A Non-Framework Multilevel Surgery May Reduce Mean Heart Rate in Patients with Very Severe Obstructive Apnea Having Confined Retroglossal Space and Framework
, Shu-Yi Huang 2,4,5, Yu-Ching Lin 2,3,4,6, Chieh-Mo Lin 4,7, Chin-Kuo Lin 4,7, Ying-Chih Huang 8 and Jian-An Su 9
Round 1
Reviewer 1 Report
The manuscript presents a study in the craniofacial field focusing on 27 very severe OSA patients, where 24 are male and 3 are female, age range 29 to 63 years. All patients had Z-palatoplasty and partial open tongue-base glossectomy. One patient had UPPP, 25 had septomeatoplasty. One and three patients had regular adenoidectomy and endoscopic sinosurgery, respectively. The study presents individual AHI and mean heart rate changes before and after surgey, and correlation of preoperative AHI vs. mean heart rate.
The following concerns need addressing to strengthen the manuscript:
- Abstract: In the section mentioning "obstructive sleep apnea (OSA) may show a higher risk of mortality and development of various cardiovascular diseases", is an annual number or percentage of cases known regarding the higher risk?
- Introduction last line: A sentence needs to be added to briefly mention the key findings of the study.
- Materials and Methods: The methods section needs to be split up into sequential subsections. It is currently presented as one long continuous text.
- Results: The beginning section mentions 1 patient had UPPP, 25 had septomeatoplasty, 1 and 3 had regular adenoidectomy and endoscopic sinosurgery, respectively. Can a table be included where the values of figures 1, 2, 3 are listed next to the above patients to correlate the results with the above conditions?
- In addition to reduced heart rate were any other effects reported in these patients or complications?
- Is there any recommendation regarding this surgery if patients have conditions like bradycardia where heart rate is already lower than normal?
- Discussion: lines 147-156, can a table be included with the method names and associated numerical parameters described in these lines?
- Conclusion: Last sentence can be split into 2 simpler and shorter sentences.
Author Response
Please see the attachment.
Author Response File: 
Author Response.docx
Reviewer 2 Report
I have researched the paper " A non-framework multilevel surgery may reduce mean heart rate in patients with very severe obstructive apnea having confined framework and retroglossal space".
The article investigates whether severe OSA patients undergoing multilevel non-framework surgery (TORS tongue base reduction, Z-palatoplasty and septomeatoplasty) may present a reduction of resting heart rate.
The heart rate is obtained by PSG before and after surgery. In "Materials and Methods" you state that each patient completed a PSG 6 months after "the post-operative anatomy was consedered stable", it is unckear to me when you decide that the anatomy is stable, on the other hand 193+-67 days is since surgery? Please clarify in the text.
The heart rate decrease is well described, and the study design is adequate.
I congratulate for the results and advice pubblication after minor revisions ( a few grammar flaws e.g. line 54 "they make a distinct subgroup and shows-to be corrected with SHOW".
Kind regards.
Author Response
Please see the attachment.
Author Response File: Author Response.docx
Reviewer 3 Report
Good initiative to take care of severe OSA, uncompliant to CPAP. The sample is small, mostly male, very severe OSA but mostly overweight. Important results but they are issues to be addressed.
Line 85. How do you define the unsuccessful CPAP? Based on compliance? Inefficient reduction of AHI?
Line 87. Are there any data about comorbidities? Cardiovascular? Medication, such as betablockers?
Line 88. Do you have any data about the Malampati score?
Line 88. PSG was performed by certified technician? In an accredited sleep Lab?
Line 111. Genre biased. Please comment
Line 111. „ All patients underwent Z-palatoplasty and partial open tongue-base glossectomy. One patient had UPPP at another hospital. Twenty-five received septomeatoplasty. One and three patients underwent regular adenoidectomy and endoscopic sinosurgery, respectively”
Can you describe the multilevel surgery concept? The patients had different interventions, at different levels, not all of them the same procedure. It is a bit unclear.
Line 117. How do you comment the approx. 50% reduction of AHI? Patient were overweight, not obese. They remain severe in terms of AHI.
Line 125: „A Spearman correlation for the data showed that postoperative proportion difference of mean heart rate was not related to any of these parameters (AHI, hypopnea in AHI ratio, desaturation index, and mean SpO2), r = (-0.1652, -0.3404, -0.1566, and128 -0.1447), p = (0.4103, 0.0823, 0.4353, and 0.4714), respectively.” Do you have a picture for these data?
Line 187. Conclusion. Fair. Small sample. It needs confirmation on RCT, but complicated to perform such studies on large sample.
Author Response
Please see the attachment.
Author Response File: Author Response.docx
Round 2
Reviewer 3 Report
To whom it may concern,
The new version of the paper added more data, details and images. The authors responded to all the questions and comments.
