| 1. |
- Fehrm, Johan, et al.
(författare)
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Adenopharyngoplasty vs Adenotonsillectomy in Children With Severe Obstructive Sleep Apnea A Randomized Clinical Trial
- 2018
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Ingår i: JAMA Otolaryngology - Head and Neck Surgery. - : American Medical Association (AMA). - 2168-6181 .- 2168-619X. ; 144:7, s. 580-586
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Tidskriftsartikel (refereegranskat)abstract
- IMPORTANCE Adenotonsillectomy (ATE) is the primary surgical method for treating obstructive sleep apnea (OSA) in children. However, children with severe OSA have an increased risk for residual OSA after ATE. Previous studies indicate that adenopharyngoplasty (APP), a modified ATE with closure of the tonsillar pillars, might improve the surgical outcome, but the overall evidence is weak. OBJECTIVE To determine whether APP is more effective than ATE for treating severe OSA in otherwise healthy children. DESIGN, SETTING. AND PARTICIPANTS A blinded randomized clinical trial was conducted at the otorhinolaryngology department at Karolinska University Hospital, Stockholm, Sweden. Eighty-three children, aged 2 to 4 years, with an obstructive apnea-hypopnea index (OAHI) score of 10 or higher, were randomized to APP (n = 36) or ATE (n = 47). Participants were recruited from December 1, 2014, through November 31, 2016. INTERVENTIONS Adenotonsillectomy was performed in all 83 patients in both groups by the cold steel technique. The APP group also underwent closure of the tonsillar pillars with 2 inverted sutures on each side. MAIN OUTCOMES AND MEASURES The primary outcome was the difference between the groups in OAHI score change before and after surgery. A higher score indicates worse problems and a score of 10 or higher is defined as severe OSA. The outcome was evaluated per protocol and with intention-to-treat analysis. Secondary outcomes were other polysomnography variables and the Obstructive Sleep Apnea-18 (OSA-18) questionnaire (possible total symptom score range, 18-126; higher scores indicate worse quality of life). Polysomnography was performed and the OSA-18 questionnaire was completed preoperatively and 6 months postoperatively. RESULTS A total of 83 children (49 [59%] boys; mean [SD] age, 36.6 [9.2] months) were included in the study. Of these, 74(89%) (APP, n = 30; ATE, n = 44) completed the study. The mean (SD) preoperative OAHI score was 23.8 (11.8) for APP and 23.8 (11.5) for ATE. Both the APP and ATE groups had a significant decrease in mean OAHI score after surgery (-21.7; 95% CI, -26.3 to -17.2; and -21.1; 95% CI, -24.5 to -17.7, respectively), but there was no significant difference between the groups (0.7; 95% CI, -4.8 to 6.1). Furthermore, no significant differences between the groups were seen regarding other polysomnography variables (eg, respiratory distress index: mean, 0.6; 95% CI, -5.0 to 6.3) or the OSA-18 questionnaire (eg, total symptom score: -0.5; 95% CI, -13 to12). One patient from each group was readmitted owing to postoperative bleeding, but no other complications were seen. CONCLUSIONS AND RELEVANCE This trial did not show that APP was more effective than ATE alone to treat otherwise healthy children with severe OSA. This finding suggests that ATE should continue to be the primary treatment for OSA in children.
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| 2. |
- Friberg, Danielle, et al.
(författare)
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Long-term evaluation of satisfaction and side effects after modified uvulopalatopharyngoplasty
- 2020
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Ingår i: The Laryngoscope. - : Wiley. - 0023-852X .- 1531-4995. ; 130:1, s. 263-268
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVES/HYPOTHESIS: We have previously shown that modified uvulopalatopharyngoplasty (UPPP) is effective to treat obstructive sleep apnea (OSA) and that the effect is stable after 24 months. This continuous report includes questionnaires and phone interviews.STUDY DESIGN: Prospective intervention study.METHODS: Sixty-five patients with apnea-hypopnea index (AHI) score ≥ 15, body mass index <36 kg/m2 , and Epworth Sleepiness Scale (ESS) score ≥ 8 underwent modified UPPP after failing nonsurgical treatment. The results from a patient questionnaire at 6 and 24 months after surgery were correlated with age, body mass index, and ESS and AHI scores. Patients reporting side effects and/or regretting the surgery after 24 months were selected for phone interviews 9 years after surgery.RESULTS: The response rate was 80% and 74% at the 6- and 24-month follow-ups, respectively. Of those who responded to the questionnaire, 96% and 83% were satisfied after 6 and 24 months, respectively; 98% and 92% recommended the surgery. Side effects (globus, mucus, and voice and swallowing disorders) occurred in 38% and 31%, respectively. Dissatisfaction correlated significantly with high postoperative AHI and ESS scores, but not with occurrence of side effects. Younger subjects had a higher rate of recommendation and lower rate of side effects than did older subjects. Phone interviews after 9 years were responded to by 14 of 16 selected patients, and the responders reported minor or no side effects.CONCLUSIONS: The vast majority of the OSA patients were satisfied 24 months after surgery, even though a third of them were experiencing side effects. Younger patients had fewer side effects than did older patients. Patients with better OSA outcomes were also more satisfied. After 9 years the side effects were no longer problematic.LEVEL OF EVIDENCE: 2b Laryngoscope, 2019.
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| 3. |
- Niessl, Julia, et al.
(författare)
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Identification of resident memory CD8+ T cells with functional specificity for SARS-CoV-2 in unexposed oropharyngeal lymphoid tissue
- 2021
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Ingår i: Science immunology. - : American Association for the Advancement of Science (AAAS). - 2470-9468. ; 6:64
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Tidskriftsartikel (refereegranskat)abstract
- Cross-reactive CD4+ T cells that recognize severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are more commonly detected in the peripheral blood of unexposed individuals compared with SARS-CoV-2–reactive CD8+ T cells. However, large numbers of memory CD8+ T cells reside in tissues, feasibly harboring localized SARS-CoV-2–specific immune responses. To test this idea, we performed a comprehensive functional and phenotypic analysis of virus-specific T cells in tonsils, a major lymphoid tissue site in the upper respiratory tract, and matched peripheral blood samples obtained from children and adults before the emergence of COVID-19 (coronavirus disease 2019). We found that SARS-CoV-2–specific memory CD4+ T cells could be found at similar frequencies in the tonsils and peripheral blood in unexposed individuals, whereas functional SARS-CoV-2–specific memory CD8+ T cells were almost only detectable in the tonsils. Tonsillar SARS-CoV-2–specific memory CD8+ T cells displayed a follicular homing and tissue-resident memory phenotype, similar to tonsillar Epstein-Barr virus–specific memory CD8+ T cells, but were functionally less potent than other virus-specific memory CD8+ T cell responses. The presence of preexisting tissue-resident memory CD8+ T cells in unexposed individuals could potentially enable rapid sentinel immune responses against SARS-CoV-2.
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| 4. |
- Sundman, Joar, et al.
(författare)
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Effectiveness of Tonsillectomy vs Modified Uvulopalatopharyngoplasty in Patients With Tonsillar Hypertrophy and Obstructive Sleep Apnea The TEAMUP Randomized Clinical Trial
- 2022
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Ingår i: JAMA Otolaryngology - Head and Neck Surgery. - : American Medical Association (AMA). - 2168-6181 .- 2168-619X. ; 148:12, s. 1173-1181
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Tidskriftsartikel (refereegranskat)abstract
- Importance Modified uvulopalatopharyngoplasty (mUPPP) is a surgical treatment for selected adults with obstructive sleep apnea (OSA). Tonsillectomy (TE) alone is a less extensive alternative treatment. Objective To investigate whether mUPPP is more effective than TE alone in treating adult patients with tonsillar hypertrophy and moderate to severe OSA. Design, Setting, and Participants This blinded randomized clinical trial compared the effectiveness of mUPPP with TE alone before surgery and 6 months postsurgery in adults with tonsillar hypertrophy (sizes 2, 3, or 4 according to the Friedman staging) and moderate to severe OSA in a university hospital in Stockholm, Sweden. Participants underwent surgery from January 2016 to February 2021; the last postsurgery follow-up was completed in September 2021. Data analyses were performed from January to September 2022. Interventions mUPPP vs TE alone. Main Outcomes and Measures Between-group differences on the apnea-hypopnea index (AHI) and Epworth sleepiness scale (ESS). Results The study cohort comprised 93 patients (mean [SD] age, 41.6 [9.4] years; 80 [86%] men; race/ethnicity were not considered) with a mean (SD) body mass index of 29.0 (2.8), calculated as weight in kg divided by height in m(2). Of these, 90 participants (97%) completed the protocol (mUPPP, n = 45; TE, n = 45). The mean (SD) AHI score (number of events per hour [events/h]) for the mUPPP group decreased by 43%, from 51.0 (22.6) to 28.0 (20.0) events/h; and for the TE group, 56%, from 56.9 (25.1) to 24.7 (22.6) events/h. The mean between-group difference in AHI score was 9.2 events/h (95% CI, 0.5 to 17.9), with a small effect size (Cohen d = 0.44) in favor of TE. For ESS scores, the between-group difference was also small, only 1.1 (95% CI, -1.3 to 3.4; Cohen d = 0.21). Neither difference was considered to be clinically relevant. Conclusions and Relevance This randomized clinical trial demonstrated that mUPPP was not more effective than TE alone in treating patients with tonsillar hypertrophy and moderate to severe OSA. However, there was a small difference in favor of TE. Because TE alone is less extensive, it could be considered as an alternative to mUPPP in this selected group of patients with OSA.
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| 5. |
- Sundman, Joar, et al.
(författare)
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Eight-Year Follow-up of Modified Uvulopalatopharyngoplasty in Patients With Obstructive Sleep Apnea
- 2021
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Ingår i: The Laryngoscope. - : John Wiley & Sons. - 0023-852X .- 1531-4995. ; 131:1, s. E307-E313
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Tidskriftsartikel (refereegranskat)abstract
- Objective To investigate whether modified uvulopalatopharyngoplasty (UPPP) for treatment of obstructive sleep apnea (OSA) remained effective after 8 years. Methods Prospective intervention study. Sixty-five patients with OSA were offered re-evaluation with polysomnography and the Epworth Sleepiness Scale (ESS) 8 years after UPPP. Results were compared with baseline and with a previous 2-year follow-up. Baseline predictors were analyzed with regression analyses. Results The dropout rate at the 8-year follow-up was 28%. The mean decrease in apnea-hypopnea index (AHI) between baseline and the 8-year follow-up was significant, 14.0 events/hour (from 52.9 to 38.9), 27% (P < .001). The mean increase in AHI between the 2-year and the 8-year follow-up was significant, 14.7 events/hour (from 24.2 to 38.9), 61% (P < .0001). Overweight at baseline predicted an AHI at the 8-year follow-up that was 22.9 events higher compared to patients with normal weight (P= .015). An increase in body mass index (BMI) of 1 kg/m(2)between baseline and the 8-year follow-up predicted a mean AHI increase of 3.8 events/hour (P= .015). The median decrease in ESS between baseline and the 8-year follow-up was significant, 7 (from 13.0 to 6.0), 54% (P < .0001). The median increase in ESS between the 2-year and the 8-year follow-up was not significant, 1.0 (from 5.0 to 6.0), 20%. Conclusion Modified UPPP was effective as a long-term treatment for OSA in selected patients, although the effect on AHI decreased over time. Daytime sleepiness remained improved even in the long term. High BMI at baseline and an increase in BMI predicted a reduced long-term respiratory outcome. Level of Evidence 3Laryngoscope, 2020
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| 6. |
- Sundman, Joar, et al.
(författare)
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Low inter-examiner agreement of the Friedman staging system indicating limited value in patient selection
- 2018
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Ingår i: European Archives of Oto-Rhino-Laryngology. - : Springer Science and Business Media LLC. - 0937-4477 .- 1434-4726. ; 275:6, s. 1541-1545
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Tidskriftsartikel (refereegranskat)abstract
- The Friedman staging system is a clinical method for selecting patients with obstructive sleep apnoea who are likely to benefit from uvulopalatopharyngoplasty. The objective of this study was to evaluate the system by determining its inter-examiner agreement. Twelve patients with obstructive sleep apnoea were examined by 14 doctors. The Friedman stage was derived from tonsil size and tongue position, and a Cohen's kappa analysis was performed to assess inter-examiner agreement. One hundred and sixty-eight ratings were performed. The median kappa for tongue position was 0.32 (first and third quartiles: 0.21 and 0.44) and was 0.62 (0.50 and 0.63) for tonsil size. The median kappa for the Friedman stage was 0.38 (0.24 and 0.55), which corresponds to only a slight or fair agreement. The Friedman staging system demonstrated a low inter-examiner agreement, indicating that the system is an uncertain method for selecting patients for uvulopalatopharyngoplasty. Level of evidence: 2B.
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| 7. |
- Sundman, Joar, et al.
(författare)
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Sleep Quality After Modified Uvulopalatopharyngoplasty : Results From the SKUP3 Randomized Controlled Trial
- 2018
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Ingår i: Sleep. - : Oxford University Press (OUP). - 0161-8105 .- 1550-9109. ; 41:1
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Tidskriftsartikel (refereegranskat)abstract
- Study Objectives: To investigate whether uvulopalatopharyngoplasty (UPPP) improves sleep quality in patients with Obstructive Sleep Apnea (OSA) using the Functional Outcomes of Sleep Questionnaire (FOSQ) and the Karolinska Sleep Questionnaire (KSQ).Methods: Randomized controlled trial used to compare modified UPPP, with controls at baseline and after six months. The controls received delayed surgery and a six-month postoperative follow-up. All operated patients were offered a 24-month follow-up. At each follow-up, patients underwent polysomnography and vigilance testing and completed questionnaires. Nine scales were evaluated: five subscales and the total score in the FOSQ and three subscales in the KSQ.Results: Sixty-five patients, mean 42.3 years (SD 11.5), Friedman stage I and II, BMI <36 kg/m 2, moderate to severe OSA, were randomized to intervention (n = 32) or control (n = 33). In the FOSQ and in the KSQ, the mean rate of missing values was 6.2% (range 0-19%) and 20.5% (3-38%), respectively. In 8 of 9 scales, significant differences were observed between the groups in favor of UPPP. There were significant correlations between results from the questionnaires and objective measures from polysomnography and the vigilance test. At the six and 24-month postoperative follow-ups, 8 of 9 scales were significantly improved compared to baseline.Conclusions: In selected patients with OSA, subjective sleep quality was significantly improved six months after UPPP compared to controls, with stable improvements 24 months postoperatively. The correlations between subjective and objective outcomes, and the long-term stability suggest a beneficial effect from surgery, although a placebo effect cannot be excluded.
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| 8. |
- Sundman, Joar
(författare)
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Uvulopalatopharyngoplasty : patient selection, long- term outcomes, and side effects
- 2020
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Uvulopalatopharyngoplasty (UPPP) is the most common surgical treatment for adult patients with obstructive sleep apnea (OSA). Its short-term efficacy, as measured through polysomnography, is well-established and has been demonstrated in two randomized controlled trials in recent years. However, less is known about subjective sleep quality, longterm efficacy, and side effects after surgery. In addition, the reliability of the most widespread clinical test for selecting patients for surgery—the Friedman staging system—is unclear. The Friedman staging system uses a combination of tonsil size and tongue position to predict the likelihood of successful surgery. The objective of studies I and II was to evaluate the staging system by determining its inter-examiner agreement. In study I, 15 doctors evaluated the system by using it on each other. In study II, 14 doctors evaluated the system by using it on 12 patients with OSA. Cohen’s kappa analysis was used. Kappa values of 1 represents perfect agreement, and values of 0 represent no more agreement than would have been expected through random chance. In study I, the median kappa was 0.36 for tongue position. In study II, the median kappa was 0.32 for tongue position, 0.62 for tonsil size, and 0.38 for the Friedman staging system. These findings correspond to poor agreement, indicating that the system is an uncertain method for selecting patients for UPPP. Uvulopalatopharyngoplasty was first described in the eighties. Since then, there has been several modifications. The modified UPPP used in this thesis includes a tonsillectomy and is performed with cold instruments. It is less radical to the palate compared to the original procedure. The objective of study III was to investigate whether modified UPPP improves sleep quality by using the Functional Outcomes of Sleep Questionnaire and the Karolinska Sleep Questionnaire. The study consisted of two parts: Part 1 was a randomized controlled trial with two study groups (intervention and controls), and Part 2 was a post-operative follow-up of all patients (intervention and controls who received delayed surgery) with an analysis of outcomes at six and 24 months after UPPP. In eight out of nine subscales, there were significant improvements between the intervention and controls in favor of UPPP. In addition, at the six- and 24-month post-operative follow-ups of all patients, eight out of nine subscales were significantly improved compared to the baseline. These findings suggest a real and lasting beneficial effect of UPPP on subjective sleep quality, although a placebo effect cannot be excluded. Previous studies have demonstrated high rates of side effects following pharyngeal surgery. The objective of study IV was to evaluate side effects and satisfaction with modified UPPP after six and 24 months. In addition, patients who reported side effects or regretted having surgery at the follow-up were contacted for an individual telephone interview approximately nine years after surgery. In our sample, the majority of patients were satisfied 24 months after surgery, despite one third experiencing side effects. Younger patients had fewer side effects than older patients. After nine years, the side effects were mostly of minor concern. Studies on the long-term effects of UPPP are few in number, often include small study samples, and use different outcome measures and surgical techniques. The objective of study V was to investigate whether modified UPPP remained effective after eight years using polysomnography and questionnaires. In addition, the study investigated whether certain baseline factors could predict long-term outcomes. The results indicated that modified UPPP had a significant positive effect as a long-term treatment for OSA, although the effect on apnea-hypopnea index also significantly decreased over time. Daytime sleepiness, on the other hand, appeared to remain improved even in the long term. High body mass index at baseline and an increase in body mass index predicted reduced longterm outcomes.
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