568284

ryngology–Head and Neck SurgeryCamacho et al

2015© The Author(s) 2010

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OTOXXX10.1177/0194599814568284Otola

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Systematic Review
Otolaryngology–

Maxillomandibular Advancement and Head and Neck Surgery

2015, V  ol. 152(4) 619­–630
© American Academy of
Tracheostomy for Morbidly Obese Obstructive Otolaryngology—Head and Neck
Surgery Foundation 2015

Sleep Apnea:  A Systematic Review and

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DOI: 10.1177/0194599814568284

Meta-analysis http://otojournal.org

Macario Camacho, MD1, Jeffrey Teixeira, MD2, Jose Abdullatif, MD3,

Jason L. Acevedo, MD4,Victor Certal, MD5,6, Robson Capasso, MD7,
and Nelson B. Powell, MD, DDS8

Sponsorships or competing interests that may be relevant to content are Keywords

disclosed at the end of this article.
obstructive sleep apnea, sleep apnea syndromes, tracheos-
tomy, maxillomandibular advancement, morbid obesity
Received June 11, 2014; revised December 2, 2014; accepted December
Abstract 23, 2014.

Objective. The objective of this study is to systematically review

polysomnography data and sleepiness in morbidly obese (body
mass index [BMI] ≥40 kg/m2) patients with obstructive sleep
apnea (OSA) treated with either a maxillomandibular advance-
ment (MMA) or a tracheostomy and to evaluate the outcomes.
Data Sources. MEDLINE, Scopus, Web of Science, and the
Cochrane Library.
Review Methods. A search was performed from inception
through April 8, 2014, in each database.
Results. Six maxillomandibular advancement studies (34
patients, age 42.42 ± 9.13 years, mean BMI 44.88 ± 4.28 kg/
m2) and 6 tracheostomy studies (14 patients, age 52.21 ±
10.40 years, mean BMI 47.93 ± 7.55 kg/m2) reported individual
patient data. The pre- and post-MMA means ± SDs for apnea-
hypopnea indices were 86.18 ± 33.25/h and 9.16 ± 7.89/h
(P < .00001), and lowest oxygen saturations were 66.58% ±
16.41% and 87.03% ± 5.90% (P < .00001), respectively. Sleepi-
ness following MMA decreased in all 5 patients for whom it was
reported. The pre- and posttracheostomy mean ± SD values
for apnea indices were 64.43 ± 41.35/h and 1.73 ± 2.68/h (P =
.0086), oxygen desaturation indices were 69.20 ± 26.10/h and
41.38 ± 36.28/h (P = .22), and lowest oxygen saturations were
55.17% ± 16.46% and 79.83% ± 4.36% (P = .011), respectively.
Two studies reported outcomes for Epworth Sleepiness Scale
for 5 patients, with mean ± SD values of 18.80 ± 4.02 before
tracheostomy and 2.80 ± 2.77 after tracheostomy (P = .0034).
Conclusion. Data for MMA and tracheostomy as treatment for
morbidly obese, adult OSA patients are significantly limited.
We caution surgeons about drawing definitive conclusions
from these limited studies; higher level studies are needed.
Introduction
Obstructive sleep apnea (OSA) is widely recognized as a
sleep disorder resulting from repetitive pharyngeal obstruc-
tion that causes hypercapnia and hypoxemia as a result of
increased airflow resistance.1-3 Continuous positive airway
pressure (CPAP) devices have been shown to decrease overall
mortality, improve daytime sleepiness, and reduce heart fail-
ure, stroke, and hospitalization time, and they are usually
1
Sleep Medicine Division, Stanford Hospital and Clinics, Redwood City,
California, USA
2
US Army, Department of Otolaryngology–Head and Neck Surgery, Walter
Reed National Military Medical Center, Bethesda, Maryland, USA
3
Department of Otorhinolaryngology, Hospital Bernardino Rivadavia,
Buenos Aires, Argentina
4
US Army, Department of Otolaryngology–Head and Neck Surgery,
Reynolds Army Community Hospital, Fort Sill, Oklahoma, USA
5
Department of Otorhinolaryngology/Sleep Medicine Centre–Hospital CUF,
Porto, Portugal
6
CINTESIS–Centre for Research in Health Technologies and Information
Systems, University of Porto, Porto, Portugal
7
Department of Otolaryngology–Head and Neck Surgery, Sleep Surgery
Division, Stanford University Medical Center, Stanford, California, USA
8
Department of Otolaryngology–Head and Neck Surgery, Sleep Surgery
Division, Stanford Hospital and Clinics, Stanford, California, USA
The views herein are the private views of the authors and do not reflect the
official views of the Department of the Army or the Department of Defense.
Corresponding Author:
Macario Camacho, MD, Major, MC, US Army, Sleep Medicine Division,
Stanford Hospital and Clinics, 2nd floor, 450 Broadway St, Redwood City,
CA 94063, USA.
Email: drcamachoent@yahoo.com

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620 Otolaryngology–Head and Neck Surgery 152(4)
proposed in the clinical setting as first-line therapy due to
high efficacy and a minimally invasive profile.4-6 However,
compliance is low, as demonstrated by studies reporting that
46% to 83% of patients are nonadherent when criteria of 4
hours per night of CPAP use for 70% of the nights are
applied.7 While obesity is a risk factor for OSA, and there is
very little controversy in the scientific community on this
causal association, the exact role of weight loss surgery on
prevention or treatment of OSA remains a controversial topic.
Obesity alters upper airway anatomy by the deposition of fat
into the tongue and the pharynx, which increases airflow
resistance and predisposes patients to OSA.8,9
Several upper airway surgeries are used to treat OSA, includ-
ing soft tissue surgery, hypoglossal nerve stimulator, maxillo-
mandibular advancement (MMA), and tracheostomy.1 Many
sleep surgeons have been reluctant to perform upper airway
surgeries in morbidly obese patients, and these patients are
often recommended to undergo either a tracheostomy or bariat-
ric surgery.10 Because morbidly obese patients are more likely
to have unusually narrow airways secondary to pharyngeal and
tongue fatty deposition,8 they often have grade 4 Friedman pal-
ate positions. However, even in the presence of a more normal
appearing airway, having a body mass index (BMI) ≥40 kg/m2
places a patient in stage IV of the Modified Friedman Staging
System, which is the category for patients considered not to be
good candidates for tonsillectomy, uvulopalatopharyngoplasty,
or tongue base reduction.10 Some case reports and case series
studies describing upper airway surgeries for OSA have reported
that the surgeries are not as successful in morbidly obese
patients, while other studies have noted a moderate to higher
level of effectiveness. Because soft tissue surgeries have not
been considered to be as successful in morbidly obese patients,
other options have been explored, including MMA11 with and
without genioglossus advancement (ie, sliding genioplasty,
geniotubercle advancement) and tracheostomies.12,13
In MMA, tension is distributed along the pharynx through
advancement of the facial skeleton, which widens the pharyngeal
space and subsequently reduces pharyngeal collapse. A recent
meta-analysis of all-comers, evaluating MMA, demonstrated a
pooled surgical success rate (defined as a 50% reduction in
apnea-hypopnea index [AHI] and an AHI of <20/h) of 86% and
cure rate (AHI ≤5) of 43.2%, concluding that MMA is a safe and
effective treatment modality for OSA.14 In the MMA meta-
analysis, a multivariate logistical regression analysis demon-
strated that patients with a lower pre-MMA BMI had a higher
likelihood of surgical success with an odds ratio (OR) of 0.84 per
1-unit increase in BMI14; however, the article did not specifically
evaluate the effectiveness in morbidly obese patients.
Tracheostomy, in contrast, provides relief from OSA by
completely bypassing the upper airway. A meta-analysis eval-
uating tracheostomy for OSA in all-comers demonstrated that
the surgery reduces apnea index (AI), oxygen desaturation
index (ODI), sleepiness, and mortality.15 Like the MMA meta-
analysis, the tracheostomy meta-analysis15 suggested that
there were improved outcomes in non–morbidly obese patients
by demonstrating that there was minimal improvement in the
pooled ODI in patients with a BMI ≥45 kg/m2.
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Because few studies have evaluated the effectiveness of
MMA and/or tracheostomy on morbidly obese patients and
previous studies have reported that an objective analysis is
lacking,10 there is currently a knowledge gap in the literature.
The objective of this study is to systematically review the lit-
erature for AI, AHI, ODI, lowest oxygen saturation, and quan-
titative scales for sleepiness in morbidly obese patients treated
with either an MMA or a tracheostomy and to evaluate the
effectiveness of these treatments.
Methods
The Preferred Reporting Items for Systematic Reviews and
Meta-Analysis (PRISMA) statement16 was followed as much
as possible throughout the article.
Search Strategy
MEDLINE, Scopus, Web of Science, and the Cochrane Library
were searched from inception through August 1, 2013, with an
update April 8, 2014. MeSH keywords and phrases searched
included “tracheostomy,” “tracheotomy,” “tracheo*,” “maxillo-
mandibular advancement,” “orthognathic surgery,” “maxillary
osteotomy,” “mandibular advancement,” “sleep apnea,” “surgi-
cal,” “surgery,” “sleep apnea syndrome,” and “obstructive sleep
apnea”. One example of a search performed on MEDLINE is:
(((“Mandibular advancement”[MeSH]) AND “Sleep Apnea
Syndromes”[MeSH]) OR ((“Tracheostomy”[MeSH]) AND
“Sleep Apnea Syndromes”[MeSH]) OR ((“Orthognathic
Surgery”[MeSH]) AND “Sleep Apnea Syndromes”[MeSH]) OR
((“Maxillary osteotomy”[MeSH]) AND “Sleep Apnea
Syndromes”[MeSH]) OR (tracheo* AND “sleep apnea”) OR
(“maxillomandibular advancement” AND “sleep apnea”)).
Each search was reviewed, and any potentially relevant
studies were cataloged. The full-text versions of the articles
were then downloaded and reviewed for determination of
inclusion in this study. The references of each study were then
reviewed, and any potentially relevant study was also cata-
loged, downloaded, and reviewed.
Study Selection
For a study to be included in this review, (1) subjects had to
be morbidly obese, adult patients who underwent either tra-
cheostomy or MMA as treatment for OSA, (2) pre- and post-
operative quantitative outcomes needed to be reported for AI,
AHI, ODI, lowest oxygen saturation, respiratory disturbance
index (RDI), and/or quantitative sleepiness scales (ie, Likert,
visual analog scales, the Stanford Sleepiness Scale, or the
Epworth Sleepiness Scale), and (3) individual patient data
needed to be reported; (4) all languages were included. We
excluded (1) studies on children, (2) studies on pregnant
women, and (3) studies involving patients who lost more than
10% of their body weight between polysomnography studies.
*References 11, 25, 28, 29, 31, 34-36, 38, 39, 41, 45, 51, 52, 54-56,
58-64, 71-77, 79, 80, 82, 83, 85, 87-92, 95, 100-102, 107, 109, 111-
115.
Camacho et al 621
Data Abstractions and Study Quality
Assessment
Authors M.C. and J.A. independently performed a literature
search to identify potentially relevant studies, download arti-
cles, and subsequently come to a consensus as to which studies
met inclusion criteria. The downloaded full-text articles for the
final studies were then stored. Data collected from the studies
included age, BMI, AI, AHI, ODI, RDI, lowest oxygen satura-
tion, and sleepiness information. If ideal body weights were
reported by the studies, they were converted to BMI. Authors
of studies not reporting sufficient data were contacted via email
in an attempt to obtain further information. The National
Institute for Health and Clinical Excellence (NICE) has per-
formed several reviews evaluating quality assessment tools for
case reports, case series, and cohort, case-controlled, and ran-
domized trials.17,18 Because the studies identified in this review
are either case reports or case series, the articles meeting inclu-
sion and exclusion criteria for this study were assessed by using
the NICE quality assessment tool.17 In this review, surgical
success was defined as a postoperative AHI <20 events per
hour with a 50% or greater reduction in the AHI,19 and surgical
cure was defined as a postoperative AHI ≤5 events per hour.20
Statistical Analysis
Statistical data were assessed with the Statistical Package for
Social Sciences (SPSS) version 20.0 and the Cochrane
Collaboration’s Review Manager (REVMAN) software ver-
sion 5.2. The null hypothesis before initiating this study was
that there was no difference before and after MMA or trache-
ostomy for polysomnography or sleepiness data. To preserve
the clustering of individual patients’ data within each study,
the 2-step approach was used as described by Riley et al.21 For
the first step, SPSS was used to combine each article’s indi-
vidual patient data using the paired t test (2-tailed), with P <
.05 being the cutoff for statistical significance. For the second
step, REVMAN was used to calculate the mean differences
and 95% confidence intervals (95% CIs) for pooled data.
REVMAN was used for studies reporting data for 2 or more
patients and with a standard deviation that is not zero. The
pooled mean differences and 95% CIs calculated by REVMAN
are reported in the “Total” rows in the tables.
AHI was reported in 2 MMA studies and RDI in 4 MMA
studies. Although AHI and RDI are distinct measures, for the
purposes of combining data between studies, the two measures
were combined and were referred to as AHI; AHI was selected
as the title for the combined data because none of the studies
described the classic polysomnography scoring criteria used to
label an index as RDI (a statement that respiratory effort-related
arousals were scored and/or that pressure esophageal manome-
ters, nasal pressure, or inductance plethysmography was used
during the studies).22 Because of the heterogeneity between
patients, the differences in reporting of polysomnography scor-
ing criteria (ie, variation in hypopnea criteria, RDI vs AHI), the
differences between threshold for interventions, and differences
in the indications for surgery between studies, the random
effects model was used. Heterogeneity was assessed by 3
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methods: (1) Forest plots were graphically inspected, (2) the I2
statistic was calculated (inconsistency cutoffs: low = 25%,
moderate = 50%, and high = 75%),23 and (3) the Cochran Q
statistic was calculated (heterogeneity cutoff P ≤ .10).24
Publication bias was not assessed for the following reasons: (1)
in most studies, the morbidly obese patients made up a very
small percentage of the overall patients, and (2) the morbidly
obese patients’ individual patient data did not lead to the publi-
cation of their respective articles, but rather the entire set of data
and patients presented by each individual article led to their
publication.
Results
Methodological Quality of Included Studies
The majority of the studies in this review were either case
series studies or case reports (Table 1). The study quality was
fair, with most included studies satisfying 4 of the 8 items on
the NICE quality assessment tool categories. Most studies
were not multi-institutional, did not state that patients were
consecutive, and were not prospective. The quality appraisal
was not performed for the case report studies.
MMA
A total of 1239 potentially relevant MMA studies were
screened for relevance, and 116 articles were downloaded for
detailed evaluation and 5 were added. After full-text review,
it was determined that 92 articles reported either polysomnog-
raphy or sleepiness outcomes.11,25-115 Of these articles, indi-
vidual patient data were reported for polysomnography or
sleepiness in 53 studies.* For the 39 MMA articles reporting
outcomes without individual patient data, the BMIs were not
reported in 11 studies,† the BMIs were reported but there was
no range given in 19 studies,‡ the BMIs were reported with
the upper limit being <40 kg/m2 in 5 studies,30,37,50,69,81 or the
BMIs were reported with the range including morbidly obese
patients in 4 studies (1 patient in 1 study40 and at least 1 but
possibly more patients in 3 other studies78,86,108). For the 4
studies in which the individual patient data were not reported
but the article commented that there were patients with a BMI
≥40 kg/m2, the corresponding authors were emailed; however,
the authors either did not respond or no longer had the raw
data.40,78,86,108 In the remaining 6 MMA studies, a total of 34
morbidly obese patients with individual patient data were
identified11,51,52,63,82,100 (Figure 1).
The 34 patients had a mean ± SD age of 42.42 ± 9.13 years
and BMI of 44.88 ± 4.28 kg/m2 (Table 2). Riley et al101 and
Li et al (a)51 did not specify the advancement distances. Doff
et al63 used a counterclockwise rotation and advancement of
10 mm at the B point of the mandible, with an 8.5-mm
advancement of the maxilla, and a modified genioplasty that
advanced by 6 mm. Fairburn et al82 advanced the mandible by
10 mm for all patients, Vicini et al52 advanced the mandible
†
References 26, 27, 46, 49, 65, 67, 68, 96, 104-106.
‡
References 32, 33, 42-44, 47, 48, 53, 57, 66, 70, 84, 93, 94, 97-99,
103, 110.
622 Otolaryngology–Head and Neck Surgery 152(4)

Table 1. General Characteristics of Included Patients and Quality Criteria of Included Studies.

General Characteristics Quality Assessment of Included Studiesa

Outcomes
Study Study Site N Follow-up BMI Analyzed 1 2 3 4 5 6 7 8
MMA studies
Doff et al63 (2013) Netherlands 1 4 mo 40 AHI, O2 sat NA NA NA NA NA NA NA NA
Vicini et al52 (2010) Italy 2 NR 48 AHI, ESS No Yes Yes Yes Yes No Yes Yes
Fairburn et al82 (2007) USA 6 3-6 mo 16-55 AHI, O2 sat No Yes No Yes No Yes Yes Yes
Li et al (a)51 (2000) USA 3 <24 mo 42-49 O2 sat, RDI No No Yes Yes No Yes Yes Yes
Li et al (b)11 (2000) USA 20 7-66 mo 40-56 AI, O2 sat, RDI No Yes Yes Yes No Yes Yes Yes
Riley et al101 (1990) USA 2 6 mo 48 O2 sat, RDI No No Yes Yes No No Yes Yes
Tracheostomy studies
Kumar et al12 (2013) USA 1 3 mo 40 AI, AHI, EDS, O2 NA NA NA NA NA NA NA NA
sat, ODI, tcCO2
Browaldh et al13 (2009) Sweden 4 5y 42-50 EDS, ODI No Yes Yes Yes No No Yes Yes
Haapaniemi et al121 Finland 7 2.5-9 y 43-60 O2 sat, quality of No Yes No Yes No No Yes Yes
(2001) life
Fletcher116,117 (1989) USA 1 4y 43 AI, HP NA NA NA NA NA NA NA NA
Fletcher et al118 (1987) USA 3 6-12 mo 40-43 AI, BP, urinary No Yes No Yes Yes No Yes No
catecholamines
Rapoport et al124 (1986) USA 2 16-60 mo 51, 64 ABG, AI, O2 sat No Yes No Yes Yes No Yes No

Abbreviations: ABG, arterial blood gas; AI, apnea index; AHI, apnea-hypopnea index; BMI, body mass index in kg/m2; BP, blood pressure; CV, cardiovascular; EDS,
excessive daytime sleepiness; ESS, Epworth Sleepiness Scale; HP, hemodynamic parameters; N, number of patients meeting study criteria, NA, not applicable;
NR, not reported; O2 sat, oxygen saturation; ODI, oxygen desaturation index; PF, pulmonary function; RDI, respiratory disturbance index; tcCO2, transcutane-
ous carbon dioxide.
a
Quality assessment of cases series checklist from National Institute for Health and Clinical Excellence (NICE): (1) Was the case series collected in more than
1 center (ie, multicenter study)? (2) Is the hypothesis/aim/objective of the study clearly described? (3) Are the inclusion and exclusion criteria (case defini-
tion) clearly reported? (4) Is there a clear definition of the outcomes reported? (5) Were data collected prospectively? (6) Is there an explicit statement that
patients were recruited consecutively? (7) Are the main findings of the study clearly described? (8) Are outcomes stratified (eg, by disease stage, abnormal test
results, patient characteristics)?

Figure 1. Flow chart for studies reporting individual patient data for morbidly obese adult patients with obstructive sleep apnea treated
with maxillomandibular advancements or tracheostomies. CPAP, continuous positive airway pressure; MMA, maxillomandibular advancement;
N, number of articles; PSG, polysomnography.
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Camacho et al 623

Table 2. Pre- and Post-MMA Means, Standard Deviations, Mean Differences, and Confidence Intervals for Polysomnography Outcomes.

Patient Characteristics Apnea-Hypopnea Index Lowest Oxygen Saturation

Study N Age, ya BMIa Pre-MMAa Post-MMAa MD (95% CI) Pre-MMAa Post-MMAa MD (95% CI)
Doff et al63 1 32 40 139 3 −136.0 73 86 13
(2013)
Vicini et al52 2 50.5 ± 23.3 47.6 ± 0.14   52.0 ± 22.6   3.0 ± 1.4 −49.0 (−80.4 — — —
(2010) to −17.6)
Fairburn et al82 6 42.7 ± 9.9 44.2 ± 5.0 101.5 ± 33.2 10.2 ± 4.5 −91.2 (−118.0 72.2 ± 13.9 88.5 ± 7.0 16.3 (3.9 to 28.8)
(2007) to −64.5)
Li (a) et al51 3 44.0 ± 5.0 45.2 ± 3.5 73.9 ± 29.1   5.8 ± 4.9 −68.0 (−101.5 76.3 ± 11.1 88.7 ± 4.5 12.4 (−1.2 to
(2000) to −34.6) 25.9)
Li (b) et al11 20 41.7 ± 7.8 44.6 ± 4.5 83.4 ± 32.3 10.1 ± 9.6 −73.3 (−88.1 63.6 ± 17.3 86.7 ± 6.1 23.1 (15.1 to
(2000) to −58.5) 31.2)
Riley et al101 2 — 48.0 ± 0.5 78.0 ± 41.0 5.5 ± 3.5 −72.5 (−129.6 66.0 ± 2.8 — —
(1990) to −15.5)
Total 34 42.4 ± 9.1 44.9 ± 4.3 −72.7 (−129.6 19.2 (13.0 to
to −15.5) 25.5)

Abbreviations: BMI, body mass index in kg/m2; CI, confidence interval; MD, mean difference; N, number of morbidly obese patients in the study.
a
Expressed as mean ± SD.

by 11 mm for all patients, and Li et al (b)11 advanced the
maxillomandibular complex by 11.7 ± 2.3 mm (range 7-15
mm). The pre- and post-MMA means ± SDs for AHIs were
86.18 ± 33.25/h and 9.16 ± 7.89/h (P < .00001). The surgical
success rate was 85.3% and the cure rate was 26.5%. The
pooled random effects analysis (n = 33) demonstrated a statis-
tically significant decrease in AHI, with a mean difference of
−72.69 (95% confidence interval [95% CI], −84.08 to −61.31;
Z score = 12.52, P < .00001; Figure 2). The I2 value (3%) and
the Cochran Q statistic (0.39) demonstrated low heterogene-
ity. Apnea indices were reported in 1 study (Li et al11) with a
mean ± SD of 38.29 ± 33.62/h pre-MMA and 1.23 ± 1.81/h
post-MMA, with a mean difference of −37.10 (95% CI,
−51.85 to −22.35).
The pre- and post-MMA mean ± SD values for lowest oxy-
gen saturations were 66.58% ± 16.41% and 87.03% ± 5.90%
(P < .00001), respectively. The pooled random effects analysis
demonstrated a statistically significant increase in lowest oxy-
gen saturations, with a mean difference of 19.24 (95% CI,
12.96-25.52); Z score = 6.00, P < .00001; Figure 3). There was
low heterogeneity among studies for the reported improvement
in lowest oxygen saturation (I2 = 5% and Cochran’s Q statistic
= 0.35). Sleepiness was specifically reported for 5 patients, with
resolution in 1 patient63 and marked improvement in 2 patients,100
and Epworth Sleepiness Scale (ESS) decreased in 2 patients
from 15 to 8 and from 14 to 8 pre- and postoperatively.52
Tracheostomy
A total of 495 potentially relevant tracheostomy studies were
screened for relevance, 47 articles were downloaded for
detailed evaluation, and 2 were added after reviewing refer-
ences, for a total of 49 full-text articles obtained.6,12,13,116-161
After detailed evaluation, it was determined that 31 articles
did not report polysomnographic or quantitative sleepiness
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data, and these were excluded from meta-analysis. The
remaining 18 articles reported polysomnographic or sleepi-
ness data before and after tracheostomy.6,12,13,116-130 For the 10
tracheostomy articles reporting polysomnography or sleepi-
ness outcomes without individual patient data, the BMIs were
not reported in 3 studies,126,127,130 the BMIs were reported but
there was no range given in 3 studies,6,128,129 the BMIs were
reported with the upper limit being <40 kg/m2 in 2 stud-
ies,119,125 the weight in kilograms was reported but no BMI
was reported in 1 study,123 and the BMIs were reported with
the range including morbidly obese patients in 1 study.120 For
the 1 study in which the individual patient data were not
reported but the article commented that there were patients
with a BMI ≥40 kg/m2, the corresponding author was con-
tacted; however, the author no longer had the raw data.120 In
the remaining 8 tracheostomy studies, a total of 15 morbidly
obese patients with individual patient data were identi-
fied12,13,116-118,121,122,124; however, 1 patient was pregnant and
therefore was excluded,122 leaving a total of 14 patients
(Figure 1).
The 14 patients had a mean ± SD age of 52.21 ± 10.40
years and BMI of 47.93 ± 7.56 kg/m2 (Table 3). The pre- and
posttracheostomy mean ± SD values for AIs were 64.43 ±
41.35/h and 1.73 ± 2.68/h (P = .0086), for ODIs were 69.20 ±
26.10/h and 41.38 ± 36.28/h (P = .22), and for lowest oxygen
saturations were 55.17% ± 16.46% and 79.83% ± 4.36% (P =
.011), respectively. With regard to the ODIs, 3 patients had
relatively unchanged values; 2 of them were older (61 and 63
years old)13 and the third patient was only 27 years old but had
known obesity hypoventilation syndrome.12 Exclusion of
these 3 patients left 2 patients with a mean ± SD pre- and post-
tracheostomy ODI of 77.50 ± 31.82/h and 7.75 ± 7.42/h,
respectively.13 Two studies reported outcomes for the
Epworth Sleepiness Scale (n = 5), with mean ± SD values of
624 Otolaryngology–Head and Neck Surgery 152(4)

Figure 2. Pooled means, standard deviations, mean differences, and confidence intervals for the apnea-hypopnea indices before and after
maxillomandibular advancement (MMA).

Figure 3. Pooled means, standard deviations, mean differences, and confidence intervals for the lowest oxygen saturations before and after
maxillomandibular advancement (MMA).

18.80 ± 4.02 before tracheostomy and 2.80 ± 2.77 after tra-
cheostomy.12,13 One study evaluated sleepiness with a ques-
tionnaire using a 1 to 5 grading scale (1 = much poorer, 2 =
poorer, 3 = similar, 4 = better, and 5 = much better), with
posttracheostomy sleepiness being 3, 4, 4, and 5 in the study’s
4 morbidly obese patients.121 The AHI was reported for only
2 patients; therefore, the surgical success and cure rates were
not calculated.
Discussion
There are 3 main findings from this review. First, both maxil-
lomandibular advancements and tracheostomies have very
limited data when used to treat morbidly obese, adult OSA.
Although the post-MMA data demonstrate an 89.4% reduc-
tion in AHI, a 20.5-point improvement in lowest oxygen satu-
ration, and decreased sleepiness in all patients for whom data
were reported, it must be pointed out that there are confound-
ers among these data, such as surgeon’s bias or judgment, that
may have allowed for more favorable outcomes. The MMA
surgical success rate for morbidly obese patients identified in
the literature is comparable to success rates for the previously
published MMA meta-analysis that evaluated all-comers14
(85.3% vs 86%, respectively); however, this study demon-
strates that the cure rate was only 26.5% for morbidly obese
patients compared with the reported cure rate of 43.2% for
all-comers. For tracheostomy patients, there was a 97.3%
reduction in AIs and a 25.4-point improvement in lowest oxy-
gen saturations. The surgical success rate was not calculated
for posttracheostomy patients because the AHI was reported
for only 2 patients. There was also an improvement overall in
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sleepiness for posttracheostomy patients in articles in which
the outcome were reported. There was no forest plot for the
tracheostomy analyses, because in any given category there
were insufficient numbers of means and standard deviations
to allow for the pooling of data in REVMAN; however, in
non-REVMAN analysis in SPSS, we could combine the data
to establish a group total. Similar to the MMA outcomes,
there may have been surgeons’ bias or other confounders that
allowed for more favorable outcomes. The results of these
published data for MMA and tracheostomy may not actually
represent what the real-world outcomes would be with regard
to morbidly obese, adult patients with OSA. To find the true
effect of these interventions would require prospective, con-
secutive patients and higher level studies, possibly having
randomization.
Second, 2 subgroups of patients had poorer results postop-
eratively. The first subgroup of patients were those 60 years or
older who underwent a tracheostomy (3 of 4 patients had an
elevated ODI after tracheostomy13,121). Only 1 MMA patient
over the age of 60 was identified, and this patient demon-
strated an improvement in AHI from 36/h to 2/h. The second
subgroup known to respond poorly to surgery consisted of
patients with obesity hypoventilation syndrome (OHS), as
demonstrated by 1 tracheostomy OSA-OHS patient (27 years
old) who had minimal reduction in AHI (from 39.6/h to
35.7/h) and an increase in ODI (from 33/h to 34.4/h) after tra-
cheostomy.12 Two MMA patients with OSA-OHS (43 and 48
years old) had elevated RDIs postoperatively (39.3/h and
37/h).11 OHS patients often require postsurgical positive-pres-
sure therapy because hypoventilation generally does not
 Camacho et al 625

improve with surgery alone. In the case study by Kumar

MD (95% CI)

30.5 (15.6 to
et al,12 an OSA-OHS patient had unimproved AHI and ODI

45.4)
after a tracheostomy; however, after positive-pressure therapy

21

—
—

—
5 was applied at night via the tracheostomy, the patient’s poly-
Lowest Oxygen Saturation

somnographic and sleepiness data normalized.

Third, future studies could be performed to evaluate the
Post-Tracha

79.3 ± 4.9
effect of MMA, tracheostomy, and other upper airway surgeries

78

—
84

—
on morbidly obese patients. The data in the currently published
literature for morbidly obese post-MMA and posttracheostomy
patients are very limited, with outcomes reported for only 34
MMA patients and 14 tracheostomy patients. A major problem
48.8 ± 14.4
Pre-Tracha

52.5 ± 3.5
with studying upper airway surgeries in morbidly obese patients
57

—
79

61
is that it is unlikely that patients would agree to participate in

Abbreviations: BMI, body mass index in kg/m2; CI, confidence interval; MD, mean difference; N, number of morbidly obese patients in the study; Trach, tracheostomy.
randomized controlled trials since it would require that they be
Table 3. Pre- and Posttracheostomy Means, Standard Deviations, Mean Differences, and Confidence Intervals for Polysomnography Outcomes.

willing to undergo randomization to either tracheostomy,

MD (95% CI)

−35.2 (−80.1

MMA, or other upper airway surgeries. However, well-planned,

to 9.7)

prospective, multi-institutional studies could be performed on

1.4

—
—

consecutive patients to allow for higher level data collection

Oxygen Desaturation Index

and analysis. Ultimately, the decision to proceed with MMA,

tracheostomy, or other upper airway surgeries should be made
Post-Tracha

43.1 ± 41.7

18.7 ± 20.6

on a case-by-case basis since surgical training, institutional

resources, and patient and/or surgeon preference will dictate the
34.4

—
—

selection of such surgery.

Limitations
78.3 ± 19.0
Pre-Tracha

There are limitations to this study. First, this study has a very
limited number of patients (34 MMA and 14 tracheostomy
33

—
—

patients). Given the very small number of patients, we cannot

draw definitive conclusions. Additionally, these patients were
Post-Tracha MD (95% CI)

−52.5 (−63.5

selected as subsets from within other studies; therefore, there

to −41.5)

is likely selection bias and additional confounders that cannot

−56.5
−114
5.4

—
—

be ignored. Second, despite our best effort to identify all the

relevant studies reporting outcomes for MMA and tracheosto-
mies in morbidly obese patients, we may have missed some
Apnea Index

0.0 ± 0.0

2.5 ± 3.5

studies. Third, the majority of the studies were lower levels of

5.4

—
—

evidence, being single-institution case series or case reports;

however, most included studies satisfied 4 of the 8 items on
the NICE quality assessment tool categories. Fourth, given
56.5 ± 29.0
Pre-Tracha

that we specifically selected individual patients within each

55 ± 7.1
114

—
—

tracheostomy and MMA study and sometimes only 1 or 2

0

patients met inclusion criteria per study (making up a small

percentage of the total patients in most of the studies), we
52.2 ± 10.4 47.9 ± 7.6
45.5 ± 3.3

54.3 ± 10.8 52.5 ± 7.1

40.7 ± 0.3

57.5 ± 8.5

believe that evaluating for publication bias for morbidly obese

BMIa

42.7

patients is not appropriate. It is likely that publication bias

40
Patient Characteristics

exists toward publishing positive findings in morbidly obese

patients; however, only 1 article was published that contained
only morbidly obese patients and presented individual patient
54.5 ± 8.9

56.5 ± 3.5

48.5 ± 4.9
Age, ya

data,11 while the remainder of the case series articles included

27

59

non–morbidly obese patients as well. Fifth, given that the cur-

rent studies are retrospective case reports or case series,
Expressed as mean ± SD.

higher level studies are needed to better evaluate the effect of

N
1

Fletcher et al118 2

14

MMA and tracheostomy (or additional upper airway surger-

et al121 (2001)

et al124 (1986)

ies) on morbidly obese patients.

et al13 (2008)
12

et al116,117
Kumar et al

Haapaniemi

Conclusion
Rapoport
Browaldh
(2013)

(1989)

(1987)
Fletcher

Data for MMA and tracheostomy as treatment for morbidly

Study

Total

obese, adult OSA patients are significantly limited. We

a

Downloaded from oto.sagepub.com at University of Sussex Library on August 10, 2015

626 Otolaryngology–Head and Neck Surgery 152(4)
caution surgeons about drawing definitive conclusions from
these limited studies; future higher level studies are needed.
Author Contributions
Macario Camacho, conception of work, analysis of data, drafting,
final approval, and accountable for all aspects of the work; Jeffrey
Teixeira, conception of work, analysis of data, initial drafting, final
approval, and accountable for all aspects of the work; Jose
Abdullatif, acquisition of data, critical revision of manuscript, final
approval of version to be published, and accountable for all aspects
of the work; Jason L. Acevedo, interpretation of the work, critical
revision of manuscript, final approval of version to be published, and
accountable for all aspects of the work; Victor Certal, interpretation
of the work, critical revision of manuscript, final approval of version
to be published, and accountable for all aspects of the work; Robson
Capasso, interpretation of the work, critical revision of manuscript,
final approval of version to be published, and accountable for all
aspects of the work; Nelson B. Powell, interpretation of the work,
critical revision of manuscript, final approval of version to be pub-
lished, and accountable for all aspects of the work.
Disclosures
Competing interests: None.
Sponsorships: None.
Funding source: The American Academy of Otolaryngology—
Head and Neck Surgery provided support for this manuscript as the
first author participated as an AAO-HNS Cochrane Scholar and
attended the 2013 Cochrane Colloquium.
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