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Obstructive Sleep Apnea Following Dynamic Sphincter Pharyngoplasty
Adam J. Oppenheimer, MD, Darryl Lau, BS, Fauziya Hassan, MD, MS, Timothy F. Hoban, MD, M. H. Newman, MD, Steven R. Buchman, MD, Steven J. Kasten, MD.
University of Michigan, Ann Arbor, MI, USA.
Heretofore, a premium has been placed on speech outcomes for patients with cleft palate. In patients who require additional surgery for velopharyngeal insufficiency (VPI), increased upper airway resistance and subsequent obstructive sleep apnea (OSA) may be incurred. This phenomenon has been previously demonstrated with the posterior pharyngeal flap. The effect of dynamic sphincter pharyngoplasty (DSP) on OSA, however, is not known. The purpose of this case series is to: 1) determine the incidence of OSA following DSP; 2) assess the changes in polysomnography (PSG) data following DSP; and 3) identify risk factors for the development of OSA following DSP. Our global hypothesis is that OSA and VPI exist on a continuum, and that speech outcomes should not be considered in isolation.
Institutional Review Board (IRB) approval was obtained for this retrospective review. Over a 13-year period, 146 patients with either idiopathic VPI, submucous cleft palate, cleft palate alone, or cleft lip and palate, underwent DSP for VPI. The diagnosis of OSA was defined as the prescription of continuous positive airway pressure therapy (CPAP) by a pediatric sleep medicine physician. The incidence of OSA pre- and postoperatively was compared using Fisher’s exact test. When available, pre- and postoperative apnea-hypopnea indices (AHIs) were compared using the pairwise, two-tailed, Student’s t-test. Patient factors, such as obesity, syndromic status, and pre-existing obstructive sleep apnea, were noted. Past surgical history, including palate repair technique, and prior tonsillectomy and/or adenoidectomy (T/A) was also reviewed. A multiple logistic regression was performed to elucidate risk factors for the development of OSA.
Among the 146 patients treated with DSP, the average age at surgery was 9.2 years (range: 4 to 40 years) and mean follow-up time was 4.5 years (range: 1 month to 12 years). The incidence of OSA increased following DSP, from 2 to 33 patients (1.4% to 22%, respectively, p = 0.05). In 23 patients (16%), both pre- and postoperative AHIs were available. There was a significant increase in AHI following DSP, from 3.1 to 8.4 apneic-hypopneic episodes per hour of sleep (p = 0.001). Previous T/A was predictive of OSA (RR = 2.4, p = 0.04).
The incidence of OSA increased following DSP, and higher average AHIs were observed postoperatively. Preoperative T/A predicts the development of obstructive sleep apnea after DSP. A high index of suspicion for OSA must be maintained in patients who require secondary speech operations for VPI; routine polysomnographic evaluation should be considered in these patients. The surgeon must be wary that improvements in speech may come at the expense of sleep.
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