The Laryngoscope C 2015 The American Laryngological, V
Rhinological and Otological Society, Inc.
Editorial Historical Classics: Oldies but Goodies The opportunity to review the Laryngoscope article written in 1985 by Dr. Shiro Fujita et al., “Evaluation of the Effectiveness of Uvulopalatopharyngoplasty,”1 is a step back in history that is especially meaningful for because Dr. Shiro Fujita was a colleague and member of the Department of Otolaryngology at Henry Ford Hospital in Detroit, Michigan. This article is an early example of a multidisciplinary team approach to disease management; three of the article’s authors continue to practice at Henry Ford Hospital. The authors represented otolaryngology, psychiatry, sleep physiology, pulmonology clinic coordinator. This article also serves as an education for current clinicians about the evolution of the diagnosis and treatment of patients with obstructive sleep apnea (OSA). It is hard to imagine a time when there was no awareness of OSA, and it is even more difficult to imagine when permanent tracheostomy was the only treatment available to the patient and clinician. Continuous positive airway pressure (CPAP), invented by Colin Sullivan, PhD, BSC, MB, FRACP, in Australia in 1980, is now the initial standard of care for OSA was not widely known or available at that time. On the other side of the world, Dr. Shiro Fujita published an article in 1981 describing a surgical procedure, uvulopalatopharyngoplasty (UPPP), to correct anatomical abnormalities in OSA syndrome. In a Japanese otolaryngology journal, he read about a procedure that would decrease snoring and believed that it would be helpful in patients with OSA. The article being reviewed today is an analysis of “66 consecutive, unselected patients, 63 men and 3 women” who underwent UPPP. All of the patients had a diagnosis of OSA syndrome based on polysomnogram and of excessive daytime sleepiness based on the results of a multiple sleep latency test. These patients would be considered as having severe OSA, with a mean apnea hypopnea index (AHI) of 59 6 25.2 and the lowest SaO2 of 40.9 6 22.8. This was a patient population that was severely disabled by its OSA syndrome. In evaluating the results of the case series, the authors described responders and nonresponders. Responders were identified as individuals with significantly lower ideal body weights, and the major site of airway compromise was the oropharynx. Nonresponders had
Laryngoscope 00: Month 2015
both oropharyngeal and hypopharyngeal abnormalities. The hypopharyngeal obstructions were described as large tongue base, an omega-shaped epiglottis, and redundant aryepiglottic folds. The Laryngoscope article “Maxillomadibular Advancement for Persistent Obstructive Sleep Apnea After Phase I Surgery in Patients Without Maxillomandibular Deficiency,” by Dr. Kasey Li et al.,2 was a natural progression of surgical procedures to deal with the nonresponders who Fujita described. Mandibular advancement was being used for patients with mandibular deficiency and OSA in the 1980s. Maxillary deficiency was identified in some OSA patients as well; thus, simultaneous advancement of the maxilla and mandible in patients with disproportionate craniofacial features was proposed. Although the procedure was highly successful in the treatment of patients with OSA, only 40% of patients demonstrated maxillary or mandibular deficiency and were considered eligible for maxillary mandibular advancement (MMA). This article proposed performing MMA on patients with OSA who had failed phase I surgery (uvulopalatoplasty, mandibular osteotomy with genioglossus advancement, and/or hyoid myotomy) and did not demonstrate maxillary or mandibular deficiency. The case series reported results on 25 patients and included improvement in respiratory distress index, lowest oxygen saturation, and a questionnaire that subjectively assessed the patient’s perception of the facial appearance after surgery. There was concern that anterior displacement of the maxilla and mandible may not be perceived favorably in patients without preexisting maxillary deficiency. All but one patient achieved an RDI < 20, and only one patient viewed the postoperative facial appearance as “unfavorable.” More importantly, all of the patients were satisfied with their results and would recommend the treatment to others. Isaac Newton commented in 1676, “If I have seen further it is by standing on the shoulders of giants” (Fig. 1). In reviewing these two historical classics, it is clear that we have gone further in surgical treatment of obstructive sleep apnea by learning from the giants in our specialty.
KATHLEEN L. YAREMCHUK, MD, MSA Department of Otolaryngology–Head and Neck Surgery, Henry Ford Hospital, Detroit, Michigan, U.S.A.
Yaremchuk: Editorial
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Fig. 1. This figure is derived from Greek mythology, where the blind giant Orion carried his servant Cedalion on his shoulders. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
BIBLIOGRAPHY 1. Fujita S, Conway WA, Zorick FJ, et al. Evaluation of the effectiveness of uvulopalatopharyngoplasty. Laryngoscope 1985;95:70–74. 2. Li KK, Riley RW, Powell NB, Guilleminault C. Maxillomandibular advancement for persistent obstructive sleep apnea after phase I surgery in patients without maxillomandibular deficiency. Laryngoscope 2000;110:1684–1688.
Laryngoscope 00: Month 2015
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Yaremchuk: Editorial
Rhinological and Otological Society, Inc.
Editorial Historical Classics: Oldies but Goodies The opportunity to review the Laryngoscope article written in 1985 by Dr. Shiro Fujita et al., “Evaluation of the Effectiveness of Uvulopalatopharyngoplasty,”1 is a step back in history that is especially meaningful for because Dr. Shiro Fujita was a colleague and member of the Department of Otolaryngology at Henry Ford Hospital in Detroit, Michigan. This article is an early example of a multidisciplinary team approach to disease management; three of the article’s authors continue to practice at Henry Ford Hospital. The authors represented otolaryngology, psychiatry, sleep physiology, pulmonology clinic coordinator. This article also serves as an education for current clinicians about the evolution of the diagnosis and treatment of patients with obstructive sleep apnea (OSA). It is hard to imagine a time when there was no awareness of OSA, and it is even more difficult to imagine when permanent tracheostomy was the only treatment available to the patient and clinician. Continuous positive airway pressure (CPAP), invented by Colin Sullivan, PhD, BSC, MB, FRACP, in Australia in 1980, is now the initial standard of care for OSA was not widely known or available at that time. On the other side of the world, Dr. Shiro Fujita published an article in 1981 describing a surgical procedure, uvulopalatopharyngoplasty (UPPP), to correct anatomical abnormalities in OSA syndrome. In a Japanese otolaryngology journal, he read about a procedure that would decrease snoring and believed that it would be helpful in patients with OSA. The article being reviewed today is an analysis of “66 consecutive, unselected patients, 63 men and 3 women” who underwent UPPP. All of the patients had a diagnosis of OSA syndrome based on polysomnogram and of excessive daytime sleepiness based on the results of a multiple sleep latency test. These patients would be considered as having severe OSA, with a mean apnea hypopnea index (AHI) of 59 6 25.2 and the lowest SaO2 of 40.9 6 22.8. This was a patient population that was severely disabled by its OSA syndrome. In evaluating the results of the case series, the authors described responders and nonresponders. Responders were identified as individuals with significantly lower ideal body weights, and the major site of airway compromise was the oropharynx. Nonresponders had
Laryngoscope 00: Month 2015
both oropharyngeal and hypopharyngeal abnormalities. The hypopharyngeal obstructions were described as large tongue base, an omega-shaped epiglottis, and redundant aryepiglottic folds. The Laryngoscope article “Maxillomadibular Advancement for Persistent Obstructive Sleep Apnea After Phase I Surgery in Patients Without Maxillomandibular Deficiency,” by Dr. Kasey Li et al.,2 was a natural progression of surgical procedures to deal with the nonresponders who Fujita described. Mandibular advancement was being used for patients with mandibular deficiency and OSA in the 1980s. Maxillary deficiency was identified in some OSA patients as well; thus, simultaneous advancement of the maxilla and mandible in patients with disproportionate craniofacial features was proposed. Although the procedure was highly successful in the treatment of patients with OSA, only 40% of patients demonstrated maxillary or mandibular deficiency and were considered eligible for maxillary mandibular advancement (MMA). This article proposed performing MMA on patients with OSA who had failed phase I surgery (uvulopalatoplasty, mandibular osteotomy with genioglossus advancement, and/or hyoid myotomy) and did not demonstrate maxillary or mandibular deficiency. The case series reported results on 25 patients and included improvement in respiratory distress index, lowest oxygen saturation, and a questionnaire that subjectively assessed the patient’s perception of the facial appearance after surgery. There was concern that anterior displacement of the maxilla and mandible may not be perceived favorably in patients without preexisting maxillary deficiency. All but one patient achieved an RDI < 20, and only one patient viewed the postoperative facial appearance as “unfavorable.” More importantly, all of the patients were satisfied with their results and would recommend the treatment to others. Isaac Newton commented in 1676, “If I have seen further it is by standing on the shoulders of giants” (Fig. 1). In reviewing these two historical classics, it is clear that we have gone further in surgical treatment of obstructive sleep apnea by learning from the giants in our specialty.
KATHLEEN L. YAREMCHUK, MD, MSA Department of Otolaryngology–Head and Neck Surgery, Henry Ford Hospital, Detroit, Michigan, U.S.A.
Yaremchuk: Editorial
1
Fig. 1. This figure is derived from Greek mythology, where the blind giant Orion carried his servant Cedalion on his shoulders. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
BIBLIOGRAPHY 1. Fujita S, Conway WA, Zorick FJ, et al. Evaluation of the effectiveness of uvulopalatopharyngoplasty. Laryngoscope 1985;95:70–74. 2. Li KK, Riley RW, Powell NB, Guilleminault C. Maxillomandibular advancement for persistent obstructive sleep apnea after phase I surgery in patients without maxillomandibular deficiency. Laryngoscope 2000;110:1684–1688.
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Yaremchuk: Editorial
