. Bacci, M.S. Basso, U. Elmore, R. Lamberti and C. Cannella

Highlights in Obesity
Endocrine Abnormalities in Obesity, Greco, E., V. Fierro, D. Giannini and V. Bonifacio
Evaluation of Obesity in Patients with Obstructive Sleep Apnea Syndrome, Giannini, D., M. Saponara, M.L. Panatta, A. Sambito and M. Fabiani
A Statistical Index to Detect Potentially Obese People, Martino, L. and A. D Amicis
Food Consumption Pattern of Overweight Subjects. Preliminary Results from the INN-CA Study, Turrini, A., P. D Acapito, D. Perrone, F. Silvi and A. D Amicis
The Distribution of Body Mass Index in an Italian Sample. Results from the INN-CA Study 1995, D'Amicis, A., A. Turrini, P. D Acapito, D. Perrone and F. Silvi
Food Consumption and Obesity in Italy. Recent Trends, D'Amicis, A., L. Martino and A. Turrini
A Body Weight Control Protocol for Obstructive Sleep Apnea Syndrome Patients, Lombardo, C. and C. Violani
Soft Palatal Dynamics, Histology, and Body Fat Distribution in Patients with Partial Upper Airway Obsctruction, Laurikainen, E., P. Halme, J. Antila, L. Viikari, Y. Tsushima, H. Kalimo
and O. Polo

Obstructive Sleep Apnea Syndrome and Systemic Diseases
Neurogenic Factors, Di Giovanni, G., S. Chiti-Batelli, M. Fusetti, B. Fioretti and A. Eibenstein
Gastroesophageal Reflux Disease and Obstructive Sleep Apnea Syndrome, Attili, A.F. and E. Papa
Nocturia: Secondary to Obstructive Sleep Apnea Syndrome or to Cervico urethral Obstruction?, De Dominicis, C., F. Peris, G. Di Crosta, F. Sciobica, A. Zuccalà, A. Mattioni, M. Saponara and M. Fabiani
Early Presbycusis in Obstructive Sleep Apnea Syndrome, Fabiani, M., R. Pucci, A. Mollica, I. Schettino, R. Roma and A. Musacchio
Obstructive Sleep Apnea and Lung Disease, Cammarella, I., N. De Luca, F. Trinchieri, P. Comite, V. Paoletti, M. Fabiani, M. Saponara, L. Tafaro and M. Fioravanti
Sleep Apnea and Driving, Haraldsson, P.-O.

Highlights on Pathophysiology
Obstructive Sleep Apnea Associated with Retropharyngeal Lipoma, Sorrenti, G., G. Scaramuzzino, G. Latini and O. Piccin
Obstructive Sleep Apnea Syndrome and Some Neurological Disorders, D'Angelo, L., V. Covelli, F.P. Serra, G. Salerno and G. Buongiorno

Pediatric Snoring and Obstructive Sleep Apnea Syndrome
Sleep-Disordered Breathing in Children, Chiti-Batelli, S., G. Di Giovanni, A. Eibenstein, A.B. Fioretti and
M. Fusetti

Obstructive Sleep Apnea Syndrome. An Unknown Pathology in Children, Galli, V., M. Polce, M. Mesolella, R. Iovine, E. Cantone and D. Testa
Pediatric Obstructive Sleep Apnea Syndrome. A Multidisciplinary Approach, Villa, M.P., J. Pagani, R. Ambrosio, B. Paggi, A. Alterio and R. Ronchetti

Highlights on Pediatric Obstructive Sleep Apnea Syndrome
Pediatric Snoring and Obstructive Sleep Apnea Syndrome, Ferrara, S., M. Tutino, D. Sammartano and P. Ferrara
Night-time Obstructive Apnea Syndrome in Pediatric Patients. Findings Regarding Growth, Sitzia, E., G.C. De Vincentiis, V. Pierro, M. Saponara and M. Fabiani
A New Technique for the Diagnosis of Pediatric Obstructive Sleep Apnea Syndrome, Pagani, J., M.P. Villa, F. Massa, A. Alterio, R. Ambrosio and R. Ronchetti
Facial and Dental Malocclusions in Allergic and Nonallergic Children with Upper Airway Obstruction, Bertolani, M.F., F. Marotti, S. Dallari, M. Tassinari, B.M. Bergamini and
I. Fontana

Facial Patterns of Children with Obstructive Sleep Apnea, Kikuchi, M., N. Higurashi, S. Miyazaki, Y. Itasaka, S. Chiba and H. Nezu

Obstructive Sleep Apnea Syndrome. From the Introduction of Polysomnography to a Multidisciplinary and Multilevel Approach, Chiti-Batelli, S., A. Eibenstein, M. Fusetti and M. Aquilini
Polysomnographic Technology. Trends, Education and Certification, Shumard, T.
Esophageal Pressure Measurements, Boudewyns, A.N.
Screening for Obstructive Sleep Apnea Syndrome, Panatta, M.L., B. Pichi, G. Balsamo, A. Zajmi, M. Saponara and
M. Fabiani,

Individualization of the Sites of Obstruction. Role of the Otorhinolaryngologist, Petrolito, G. and R. Spinato
Cephalometric Variables in the Diagnosis of Obstructive Sleep Apnea Syndrome, D'Ambrosio, F., D. Proietti, S. Masieri, A. Roncacci, M. Saponara and M. Fabiani
The Clinical Assessment of Daytime Sleepiness in Patients with Obstructive Sleep Apnea, Johns, M.W.

Highlights on Diagnosis
Somnoscopy. A Technique for Analysis and Post-surgical Follow-up in Snoring and Obstructive Sleep Apnea Syndrome Patients, Herrmann, I.F., S. Arce Recio, A. Rollo and M. Aquilini,
An Abbreviated Method for Assessing Upper Airway Function in Obstructive Sleep Apnea, Boudewyns, A.N., N. Punjabi, P.H. Van de Heyning, W.A. De Backer, C. O Donnell, H. Schneider, P.L. Smith and A.R. Schwartz
Allergometric Screening in Obstructive Sleep Apnea Syndrome Patients, Masieri, S., R. Roma, F. D Ambrosio and F. Germano
Cephalometric and Endoscopic Features in Snorers and Patients with Obstructive Sleep Apnea. A Multivariate Analysis, Sorrenti, G., O. Piccin, G. Latini, G. Scaramuzzino, S. Mondini, F. Cirignotta and G.C. Modugno
Sleep Apnea and Morbidity, Partinen, M., J. Kaprio, C. Hublin and M. Koskenvuo
Objective Evaluation of the Pharyngeal Airway in Snoring and Obstructive Sleep Apnea Syndrome Patients Using Acoustic
Reflectometry, Kamal, I.
Advantages of Measuring Airflow in the Hypo- and Epipharynx with Internal Thermistors, Akre, H.
Dysautonomia in Patients with Mild Sleep-Disordered Breathing, Woodson, T.B., L.T. Brusky and S. Jaradeh
Arterial Baroreflex During Sleep, Bonsignore, G., M.R. Bonsignore, G. Parati, M. Di Rienzo and G. Insalaco
Use of Medical Resources by Obstructive Sleep Apnea Syndrome Patients Ten Years Prior to Diagnosis, Kryger, M.H., J. Ronald, K. Delaive, L. Roos and J. Manfreda

Surgical Therapy
Indications for Surgery in Obstructive Sleep Apnea Syndrome, Minni, A., I. Ottaviani, R. Filipo
Treating Nasal Obstruction in Obstructive Sleep Apnea Syndrome, Verse, T., and W. Pirsig
Naso-Mesopharyngeal Pathology and Snoring. Incidence and Surgical Treatment, Sulsenti, G.
Turbinate Surgery by Radiofrequency for Sleep-Disordered Breathing, Speciale, R., S. Restivo, G.F. Cupido, S. Gallina and A.M. Giammanco
The Role of Functional Septoplasty and Submucous Diathermy of the Lower Turbinates in Snoring, Manola, M., F. Longo, F. Ionna, G. Salerno, F. Gargiulo and L. D Angelo
External Multi-Layer Surgery in the Treatment of Obstructive Sleep Apnea Syndrome, Minni, A., P. Grandinetti and R. Filipo
Uvulopalatal Flap Technique for the Treatment of Obstructive Sleep Apnea Syndrome. Long-term Results, Djupesland, G., O. Skatvedt, O.B. Godtlibsen and O. Krogstad
Long-term Follow-up of Obstructive Sleep Apnea Syndrome Following Surgery in Children and Adults, Ikeda, K., M. Sato, M. Suzuki, T. Oshima, M. Ogura, A. Shimomura, H. Suzuki and T. Takasaka
Congenital Craniofacial Malformations and Obstructive Sleep Apnea Syndrome, Iannetti G., P. Cascone and M.T. Fadda
The Efficiency of Adenotonsillectomy in Children Suffering from Sleep Apnea Syndrome and Snoring. A Prospective Study with Pulsoximetric and Polysomnographic Results, Nuyens, M.R., S. Vella, C. Bassetti and R. Häusler
Adult and Pediatric Coblation Tonsillectomy. Double Blind Randomized Controlled Studies and Complication Rates in 800 Patients, Timms, M.S., R.H. Temple and A. Belloso
Results of the Treatment of Obstructive Sleep Apnea Syndrome in Children, Cassano, P., N. De Candia, M.L. Fiorella and R. Fiorella
Out-patient Treatment of Snoring and Sleep Apnea Syndrome with CO2 Laser-Assisted Uvulopalatoplasty, Kamami, Y.V., L. Pandraud and A. Bougara
Laser-Assisted Uvulopalatopharyngoplasty. A Meta-Analysis, Verse, T., and W. Pirsig
Interstitial Diode Laser Treatment for Obstructive Sleep Apnea Syndrome, Narducci, E., G.A. Redaelli, G. Radaelli and F. Riggio
Radiofrequency Ablation of the Soft Palate (Somnoplasty®) in the Treatment of Habitual Snoring. Results of a Europan Multicenter Trial, Boudewyns, A.N., E. Hamans and P.H. Van de Heyning
Uvulopalatoplasty for Snoring and Mild Obstructive Sleep Apnea. Experience in 280 Patients, Bertoletti, F., N. Lattuada, G.F. Tassi, G. Corica and G. Redaelli
Uvulopalatoplasty by Radiosurgery, Restivo, S., R. Speciale, G.F. Cupido, S. Gallina and A.M. Giammanco
Coblation Surgery for Reducing Tonsil Volume in Slight Obstructive Sleep Apnea Syndrome, Fabiani, M., R. Roma and A. Sciuto
Tongue Suspension and Further Surgical Developments for the Tongue Base, Fibbi, A. and G. Bertino
Tracheotomy and Tracheostomy in Obstructive Sleep Apnea Syndrome, Patrizi, M. and P. De Carli
Obstructive Sleep Apnea Syndrome. Anesthesiological Problems, Romano, R.

Highlights on Surgical Therapy
Hyoid Position Correlates with Respiratory Events and Pulmonary Function in Obstructive Sleep Apnea Patients, Fetoni, A.R., E. Scarano, G. Cadoni, F. Mormile, A. Sposi, F. Salvia and M. Maurizi,
The Use of Microdebrider or Shaver in Snoring and Obstructive Sleep Apnea Syndrome, Corradini, C., M. Rigante, L. Calò and G. Cadoni
Uvulopharyngopalatoplasty According to Kamami with the Diode Laser in Patients Suffering from Snoring, Perano, D., E. Narducci and G. Redaelli
Nasal Respiratory Function after Pyramid Surgery, Bertoli, G.A., R. Romeo, G. Bava, C. Del Pero and O.M.F. Romeo
Novel Surgical Techniques for Tongue Base Obstruction Associated with Sleep Apnea, Terris, D.J. and L.D. Kunda
Modified Uvulopalatoplasty: Retrospective Survey of Patient Satisfaction, Bhatt, C., S. Kale and T.N. Reddy
Snoring and Obstructive Sleep Apnea Syndrome Treated by Cost-Effective, Low Pain, Pharyngeal Volume Reduction under Local Anesthesia. Coblation-Assisted Upper-Airway Procedures, Tvinnereim, M.
Improvement of Sleep-Breathing Disturbances Post Repose Tongue Stabilization Procedures, Derowe, A., G. Siegel, B. Wenig and A. Biran
Long-Term Follow-up of Patients Undergoing Palatal Somnoplasty, Trotter, M.I., A. D Souza and D.W. Morgan

Nonsurgical Therapies
Functional Electrical Stimulation of the Nervus Hypoglossus for Obstructive Sleep Apnea Syndrome Treatment, Boudewyns, A.N., W.A. De Backer, A.R. Schwartz and P.H. Van de Heyning
Considerations on the Use of Mechanical Nasal Dilator Devices, De Seta, E., G.A. Bertoli, M. Viccaro and R. Filipo
Oral Appliances for the Treatment of Snoring and Obstructive Sleep Apnea, Bloch, K.E., O. Senn and A. Iseli
Ventilatory Therapy in Obsctructive Sleep Apnea Syndrome. Indications and Limitations in the Treatment of Obstructive Sleep Apnea Syndrome, Perrone, A., G. Lucantoni, V. Masciangelo and C. Magliocco
Continuous Positive Airway Pressure Compliance in Obstructive Sleep Apnea Syndrome Patients, Aquilini, M., S. Chiti-Batelli, A. Eibenstein and M. Fusetti
Nasal Positive Airway Pressure, Akers, D.A.
Effectiveness of Nonsurgical Therapy in Early Obstructive Sleep Apnea, Di Martino, E.F.N., M. Rieger, R. Saadi and M. Westhofen

Highlights on Nonsurgical Therapies
Effect of the Modified 'Twin Block' Dental Appliance on Obstructive Sleep Apnea Syndrome, Andretta, M., A. Vianello, L. Ritrovato, C. Angelini, L. Ruffato, F. Miotti and M. Bevilacqua
Obstructive Sleep Apnea Syndrome and Chronic Obstructive Pulmonary Disease. Correlation and Treatment of the Two Pathologies in the Overlap, Syndrome, Perrone, A., G. Lucantoni, V. Masciangelo and C. Magliocco
Impact of a Pressure Ramp on Compliance with Continuous Positive Airway Pressure Therapy for Sleep Apnea/Hypopnea, Sanders, M., K. Studnicki and P. Strollo Jr
Impact of Non-Invasive Nocturnal Positive Pressure Ventilation on Sleep and Arterial Blood Gases, Sanders, M., K. Fernandes and P. Strollo Jr.
Auto Adjusted Continuous Postitive Airway Pressure in the Treatment of Sleep Apnea/Hypopnea Syndrome, Meurice, J.C.

A Cost Benefit Analysis of Obstructive Sleep Apnea Syndrome, Macchi, A., L. Della Vecchia and R. Lazzaro
Obstructive Sleep Apnea Treatment in a General ENT Practice in The Netherlands, Glazenburg, B.E., H. Spoelstra and K. Wiggers
Snoring and Sleep Apnea/Hypopnea Syndrome. A Survey of the Effects of an Informative Campaign on a Resident Population, Papalia, M.A., E. Narducci, M. Tondini and G. Radaelli

Index of authors

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