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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4538_Библиотеки_им_академика_М_И_Перельмана

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C. Manuele and M. Antonio
Take-Home Message
• Recent evidence suggests that OSA might be associated with alterations in the
auditory and vestibular systems, increasing the risks of Hearing Loss (HL), tin-
nitus, and dizziness.
• OSA could cause damage to other ENT organs by altering sensitive and motor
functions of the pharynx and larynx.
• Newer intra-pharyngeal remodelling surgical procedures, less invasive or mor-
bid, improving patients’ compliance, and nasal surgery make OSA surgery a
reasonable alternative. To patients that do not tolerate CPAP. Also, nasal surgery
provides a way of improving CPAP adherence by reducing nasal resistance.
References
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29. Teklu M, Gouveia CJ, Yalamanchili A, etal. Predicting obstructive sleep apnea status with the reux symptom index in a sleep study population. Laryngoscope. 2020;130(12):E952–7.
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30. Chi JCY, Lee SD Huang RJ, etal. CPAP treatment improves pure tone audiometry threshold in sensorineural hearing loss patients with sleep-disordered breathing. Int J Environ Res Public Heal 2021;18(13): 6768. doi:https://doi.org/10.3390/IJERPH18136768.
31. Alessandrini M, Liguori C, Viziano A, etal. Postural and vestibular changes related to CPAP treatment in moderate-to-severe OSA patients: a 12-month longitudinal study. Sleep Breath. 2018;23(2):665–72. https://doi.org/10.1007/S11325- 018- 1754- Z.
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33. She W, Zhang Q, Chen F, Jiang P, Wang J.Peri-uvulopalatopharyng oplasty otoacoustic emis­sions in patients with obstructive sleep apnea-hypopnea syndrome. Zhonghua Er Bi Yan Hou Ke Za Zhi. 2004;39(1):48–51.
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36. Caparroz F, Campanholo M, Stefanini R, etal. Laryngopharyngeal reux and dysphagia in patients with obstructive sleep apnea: is there an association? Sleep Breath. 2019;23(2):619–26.
https://doi.org/10.1007/S11325- 019- 01844- 0.
37. Shaheen NJ, Madanick RD, Alattar M, etal. Gastroesophageal reux disease as an etiology of sleep disturbance in subjects with insomnia and minimal reux symptoms: a pilot study of prevalence and response to therapy. Dig Dis Sci. 2007;53(6):1493–9. https://doi.org/10.1007/
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39. Aviv JE, Liu H, Parides M, Kaplan ST, Close LG. Laryngopharyngeal sensory de­cits in patients with laryngopharyngeal reux and dysphagia. Ann Otol Rhinol Laryngol. 2000;109(11):1000–6. https://doi.org/10.1177/000348940010901103.
40. Han D, Xu W, Hu R, Zhang L.Voice function following Han’s uvulopalatopharyngoplasty. J Laryngol Otol. 2012;126(1):47–51. https://doi.org/10.1017/S0022215111002325.
41. Montero Benavides A, Fernández Pozo R, Toledano DT, Blanco Murillo JL, López Gonzalo E, Hernández GL.Analysis of voice features related to obstructive sleep apnoea and their applica­tion in diagnosis support. Comput Speech Lang. 2014;28(2):434–52. https://doi.org/10.1016/J.
CSL.2013.08.002.
42. Roy N, Merrill RM, Pierce J, Sundar KM.Voice disorders in obstructive sleep apnea: preva­lence, risk factors, and the role of CPAP. Ann Otol Rhinol Laryngol. 2019;128(3):249–62.
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43. Roy N, Merrill RM, Pierce J, Sundar KM.Evidence of possible irritable larynx syndrome in obstructive sleep apnea: an epidemiologic approach. J Voice. 2021;35(6):932.e29–38. https://
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47. Bachour A, Maasilta P. Mouth breathing compromises adherence to nasal continuous positive airway pressure therapy. Chest. 2004;126(4):1248–54. https://doi.org/10.1378/
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48. Bortolotti M. The cause of dry mouth during CPAP application. J Clin Sleep Med. 2017;13(4):647. https://doi.org/10.5664/JCSM.6568.
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49. Hamdan AL, Sabra O, Rifai H, Tabri D, Hussari A.Vocal changes in patients using nasal continuous positive airway pressure. J Voice. 2008;22(5):603–6. https://doi.org/10.1016/J.
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50. Saylam G, Şahin M, Demiral D, etal. Does CPAP treatment affect the voice? Turkish J Med Sci. 2016;46(6):1749–54. https://doi.org/10.3906/SAG- 1512- 52.
51. Atan D, Özcan KM, İkincioğulları A, etal. The effect of obstructive sleep apnea syndrome and continuous positive airway pressure treatment on voice performance. Sleep Breath. 2014;19(3):777–82. https://doi.org/10.1007/S11325- 014- 1092- 8.
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56. Balsalobre L, Pezato R, Gasparini H, Haddad F, Gregório LC, Fujita RR.Acute impact of con­tinuous positive airway pressure on nasal patency. Int Forum Allergy Rhinol. 2017;7(7):712–7.
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58. Walker RP, Grigg-Damberger MM, Gopalsami C. Uvulopalatopharyngoplasty versus laser­assisted uvulopalatoplasty for the treatment of obstructive sleep apnea. Laryngoscope. 1997;107(1):76–82. https://doi.org/10.1097/00005537- 199701000- 00016.
59. Rinaldi V, Costantino A, Moffa A, et al. Postoperative pain and wound healing after coblation-assisted barbed anterior Pharyngoplasty (CABAPh): an observational study. Indian J Otolaryngol Head Neck Surg. 2019;71(Suppl 2):1157. https://doi.org/10.1007/
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Dentistry inObstructive Sleep Apnea
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LuisD.AneybaLópez, AntonioLuigiGracco, S.R.Falardo, FrancescaMilano, GiovanniBruno, AlbertoDe Stefani, FrancescaZalunardo, AntonioRomero-Garcia, CarlosA.CarrascoRueda, IlanVinitzkyBrener, MiguelMeiraeCruz, EmmaPatriciaGarcíaCampos, andDominikEttlin
L. D. AneybaLópez (*) Mexican Association of Oral Sleep Medicine, Sleepadent Dental Sleep Center, Monterrey, Nuevo Leon, Mexico e-mail: info@sleepadent.com
A. L. Gracco Italian Society of Dental Sleep Medicine, University of Padova, Padova, Italy e-mail: antonio.gracco@unipd.it
S. R. Falardo Atalaia Sleep Academy, Atalaia-Montijo, Portugal
F. Milano University of Padova, Padova, Italy
G. Bruno · A. De Stefani · F. Zalunardo Dental Sleep Medicine, University of Padova, Padova, Italy
A. Romero-Garcia University of Valencia, Valencia, Spain e-mail: tonirome@uv.es
C. A. CarrascoRueda · I. V. Brener Stomatology Department, Instituto Nacional de Enfermedades Respiratorias, Ciudad de México, Mexico
Mexican Association of Oral Sleep Medicine, Monterrey, Nuevo Leon, Mexico
M. MeiraeCruz Sleep Unit, Cardiovascular Center of University of Lisbon, Lisbon School of Medicine and Centro Europeu do Sono, Lisbon, Portugal e-mail: mcruz@medicina.ulisboa.pt
E. P. G. Campos Mexican Association of Oral Sleep Medicine, Monterrey, Nuevo Leon, Mexico
Instituto Mexicano de Medicina Integral del Sueño, Ciudad de México, Mexico
D. Ettlin Center of Dental Medicine, University of Zurich, Zurich, Switzerland e-mail: Dominik.Ettlin@zzm.uzh.ch
12
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 P. M. Baptista et al. (eds.), Obstructive Sleep Apnea,
https://doi.org/10.1007/978-3-031-35225-6_12
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12.1 Introduction
In the vast universe of sleep medicine, the dentist is also part of the multidisci­plinary team described in this book.
The dentist must undergo training in dental sleep medicine. Apart from review­ing respiratory sleep disorders (OSA), it also deals with issues such as orofacial pain, oral moisture disorders, gastroesophageal reux disorders, and jaw movement disorders [1].
There is an actual amount of information in the literature on this subject pro­moted globally by various academies and associations. The most important ones are the American Academy of Dental Sleep Medicine and the European Academy of Dental Sleep Medicine. In other countries, dental colleagues are organizing to pro­mote, train and treat these patients suffering from obstructive sleep apnea (OSA).
Within this training, the dentist must explore beyond the topics of conventional dentistry, searching to understand the physiology of breathing and the diversity of tests available to measure sleep. There is also a need for collaboration with various medical specialists focused on this eld of sleep medicine. It becomes a very impor­tant barrier for the dentist who wants to embark on this path in sleep medicine and treat the various respiratory sleep disorders such as Obstructive Sleep Apnea and Snoring.
In their daily practice, dentists can identify various observable clinical, such as the narrow maxillary, mandibular arches with high palatal vaults, tonsillar hypertro­phy, macroglossia, retrognathia or micrognathia, and chronic periodontitis, tooth loss, deep overbite, and neck circumference size [2]. These signs make us suspect of OSA, especially if they are accompanied by daytime sleepiness (falling asleep during the dental procedure), the referral of with important snoring with respiratory pauses in our clinical history.
The presence of obstructive sleep apnea should be determined before proposing treatment with oral appliances.
There are many indications for the use of oral appliances:
1. Patients diagnosed with primary snoring,
2. UARS, patients with mild obstructive sleep apnea,
3. Patients with moderate obstructive sleep apnea and low BMI,
4. Patients diagnosed with moderate–severe obstructive sleep apnea with a failure
of CPAP tting,
5. Patients who have undergone oropharyngeal surgery by our otolaryngologist
colleagues and who have failed the procedure,
6. Patients who are CPAP users and prefer the Oral Appliance (they must be
candidates),
7. Patients who need to use the appliance when traveling,
8. And the use in conjunction with CPAP, which is rare [3].
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12.2 Radiographic Analysis inPatients withOSA
Dentists and in particular, orthodontists can play a crucial role in identifying patients with facial features that may predispose them to OSA.However, another helpful tool is given by radio diagnostics.
Patients with a Class II skeletal malocclusion or maxillomandibular retrusion have a greater risk of presenting OSA due to greater ease of collapse of the soft tis­sues, which are contained by a skeletal compartment of insufcient size.
One of the most used radiological investigations to identify any predisposing features to OSA is the lateral x-ray of the skull in a lateral–lateral projection. Although this radiograph has the limitations of two dimensions, a cephalometric analysis can be done [4]. A hyoid bone positioned in a particularly caudal position with a distance from the mandibular plane greater than 15mm is a risk factor for the onset of respiratory sleep disturbances. Mandibular retrusion and increased anterior facial heights, easily observed in the lateral x-ray, can also predispose to obstruction in the retrolingual site [5, 6] (Fig.12.1).
In addition to the bone characteristics, it is also possible to evaluate any adeno­tonsillar hypertrophy.
Other measurements to be taken into account in cephalometry are tongue base­posterior nasal spine, sella-nasion-B point angle (SNB), maximum uvula thickness, tongue base-tongue tip, and nasion-anterior nasal spine (N-ANS) [7]. A retrospec­tive cephalometric study on upper airway spaces in different facial types determined a difference in the median posterior-palatal space measurement, in the oropharynx region, that was reduced for individuals with a dolichofacial pattern [8].
Fig. 12.1 Example of teleradiography in lateral projection of the skull in which the aforementioned structures can be observed
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The advantages of the lateral x-ray are the ease of execution, noninvasiveness, reproducibility, and low cost. These characteristics are balanced by some disadvan­tages: the two-dimensionality, the upright position, the waking state in the execu­tion, and the insufcient recognition of relevant anatomical landmarks.
In some cases, the two-dimensionality of teleradiography can represent a limit that can mislead the clinician: the sagittal size of the airways and pharyngeal airway space is difcult to evaluate using teleradiography.
This radiography is a support tool for the clinical evaluation of the patient, but it cannot represent a screening or diagnostic tool. In fact, there are no cephalometric values that identify the patient with OSA.
Radiodiagnosis also makes three-dimensional images available to the clinician thanks to Computed Tomography (CT). It allows for delineating the anatomy of the maxillofacial region with greater precision. CBCT provides detailed and three­dimensional images of the entire facial massif, overcoming the overlaps between the different structures and the distortion of the image of the lateral radiography [9]. Therefore, it is widely used to evaluate the upper airways and to identify predispos­ing factors of an anatomical nature in patients with OSA, be they adults or pediat­rics. Through the CBCT, it is possible to evaluate, the size of the pharyngolaryngeal space through software analysis (Fig.12.2).
Fig. 12.2 The image highlights the airspace of the upper airways. The point with the smallest caliber is highlighted in green
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Furthermore, there is the possibility to evaluate pharyngeal wall thickness in the presence of bone or some soft tissues anomalies. Some characteristics that alter physiological respiration and which are identiable in CBCT are nasal polyps, nasal turbinates hypertrophy, concha bullosa or paradoxical curvature, hypertrophy of the soft palate or uvula, reduced transverse dimension of the jaws and dental arches, hypertrophy of the palatine tonsils or obliteration of the maxillary sinuses (Fig.12.3).
Thanks to the sagittal projection reconstructions, it is possible to evaluate the length of the soft palate and the lingual structure, especially concerning the oral oor and the mandibular plane (Fig.12.4).
Fig. 12.3 Coronal and axial cuts highlight problems affecting the maxillary sinuses
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Fig. 12.4 Sagittal slice of a CBCT
L. D. AneybaLópez et al.
CBCT of the skull can also be used to plan any oropharyngeal or maxillofacial surgery [10].
The anatomical features that inuence the anteroposterior dimensions of the air­ways are multiple; however, the sagittal pharyngeal diameter is not seem to be affected by being overweight [11, 12].
Furthermore, CBCT is used more and more frequently by dentists who treat patients with OSAS using mandibular advancement devices (MAD) to investigate the state of health of the condyles, and the temporomandibular joint (TMJ).
In any case, it is necessary to consider the high cost of CBCT and the increased exposure to radiation. It has been suggested that a CBCT should be requested for an adult patient with a diagnosis or solid clinical suspicion of OSA before starting treatment identify all potential predisposing anatomical factors and establish the best therapeutic strategy [13].
On the other hand, in the case of children, they should be thoroughly examined before requesting a CBCT, and only in cases that are nonresponsive to treatment.
Magnetic Resonance (MRI) provides added information. Its use allows informa­tion of the soft tissues in the oropharyngeal area.. Evaluation of the lingual
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