Obstructive sleep apnoea (OSA) is characterized by repeated upper airway collapse leading to oxygen desaturation resulting in cardiovascular and neurocognitive sequelae. Upper airway surgeries such as palatopharyngoplasty, tongue base surgery, and maxillomandibular advancement can improve patient tolerance of continuous positive airway pressure, quality of life, and the severity of OSA. Upper airway stimulation (UAS) of the hypoglossal nerve is a contemporary US Food and Drug Administration-approved treatment modality for OSA with a fundamentally different mechanism. We report the case of a 65-year-old male with a high body mass index, hypertension, diabetes, dentofacial deformity, and severe OSA. He presented with a respiratory distress index (RDI) of 89.1 events per hour, apnoea-hypopnoea index (AHI) of 82.7 events per hour, and minimum oxygen saturation of 75%. He chose to undergo UAS. Initially, complete concentric collapse of the velum was found during drug-induced sedation endoscopy, which was converted by palatopharyngoplasty to meet inclusion criteria for UAS. The patient achieved surgical cure with postoperative RDI and AHI of 2 events per hour with minimum oxygen saturation of 83%, and resolution of daytime somnolence. UAS is an effective surgical option to broaden the surgeon\'s ability to treat OSA, especially if facial skeletal surgery is contraindicated or declined by the patient with dentofacial deformity.

BACKGROUND: Chronic insomnia and obstructive sleep apnea are both common sleep disorders. Chronic insomnia is thought to result from stress-related physiologic hyperarousal (somatic arousal) that makes it difficult for an individual to fall or stay asleep. Obstructive sleep apnea is thought to result from obstructive respiratory events causing arousals, sleep fragmentation, and recurrent oxygen desaturation. Although the two disorders seem different, they predispose to the same long-term, stress-related illnesses, and when they occur in the same individual, each affects the other\'s response to treatment; they interact. This report of three cases describes patients with both chronic insomnia and obstructive sleep apnea in whom the chronic insomnia remitted with no specific treatment following treatment of obstructive sleep apnea with maxillomandibular advancement.
METHODS: Our three Caucasians patients each presented with severe, chronic insomnia associated with somatic arousal and fatigue occurring either alone, in association with bipolar disorder, or with temporomandibular joint syndrome. Polysomnography revealed that each patient also had mild obstructive sleep apnea, despite only one snoring audibly. One patient experienced a modest improvement in her somatic arousal, insomnia severity, and fatigue with autotitrating nasal continuous positive airway pressure, but the other two did not tolerate nasal continuous positive airway pressure. None of the patients received treatment for insomnia. All three patients subsequently underwent maxillomandibular advancement to treat mild obstructive sleep apnea and experienced prolonged, complete resolution of somatic arousal, chronic insomnia, and fatigue. The patient with bipolar disorder also experienced complete remission of his symptoms of depression during the 1 year he was followed postoperatively.
CONCLUSIONS: These three cases lend support to the hypothesis that chronic insomnia and obstructive sleep apnea share a pathophysiology of chronic stress. Among patients with obstructive sleep apnea, the stress response is directed at inspiratory airflow limitation during sleep (hypopnea, snoring, and inaudible fluttering of the throat). Therefore, when chronic insomnia and obstructive sleep apnea occur in one individual, aggressive treatment of obstructive sleep apnea may lead to a reduction in chronic stress that causes the patient\'s chronic insomnia to remit.

Obstructive sleep apnea (OSA) is characterized by episodes of pharyngeal collapse during sleep. Craniofacial alterations such as retrognathia are often found in OSA patients. Maxillomandibular advancement (MMA) surgeries increase the pharyngeal space and are a treatment option for OSA. The aim of this study was to present a successful case of MMA surgery in the treatment of OSA. A patient with moderate OSA (apnea-hypopnea index (AHI)=25.2) and mandibular retrognathism and Maxillomandibular asymmetry underwent MMA surgery. The apnea-hypopnea index (AHI) were considerably improved after six months (IAH =6.7) and one year of treatment (IAH=0.2).

BACKGROUND: Obstructive sleep apnea (OSA) is a secondary cause of intracranial hypertension (IH). Decreased jugular venous drainage has been seen in patients with idiopathic IH.
METHODS: A complex case of a 48-year-old female whose idiopathic IH was put into remission after counterclockwise maxillomandibular advancement (CC-MMA), despite persistence of her OSA.
CONCLUSIONS: This case highlights the relationship between OSA and IH and points to the significant morbidity that can result from mild OSA and from what are considered borderline intracranial pressures. This indicates the need for a high index of suspicion for actual underlying pathology that can be surgically corrected when patients manifest symptoms of a somatic syndrome. This is the first report in the medical literature of clinical elimination of IH by CC-MMA. The authors propose that this positive outcome was effected via mandibular advancement producing a decrease in jugular venous resistance, allowing improved absorption of cerebrospinal fluid.