Evaluation of multiple surgeries as therapeutic options for Obstructive Sleep Apnea Syndrome

Some are the risk factors related to OSAS, such as: male gender, 40 years of age or over and, in particular, obesity [1,4,5]. These would be involved in the multi-factorial etiology related to a functional and structural reduction of the caliber of the upper airways (UA). Diagnosis is made through clinical history, by physical otolaryngologic examination, combined with fi beroptic nasopharyngolaryngoscopy (NPL) and polysomnography (PSG). PSG is the only objective way to diagnose and quantify the severity of OSAS, its performance being essential not only for diagnostic, but also as an aid in the control of improvement and cure after therapeutic measures have been taken.


Introduction
Obstructive Sleep Apnea Syndrome (OSAS) consists of a chronic disturbance, characterized by repeated episodes of collapse of the upper airways that lead to fragmented sleep.
It is directly related to arterial hypertension, cardiovascular diseases, excessive daytime sleepiness, and a decrease in the quality of life [1][2][3].
The pathogenesis of OSAS and its physiopathology are complex, and its primary aggression mechanism would depend on repetitive episodes of hypoxia during apnea events followed by Reoxygenation, causing infl ammatory changes and atherosclerosis2.
Some are the risk factors related to OSAS, such as: male gender, 40 years of age or over and, in particular, obesity [1,4,5]. These would be involved in the multi-factorial etiology related to a functional and structural reduction of the caliber of the upper airways (UA). Diagnosis is made through clinical history, by physical otolaryngologic examination, combined with fi beroptic nasopharyngolaryngoscopy (NPL) and polysomnography (PSG). PSG is the only objective way to diagnose and quantify the severity of OSAS, its performance being essential not only for diagnostic, but also as an aid in the control of improvement and cure after therapeutic measures have been taken.
A variety of conservative therapeutic strategies and surgeries are available to manage OSAS and have been intensely studied over the last two decades. Many patients respond well to weight loss, behavioral measures, oral motor speech therapy, the use of intraoral devices, and to Continuous Positive Airway Pressure (CPAP). However, conservative treatment of OSAS requires willpower, long-term follow up, and com pliance with proposed techniques, for which reason, it is oftentimes not therapeutically successful. CPAP, despite being a treatment with well-established effi cacy, has a long-term compliance below 50% (using CPAP on average 4 hours nightly during 70% of nights) [6,7].
There are many surgical procedures to treat OSAS.
The low success rate of approximately 40% of individual Uvulopalatopharyngoplasty in non-selected patients with mild to severe OSAS spread the idea that combinations of surgical procedures would be the best option treatment [8]. The precise identifi cation of the anatomic location of the collapsed UA is essential for the planning of adequate surgical interventions, which in most cases are multiple. Therefore, there is a need for different levels of surgery in order to achieve therapeutic success. The object of this study is to objectively determine the effi ciency of multiple surgeries in the treatment of moderate to severe OSAS.  [9], Apnea was defi ned as absence of respiratory air fl ow with breathing effort at least 10 seconds, while hypopnea was defi ned as a decrease in the respiratory airfl ow greater than 50%, accompanied by oxygen desaturation greater than 3% and awakening. After

Results
Of the 50 studied patients, 4 were female and 46 male.    difference of AHI pre and postoperative obtained 28,08 ±30,82, The combinations of the procedures were diversifi ed ( Table   2) and promoted AHI reduction.
Criteria for surgical success was defi ned as an AHI reduction greater than 50%, with an apnea index less than 208, therefore 33 patients (66%) were successful, while 17 (34%) cases failed.
When considering an AHI < 5 events/hour, attempting to defi ne a cure for OSAS, 15 (30%) patients presented with this value at the post-operative polysomnography. In performing linear regression and ROC curve, we evaluated the chance of an AHI reduction after performing each type surgery. Therefore, we evaluated the best sensitivity and specifi city point of each surgery performed. We observed that those submitted to craniofacial surgery upon analysis of sensitivity had 85, 7% chance of reducing chances preoperative AHI by 38,4 events/hour, and upon analysis of specifi city, 69,8% chance of not presenting such a reduction (AUC 0,791).
Those submitted to hypo pharynx surgery, upon analysis of sensibility, have a 72% chance of reducing preoperative AHI by 17, 42 events/hour, and upon analysis of specifi city, 43% chance of not presenting such a reduction (AUC 0,681). Those submitted to palatal surgery have an 81,3% chance of reducing preoperative AHI by 12,31 events/hour, when evaluating sensitivity, and 50% chance of not presenting such a reduction when evaluating specifi city (AUC 0,542). Nasal surgery, under the sensitivity analysis perspective, has a 62,2% chance of  GGA, but also those submitted to MMA, showed therapeutic success according to analysis of pre-and post-operative AHI in 78% and 93% of the cases, respectively [13]. Neruntarat described response to GGA combined with hyoid myotomy in 70% of the patients, with long-term success [14]. In addition, he states that performing single UPFP does not lead to absolute success, since the obstruction of the UA many times occurs in multiple sites, therefore all of these sites must be addressed [15]. Li  individually. Nevertheless, the main objective of this study is to determine the effi ciency of multiple surgeries for treating OSAS, with no restriction to any particular approach. Even so, we observed important data when we selectively analyzed procedures at different levels, but as already reported due to the short n we can't use the isolated value of the effi cacy from each procedure.