Sleep Apnea Syndromes: Fischer Y

Verse T, de la Chaux R, Dreher A, Fischer Y, Grundmann T, Hecksteden K, Hörmann K, Hohenhorst W, Ilgen F, Kühnel T, Mahl N, Maurer JT, Pirsig W, Roth B, Siegert R, Stuck BA, Anonymous00280. · Klinik für HNO-Heilkunde, Asklepios Klinik Harburg, Hamburg. · Laryngorhinootologie. · Pubmed #17464894 No free full text.

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Gronau S, Fischer Y. · Hals-Nasen-Ohrenklinik, Universität Ulm. · Laryngorhinootologie. · Pubmed #16142626 No free full text.

Abstract: BACKGROUND: In contrast to tonsillectomy, only intracapsular parts of palatine tonsil are resected in tonsillotomy. This procedure has been revived for treatment of tonsillar hypertrophy causing obstructive sleep apnoea. Tonsillar hypertrophy is the most relevant cause for obstructive sleep apnoea in children often associated with malnutrition due to problems with swallowing. In these patients tonsillotomy is performed, because it is less painful, the children recover more quickly and the results on snoring, difficulty breathing and apnoea are equal in comparison to conventional tonsillectomy. In patients elder than 8 years or suffering from chronic or recurrent tonsillitis, tonsillectomy is the preferable surgical modality, because scarring and persistent inflammation in tonsillar remnants may be urge revision surgery. CONCLUSION: Tonsillotomy is a good alternative for tonsillectomy in children with symptomatic hypertrophy of the palatine tonsils.

Fischer Y, Junge-Hülsing B, Rettinger G, Panis A. · Department of Otorhinolaryngology, University Hospital of Ulm, Prittwitzstrasse 43, Ulm, Germany. · Clin Otolaryngol Allied Sci. · Pubmed #14961847 No free full text.

Abstract: Electroencephalogram (EEG) evaluation with polysomnography (PSG) according to the Rechtschaffen & Kales (R&K) rules is time and cost consumptive, but ambulatory polygraphy systems do not allow EEG recording routinely. As a consequence, the number of sleep disordered events cannot be calculated exactly. QUISI is a one-channel, self-applicable ambulatory EEG recording device. The present study was designed as a prospective, non-randomized clinical trial. This investigation evaluated the results of 40 patients with primary snoring and obstructive sleep apnoea measured with level 1 PSG and QUISI simultaneously. Fifteen patients (37.5%) were primary snorers with normal sleep profiles, whereas 25 patients (62.5%) suffered from obstructive sleep apnoea (OSA) with a Respiratory Disturbance Index (RDI) of 38.6 +/- 23.8. The mean total sleeping time (TST) was underestimated by 4.5%, while Sleep Efficiency Index (SEI) was understimated by 4.6% by the QUISI device compared with PSG. The correlation between the QUISI and the PSG estimates for single sleep stages demonstrated only moderate correlation. The statistical significance for sleep stage 2 was r = 0.42, P = 0.002; for sleep stage 3/4, r = 0.31, P = 0.02; and for WAKE, r = 0.33, P = 0.01. Sleep stage 2 as well as sleep stage 3/4 were underestimated by QUISI substantially (difference: -5.6% and -10.3%), while WAKE was overestimated by QUISI to a larger amount (difference: +10.4%). Sensitivity and specificity of QUISI to recognize pathological sleep profiles compared with PSG/R&K were 0.92 and 0.96 respectively. QUISI is able to evaluate normal versus altered sleep profiles in patients with primary snoring and OSA. Comparing the quartile ranges, we found substantial differences between QUISI and PSG/R&K. QUISI gives an impression of sleep architecture and objective verification of a sleep disturbance in an ambulant setting but cannot replace the sleep laboratory-based PSG.

Smith E, Wenzel S, Rettinger G, Fischer Y. · Hals-Nasen-Ohren-Klinik Universität Ulm. · Laryngorhinootologie. · Pubmed #18409129 No free full text.

Abstract: BACKGROUND: To study the effectiveness of adenotomy (AT), adenotonsillectomy (ATE) and adenotonsillotomy (ATT) with respect to the quality of life improvement in children with obstructive sleep disorders (OSD), OSA 18 survey and Brouillette score were used. METHODS: Prospectively, 92 children with an age ranging from 2 to 6 years with OSD underwent AT, ATE or ATT at the University hospital of Ulm (Germany), respectively. 30 age-matched children served as controls. Caregivers were requested to complete the Brouillette score and the OSA 18 survey, which are validated instruments for detecting symptoms and quality of life change in children with OSDs, at the initial office visit prior to surgery (BS/1 and OSA 18/1) and 7 - 14 months after surgery (BS/2 and OSA 18/2). RESULTS: The mean total score of the OSA 18 survey for AT, ATE and ATT was reduced significantly after these operations (p < 0.001). Similar results were also observed in the Brouillette score (p < 0.002). The improvement of life quality in the AT group was less effective than in the ATE and ATT group. CONCLUSION: ATE and ATT have about the same effectiveness to improve life quality for children with OSD. Children after ATE or ATT have a comparable life quality as healthy children (Mann Whitney U-test; p approximately 0.15), while children who only received AT have a slightly lower life quality after the operation. In summary, ATT was recommend.

Fischer Y, Keck T, Leiacker R, Rozsasi A, Rettinger G, Gruen PM. · Department of Otorhinolaryngology, Laboratory for Sleep Research and Sleep Medicine, University of Ulm, Frauensteige 12, 89075 Ulm, Germany. · Sleep Breath. · Pubmed #18311494 No free full text.

Abstract: The purpose of this study was to determine the objective short-term influence of nasal continuous positive airway pressure (nCPAP) therapy, nasal mask leak (NML) and heated humidifiers (HH) to nasal conditioning of spontaneously breathing subjects. This was a prospective, non-randomized, non-blinded day-time study. Eighteen healthy subjects were enrolled in the study. All subjects received nCPAP therapy for 60 min in three different conditions successively: (1) nCPAP without humidification, (2) nCPAP with a defined leakage of nasal mask (slashed circle 28.3 mm2) and (3) nCPAP with HH. Nasal humidity and temperature were measured in the anterior turbinate area using a miniaturized thermocouple and a relative humidity sensor. The measurements were accomplished at the beginning of therapy, after 60, 120 and 180 min. Absolute humidity (aH) in the anterior turbinate area decreased significantly (p = 0.0075) from 17.41 +/- 3.81 mg/l (baseline) to 15.27 +/- 2.21 mg/l (nCPAP alone). With attachment of a NML, aH decreased from 15.27 mg/l not significantly (p = 0.058) to 13.77 +/- 2.28 mg/l (nCPAP and NML) compared to nCPAP alone. After addition of heated humidification to nCPAP, aH increased again from 13.77 mg/l significantly (p = 0.042) to 15.29 +/- 3.51 mg/l (nCPAP and HH) compared to aH (nCPAP+NML). No difference was found between aH (nCPAP and HH) and aH (nCPAP alone). Airway temperature did not change significantly after application of nCPAP alone, nCPAP and NML, and nCPAP and HH. These data indicate that nCPAP therapy with NML tends to have more remarkable reduction of the nasal humidity than nCPAP therapy without NML. nCPAP with heated humidifier is able to compensate the dehydration effects induced by nCPAP therapy with NML by increasing the aH at the anterior turbinate area to the levels observed during breathing with nCPAP alone.

Wenzel S, Smith E, Leiacker R, Fischer Y. · Universitätsklinik und Poliklinik für Hals-, Nasen- und Ohrenheilkunde, Universität Ulm. · Laryngorhinootologie. · Pubmed #17806000 No free full text.

Abstract: BACKGROUND: Treating the positional obstructive sleep apnea with a vest preventing the supine position is well known to be riskless and inexpensive. It was the aim of this study to test the efficacy and, for the first time, the longterm compliance of this treatment. METHODS: 14 patients with positional obstructive sleep apnea (age 48.2 +/- 12.1 years; body-mass-index: 28.1 +/- 4.6 kg/m2 mean, +/- SD) were investigated polysomnographically without and with a vest preventing the supine position. 13.7 +/- 15.9 months later the patients were asked about the comfort of the vest and the nocturnal using time using the Likert-scale, and data about the latest Epworth Sleepiness Scale (ESS) was collected. RESULTS: The respiratory disturbance index (RDI) was reduced statistically significant from 31.3 +/- 12.9/h to 13.8 +/- 9.0/h by wearing the vest (p < 0.001). Total sleep time at an oxygen saturation below 90% decreased from 8.2 +/- 7.1% to 3.8 +/- 4.5% (p < 0.001), the snoring time from 15.4 +/-19.6 % to 9.8 +/-13.1% (p < 0.05) of the total sleep time (TST) and the arousal index from 23.1 +/-16.0/h to 18.6 +/-11.4/h (p < 0.05). 24 +/-28.8 months later 28.6% of the patients were still using the vest. Of these patients the ESS decreased from 8.5 +/-3.2 to 6.5 +/-2.9 (p < 0.05). 72.4% of the patients refused the longterm therapy with the vest because of its low wearing comfort. CONCLUSIONS: Although the vest approved to be effective against positional obstructive sleep apnea, the longterm compliance is low because of its need getting used to.

Fischer Y, Neagos A, Gronau S, Rettinger G. · Klinik und Poliklinik für Hals-Nasen-Ohrenheilkunde. Universitätsklinik Ulm. Frauensteige 12-89075 Ulm. · Laryngorhinootologie. · Pubmed #16773743 No free full text.

Abstract: BACKGROUND: Clinical findings in sleep related breathing disorders (SRBD) and primary snoring are not only of diagnostic but also of therapeutic relevance because clinical findings may be used for the selection of surgical interventions such as uvulopalatopharyngoplasty (UPPP), maxillofacial surgery or radiofrequency induced surgical alternatives. We developed a standardized protocol for clinical examination of the upper airway using pictograms. MATERIAL AND METHODS: To determine the interinvestigators variability various parameters such as length of the uvula, position of tongue base, Angle-classification, webbing of posterior pillar and tonsil size were assessed by a number of residents and an assistant professor for Otorhinolaryngology and sleep medicine simultaneously. RESULTS: 95 patients (81 male and 14 female) with a mean age of 47.0 +/- 1.21 years, a Body-Mass-Index (BMI) of 27.2 +/- 0.46 kg/m2, and an Apnea-Hypopnea-Index (AHI) of 17.7 +/- 2.4 were examined. The appearance of the uvula has only little variations between different investigators (corr.: 0.943). The interinvestigator variability is also low for position of tongue base (corr.: 0.931) and Angle-classification (corr.: 0.893). The results of tonsil size and webbing assessment seems to have a higher variability (corr.: 0.880 and 0.693). Statistical significance for all parameters was p=<0.0001. CONCLUSION: As to our knowledge, this is the first controlled study to record intraobserver variations of clinical findings of the upper airway. Standardized protocols are mandatory, and the variability of the measurements must be taken into account if results of different investigations must be compared or if changes after therapeutic interventions are to be investigated.

Fischer Y, Rettinger G, Dorn M. · Universitätsklinik und Poliklinik für Hals-Nasen-Ohrenheilkunde, Ulm. · Laryngorhinootologie. · Pubmed #16673300 No free full text.

Abstract: BACKGROUND: To study short-term and long-term changes in quality of life (QOL) in children before and after adenotonsillectomy (T and A) for obstructive sleep disorders (OSDs). MATERIALS AND METHODS: Prospective study of 20 children underwent T and A for OSDs at the University hospital of Ulm/Germany. Caregivers were asked to complete the Brouillette-Score (BS) and OSA-18 survey, validated instruments for detecting symptoms and QOL change in children with OSDs, at the initial office visit prior to surgery (BS/1 and OSA-18/1) within 7.5 +/- 1.14 weeks after surgery (BS/2 and OSA-18/2), and 14.8 +/- 1.98 months after surgery (BS/3 and OSA-18/3). The BS comprises 3 items including: difficulty breathing during sleep, apnea observed by the caregivers and snoring. The OSA-18 survey comprises 18 items in 5 domains of sleep disturbance, physical suffering, emotional distress, daytime problems, and caregiver concerns. Scores from the preoperative and postoperative surveys were compared using the paired T-test and SPEARMAN-RANK test. RESULTS: 13 children were male (65 %). The mean age at the time of inclusion in the study was 6.2 +/- 1.63 years, mean preoperative body mass index (BMI) was 17.4 +/- 1.24 kg/m(2). Brouillette-Score: The mean Brouillette-Score before T and A (2.72) was significantly higher ( P = or < .001) than in the short-term (- 2.19) and in the long-term. (- 3.54). OSA-18 SURVEY: The mean total score for OSA-18/1 (83.4) was significantly higher ( P = or < .001) than the mean total score for OSA-18/2 (29.8) and OSA-18/3 (25.6). The overall correlation between BS and OSA-18 was R = .887 ( P = or < .001). CONCLUSION: Children with suspicious OSDs demonstrate significant short term and long-term improvement in the Brouillette-Score and OSA-18 survey. Caregivers perceive a long-term improvement for a minimum of one year in QOL after T and A for OSDs, although these improvements are not uniform across all domains of the OSA-18 survey. Use of the Brouillette-Score and the OSA-18 survey should decrease the need for polysomnographic monitoring and facilitate selection of children for T and A, whereas the OSA-18 questionnaire permits the more differentiated finding.

Fischer Y, Neagos A, Pirsig W. · Universitätsklinik und Hochschulambulanz für Hals-Nasen-Ohren-Heilkunde, Ulm. · HNO. · Pubmed #16211411 No free full text.

Abstract: Sleep-related breathing disorders (SBAS) affect approximately 8% of the population of middle aged adults. At the age of 20 years, approximately 10% of the population snore, while at the age of 60 about 50% of men snore. Some 9% of middle aged women and 24% of middle aged men have an apnea hypopnea index (AHI) of >5 (number of nocturnal apnea and hypopnea per hour of sleep). Sleep apnea hypopnea syndrome is found in 2% of the women and 4% of the men, i.e. they have an AHI>5 associated with daytime sleepiness. Forms, check lists, summaries and patient-readable questionnaires have proved helpful in the evaluation of SBAS.

Fischer Y, Gronau S. · Klinik und Hochschulambulanz für Hals-Nasen-Ohrenheilkunde, Universitätsklinik Ulm. · Laryngorhinootologie. · Pubmed #15712049 No free full text.

Abstract: Sleep-disordered breathing (SDB) caused by enlarged tonsils and adnoids is common in early childhood. SDB without alterations in alveolar ventilation or sleep architecture is called primary snoring and affects up to 3-12 % of young children. In contrast, SDB with associated apneas or hypopneas affects between 0.7-3 % and is called obstructive sleep apnea syndrome (OSAS). OSAS and primary snoring should be distinguished with polysomnography (PSG). Despite the large number of patients undergoing tonsillectomy and adenoidectomy, the ability to assess patients-based preoperative diagnosis and surgical outcomes polysomnographically is limited. As a consequence it remains difficult which children will or will not benefit from surgical intervention. In the context of OSAS diagnosis, a discriminative survey is desired, one that cold classify differences before surgery as small, moderate or large. A promising office based surrogate measure are disease-specific quality-of-life surveys. Change within patients can be measured using an evaluative survey, administered before and after an intervention.

Fischer Y, Khan M, Mann WJ. · Department of Otolaryngology, University of Ulm, Prittwitzstrasse 43, D-89075 Ulm, Germany. · Laryngoscope. · Pubmed #14520107 No free full text.

Abstract: OBJECTIVES/HYPOTHESIS: The concept of two-level pharyngeal collapse in patients with obstructive sleep apnea is too simplified. Aggressive multilevel surgeries addressing several airway segments, including skeletal surgery, demonstrate improved success rates. STUDY DESIGN: The study aimed to evaluate the safety and efficacy of multilevel radiofrequency application to soft palate, tonsils, and base of tongue in 16 white patients (mean age, 56.9 +/- 11.1 y; mean body mass index, 27.3 +/- 2.6 kg/m2) with obstructive sleep apnea. There was one dropout. Therapeutic effects after one treatment session were assessed 20.6 +/- 12.6 weeks postoperatively. Treatment outcome measurements were based on Epworth Sleepiness Scale, Likert scales, and polysomnography. METHODS: Every patient received 16 treatment sites with a total dose of 9750 J radiofrequency energy into soft palate, base of tongue, and tonsils. Success was defined as respiratory disturbance index equal to or less than 20 or at least 50% improvement if baseline respiratory disturbance index was less than 20. Statistical analysis was determined with the Spearman rank test. RESULTS: Mean score on Epworth Sleepiness Scale decreased from 11.1 to 8.2 (P =.0001). Of the patients, 53.3% reported improvement of their daytime sleepiness. Snoring was assessed with 10-point Lickert scale, and score decreased from 7.5 to 4.9 (P =.08). Mean respiratory disturbance index decreased from 32.6 +/- 17.4 to 22.0 +/- 15.0 (P =.003). By our definition of success, 5 of 15 patients (33%) have been treated successfully surgically and 4 of 15 (27%) had remarkable improvement after one treatment session; 1 patient (6.6%) demonstrated deterioration. There were two adverse effects, one superficial ulceration of the soft palate and one unilateral tonsillar abscess formation, with an overall complication rate of 13.3% for our patients and 0.41% for all treatment sites (n = 240). CONCLUSION: Moderate to severe obstructive sleep apnea usually requires multilevel pharyngeal surgery. Radiofrequency offers the potential of altering the upper airway on different sites.

Fischer Y, Yakinthou A, Mann WJ. · Gesundheitsökonomin (ebs), Klinik und Poliklinik für Hals-Nasen-Ohren-Heilkunde, Universitätsklinik Ulm. · HNO. · Pubmed #12835844 No free full text.

Abstract: BACKGROUND: It is estimated that in patients with sleep-related breathing disorders the probability of a cerebral vascular infarction (CVI) is 3.1 times that in patients without sleep apnea and that 25-50% of all patients who have a stroke suffer from sleep apnea (OSA) and have a respiratory disturbance index (RDI) higher than 10. CVI may be caused by variations in intracranial pressure or in intracranial hemodynamics owing to decreasing pO(2) and increasing pCO(2) during cessation of airflow. It is suspected that the most common causes of sudden deafness are vasospasm, thrombosis, embolism, hypercoagulation and sludging. The present study analyzed the prevalence of sleep apnea in patients with sudden hearing loss. PATIENTS AND METHODS: A 7-channel polygraph was used to test 33 subjects with normal hearing and 27 patients suffering from sudden hearing loss. Statistical analyses were performed with a Chi-square test and the Mann-Whitney test. RESULTS: We found that 29.6% of the patient group and 21.2% of those in the study control group were suffering from OSA and had RDI >10; this difference was not significant ( p=0.554). Sudden hearing loss may also be an indicator of arteriosclerosis secondary to such risk factors as hypertension ( p=0.005), diabetes ( p=0.003), and hyperlipidemia ( p=0.004), which were highly significant for the patient group. CONCLUSION: Patients who develop sudden hearing loss tend to have OSA more frequently than those in the control group owing to the similar risk factors for cerebral infarction and sudden hearing loss.

Fischer Y, Hafner B, Mann WJ. · Universitäts-HNO-Klinik Mainz (Direktor: Prof. Dr. W.J. Mann). · HNO. · Pubmed #10663047 No free full text.

Abstract: Twenty-nine patients (26 male and 3 female) with habitual or obstructive snoring and socially disturbing character were followed over a ten week period. All patients were treated with radiofrequency volumetric tissue reduction (RFVTR) of the soft palate. In 21 patients this operation was combined with other surgery of the upper airway, eight patients had soft palate reduction with RFVTR exclusively. With this method an electrode is positioned in the musculature of the soft palate submucosally. RFVTR may be performed under local anesthesia and has to be repeated if necessary. Ten weeks postoperatively 24 of 29 patients, respectively their social-partners, reported subjective reduction of snoring after the first treatment. Markable improvement of snoring was seen in 20 of 29 patients postoperatively and reduction of the respiratory-disturbance-index (RDI) for more than 10 was noticed in 7/29 patients polysomnographically. 5/8 patients who were treated with RFVTR exclusively, showed reduction of snoring and 3/8 patients had RDI-reduction for more than 10. We conclude, that RFVTR of the soft palate is successful in the treatment of snoring and may be helpful in the treatment of mild obstructive-sleep-apnea-syndrome (OSAS).