The Emergence of Central Sleep Apnea after Maxillo-Mandibular Advancement Surgery for Obstructive Sleep Apnea

The Emergence of Central Sleep Apnea after Maxillo-Mandibular Advancement Surgery for Obstructive Sleep Apnea

Investigators: Dr. Matthew Fay, Dr.Reginald Goodday 

The emergence of central sleep apnea (CSA) can occur after treatment for obstructive sleep apnea (OSA). Several terms have been proposed for this phenomenon including complex central sleep apnea syndrome (CompSAS) and treatment emergent central sleep apnea. CompSAS is defined as the persistence or emergence of central apnea events discovered after stabilization of upper airway obstruction. Although several definitions have been proposed, one common criterion for the diagnosis of CompSAS is a Central Apnea Index (CAI) of 5 or greater after undergoing treatment for OSA.  The prevalence of this condition is between 3% and 20% with the application of continuous positive airway pressure (CPAP). The literature on this topic relates mainly to the treatment of OSA with CPAP, with only a few documented case reports of this condition after PAP (positive airway pressure)-independent OSA treatment such as maxillo-mandibular advancement (MMA), mandibular repositioning devices and tracheostomy.  As MMA is an appropriate treatment alternative for patients who cannot tolerate CPAP, clinicians should be aware of this potential sequelae. The purpose of this study is to determine the incidence of central sleep apnea emerging after maxillo-mandibular advancement surgery to treat OSA.

Between 1996 and 2015, two-hundred and sixty-nine patients were treated for OSA at the Atlantic Centre for Oral and Maxillofacial Surgery in Halifax, Nova Scotia, Canada. A retrospective study was carried out on all patients who obtained polysomnograms taken before and at least 6 months after surgery. One-hundred and thirteen patients met this criterion. The rates of pre and post-operative central sleep apnea were assessed.

Thirty nine patients (34.5%) had no central events before or after treatment with MMA. Forty patients (35.4%) recorded central apnea events prior to treatment. Of these patients, thirty-nine recorded a decrease in the total number of central events following MMA surgery. One patient had a pre-operative CAI of 0.2 and recorded a post-operative CAI of 11.2. Thirty four patients (30.1%) recorded no pre-operative central events (CAI of 0) but had central events after surgery (CAI ranging from 0.2-8.1). Thirty-five patients (31.0%) recorded the emergence of central events on post-operative polysomnograms. Only two patients (1.8%), however, had the emergence of clinically significant post-operative central sleep apnea (CAI >5) and would qualify under currently accepted definitions of CompSAS. Both of these patients had low pre-operative central sleep apnea indices (CAI of 0 and 0.2) and recorded significant central sleep apnea post-operatively (CAI of 8.1 and 11.2 respectively).

The incidence of central sleep apnea after maxillo-mandibular advancement surgery is not as well studied as the emergence of central apnea after treatment for OSA with CPAP. Our findings show a number of patients (31.0%) had emergent central sleep apnea, however the majority fall below the threshold for clinical significance (CAI<5). Of the patients in our study, only two (1.8%) had a clinically significant number of central events (CAI >5) after treatment. This rate is less than those reported for patients treated for OSA with CPAP (3-20%). These findings help to support maxillo-mandibular advancement surgery for OSA as a reasonable alternative for patients who are unable to tolerate CPAP.

References:

1. Central Sleep Apnea. The complex sleep apnea syndrome (CompSAS). Selim, B. et al. Sleep Medicine Clinics 2014;9.1:37-47.
2. Complex Sleep Apnea. Castriotta, R. and Majid, R. Sleep Medicine Clinics 2013; 8.4: 463-475.