- Email: [email protected]
Quality of Life Assessment After Maxillomandibular Advancement Surgery for Obstructive Sleep Apnea
Accepted Manuscript Quality of Life Assessment Following Maxillomandibular Advancement Surgery for Obstructive Sleep Apnea Kevin J. Butterfield, MD, DDS, Patricia L.G. Marks, BScH, Laurie McLean, MD, Jack Newton, DDS PII:
S0278-2391(16)00135-X
DOI:
10.1016/j.joms.2016.01.043
Reference:
YJOMS 57127
To appear in:
Journal of Oral and Maxillofacial Surgery
Received Date: 24 November 2015 Revised Date:
13 January 2016
Accepted Date: 22 January 2016
Please cite this article as: Butterfield KJ, Marks PLG, McLean L, Newton J, Quality of Life Assessment Following Maxillomandibular Advancement Surgery for Obstructive Sleep Apnea, Journal of Oral and Maxillofacial Surgery (2016), doi: 10.1016/j.joms.2016.01.043. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Quality of Life Assessment Following Maxillomandibular Advancement Surgery for Obstructive Sleep Apnea
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Kevin J. Butterfield, MD, DDS,* Patricia L.G. Marks, BScH† Laurie McLean, MD,§ Jack Newton, DDS|| * Chief, Division of Dentistry/Oral and Maxillofacial Surgery, Ottawa Hospital, and Assistant Professor, Department of Otolaryngology, University of Ottawa School of Medicine, Ottawa, Ontario, Canada † Medical student, University of Toronto, Toronto, Ontario, Canada
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§ Assistant Professor, Department of Otolaryngology, University of Ottawa School of Medicine, Ottawa, Ontario, Canada
Correspondence to Dr. Butterfield
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Mailing address: 239 Argyle Avenue Ottawa, ON, Canada K2P 1B8
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|| Research Assistant, Division of Dentistry/Oral and Maxillofacial Surgery, Ottawa Hospital, Ottawa, Ontario, Canada
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Phone: +1-613-232-4203 Fax: +1-613-238-7822 Email: [email protected]
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ABSTRACT Purpose: While maxillomandibular advancement (MMA) surgery is highly efficacious for management of
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obstructive sleep apnea (OSA), little information exists regarding the subjective impact of this treatment modality. The present study was undertaken to investigate the impact of MMA on
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patient-perceived quality of life (QOL) in OSA.
Methods:
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A retrospective cohort study of patients treated with MMA for OSA between May 2010 and April 2015 was performed. The primary outcome measure was a change to QOL detected by the Ottawa Sleep Apnea Questionnaire (OSA-Q), which assesses MMA-related changes to QOL on a 5-point Likert scale. The secondary outcome measure was a change to the Apnea Hypopnea
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Index (AHI).
Results: Twenty-two patients participated in the present study. Mean maxillary and mandibular advancement were 8.36 and 11.08mm, respectively. AHI decreased from 42.4 to 6.9 events/h (p <
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0.001), postoperatively. QOL improved significantly following MMA (OSA-Q score: 3.98 ± 0.35, p < 0.001). Sleep quality (4.35 ± 0.63), daytime function (4.13 ± 0.46), physical health (4.19
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± 0.45), mental and emotional health (4.02 ± 0.55), and sexual health (3.78 ± 0.62) categories all improved postoperatively (p < 0.001). MMA-related side effects did not adversely affect QOL.
Conclusion: MMA for OSA significantly improves patient’s subjective overall quality of life, with few MMA related side effects.
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INTRODUCTION
Obstructive sleep apnea (OSA) is a serious and prevalent condition with an increasing incidence1– . OSA is associated with autonomic5,6 and metabolic dysfunction4,7–9, in addition to numerous
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cardiovascular and cerebrovascular sequelae4,10–13. As such, effective treatment is critical to
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improving patient health and longevity.
In addition to serious health consequences, patients with OSA experience diminishment to their quality of life (QOL), including reduced sleep quality, excessive daytime somnolence, and
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impaired mental, emotional, and sexual health on QOL assessments1,4,14–21.
Continuous positive airway pressure (CPAP) is the gold standard for management of OSA, and studies have shown CPAP use to result in an attenuation of the disease process and severity11,22–24,
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as well as QOL improvements17,19,22,25–27. Despite this, tolerability and compliance are low28–30, and patients seek alternative treatment options. Maxillomandibular advancement surgery (MMA) is a highly successful23,31–42 surgical alternative to CPAP therapy that achieves objective
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improvements in OSA comparable to CPAP23,24,32,43,44. By advancing the bony insertion sites of the pharyngeal musculature, MMA tautens and reduces the collapsibility of the pharyngeal
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airway23,45–47, resulting in a long-term reduction in objective disease severity. However, the subjective impact of MMA on OSA is poorly understood. Few studies18,48 have used a formalized sleep-related quality of life questionnaire to evaluate the subjective clinical impact of MMA as a treatment modality. The paucity of information on this topic highlights the need for further study, as findings will inform clinicians and allow prospective patients to make a better-informed decision when considering MMA for management of their OSA.
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The purpose of this study was (1) to quantify the subjective change to QOL in patients who have undergone MMA for management of OSA, (2) to assess the impact of the treatment-related side effects of MMA on patient QOL, and (3) to evaluate the relationship between objective changes
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in OSA severity with subjective changes to QOL. We hypothesized that the reduction in OSA disease severity by MMA would improve QOL. While some patients may experience post-
surgical symptoms during their recovery, we predicted that MMA for OSA significantly improves
METHODS
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patients’quality of life.
The Ethics Review Board of the Ottawa Hospital Research Institute approved this study and all
Study design and sample
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patients consented to participate.
This was a retrospective cohort study and postoperative quality of life assessment of patients
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treated with MMA at the same oral & maxillofacial surgery clinic for management of OSA. Consecutive patients who had undergone MMA surgery for OSA between May 2010 and April
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2015 were invited to complete the Ottawa Sleep Apnea Questionnaire (OSA-Q).
Inclusion criteria were: diagnosis of OSA by a sleep medicine physician; pre and post-operative polysomnography; site of obstruction in the oropharynx; clinical and fibreoptic nasopharyngoscopic examination; sufficient health to undergo MMA; Body Mass Index (BMI) less than 40 kg/m2; class I or II dental occlusion; between 18 and 70 years old at the time of surgery; and minimum 4 weeks post-operative upon questionnaire completion. Exclusion criteria
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were: insufficiently healthy to undergo maxillofacial surgery; BMI greater than 40 kg/m2; and class III dental occlusion.
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Surgery All patients were treated by the same oral & maxillofacial surgeon (KJB) with a standard LeFort I osteotomy and bilateral ramus sagittal split osteotomy with rigid internal fixation. Two patients
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underwent a concomitant cosmetic genioplasty that did not include the genial tubercles.
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The Ottawa Sleep Apnea Questionnaire
The Ottawa Sleep Apnea Questionnaire (OSA-Q) was developed using a combination of information from the literature and clinical experience to determine the aspects of life affected in those who suffer from OSA and who undergo MMA for its clinical management.
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The OSA-Q is a combined quality of life and descriptive questionnaire, with 41 QOL questions on a 5-point Likert scale. The first 30 questions relate to key areas affected by OSA: sleep quality, daytime function, physical health, mental and emotional health, and sexual health. Since
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a lower response rate for questions relating to intimacy and sexual health has been reported previously17, these questions were optional so as to encourage more patients to complete the
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questionnaire. The eight remaining Likert-scale questions aim to assess the treatment-related side effects of MMA upon QOL, by considering patient experiences with surgical recovery and dental function. Side effects analyzed include: change in speech quality; change in swallowing ability; postoperative pain level; change in headache frequency; velopharyngeal insufficiency symptoms; chewing function; dental alignment; and any changes in temporomandibular joint function. Descriptive information relating to gender, weight, perceived degree of facial paresthesia, duration of postoperative period, satisfaction with surgery, and impressions with the surgical experience were asked of each patient.
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Questionnaire administration and scoring All postoperative patients who met the inclusion criteria were invited to participate in the study and given one month to complete the questionnaire. Two weeks after initial receipt of the OSA-
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Q, patients who had not returned the completed questionnaire were contacted to reconfirm their interest in the study. Patients who had not completed the questionnaire after one month were
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excluded from the study, as they were considered to have withdrawn their consent to participate.
The Likert scale questions were weighted in the following way: 1 = “strongly disagree,” 2 =
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“disagree,” 3 = “neither agree nor disagree,” 4 = “agree,” and 5 = “strongly agree,” in response to 38 statements about changes to quality of life. Within-category responses were averaged to yield a score out of 5. A score of 3 was considered to be no change to QOL, greater than 3 as an improvement, and less than 3 a reduction to QOL for the OSA-related QOL questions. A score of 3 or greater indicated no negative impact to QOL, and a score less than 3 signified a negative
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impact of MMA on QOL for the treatment-related OSA-Q questions.
Study variables
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The independent variables in the present study included the time of treatment and magnitude of advancement of the maxillomandibular complex. Dependent variables in this study were
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responses to the OSA-Q and the Apnea Hypopnea Index (AHI).
Statistical analysis
Data collection and statistical analysis were performed using Microsoft Excel, version 14.4.7 (Microsoft Corp, Redmond, WA) and the Real Statistics Resource Pack software (Release 3.5.3; Copyright 2013-2015; Charles Zaiontz. www.realstatistics.com) for non-parametric tests. Surgical success was defined as a minimum 50% reduction to AHI and a postoperative AHI less than 20 events/hour. Surgical cure was defined as a postoperative AHI less than 5 events/hour.
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Paired student t-tests were performed to compare pre- and post-operative AHI, ESS and BMI. A one-sample Wilcoxon signed-rank test was performed using a median score of 3 (no change) to evaluate for significant changes to QOL postoperatively. Results were expressed as mean ±
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standard deviation. Sample size is reported for questions without a 100% response rate. The relationship between QOL and AHI was evaluated using Spearman rank correlations. A p-value
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less than 0.05 was considered to be statistically significant for all measures.
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RESULTS
Twenty-two patients (19 male, 3 female) met the inclusion criteria and consented to participate in this study (100% completion). Participants were 45.9 ± 11.6 years old at the time of questionnaire completion. Two patients had previously undergone uvulopalatopharyngoplasty, and one patient
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had undergone a laser-assisted uvulopalatoplasty. Maxillary and mandibular advancement were 8.36 ± 2.38mm and 11.08 ± 2.45mm, respectively. Pre- and post-operative BMI were 29.63 ± 3.87 and 28.98 ± 3.77 kg/m2 (p = 0.18), respectively. AHI decreased from 42.4 ± 26.7 to 6.9 ±
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6.22 (p<0.001) events/hour, and ESS decreased from 12.67 ± 5.01 to 6.00 ± 3.20 (p<0.001), following MMA. The surgical success and cure rates were 81.8% and 50.0%, respectively. The
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improvement to time spent in rapid eye movement sleep (REM) was also significant (11.58 ± 6.22% to 16.78 ± 7.15%, p = 0.030). While 86% of patients reported that they were still subjectively experiencing some degree of facial paresthesia, 50% had at least a 75% restoration of sensation.
The OSA-Q was completed between 2 and 61 months postoperatively. Category scores are summarized in Table 1. Overall, patients reported an improvement in quality of life postoperatively (global OSA-Q score: 3.98 ± 0.35; p < 0.001), and the results of each assessed
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OSA-related QOL criteria are ranked and presented in Figure 1. The category scores for OSArelated QOL were: sleep quality: 4.35 ± 0.63; daytime function: 4.13 ± 0.46; physical health: 4.19 ± 0.45; mental and emotional health: 4.02 ± 0.55; and sexual health: 3.78 ± 0.62 (p < 0.001 for
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all). OSA- related QOL question response scores are presented, ranked within each category, in Table 2 and Figure 2.
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Significant improvement to quality of life occurred in the following parameters of the sleep
quality category: patient-perceived sleep quality (4.77 ± 0.43, p < 0.001); and reduction in the
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frequency of snoring (4.59 ± 0.50, p < 0.001), CPAP use (4.81 ± 0.51, p < 0.001; n = 21), and apneas witnessed by a bed partner (4.79 ± 0.58, p < 0.001; n = 14). Patients reported less nighttime sweating (4.18 ± 0.73, p < 0.001) and waking (4.05 ± 0.90, p < 0.001); reduced frequency of waking to urinate (3.86 ± 0.89, p < 0.001); and an increased ease of rising and feeling refreshed in the morning (4.18 ± 0.66 and 4.32 ± 0.78, respectively; p < 0.001). Of the
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patients who used sleeping pills prior to MMA (n = 7), three reported a reduction in their frequency of postoperative use (score: 3.43 ± 1.27, p = 0.174).
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Subjective daytime functioning was significantly greater postoperatively. Patients reported an improved ability to stay awake (4.64 ± 0.49, p < 0.001), concentrate (4.00 ± 0.98, p < 0.001),
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perform at work (4.14 ± 0.71, p < 0.001), and remain alert (4.23 ± 0.69, p < 0.001). Memory also improved postoperatively (3.82 ± 1.05, p = 0.003), and patients were less likely to avoid activities due to fatigue than they were prior to undergoing MMA (3.95 ± 0.90, p < 0.001).
Patient perception of physical health was positively impacted by MMA. Patients reported having more energy (4.41 ± 0.59, p < 0.001) and greater levels of physical activity (4.00 ± 0.76, p < 0.001). An improved ability to breathe (4.14 ± 0.77, p < 0.001), and a sense of better overall health (4.23 ± 0.61, p < 0.001) also occurred postoperatively.
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Mental and emotional health also improved significantly following surgical intervention. Patients felt that they had more patience (3.82 ± 0.59, p < 0.001), were less likely to become angered or
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annoyed (3.91 ± 0.61, p < 0.001), and had a better overall mood (3.95 ± 0.72, p < 0.001). Interpersonal relationships also improved postoperatively (3.64 ± 0.73, p = 0.002). Patients were less anxious about the consequences of MMA on their long-term health (4.64 ± 0.66, p < 0.001)
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and about making sleeping arrangements away from home (4.50 ± 0.60, p < 0.001). Patients were also better able to manage stress (3.95 ± 0.72, p < 0.001) and make decisions (3.77 ± 0.61, p <
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0.001).
Of the patients who completed the sexual health component of the OSA-Q, most patients’ relationships with their significant other improved postoperatively (OSA-Q score: 4.00 ± 0.82, p = 0.002; n = 16). However ,only 37% of patients perceived an improvement in their desire for
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sexual intimacy (3.56 ± 0.92, p = 0.015; n = 18).
The category scores for the recovery and dental function categories were 3.89 ± 0.89 (p < 0.001)
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and 3.50 ± 0.78 (p = 0.001), respectively (Table 1). Individual MMA-related side-effects question responses are presented, ranked within each category in Table 3 and Figure 2. Patients did not
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find a significant change to their speech quality postoperatively (3.14 ± 1.08, p = 0.287), while the change in swallowing ability was significant (3.59 ± 0.96, p = 0.010). Postoperative pain was tolerable (4.09 ± 0.61, p < 0.001) and unaccompanied by an increased frequency of headaches (4.09 ± 0.68, p < 0.001) or symptoms of velopharyngeal insufficiency (VPI; 4.55 ± 0.91, p < 0.001). Patients did not experience a significant improvement to chewing ability (3.09 ± 0.81, p = 0.312), while they did feel their teeth alignment was improved (3.86 ± 0.77, p < 0.001). Change to temporomandibular joint function (TMJ) was also experienced postoperatively (3.55 ± 1.10, p = 0.019).
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Almost all patients were satisfied with the management of their OSA by MMA (95.5%). Most patients considered their postoperative facial appearance to be acceptable (90.9%), would repeat
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the procedure (90.9%), and recommend MMA to others for OSA management (86.4%).
The magnitude of change in AHI was significantly correlated to a reduction in the frequency of
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nocturnal awakenings to urinate (rs = -0.51, p = 0.014) and sleeping pill use (rs = -0.59, p = 0.004; n = 7), however only eight patients used sleeping pills at baseline. The relative change in AHI
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(%) was also significantly correlated to sleeping pill use (rs = -0.59, p = 0.004; n = 7). The correlations between absolute change in AHI and subjective improvement in daytime breathing (rs = -0.38, p = 0.081), stress management (rs = -0.38, p = 0.083), and decisiveness (-0.38, p =
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0.077) approached significance.
DISCUSSION
The purpose of this study was to: (1) quantify the subjective change to QOL in patients who have
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undergone MMA for management of OSA; (2) assess the impact of the treatment-related side effects of MMA on patient QOL; and (3) evaluate the relationship between objective changes in
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OSA severity with subjective changes to QOL. We hypothesized that the reduction in OSA disease severity by MMA would improve QOL. While some patients may experience postsurgical symptoms during their recovery, we predicted that MMA for OSA significantly improves patients’quality of life.
Maxillomandibular advancement surgery is a well-established surgical treatment for OSA. MMA has long-term stability and a high rate of surgical success for OSA management23,31–42,48. This surgery is an appropriate alternative treatment for patients who are unable to tolerate CPAP, as it
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achieves similar objective improvements to disease severity23,24,32,43,44. Despite this, CPAP has been the focus of the majority of QOL assessments in the treatment of OSA49. While CPAP has a demonstrated efficacy for improving QOL, understanding the patient-perceived impact of MMA
for study of the subjective impact of MMA upon OSA patients.
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upon their QOL is equally important. The paucity of information on this topic highlights the need
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The present study investigated the changes in patient perception of QOL following MMA for the surgical management of OSA. We hypothesized that despite the possible treatment-related side
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effects of undergoing corrective jaw surgery; overall quality of life would improve following MMA as disease severity decreases. In addition, we predicted that changes to quality of life would be correlated to changes in AHI.
While numerous quality of life questionnaires are used in OSA15,50–52, both pre- and post-
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operative assessments are necessary to evaluate the change in QOL. The Calgary Sleep Apnea Quality of Life Index (SAQLI)15considers not only the change to health-related QOL, but also accounts for the possible negative side effects of treatment on QOL. While this approach makes
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the SAQLI a more accurate assessment of the overall change in QOL15, this questionnaire also requires pre- and post-intervention assessments. The Ottawa Sleep Apnea Questionnaire (OSA-
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Q) was therefore developed to fill a void, namely to enable retrospective study of QOL and also account for the treatment-related impact of MMA on QOL.
The present study found significant improvements to QOL in patients who underwent MMA for management of OSA, in agreement with previous MMA studies that used the Functional Outcomes of Sleep Questionnaire (FOSQ) and the SAQLI18,48. Sleep quality was the OSA-related QOL category with the most profound postoperative change, followed by physical health, daytime function, mental and emotional health, and sexual health. Improvement to these
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subjective measures of QOL was accompanied by a significant objective reduction in AHI and disease severity. Recovery from surgery and postoperative dental function were acceptable to
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patients; MMA side effects were not considered to have adversely affected QOL.
The greatest improvements to the sleep quality category of the OSA-Q occurred in patient-
perceived quality of sleep, and reduction in snoring, observed apneas, and CPAP use on the OSAQ. Other MMA studies have similarly reported a subjective improvement to sleep quality18 and
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reduction in snoring23 and CPAP use42 postoperatively. By comparison, CPAP improves the
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symptoms component of the SAQLI17,25, which also contains questions about sleep quality. Similarly, CPAP use has improved the sleep and rest component of the Functional Limitations Profile (FLP)21 and the nocturnal symptoms component of the Quebec Sleep Questionnaire (QSQ)53. CPAP also reduced snoring, nocturnal awakenings and breathing cessations in a study
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that did not use a formally validated questionnaire54.
Subjective daytime functioning also improved following MMA, with the greatest improvements occurring in daytime sleepiness, alertness, concentration, and performance at work. The general
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productivity component of the FOSQ similarly assesses memory, concentration and work performance50; the daily functioning component of the SAQLI subjectively assesses memory,
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concentration, and daytime sleepiness15; and the diurnal symptoms section of the QSQ accounts for daytime sleepiness, memory, and concentration51. In agreement with the findings of the present study, previous MMA studies have found improvement in daytime sleepiness, memory, and concentration23, and improved general productivity on the FOSQ18. By comparison, CPAP use increases performance at work and alertness21, and improves the daily functioning component of the SAQLI17,19,25 and the diurnal symptoms component of the QSQ53. However, these improvements have not been found consistently with CPAP studies using the FOSQ17,55.
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Patient-perceived physical health improved significantly postoperatively, especially improvements to energy, sense of overall health, and ease of daytime breathing. While the FOSQ has little content overlap with the physical health subscale of the OSA-Q, a significant
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improvement to activity was detected by the FOSQ following MMA for OSA management18. By comparison, the SAQLI and the 36-Item Short-Form Health Survey (SF-36) both consider the subjective impact of OSA on energy and physical well-being. Both the symptoms and daily
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functioning domains of the SAQLI improved upon treatment with CPAP17,19,25, which may
suggest agreement between the efficacy of MMA and CPAP at improving subjective physical health. By contrast, improvements assessed by the SF-36 have not been consistently reported with
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CPAP use17,25,26,54,56.
Mental and emotional health improved significantly postoperatively, most notably as a reduced worry over the long-term health consequences of OSA, and stress over sleeping arrangements
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away from home. Lesser improvements in: mood; stress management; patience and frequency of getting angered or annoyed; decisiveness; and interpersonal relationships also occurred postoperatively. Prinsell et al.23 similarly reported that patients had improved temperament
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following MMA. In comparison to the OSA-Q, the mental health component of the SF-36 also assesses moodiness. One study that grouped CPAP and upper airway surgery found significant
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improvement to this domain of the SF-3656 following treatment; however, this improvement has not been consistently found in other CPAP studies using the SF-3621,25,26,54. Studies that have used the FOSQ, FLQ, SAQLI and QSQ to assess QOL changes with CPAP have demonstrated improvement in similar subscales17,21,25,53, while one study in patients with severe OSA but without daytime symptoms failed to demonstrate this improvement55.
The present study found statistically significant improvement in sexual health following MMA, albeit the improvement was less profound than the changes to the other components of QOL
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assessed. Both patients’ relationships with their significant other and desire for sexual intimacy had small improvements postoperatively. This is in agreement with the findings of Lye and colleagues18, who demonstrated an improvement to the sexual intimacy component of the FOSQ
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following MMA. Billings et al.17 similarly reported improvement in the sexual intimacy with CPAP use, while other CPAP studies26,55 have failed to detect such a change on the FOSQ.
Inconsistency between our findings and those of CPAP studies may indicate a superiority of
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MMA over CPAP to improve this aspect of patient QOL, but it is more likely the result of
differences in the questionnaires used to evaluate this aspect of QOL, as well as participant
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response rate17, gender distribution, or subjects’ relationship status between studies.
In addition to the positive OSA-related QOL changes following MMA, patients did not find that surgical recovery deleteriously affected their QOL. Patients did not experience an appreciable change to their speech quality, consistent with a previous finding in OSA patients who underwent
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MMA following UPPP47. While VPI posed a concern for almost 10% of patients who underwent MMA after UPPP in the same study47, none of the patients who had undergone either UPPP or LAUP in the present study experienced symptoms of VPI. Postoperative pain was well-tolerated
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by all patients in the present study, and unaccompanied by an increase in headaches or dysphagia, in contrast to the 12% occurrence of difficulty swallowing previously reported57. Interestingly, Li
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and colleagues57 found that postoperative pain did not differ between UPPP and MMA.
Facial paresthesia was subjectively present in the majority of the study population. However, patients have not previously found paresthesia to negatively impact the improvement to diseaserelated QOL that occurs with MMA23,24. Boyd et al. found in their study of OSA patients undergoing MMA that objective sensation was present for all patients, yet 40% of patients subjectively perceived a decrease in sensation48. Notwithstanding the subjective presence of
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decreased sensation in the present study, high levels of satisfaction with surgery were still reported; this is in agreement with findings in healthy subjects undergoing MMA58.
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The MMA-related impact upon dental function did not adversely affect QOL, and also resulted in an improvement in teeth alignment. Changes to chewing function were not significant, and only three patients experienced altered TMJ function. By comparison, postoperative malocclusion has
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been found in other OSA patients following MMA24, while TMJ59 and chewing function58,60 were
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not found to be altered following MMA for patients with and without OSA, respectively.
The side-effects of MMA in the present study did not compromise the improvements to QOL achieved by undergoing treatment. In agreement with this finding, Boyd and colleagues demonstrated that MMA did not have a significant negative impact on QOL using the SAQLI48. In contrast, there are conflicting reports as to whether the treatment-related side-effects of CPAP
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use negatively impact QOL22,25. Although preliminary findings suggest that the treatment-related side-effects are greater for CPAP than MMA, further study is necessary to definitely draw a
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conclusion.
Patients reported a high degree of satisfaction with MMA in the present study. In agreement with
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previous MMA studies23,24,42,48,58–61, 91% of patients in this study were satisfied with their facial appearance, and 91% of patients would repeat the procedure in the present study, as compared to 95-96% of patients in other studies24,57. Our study reported slightly higher satisfaction with OSA management and willingness to recommend MMA to others for OSA than the respective 91 and 79% reported by Ubaldo and colleagues42. The consistently high levels of satisfaction indicate that MMA is an excellent treatment alternative for patients who are CPAP intolerant.
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Absolute and relative changes in AHI were significantly correlated to parameters of QOL assessed in the present study. An absolute reduction in AHI was linearly associated with reduced frequency of nighttime awakenings to urinate and sleeping pill use. A relative reduction in AHI
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was also associated with reduced sleeping pill use, however only seven patients used sleeping pills preoperatively. Previous research has demonstrated both reductions in AHI and
improvements to QOL following MMA, but has not found a linear relationship between these
outcome variables18,62, except for a weak relationship to the emotional function category of the
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SAQLI in one study17. Flemons et al62 have considered this to be an indication that OSA severity
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indices are insufficient as measures of disease severity. Indeed, Lye and colleagues18 advocate for the use of QOL questionnaires in combination with objective measures of disease severity, to ensure that subjective disease severity is also sufficiently addressed in clinical management of OSA.
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Several limitations were present in this study. The small sample size and unequal gender distribution limited our ability to control for the possible confounding effects of age and gender. Due to the retrospective nature of the present study, it was not possible to obtain a preoperative
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quality of life assessment and so a pre-existing validated questionnaire could not be used. As many patients experience a dramatic reduction in disease severity following MMA, it is possible
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that the results of the present study were subject to recall bias. However, since the purpose of the quality of life assessment was to evaluate patient perceived satisfaction with life following treatment, it is more important that the patient considers their quality of life to have improved than it is to quantify a difference in pre- and post-operative questionnaire scores. Given the welldocumented impairment to QOL resulting from OSA14,16,19–21 and the improvement to QOL with proper management with CPAP17,19,22,25–27, it is likely that the improvement to QOL observed in this study is a true effect resulting from the high efficacy of MMA at reducing disease severity.
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Additionally, the variety of questionnaires used to assess QOL within the literature prevents quantitative comparison of QOL changes between studies and treatment modalities.
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In conclusion, MMA is a highly effective surgical treatment, achieving both objective and subjective improvements to disease severity in patients suffering from OSA without significant adverse side-effects. MMA’s most profound impact was on subjective sleep quality, within the
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assessed categories. While little change to sexual health is perceived postoperatively, MMA improves subjective daytime functioning, physical health, and mental and emotional health.
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Future investigations to validate the OSA-Q and multicenter studies to further assess the subjective impact of MMA on OSA patient quality of life are warranted. This information will enable clinicians to provide their patients with a more accurate prediction of the overall effects of MMA, so patients can make a more informed decision about their preferred treatment modality
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for management of their OSA.
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Table 1. OSA-Q category scores SD
Sig.
Sleep Quality
4.35
0.63
< 0.001
Daytime Function
4.13
0.46
< 0.001
Physical Health
4.19
Mental and Emotional Health
4.02
Sexual Health
3.78
Recovery
3.89
Dental Function
3.50
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Mean
< 0.001
0.55
< 0.001
0.62
< 0.001
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Global OSA-Q Score
0.45
3.98
0.89
< 0.001
0.78
0.001
0.35
< 0.001
OSA-Q, Ottawa Sleep Apnea Questionnaire; SD, standard deviation; Sig., significance;
SD
Sig
4.77
0.43
< 0.001
4.59
0.50
< 0.001
Reduced CPAP use
4.81
0.51
< 0.001
Reduced observed apnea
4.79
0.58
< 0.001
Less night time sweating
4.18
0.73
< 0.001
Reduced frequency of night waking
4.05
0.90
< 0.001
Reduced frequency of waking to urinate
3.86
0.89
< 0.001
Increased ease of getting up
4.18
0.66
< 0.001
Feeling more refreshed in the morning
4.32
0.78
< 0.001
Reduced sleeping pill use
3.43
1.27
0.174
Sleep Quality Improved sleep quality
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Mean
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Table 2. OSA-Q scores for OSA-related questions
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Reduced frequency of snoring
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Daytime Function 4.64
0.49
< 0.001
Improved concentration
3.96
0.98
< 0.001
Better performance at work
4.14
0.71
< 0.001
Greater alertness
4.23
Improved memory
3.82
Less avoidance of activities due to fatigue
3.95
4.41
< 0.001
1.05
0.003
0.90
< 0.001
0.59
< 0.001
4.00
0.76
< 0.001
4.14
0.77
< 0.001
4.23
0.61
< 0.001
3.82
0.59
< 0.001
Reduced ease of getting annoyed or angry
3.91
0.61
< 0.001
Better overall mood
3.95
0.72
< 0.001
3.64
0.73
0.002
Reduced worry over health
4.64
0.66
< 0.001
Reduced stress over sleep arrangements
4.50
0.60
< 0.001
Improved stress management
3.95
0.72
< 0.001
Improved decisiveness
3.77
0.61
< 0.001
Improved relationship with significant other
4.00
0.82
0.002
Improved desire for sexual intimacy
3.56
0.92
0.015
Increased physical activity Improved ease of daytime breathing Better overall health Mental and Emotional Health
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More patience
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Greater energy
0.69
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Physical Health
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Improved ability to stay awake
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Improved interpersonal relationships
Sexual Health
OSA-Q, Ottawa Sleep Apnea Questionnaire; OSA, obstructive sleep apnea; SD, standard deviation; Sig., significance; CPAP, continuous positive airway pressure
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Table 3. OSA-Q scores for MMA-related questions Mean
SD
Sig.
Change in speech quality
3.14
1.08
0.287
Change in swallowing ability
3.59
0.96
0.010
Tolerable postoperative pain
4.09
0.61
< 0.001
No increase in headache frequency
4.09
Absence of VPI symptoms
4.55
Improved chewing function Improved teeth alignment Change in TMJ
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< 0.001
0.91
< 0.001
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Dental function
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Recovery
3.09
0.81
0.312
3.86
0.77
< 0.001
3.55
1.10
0.019
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OSA-Q, Ottawa Sleep Apnea Questionnaire; MMA, maxillomandibular advancement; SD, standard deviation; Sig., significance; VPI, velopharyngeal insufficiency; TMJ, temporomandibular joint
Figure 1. Score responses to the OSA-quality of life component of the OSA-Q, ordered by
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magnitude. Results with green bars signify the most substantial impact of MMA on quality of life
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(scores greater than 4); blue bars indicate less profound changes in QOL (score between 3 and 4).
Figure 2. Summary score responses to the OSA-Q for both the OSA-related and MMA-related QOL criteria, by category. Within-category responses are ordered by magnitude of impact on QOL.
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S0278-2391(16)00135-X
DOI:
10.1016/j.joms.2016.01.043
Reference:
YJOMS 57127
To appear in:
Journal of Oral and Maxillofacial Surgery
Received Date: 24 November 2015 Revised Date:
13 January 2016
Accepted Date: 22 January 2016
Please cite this article as: Butterfield KJ, Marks PLG, McLean L, Newton J, Quality of Life Assessment Following Maxillomandibular Advancement Surgery for Obstructive Sleep Apnea, Journal of Oral and Maxillofacial Surgery (2016), doi: 10.1016/j.joms.2016.01.043. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Quality of Life Assessment Following Maxillomandibular Advancement Surgery for Obstructive Sleep Apnea
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Kevin J. Butterfield, MD, DDS,* Patricia L.G. Marks, BScH† Laurie McLean, MD,§ Jack Newton, DDS|| * Chief, Division of Dentistry/Oral and Maxillofacial Surgery, Ottawa Hospital, and Assistant Professor, Department of Otolaryngology, University of Ottawa School of Medicine, Ottawa, Ontario, Canada † Medical student, University of Toronto, Toronto, Ontario, Canada
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§ Assistant Professor, Department of Otolaryngology, University of Ottawa School of Medicine, Ottawa, Ontario, Canada
Correspondence to Dr. Butterfield
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Mailing address: 239 Argyle Avenue Ottawa, ON, Canada K2P 1B8
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|| Research Assistant, Division of Dentistry/Oral and Maxillofacial Surgery, Ottawa Hospital, Ottawa, Ontario, Canada
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Phone: +1-613-232-4203 Fax: +1-613-238-7822 Email: [email protected]
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ABSTRACT Purpose: While maxillomandibular advancement (MMA) surgery is highly efficacious for management of
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obstructive sleep apnea (OSA), little information exists regarding the subjective impact of this treatment modality. The present study was undertaken to investigate the impact of MMA on
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patient-perceived quality of life (QOL) in OSA.
Methods:
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A retrospective cohort study of patients treated with MMA for OSA between May 2010 and April 2015 was performed. The primary outcome measure was a change to QOL detected by the Ottawa Sleep Apnea Questionnaire (OSA-Q), which assesses MMA-related changes to QOL on a 5-point Likert scale. The secondary outcome measure was a change to the Apnea Hypopnea
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Index (AHI).
Results: Twenty-two patients participated in the present study. Mean maxillary and mandibular advancement were 8.36 and 11.08mm, respectively. AHI decreased from 42.4 to 6.9 events/h (p <
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0.001), postoperatively. QOL improved significantly following MMA (OSA-Q score: 3.98 ± 0.35, p < 0.001). Sleep quality (4.35 ± 0.63), daytime function (4.13 ± 0.46), physical health (4.19
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± 0.45), mental and emotional health (4.02 ± 0.55), and sexual health (3.78 ± 0.62) categories all improved postoperatively (p < 0.001). MMA-related side effects did not adversely affect QOL.
Conclusion: MMA for OSA significantly improves patient’s subjective overall quality of life, with few MMA related side effects.
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INTRODUCTION
Obstructive sleep apnea (OSA) is a serious and prevalent condition with an increasing incidence1– . OSA is associated with autonomic5,6 and metabolic dysfunction4,7–9, in addition to numerous
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cardiovascular and cerebrovascular sequelae4,10–13. As such, effective treatment is critical to
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improving patient health and longevity.
In addition to serious health consequences, patients with OSA experience diminishment to their quality of life (QOL), including reduced sleep quality, excessive daytime somnolence, and
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impaired mental, emotional, and sexual health on QOL assessments1,4,14–21.
Continuous positive airway pressure (CPAP) is the gold standard for management of OSA, and studies have shown CPAP use to result in an attenuation of the disease process and severity11,22–24,
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as well as QOL improvements17,19,22,25–27. Despite this, tolerability and compliance are low28–30, and patients seek alternative treatment options. Maxillomandibular advancement surgery (MMA) is a highly successful23,31–42 surgical alternative to CPAP therapy that achieves objective
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improvements in OSA comparable to CPAP23,24,32,43,44. By advancing the bony insertion sites of the pharyngeal musculature, MMA tautens and reduces the collapsibility of the pharyngeal
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airway23,45–47, resulting in a long-term reduction in objective disease severity. However, the subjective impact of MMA on OSA is poorly understood. Few studies18,48 have used a formalized sleep-related quality of life questionnaire to evaluate the subjective clinical impact of MMA as a treatment modality. The paucity of information on this topic highlights the need for further study, as findings will inform clinicians and allow prospective patients to make a better-informed decision when considering MMA for management of their OSA.
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The purpose of this study was (1) to quantify the subjective change to QOL in patients who have undergone MMA for management of OSA, (2) to assess the impact of the treatment-related side effects of MMA on patient QOL, and (3) to evaluate the relationship between objective changes
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in OSA severity with subjective changes to QOL. We hypothesized that the reduction in OSA disease severity by MMA would improve QOL. While some patients may experience post-
surgical symptoms during their recovery, we predicted that MMA for OSA significantly improves
METHODS
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patients’quality of life.
The Ethics Review Board of the Ottawa Hospital Research Institute approved this study and all
Study design and sample
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patients consented to participate.
This was a retrospective cohort study and postoperative quality of life assessment of patients
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treated with MMA at the same oral & maxillofacial surgery clinic for management of OSA. Consecutive patients who had undergone MMA surgery for OSA between May 2010 and April
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2015 were invited to complete the Ottawa Sleep Apnea Questionnaire (OSA-Q).
Inclusion criteria were: diagnosis of OSA by a sleep medicine physician; pre and post-operative polysomnography; site of obstruction in the oropharynx; clinical and fibreoptic nasopharyngoscopic examination; sufficient health to undergo MMA; Body Mass Index (BMI) less than 40 kg/m2; class I or II dental occlusion; between 18 and 70 years old at the time of surgery; and minimum 4 weeks post-operative upon questionnaire completion. Exclusion criteria
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were: insufficiently healthy to undergo maxillofacial surgery; BMI greater than 40 kg/m2; and class III dental occlusion.
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Surgery All patients were treated by the same oral & maxillofacial surgeon (KJB) with a standard LeFort I osteotomy and bilateral ramus sagittal split osteotomy with rigid internal fixation. Two patients
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underwent a concomitant cosmetic genioplasty that did not include the genial tubercles.
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The Ottawa Sleep Apnea Questionnaire
The Ottawa Sleep Apnea Questionnaire (OSA-Q) was developed using a combination of information from the literature and clinical experience to determine the aspects of life affected in those who suffer from OSA and who undergo MMA for its clinical management.
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The OSA-Q is a combined quality of life and descriptive questionnaire, with 41 QOL questions on a 5-point Likert scale. The first 30 questions relate to key areas affected by OSA: sleep quality, daytime function, physical health, mental and emotional health, and sexual health. Since
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a lower response rate for questions relating to intimacy and sexual health has been reported previously17, these questions were optional so as to encourage more patients to complete the
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questionnaire. The eight remaining Likert-scale questions aim to assess the treatment-related side effects of MMA upon QOL, by considering patient experiences with surgical recovery and dental function. Side effects analyzed include: change in speech quality; change in swallowing ability; postoperative pain level; change in headache frequency; velopharyngeal insufficiency symptoms; chewing function; dental alignment; and any changes in temporomandibular joint function. Descriptive information relating to gender, weight, perceived degree of facial paresthesia, duration of postoperative period, satisfaction with surgery, and impressions with the surgical experience were asked of each patient.
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Questionnaire administration and scoring All postoperative patients who met the inclusion criteria were invited to participate in the study and given one month to complete the questionnaire. Two weeks after initial receipt of the OSA-
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Q, patients who had not returned the completed questionnaire were contacted to reconfirm their interest in the study. Patients who had not completed the questionnaire after one month were
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excluded from the study, as they were considered to have withdrawn their consent to participate.
The Likert scale questions were weighted in the following way: 1 = “strongly disagree,” 2 =
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“disagree,” 3 = “neither agree nor disagree,” 4 = “agree,” and 5 = “strongly agree,” in response to 38 statements about changes to quality of life. Within-category responses were averaged to yield a score out of 5. A score of 3 was considered to be no change to QOL, greater than 3 as an improvement, and less than 3 a reduction to QOL for the OSA-related QOL questions. A score of 3 or greater indicated no negative impact to QOL, and a score less than 3 signified a negative
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impact of MMA on QOL for the treatment-related OSA-Q questions.
Study variables
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The independent variables in the present study included the time of treatment and magnitude of advancement of the maxillomandibular complex. Dependent variables in this study were
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responses to the OSA-Q and the Apnea Hypopnea Index (AHI).
Statistical analysis
Data collection and statistical analysis were performed using Microsoft Excel, version 14.4.7 (Microsoft Corp, Redmond, WA) and the Real Statistics Resource Pack software (Release 3.5.3; Copyright 2013-2015; Charles Zaiontz. www.realstatistics.com) for non-parametric tests. Surgical success was defined as a minimum 50% reduction to AHI and a postoperative AHI less than 20 events/hour. Surgical cure was defined as a postoperative AHI less than 5 events/hour.
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Paired student t-tests were performed to compare pre- and post-operative AHI, ESS and BMI. A one-sample Wilcoxon signed-rank test was performed using a median score of 3 (no change) to evaluate for significant changes to QOL postoperatively. Results were expressed as mean ±
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standard deviation. Sample size is reported for questions without a 100% response rate. The relationship between QOL and AHI was evaluated using Spearman rank correlations. A p-value
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less than 0.05 was considered to be statistically significant for all measures.
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RESULTS
Twenty-two patients (19 male, 3 female) met the inclusion criteria and consented to participate in this study (100% completion). Participants were 45.9 ± 11.6 years old at the time of questionnaire completion. Two patients had previously undergone uvulopalatopharyngoplasty, and one patient
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had undergone a laser-assisted uvulopalatoplasty. Maxillary and mandibular advancement were 8.36 ± 2.38mm and 11.08 ± 2.45mm, respectively. Pre- and post-operative BMI were 29.63 ± 3.87 and 28.98 ± 3.77 kg/m2 (p = 0.18), respectively. AHI decreased from 42.4 ± 26.7 to 6.9 ±
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6.22 (p<0.001) events/hour, and ESS decreased from 12.67 ± 5.01 to 6.00 ± 3.20 (p<0.001), following MMA. The surgical success and cure rates were 81.8% and 50.0%, respectively. The
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improvement to time spent in rapid eye movement sleep (REM) was also significant (11.58 ± 6.22% to 16.78 ± 7.15%, p = 0.030). While 86% of patients reported that they were still subjectively experiencing some degree of facial paresthesia, 50% had at least a 75% restoration of sensation.
The OSA-Q was completed between 2 and 61 months postoperatively. Category scores are summarized in Table 1. Overall, patients reported an improvement in quality of life postoperatively (global OSA-Q score: 3.98 ± 0.35; p < 0.001), and the results of each assessed
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OSA-related QOL criteria are ranked and presented in Figure 1. The category scores for OSArelated QOL were: sleep quality: 4.35 ± 0.63; daytime function: 4.13 ± 0.46; physical health: 4.19 ± 0.45; mental and emotional health: 4.02 ± 0.55; and sexual health: 3.78 ± 0.62 (p < 0.001 for
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all). OSA- related QOL question response scores are presented, ranked within each category, in Table 2 and Figure 2.
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Significant improvement to quality of life occurred in the following parameters of the sleep
quality category: patient-perceived sleep quality (4.77 ± 0.43, p < 0.001); and reduction in the
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frequency of snoring (4.59 ± 0.50, p < 0.001), CPAP use (4.81 ± 0.51, p < 0.001; n = 21), and apneas witnessed by a bed partner (4.79 ± 0.58, p < 0.001; n = 14). Patients reported less nighttime sweating (4.18 ± 0.73, p < 0.001) and waking (4.05 ± 0.90, p < 0.001); reduced frequency of waking to urinate (3.86 ± 0.89, p < 0.001); and an increased ease of rising and feeling refreshed in the morning (4.18 ± 0.66 and 4.32 ± 0.78, respectively; p < 0.001). Of the
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patients who used sleeping pills prior to MMA (n = 7), three reported a reduction in their frequency of postoperative use (score: 3.43 ± 1.27, p = 0.174).
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Subjective daytime functioning was significantly greater postoperatively. Patients reported an improved ability to stay awake (4.64 ± 0.49, p < 0.001), concentrate (4.00 ± 0.98, p < 0.001),
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perform at work (4.14 ± 0.71, p < 0.001), and remain alert (4.23 ± 0.69, p < 0.001). Memory also improved postoperatively (3.82 ± 1.05, p = 0.003), and patients were less likely to avoid activities due to fatigue than they were prior to undergoing MMA (3.95 ± 0.90, p < 0.001).
Patient perception of physical health was positively impacted by MMA. Patients reported having more energy (4.41 ± 0.59, p < 0.001) and greater levels of physical activity (4.00 ± 0.76, p < 0.001). An improved ability to breathe (4.14 ± 0.77, p < 0.001), and a sense of better overall health (4.23 ± 0.61, p < 0.001) also occurred postoperatively.
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Mental and emotional health also improved significantly following surgical intervention. Patients felt that they had more patience (3.82 ± 0.59, p < 0.001), were less likely to become angered or
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annoyed (3.91 ± 0.61, p < 0.001), and had a better overall mood (3.95 ± 0.72, p < 0.001). Interpersonal relationships also improved postoperatively (3.64 ± 0.73, p = 0.002). Patients were less anxious about the consequences of MMA on their long-term health (4.64 ± 0.66, p < 0.001)
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and about making sleeping arrangements away from home (4.50 ± 0.60, p < 0.001). Patients were also better able to manage stress (3.95 ± 0.72, p < 0.001) and make decisions (3.77 ± 0.61, p <
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0.001).
Of the patients who completed the sexual health component of the OSA-Q, most patients’ relationships with their significant other improved postoperatively (OSA-Q score: 4.00 ± 0.82, p = 0.002; n = 16). However ,only 37% of patients perceived an improvement in their desire for
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sexual intimacy (3.56 ± 0.92, p = 0.015; n = 18).
The category scores for the recovery and dental function categories were 3.89 ± 0.89 (p < 0.001)
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and 3.50 ± 0.78 (p = 0.001), respectively (Table 1). Individual MMA-related side-effects question responses are presented, ranked within each category in Table 3 and Figure 2. Patients did not
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find a significant change to their speech quality postoperatively (3.14 ± 1.08, p = 0.287), while the change in swallowing ability was significant (3.59 ± 0.96, p = 0.010). Postoperative pain was tolerable (4.09 ± 0.61, p < 0.001) and unaccompanied by an increased frequency of headaches (4.09 ± 0.68, p < 0.001) or symptoms of velopharyngeal insufficiency (VPI; 4.55 ± 0.91, p < 0.001). Patients did not experience a significant improvement to chewing ability (3.09 ± 0.81, p = 0.312), while they did feel their teeth alignment was improved (3.86 ± 0.77, p < 0.001). Change to temporomandibular joint function (TMJ) was also experienced postoperatively (3.55 ± 1.10, p = 0.019).
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Almost all patients were satisfied with the management of their OSA by MMA (95.5%). Most patients considered their postoperative facial appearance to be acceptable (90.9%), would repeat
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the procedure (90.9%), and recommend MMA to others for OSA management (86.4%).
The magnitude of change in AHI was significantly correlated to a reduction in the frequency of
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nocturnal awakenings to urinate (rs = -0.51, p = 0.014) and sleeping pill use (rs = -0.59, p = 0.004; n = 7), however only eight patients used sleeping pills at baseline. The relative change in AHI
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(%) was also significantly correlated to sleeping pill use (rs = -0.59, p = 0.004; n = 7). The correlations between absolute change in AHI and subjective improvement in daytime breathing (rs = -0.38, p = 0.081), stress management (rs = -0.38, p = 0.083), and decisiveness (-0.38, p =
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0.077) approached significance.
DISCUSSION
The purpose of this study was to: (1) quantify the subjective change to QOL in patients who have
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undergone MMA for management of OSA; (2) assess the impact of the treatment-related side effects of MMA on patient QOL; and (3) evaluate the relationship between objective changes in
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OSA severity with subjective changes to QOL. We hypothesized that the reduction in OSA disease severity by MMA would improve QOL. While some patients may experience postsurgical symptoms during their recovery, we predicted that MMA for OSA significantly improves patients’quality of life.
Maxillomandibular advancement surgery is a well-established surgical treatment for OSA. MMA has long-term stability and a high rate of surgical success for OSA management23,31–42,48. This surgery is an appropriate alternative treatment for patients who are unable to tolerate CPAP, as it
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achieves similar objective improvements to disease severity23,24,32,43,44. Despite this, CPAP has been the focus of the majority of QOL assessments in the treatment of OSA49. While CPAP has a demonstrated efficacy for improving QOL, understanding the patient-perceived impact of MMA
for study of the subjective impact of MMA upon OSA patients.
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upon their QOL is equally important. The paucity of information on this topic highlights the need
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The present study investigated the changes in patient perception of QOL following MMA for the surgical management of OSA. We hypothesized that despite the possible treatment-related side
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effects of undergoing corrective jaw surgery; overall quality of life would improve following MMA as disease severity decreases. In addition, we predicted that changes to quality of life would be correlated to changes in AHI.
While numerous quality of life questionnaires are used in OSA15,50–52, both pre- and post-
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operative assessments are necessary to evaluate the change in QOL. The Calgary Sleep Apnea Quality of Life Index (SAQLI)15considers not only the change to health-related QOL, but also accounts for the possible negative side effects of treatment on QOL. While this approach makes
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the SAQLI a more accurate assessment of the overall change in QOL15, this questionnaire also requires pre- and post-intervention assessments. The Ottawa Sleep Apnea Questionnaire (OSA-
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Q) was therefore developed to fill a void, namely to enable retrospective study of QOL and also account for the treatment-related impact of MMA on QOL.
The present study found significant improvements to QOL in patients who underwent MMA for management of OSA, in agreement with previous MMA studies that used the Functional Outcomes of Sleep Questionnaire (FOSQ) and the SAQLI18,48. Sleep quality was the OSA-related QOL category with the most profound postoperative change, followed by physical health, daytime function, mental and emotional health, and sexual health. Improvement to these
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subjective measures of QOL was accompanied by a significant objective reduction in AHI and disease severity. Recovery from surgery and postoperative dental function were acceptable to
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patients; MMA side effects were not considered to have adversely affected QOL.
The greatest improvements to the sleep quality category of the OSA-Q occurred in patient-
perceived quality of sleep, and reduction in snoring, observed apneas, and CPAP use on the OSAQ. Other MMA studies have similarly reported a subjective improvement to sleep quality18 and
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reduction in snoring23 and CPAP use42 postoperatively. By comparison, CPAP improves the
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symptoms component of the SAQLI17,25, which also contains questions about sleep quality. Similarly, CPAP use has improved the sleep and rest component of the Functional Limitations Profile (FLP)21 and the nocturnal symptoms component of the Quebec Sleep Questionnaire (QSQ)53. CPAP also reduced snoring, nocturnal awakenings and breathing cessations in a study
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that did not use a formally validated questionnaire54.
Subjective daytime functioning also improved following MMA, with the greatest improvements occurring in daytime sleepiness, alertness, concentration, and performance at work. The general
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productivity component of the FOSQ similarly assesses memory, concentration and work performance50; the daily functioning component of the SAQLI subjectively assesses memory,
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concentration, and daytime sleepiness15; and the diurnal symptoms section of the QSQ accounts for daytime sleepiness, memory, and concentration51. In agreement with the findings of the present study, previous MMA studies have found improvement in daytime sleepiness, memory, and concentration23, and improved general productivity on the FOSQ18. By comparison, CPAP use increases performance at work and alertness21, and improves the daily functioning component of the SAQLI17,19,25 and the diurnal symptoms component of the QSQ53. However, these improvements have not been found consistently with CPAP studies using the FOSQ17,55.
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Patient-perceived physical health improved significantly postoperatively, especially improvements to energy, sense of overall health, and ease of daytime breathing. While the FOSQ has little content overlap with the physical health subscale of the OSA-Q, a significant
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improvement to activity was detected by the FOSQ following MMA for OSA management18. By comparison, the SAQLI and the 36-Item Short-Form Health Survey (SF-36) both consider the subjective impact of OSA on energy and physical well-being. Both the symptoms and daily
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functioning domains of the SAQLI improved upon treatment with CPAP17,19,25, which may
suggest agreement between the efficacy of MMA and CPAP at improving subjective physical health. By contrast, improvements assessed by the SF-36 have not been consistently reported with
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CPAP use17,25,26,54,56.
Mental and emotional health improved significantly postoperatively, most notably as a reduced worry over the long-term health consequences of OSA, and stress over sleeping arrangements
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away from home. Lesser improvements in: mood; stress management; patience and frequency of getting angered or annoyed; decisiveness; and interpersonal relationships also occurred postoperatively. Prinsell et al.23 similarly reported that patients had improved temperament
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following MMA. In comparison to the OSA-Q, the mental health component of the SF-36 also assesses moodiness. One study that grouped CPAP and upper airway surgery found significant
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improvement to this domain of the SF-3656 following treatment; however, this improvement has not been consistently found in other CPAP studies using the SF-3621,25,26,54. Studies that have used the FOSQ, FLQ, SAQLI and QSQ to assess QOL changes with CPAP have demonstrated improvement in similar subscales17,21,25,53, while one study in patients with severe OSA but without daytime symptoms failed to demonstrate this improvement55.
The present study found statistically significant improvement in sexual health following MMA, albeit the improvement was less profound than the changes to the other components of QOL
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assessed. Both patients’ relationships with their significant other and desire for sexual intimacy had small improvements postoperatively. This is in agreement with the findings of Lye and colleagues18, who demonstrated an improvement to the sexual intimacy component of the FOSQ
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following MMA. Billings et al.17 similarly reported improvement in the sexual intimacy with CPAP use, while other CPAP studies26,55 have failed to detect such a change on the FOSQ.
Inconsistency between our findings and those of CPAP studies may indicate a superiority of
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MMA over CPAP to improve this aspect of patient QOL, but it is more likely the result of
differences in the questionnaires used to evaluate this aspect of QOL, as well as participant
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response rate17, gender distribution, or subjects’ relationship status between studies.
In addition to the positive OSA-related QOL changes following MMA, patients did not find that surgical recovery deleteriously affected their QOL. Patients did not experience an appreciable change to their speech quality, consistent with a previous finding in OSA patients who underwent
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MMA following UPPP47. While VPI posed a concern for almost 10% of patients who underwent MMA after UPPP in the same study47, none of the patients who had undergone either UPPP or LAUP in the present study experienced symptoms of VPI. Postoperative pain was well-tolerated
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by all patients in the present study, and unaccompanied by an increase in headaches or dysphagia, in contrast to the 12% occurrence of difficulty swallowing previously reported57. Interestingly, Li
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and colleagues57 found that postoperative pain did not differ between UPPP and MMA.
Facial paresthesia was subjectively present in the majority of the study population. However, patients have not previously found paresthesia to negatively impact the improvement to diseaserelated QOL that occurs with MMA23,24. Boyd et al. found in their study of OSA patients undergoing MMA that objective sensation was present for all patients, yet 40% of patients subjectively perceived a decrease in sensation48. Notwithstanding the subjective presence of
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decreased sensation in the present study, high levels of satisfaction with surgery were still reported; this is in agreement with findings in healthy subjects undergoing MMA58.
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The MMA-related impact upon dental function did not adversely affect QOL, and also resulted in an improvement in teeth alignment. Changes to chewing function were not significant, and only three patients experienced altered TMJ function. By comparison, postoperative malocclusion has
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been found in other OSA patients following MMA24, while TMJ59 and chewing function58,60 were
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not found to be altered following MMA for patients with and without OSA, respectively.
The side-effects of MMA in the present study did not compromise the improvements to QOL achieved by undergoing treatment. In agreement with this finding, Boyd and colleagues demonstrated that MMA did not have a significant negative impact on QOL using the SAQLI48. In contrast, there are conflicting reports as to whether the treatment-related side-effects of CPAP
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use negatively impact QOL22,25. Although preliminary findings suggest that the treatment-related side-effects are greater for CPAP than MMA, further study is necessary to definitely draw a
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conclusion.
Patients reported a high degree of satisfaction with MMA in the present study. In agreement with
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previous MMA studies23,24,42,48,58–61, 91% of patients in this study were satisfied with their facial appearance, and 91% of patients would repeat the procedure in the present study, as compared to 95-96% of patients in other studies24,57. Our study reported slightly higher satisfaction with OSA management and willingness to recommend MMA to others for OSA than the respective 91 and 79% reported by Ubaldo and colleagues42. The consistently high levels of satisfaction indicate that MMA is an excellent treatment alternative for patients who are CPAP intolerant.
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Absolute and relative changes in AHI were significantly correlated to parameters of QOL assessed in the present study. An absolute reduction in AHI was linearly associated with reduced frequency of nighttime awakenings to urinate and sleeping pill use. A relative reduction in AHI
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was also associated with reduced sleeping pill use, however only seven patients used sleeping pills preoperatively. Previous research has demonstrated both reductions in AHI and
improvements to QOL following MMA, but has not found a linear relationship between these
outcome variables18,62, except for a weak relationship to the emotional function category of the
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SAQLI in one study17. Flemons et al62 have considered this to be an indication that OSA severity
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indices are insufficient as measures of disease severity. Indeed, Lye and colleagues18 advocate for the use of QOL questionnaires in combination with objective measures of disease severity, to ensure that subjective disease severity is also sufficiently addressed in clinical management of OSA.
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Several limitations were present in this study. The small sample size and unequal gender distribution limited our ability to control for the possible confounding effects of age and gender. Due to the retrospective nature of the present study, it was not possible to obtain a preoperative
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quality of life assessment and so a pre-existing validated questionnaire could not be used. As many patients experience a dramatic reduction in disease severity following MMA, it is possible
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that the results of the present study were subject to recall bias. However, since the purpose of the quality of life assessment was to evaluate patient perceived satisfaction with life following treatment, it is more important that the patient considers their quality of life to have improved than it is to quantify a difference in pre- and post-operative questionnaire scores. Given the welldocumented impairment to QOL resulting from OSA14,16,19–21 and the improvement to QOL with proper management with CPAP17,19,22,25–27, it is likely that the improvement to QOL observed in this study is a true effect resulting from the high efficacy of MMA at reducing disease severity.
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Additionally, the variety of questionnaires used to assess QOL within the literature prevents quantitative comparison of QOL changes between studies and treatment modalities.
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In conclusion, MMA is a highly effective surgical treatment, achieving both objective and subjective improvements to disease severity in patients suffering from OSA without significant adverse side-effects. MMA’s most profound impact was on subjective sleep quality, within the
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assessed categories. While little change to sexual health is perceived postoperatively, MMA improves subjective daytime functioning, physical health, and mental and emotional health.
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Future investigations to validate the OSA-Q and multicenter studies to further assess the subjective impact of MMA on OSA patient quality of life are warranted. This information will enable clinicians to provide their patients with a more accurate prediction of the overall effects of MMA, so patients can make a more informed decision about their preferred treatment modality
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for management of their OSA.
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Table 1. OSA-Q category scores SD
Sig.
Sleep Quality
4.35
0.63
< 0.001
Daytime Function
4.13
0.46
< 0.001
Physical Health
4.19
Mental and Emotional Health
4.02
Sexual Health
3.78
Recovery
3.89
Dental Function
3.50
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Mean
< 0.001
0.55
< 0.001
0.62
< 0.001
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Global OSA-Q Score
0.45
3.98
0.89
< 0.001
0.78
0.001
0.35
< 0.001
OSA-Q, Ottawa Sleep Apnea Questionnaire; SD, standard deviation; Sig., significance;
SD
Sig
4.77
0.43
< 0.001
4.59
0.50
< 0.001
Reduced CPAP use
4.81
0.51
< 0.001
Reduced observed apnea
4.79
0.58
< 0.001
Less night time sweating
4.18
0.73
< 0.001
Reduced frequency of night waking
4.05
0.90
< 0.001
Reduced frequency of waking to urinate
3.86
0.89
< 0.001
Increased ease of getting up
4.18
0.66
< 0.001
Feeling more refreshed in the morning
4.32
0.78
< 0.001
Reduced sleeping pill use
3.43
1.27
0.174
Sleep Quality Improved sleep quality
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Mean
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Table 2. OSA-Q scores for OSA-related questions
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Reduced frequency of snoring
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Daytime Function 4.64
0.49
< 0.001
Improved concentration
3.96
0.98
< 0.001
Better performance at work
4.14
0.71
< 0.001
Greater alertness
4.23
Improved memory
3.82
Less avoidance of activities due to fatigue
3.95
4.41
< 0.001
1.05
0.003
0.90
< 0.001
0.59
< 0.001
4.00
0.76
< 0.001
4.14
0.77
< 0.001
4.23
0.61
< 0.001
3.82
0.59
< 0.001
Reduced ease of getting annoyed or angry
3.91
0.61
< 0.001
Better overall mood
3.95
0.72
< 0.001
3.64
0.73
0.002
Reduced worry over health
4.64
0.66
< 0.001
Reduced stress over sleep arrangements
4.50
0.60
< 0.001
Improved stress management
3.95
0.72
< 0.001
Improved decisiveness
3.77
0.61
< 0.001
Improved relationship with significant other
4.00
0.82
0.002
Improved desire for sexual intimacy
3.56
0.92
0.015
Increased physical activity Improved ease of daytime breathing Better overall health Mental and Emotional Health
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More patience
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Greater energy
0.69
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Physical Health
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Improved ability to stay awake
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Improved interpersonal relationships
Sexual Health
OSA-Q, Ottawa Sleep Apnea Questionnaire; OSA, obstructive sleep apnea; SD, standard deviation; Sig., significance; CPAP, continuous positive airway pressure
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Table 3. OSA-Q scores for MMA-related questions Mean
SD
Sig.
Change in speech quality
3.14
1.08
0.287
Change in swallowing ability
3.59
0.96
0.010
Tolerable postoperative pain
4.09
0.61
< 0.001
No increase in headache frequency
4.09
Absence of VPI symptoms
4.55
Improved chewing function Improved teeth alignment Change in TMJ
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< 0.001
0.91
< 0.001
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Dental function
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Recovery
3.09
0.81
0.312
3.86
0.77
< 0.001
3.55
1.10
0.019
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OSA-Q, Ottawa Sleep Apnea Questionnaire; MMA, maxillomandibular advancement; SD, standard deviation; Sig., significance; VPI, velopharyngeal insufficiency; TMJ, temporomandibular joint
Figure 1. Score responses to the OSA-quality of life component of the OSA-Q, ordered by
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magnitude. Results with green bars signify the most substantial impact of MMA on quality of life
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(scores greater than 4); blue bars indicate less profound changes in QOL (score between 3 and 4).
Figure 2. Summary score responses to the OSA-Q for both the OSA-related and MMA-related QOL criteria, by category. Within-category responses are ordered by magnitude of impact on QOL.
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