Surgery for Snoring and Obstructive Sleep Apnea Syndrome: Diagnosis and Therapy of Sleep Respiratory Disorders for the Otorhinolaryngologist

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Mario Fabiani
Kugler Publications, 2003 - Sleep apnea syndromes - 624 pages

'Bocca della Veritą' or 'Mouth of Truth' is the logo of the Unit for the Study and Therapy of Sleep Respiratory Disorders at the University of Rome 'La Sapienza'. It was chosen because its round shape with surprised expression, small nose and open mouth mirrors the typical face of a patient with OSAS (pre-therapy). The stone (diameter 1.75 m) in fact represents the face of a screaming faun and was originally found in the Mercury Temple area. According to popular legend, anyone putting his hand in the mouth will have it cut off if he has told a lie.

When I first became involved in the field of OSAS about ten years ago, I had no idea that this activity would become foremost in both my professional and my academic life.

My curiosity was aroused when a patient of mine, an extremely fat patient, whom I had been following for a long time regarding a hearing problem, asked me for a prescription for CPAP. He had read in a newspaper that this device could solve his nocturnal respiration and diurnal hypersomnolence problems. Suddenly, I was confronted with documentation on snoring, OSAS, polysomnography, upper airway surgery, and positive pressure devices. 

I was then, and still am now, a Professor of Audiology. Audiology was and still is the object of my love, but it is mainly a speculative discipline. It involves physics, electronics, psychology, rehabilitation, and great possibilities for basic research. However, only rarely does an audiological patient obtain full satisfaction clinically. Patients with neurosensorially-based deafness can be rehabilitated, but with difficulty; conductive hearing loss is light and recovers automatically in most cases; in a few cases, the patient can be packed up and delivered to the ear surgeon or audioprosthetic technician. 

Vertigo is dramatic, but recovers spontaneously or after long-term rehabilitation, or it is categorized as a neurological symptom. Tinnitus is frustrating and the audiologist centers most of his time and energy on trying to convince the patient to forget it. In fact, it is very rare to see a patient affected by an audiological disease recover after intervention by an audiologist. Furthermore, most patients are either very old or very young.

With OSAS patients, things are very different. The patient is usually at the peak of his life; he has serious disturbances in his social, familial, and working spheres; he is sedentary and is often a manager with a disordered of lifestyle (does not partake in any sport; smokes and drinks too much), he has become irritable, apathetic, and is starting to worry about dying during the night or suffocating. He has been followed for years for his arterial hypertension and latent arrhythmia. He, or often she, is a snorer and, after complaints from their partner, sleeps in a separate room. His sex life is affected, and he often gets up during the night convinced that he has prostatic problems too. 

Unfortunately, for many years, no-one thought that these kinds of patients should consider consulting an otolaryngologist, and, at the same time, otolaryngologists never thought of taking care of this pathology.

As soon I started to see the first cases and was able to solve their obstruction, the number of patients being referred grew dramatically, as did my skill in this field. It was a really rewarding job. After years of hyperspecialistic practice, I returned to patient care in its entirety. Sometimes, a simple intervention such as nasal septoplasy or tonsillectomy, i.e., one of those interventions so often underestimated by more expert colleagues, was able to solve some of the serious problems of life. In the meantime, specific new techniques came into being: radiofrequencies, oral appliances, diode lasers, tongue suspension devices, while, at the same time, diagnostic instrumentation such as polysomnography became more flexible and could more easy to be applied to obstructive disorders. 

By 1997, my department was in an uproar about OSAS since I had got most of my colleagues interested in becoming involved, and the first sponsor was my former chief, Roberto Filipo, who gave me his approval, space to work in, and encouragement to overcome all the problems. My other colleagues, and I would like to mention all of them here: Giorgio Bandiera, Maurizio Barbara, Gian Antonio Bertoli, Ferdinando D'Ambrosio, Elio De Seta, Simonetta Masieri, Antonio Minni, Simonetta Monini, Virgilio Pizzichetta, Mario Patrizi, Maurizio Saponara, and Antonino Sciuto, either directly or indirectly, also offered to put their experience into writing various sections for this book. A specific section was also organized at the Institute, and I was able to coordinate some of our residents who have recently taken on the task of apostles, spreading the knowledge they acquired on OSAS during their time with us to other hospitals in the region. I must mention them too, since very often they did most of the work, and in OSAS, that is a lot of work: Francesca Auriti, Angelo Clarici, Fulvio Di Fulvio, Arianna Mattioni, Angela Mollica, Maria Laura Panatta, Barbara Pichi, Raniero Pucci, Mario Rinaldi, Rocco Roma, Anna Sambito, Ilenia Schettino, Rocco Schettino, Emanuela Sitzia, Artur Zajmi, and others. 

The diagnosis and treatment of, and scientific research into, OSAS is a multidisciplinary task, and I succeeded in involving many professors from related disciplines at the hospital of the University 'La Sapienza': Carlo Cannella for Alimentation and Human Nutrition, Eugenio Gaudio for Anatomy, Giuseppe Calcagnini for Cardiology, Vincenzo Bonifacio and Debora Giannini for Endocrinology, Adolfo Francesco Attili for Gastroenterology, Franco Angelico for Internal Medicine, Giorgio Iannetti for Maxillo-Facial Surgery, Giuseppe Amabile for Neurology, Maria Pia Villa for Pediatrics, Alessandro Perrone and Ilio Cammarella for Pneumology, and Carlo De Dominicis for Urology. They used their experience in treating these patients and present their results in their contributions to this book.

During the same period, the diagnosis and therapy of OSAS was spreading fast to all otolaryngological units at universities and hospitals throughout Italy. It was easy for me to share my enthusiasm, and thus we built up a network of close cooperation. Any otolaryngologist will know these contributors so well that it would be easy for him to find their papers in this book, but still I want to mention those who were closest in advising and helping me: Marco Fusetti from L'Aquila, Luigi D'Angelo and Vieri Galli from Naples, Pietro Ferrara, Riccardo Speciale and Salvatore Restivo from Palermo, Oskar Schindler from Turin, and Maurizio Maurizi and Vittorio Pierro from Rome.

The time was now ripe to confront the world nomenclature on OSAS. The dream to share a rendezvous with all (or most of) the prominent people from all the disciplines involved in both the clinical and scientific research on OSAS was realized in 1997 at the 'ROMA OSAS - First International Conference on the Diagnosis and Therapy of Snoring and OSAS', which was followed by a second meeting in the year 2000, and a third in 2002. I only have to mention the names of the presidents of these conferences to testify to the high quality that was achieved: Giovanni Bonsignore, Gisle Djupesland, Roberto Filipo,
Christian Guilleminault, Meir Kryger, Elio Lugaresi. It would be inappropriate to mention here only some of those who also took part, and there are too many to mention them all, since they are all equally important. I was very honored to ask them for and to receive papers for this book. Some of the abstracts presented at these conferences are also included in this book as highlights on various subjects, due to their particular relevance. 

And so, finally, you now know how this book was born. It is the collection of an enthusiastic beginner who persuaded his friends and/or colleagues from his department, his university, his country, and the entire scientific community, to submit papers on the basics and state-of-the-art of relevant topics regarding snoring and OSAS, which, hopefully, in its turn will help those other enthusiastic beginners who wish to improve their knowledge on the care of apneic patients. Also, even though many of the chapters are written by participants at the ROMA OSAS Conferences, this book is not an abstract volume of those meetings. It does, however, represent the scientific development unearthed on those occasions. For this reason, I think it would also be a valid textbook on OSAS from an otolaryngological point of view.

After the many thanks due to the contributors, my final thanks must go to the person who had the patience to cooperate with me on the editorial work: Peter Bakker of Kugler Publications. My confrontations with him were often thorny, but we both had the same goal in mind: to offer you the best possible product. We hope that you will agree with us that this book will be a useful addition, both to your practice and to your continuing education.

Mario Fabiani



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Gaudio E and A Vetuschi AnatomoPhysiology of the Upper Airways
Amabile G F Pauri and F Fattapposta Neurological correlations
Calcagnini G and F De Pasquale Obstructive Sleep Apnea and Cardio
M Saponara L Bruno M Fabiani and V Bonifacio
Pinto A V Bacci M S Basso U Elmore R Lamberti and C Cannella
M Saponara M L Panatta A Sambito and M Fabiani
DAmicis A A Turrini P DAcapito D Perrone and F Silvi The Dis
DAmicis A L Martino and A Turrini Food Consumption and Obesity
Akre H Advantages of Measuring Airflow in the Hypo
Verse T and W Pirsig Treating Nasal Obstruction in Obstructive Sleep
Speciale R S Restivo G F Cupido S Gallina and A M Giammanco
Djupesland G O Skatvedt O B Godtlibsen and O Krogstad Uvulopala
Iannetti G P Cascone and M T Fadda Congenital Craniofacial
R S Vella C Bassetti and R Häusler The Efficiency
Cassano P N De Candia M L Fiorella and R Fiorella Results of
Verse T and W Pirsig LaserAssisted Uvulopalatopharyngoplasty

Attili A F and E Papa Gastroesophageal Reflux Disease and Obstructive
N De Luca F Trinchieri P Comite V Paoletti
V Covelli F P Serra G Salerno and G Buongiorno
M Polce M Mesolella R Iovine E Cantone and D Testa
Ferrara S M Tutino D Sammartano and P Ferrara Pediatric Snoring
Pagani J M P Villa F Massa A Alterio R Ambrosio and R Ronchetti
Boudewyns A N Esophageal Pressure Measurements
Petrolito G and R Spinato Individualization of the Sites of Obstruction
W The Clinical Assessment of Daytime Sleepiness in Patients
F S Arce Recio A Rollo and M Aquilini Somnoscopy
Sorrenti G O Piccin G Latini G Scaramuzzino S Mondini
Boudewyns A N E Hamans and PH Van de Heyning Radiofrequency
Fibbi A and G Bertino Tongue Suspension and Further Surgical
Fetoni A R E Scarano G Cadoni F Mormile A Sposi F Salvia
Bertoli G A R Romeo G Bava C Del Pero and O M F Romeo Nasal
I A DSouza and D W Morgan LongTerm Followup
Boudewyns A N W A De Backer A R Schwartz and PH Van
Perrone A G Lucantoni V Masciangelo and C Magliocco Ventilatory
Martino E F N M Rieger R Saadi and M Westhofen Effectiveness
K Studnicki and P Strollo Jr Impact of a Pressure Ramp

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Page 45 - Bixler EO, Vgontzas AN, Lin HM, et al. Prevalence of sleep-disordered breathing in women: effects of gender. Am J Respir Crit Care Med 2001; 163:608-613.
Page 574 - Clark GT, Blumenfeld I, Yoffe N, Peled E, Lavie P. A cross-over study comparing the efficacy of continuous positive airway pressure with anterior mandibular positioning devices on patients with obstructive sleep apnea. Chest 1996;109: 1477-83.

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