睡眠阻塞性呼吸中止對舌癌病患手術治療後的影響及Silent Nite®口內裝置對睡眠阻塞性呼吸中止的療效

The influence of obstructive sleep apnea in tongue cancer patients after cancer therapy and the efficacy of Silent Nite® oral appliance in the treatment of obstructive sleep apnea

陳萬宜(Man-Yee Chan)

指導教授 ： 周明勇

中山醫學大學/口腔醫學院/口腔醫學研究所/博士(2012年)

https://doi.org/10.6834/CSMU.2012.00029

摘要

研究目的：包括兩部份的回溯性研究，第一部份旨在探討舌部鱗狀上皮細胞癌患者於原病灶手術切除後的睡眠呼吸中止症盛行率，以及探討睡眠呼吸中止症在舌癌病患的相關因素。第二部份旨在探討下顎前移裝置(Silent Nite®)對治療打鼾及睡眠呼吸中止症的功效。

研究方法及資料：第一部份為26位舌部鱗狀上皮細胞癌患者，其中24位男性2位女性，年齡37-71歲，於原病灶手術切除後，探討睡眠呼吸中症的盛行率。收案病患需在手術後追縱6個月至11年，然後接受夜間睡眠多項生理分析檢查，若呼吸中止和部份中止指數大於每小時5次者，視為患有睡眠呼吸中止症。第二部份為評估43位睡眠呼吸中止症患者使用Silent Nite®口內裝置的治療效能，接受夜間睡眠多項生理分析檢查，若呼吸中止和部份中止指數(AHI)大於5者，視為患有睡眠呼吸中止症；若AHI少過5則視為治療成功；又若AHI大過5，但與治療前比較時減少一半者，視為部份治療成功。

研究結果：在舌癌患者的研究部份，AHI少於5者，其BMI為22.8kg/m2。但AHI大於5者，其BMI為28.3kg/m2，两組間具統計意義(p=0.018)。若以AHI大於5者，視為患有睡眠呼吸中止症時，26位患者中有14位(53.85%)具有此臨床症狀。若比較睡眠呼吸中症患者與非患者之間的年齡、腫瘤大小、舌切除範圍、頸部淋巴廓清術方式或傷口重建方法時，並無統計意義。使用Silent Nite®口內裝置的患者的阻

塞性睡眠呼吸中止的治療效果，與其年齡、性別、BMI或中樞性睡眠呼吸中止均無統計意義。對全部患者評估，該口內裝置可使AHI由16.24 ± 2.45 次/小時降至 to 8.37 ± 0.01 次/小時，具統計意義(p<0.001)。其中18人(40%)完全有效(AHI<5次/小時)，6人(14%)部份有效(AHI的減少50%，但仍AHI >5次/小時)。
結論與建議：舌部鱗狀上皮細胞癌患者於原病灶手術切除後的睡眠呼吸中止症盛行率遠高於一般民眾(與其他文獻比較)，本研究的限制是病患樣本數量。其次是手術前應接受夜間睡眠多項生理分析檢查，因為此可做手術前後的各項睡眠品質比較。儘管Silent Nite®口內裝置在本研究中有其限制，但對於不願或無法適應經鼻連續陽壓呼吸器治療，又或無法接受手術的高風險患者，此裝應為有效的替代治療方法。

關鍵字

呼吸中止和部份中止指數(AHI) ； 身體質量指數(BMI) ； 經鼻連續陽壓呼吸器(nCPAP) ； 下顎前移裝置(MAA) ； 口內裝置(OA) ； 口腔癌 ； 夜間睡眠多項生理分析檢查 (PSG) ； Silent NiteR ； 鱗狀上皮細胞癌 (SCC) ； 舌癌

並列摘要

Objective：This research is about OSA which consists of 2 studies. The first study is to determine the prevalence of obstructive sleep apnea (OSA) in patients with squamous cell carcinoma (SSC) of the tongue after primary surgical resection and to correlate the presence of OSA with the occurrence of obstructive apnea in this patient population. The second study aims to evaluate the efficacy of mandibular advancement appliance (Silent NiteR) in the treatment of snoring and obstructive sleep apnea.

Methods and materials: A retrospective study was done to determine the prevalence of obstructive sleep apnea (OSA) among 26 Taiwanese patients, 24 males and 2 females, aged 37~71 years after surgical resection of SSC of the tongue. Patients who had a follow-up after treatment of 6 months to 11 years were eligible for inclusion. During the post-treatment period, the occurrence of OSA was determined in these patients. Overnight polysomnography (PSG) was also used to determine the apnea-hypopnea index (AHI). Patients were considered to have OSA if the AHI value was more than 5 events per hour.
Another retrospective study was done to evaluate the efficacy of Silent NiteR oral appliance in the treatment of snoring and obstructive sleep apnea among 43 Taiwanese patients with obstructive sleep apnea. An overnight polysomnography was used to determine the apnea-hypopnea index (AHI) and other parameters. Patients were considered to have OSA if the AHI value is more than 5. Complete response was defined as a resolution of symptoms with reduction in AHI to less than 5 events per hour. Partial response was defined as improved symptoms of 50% reduction in AHI with remaining 5 events per hour or more.

Results: The results of oral cancer study showed that in patients with an AHI value of < 5, there was a mean body-mass index (BMI) of 22.8 kg/m2, while in patients with an AHI value of > 5, there was a mean BMI of 26.3 kg/m2. The BMI distribution between patients with AHI value of < 5 and of > 5 was statistically significant (p = 0.018). Using the definition of clinically significant sleep apnea as AHI > 5, 14 of 26 patients (53.85%) had clinical OSA. The OSA and non-OSA groups showed no statistical significance in terms of age, tumor size, tongue ablation, radical and suprahyoid neck dissection, or wound reconstruction methods.
The results of Silent NiteR oral appliance study showed that there was no statistical difference in terms of age, gender, BMI, and central apnea. For the entire group, the oral device reduced the mean of AHI from 16.24 ± 2.45 events/h to 8.37 ± 0.01 events/h with statistical significance (p<0.001). Seventeen subjects (40%) had complete response (a reduction in apnea/hypopnea index to < 5 events/h). Six subjects (14%) had a partial response (50% reduction in AHI but the AHI remained >5 events/h).

Conclusions: The incidence of OSA in the patient population with SSC of the tongue was found to be significantly higher than that of the general population which compared with other published articles. The limitations of this study were the patient sample size. Moreover, there was no pre-surgical PSG record obtained from the patients to compare the sleep quality before and after cancer therapy.
Silent NiteR oral appliance, despite its limitations presented in this study, may be an alternative and effective method for treatment of OSA patients especially for those who were unwilling/unable to use nasal continuous positive airway pressure (nCPAP) or for patients who were of high surgical risks.

並列關鍵字

apnea-hypopnea index (AHI) ； body mass index (BMI) ； nasal continuous positive airway pressure (nCPAP) ； mandibular advancement appliances (MAA) ； mandibular repositioning appliance (MRA) ； oral appliances (OA) ； oral cancer, obstructive sleep apnea (OSA) ； polysomnography (PSG) ； Silent NiteR ； squamous cell carcinoma (SCC) ； tongue cancer

參考文獻

1. Punjabi NM. The epidemiology of adult obstructive sleep apnea. Proceedings Of The American Thoracic Society 2008;5:136-143.

2. Cistulli PA, Grunstein RR. Medical devices for the diagnosis and treatment of obstructive sleep apnea. Expert Rev Med Devices 2005;2:749-763.

3. Arias MA, Sanchez AM. Obstructive sleep apnea and its relationship to cardiac arrhythmias. J Cardiovasc Electrophysiol 2007;18:1006-1014.

4. Ip MS, Lam B, Lauder IJ, Tsang KW, Chung KF, Mok YW et al. A community study of sleep-disordered breathing in middle-aged Chinese men in Hong Kong. Chest 2001;119:62-69.

6. Ferguson KA, Ono T, Lowe AA, Keenan SP, Fleetham JA. A randomized crossover study of an oral appliance vs nasal-continuous positive airway pressure in the treatment of mild-moderate obstructive sleep apnea. Chest 1996;109:1269-1275.