以舌提昇式下顎前突裝置治療阻塞性睡眠呼吸中止症患者之臨床病例探討:先驅性研究

Abstract

目的: 依照過去經驗使用 t-MAD (tongue-backing mandibular advancement device) 來治療阻塞性睡眠呼吸中止症 (OSA) 病患,仍然會有些許無法解決的問題, 本研究目的在於設計新的、有助於提升舌頭的口內裝置,藉此來測試修飾後的 舌 提 昇 式 式 下 顎 前 突 裝 置 (tongue-raising mandibular advancement device, tr-MAD)之可行性。 實驗材料與方法: 本實驗的對象為西元 2013 年 12 月至 2014 年 4 月間至國立台大醫院睡眠 中心特別門診就診病患中,具有 OSA 臨床症狀及經 PSG 測定之後,判定為輕 度以上之 OSA 患者(AHI>5),並至台大醫院牙科部睡眠特別門診接受口內裝 置之治療。納入本試驗的對象,一部分為配戴現行口內裝置(t-MAD)已達到 AHI reduction 的效果,但仍然有殘餘的鼾聲問題,另一部分的新病人為臨床上 利用側顱攝影篩選出 hyoid bone level 相對較低 (低於 C3 level)且微開口時舌頭 位置較低(低於咬合平面)的患者。 上述患者於治療前紀錄其年齡,量取基礎生理指數包括身高、體重,計算 身體質量指數;此外並拍攝側顱 X 光片進行側顱分析,並以磁振掃描攝影進行 呼吸道的分析。於口內裝置治療後一個月至睡眠中心回診,再度接受 PSG 之測 定以及磁振掃描攝影分析;經過一星期的清除期(washout period)後,配戴另 一種口內裝置再次安排 PSG 之測定以及磁振掃描攝影分析,以評估並比較不同 口內裝置的治療效果及對生理構造的影響。 治療前 OSA 嚴重度定義如下:輕度(5≤AHI<15)、中度(15≤AHI<30)、 重度(30≤AHI<50)、極重度(AHI≥50)。治療成功率之分類,是以治療後 AHI 降低的比例以及治療後的 AHI 作區分,依照 AHI 降低百分比和治療後的 AHI iii 分為四組:(1) True success(△AHI≥50% and 2nd AHI<15)(2) Success(△ AHI≥50% but 2nd AHI≥15)(3) Partial success(△AHI<50%)(4) Failure(△ AHI<0%)。而其中 true success、success 合併成 Responder,而 partial success、 failure 合併成 Non-responder。 結果: 本研究中共有 17 位受試者,對於 OSA 病患的治療改善程度 t-MAD 與 tr-MAD 相比,成功率為 67% vs. 70.6%。 多功能睡眠生理檢查報告顯示:t-MAD 及 tr-MAD 之間各項變數在 t 檢定 之下並沒有顯著差異。 磁振掃描攝影分析顯示:tr-MAD 對比 t-MAD 在呼吸道的改變有更顯著的 表現,包括在 PNS 後方呼吸道,左右徑增加的量以及前後徑增加的量,tr-MAD 明顯優於 t-MAD,兩者達到統計上的顯著差異(p=0.045)。 對於部分受試者,配戴 t-MAD 後仍然有惱人的鼾聲問題者,在配戴 tr-MAD 後對於鼾聲有明顯改善。 總結: 對於治療某些 OSA 患者,包括 t-MAD 治療後仍有殘餘鼾聲問題者,在 t-MAD 中加入提升舌頭的機制似乎是一個可行性的改變。

Objectives: The aim of this study was to test the feasibility of a modification of the tongue-backing mandibular advancement device (t-MAD), by incorporating a design to raise the tongue (tr-MAD) in treating obstructive sleep apnea (OSA) patients. Materials and Methods: From Dec. 2013 to Apr. 2014 OSA patients (AHI≧5) managed in Clinic of Sleep Dentistry and met the following criteria were invited to this trial: 1. OSA patients responded well with t-MAD in term of AHI reduction, but still bothered with snoring. 2. New OSA patients either with hyoid bone located below C3 revealed by lateral cephalometric x-ray, or the dorsal surface of the tongue lower than occlusal plane during mouth light opening clinically. All subjects were given both t-MAD and tr-MAD for treatment. Subjectively comments and polysomnography was used to access the feasibility of the tr-MAD, and to compare their treatment outcomes. MRI was also used to evaluate their effects on the upper airway configuration. The OSA severity was classified into mild (5≤ AHI<15), moderate (15≤AHI <30), severe (30≤AHI<50), and extremely severe (AHI ≥50). The response to oral appliance was classified according to percentage of AHI reduction, and AHI after treatment: (1) True success(△AHI≥50% and 2nd AHI<15)(2) Success(△ AHI≥50% but 2nd AHI≥15)(3) Partial success(△AHI<50%)(4) Failure(△ AHI<0%). True success and success were defined as responder, meanwhile partial v success and failure were define as non-responder. Results: 17 patients have participated to this study. The treatment outcomes of t-MAD and tr-MAD were comparable, namely the success rates were 67% and 70.6%, respectively. PSG studies showed no different improvement brought by both t-MAD and tr-MAD. However, MRI scan showed tr-MAD can result in more upper airway configuration changes than those with t-MAD, including PNS level, anterior-posterior dimension, and medial-lateral dimension. For those who were still bothered by snoring while using the t-MAD, also reported snoring reduction with the newly designed tr-MAD. Conclusion: Incorporated a tongue raising mechanism within a tongue-backing mandibular advancement device seems to be a feasible modification indicated in certain OSA patients.