THE PATIENT STRONGLY MOTIVATED TOWARDS THE TREATMENT? & ENT

Transcription

1 SNORING & OSAHS SURGERY International Workshop Preoperative Diagnostic Protocol < 15 min

2 Filippo Montevecchi M.D. Department of Special Surgery Head & Neck Surgery, Oral Surgery Unit (Head: C.Vicini) G.B. Morgagni L.Pierantoni Hospital ASL of Forlì ITALY University of Pavia School of Medicine ENT Clinic Ronchopathy Surgery Course University of Parma School of Medicine Maxillo-Facial Clinic SDB Surgery Course AIMS Board & ENT-Maxillo Maxillo-Facial Joint Commission DIAGNOSTIC WORK-UP What do we need in order to help this lady?

3 DIAGNOSTIC WORK-UP: (PID) SDB PATIENT IDENTITY DOCUMENT Age Sex BMI Profession Comorbidities (& ASA Grading) NOH TS (NOHL) mouth opening (mm) & facial bone status Mallampati score AHI/RDI/ODI ESS (& Psychometrics) Motivation notes DIAGNOSTIC WORK-UP CASE HISTORY, BIOMETRICS PHYSICAL EXAMINATION PANOREX and LATERAL TELERADIOGRAPHY SLEEP STUDIES PSYCHOMETRICS AWAKE & SLEEP ENDOSCOPY

4 Case History Free Interview ( age, occupation, reasons for the consultation ti, duration of snoring problems, daytime sleepiness, choking, cognitive function impairment, i comorbidities, previous treatments) IS THE PATIENT STRONGLY MOTIVATED TOWARDS THE TREATMENT? General & ENT Ph. Examination BMI end Neck circumference, Neck mobility Chin-Hyoid distance Mouth opening (inter-incisive incisive distance) Microgenia Tongue (Mallampati), Tonsils (Friedman) Septal caudal deviations, valve collapse Evidence of TMJ disfunction

5 IMAGING Panorex Lateral Cephalometry (H&N TC) (H&N NMR)

6 PANOREX Position of the Spix Spine Presence of the 38 and 48 (extraction in case of MMA) Mandibular nerve canal Structure and thickness of the bone Teeth Status Overview LATERAL CEPHALOMETRY Evaluate the skeletal conformation of the patient (micrognatia, retrognatia, prognatism) Evaluate the posterior airway space Position of the hyoid bone (verticalization and posterior positioning of the tongue)

7 ENDOSCOPY Last but not least Upper aerodigestive ways endoscopy PATIENT AWAKE (A-VFNPL): 1. Static 2. Dynamic during SLEEP/SEDATION (S-VFNPL): 1. Spontaneous 2. Drug induced * VFNPL):» SLEEP ENDOSCOPY» * halotane, midazolam, diazepam, propofol, other

8 NOH classification by Claudio Vicini & Eugenio Mira 1999 NOH classification NOH system in staging and morphological grading g of sleep disordered breathing

9 Like oncologic TNM classification NOH aims to: Express in a concise form all the obstructive sites Evaluate the degree of obstruction of each single site Describe the collapse pattern of every single site history Sources of information for NOH classification : physical examination endoscopy imaging

10 Obstructive components (SITES) Nasal & nasopharyngeal Oropharyngeal Hypopharyngeal SDB: pathological sites Obstructive components (SCORE) N The overall nasal evaluation must include the valve area, septum, turbinates, nasal cavities, nasopharynx

11 Obstructive components (SCORE) O Oropharynx is evaluated with Muller s manoeuvre Obstructive components (SCORE) H Hypopharynx is evaluated with Muller s manoeuvre

12 Evaluation of Obstruction Severity obstruction severity obstruction percentage (Muller) O Absent 0% 1 Slight 0-25% 2 Moderate 25-50% 50% 3 Severe 50-75% 4 Complete 100% Obstructive components (PATTERN) Cll Collapse pattern: Antero-Posterior Lateral or Transversal Circular

13 NOH treatment oriented classification/grading of anatomical abnormabilities according to the site Nose & Nasopharynx History, PhEx, Endo, Imaging Oro pharynx PhEx, Endo, Imaging Hypo pharynx ex.: N2/O3c/H2t Endo, Imaging O, 1, 2, 3, 4 Increasing severity of obstruction a,l-t,c, male, 48 yrs severe OSAS BMI 29.8 N0/O4c/H1

14 female, 8 yrs medium OSAS N4/O4c/H0 Advantages: makes topodiagnosis possible all sites included grading of obstruction requires low tech surgically oriented

15 Limits: subject to individual interpretation same limits of Muller m. same limits of cephalography p SLEEP STUDIES Cardio Respiratory Polygraphy Unattended d d Polysomnography Full Night Lab Polysomnography Selection Rules: AIMPS AIPO Guidelines

16 UNATTENDED CARDIORESPIRATORY EXAMINATION. ( Poly-Mesam Mesam ) UNATTENDED POLYSOMNOGRAPHY ( Somno- Screen )

17 ATTENDED FULL NIGHT PSG In our Centre all the patients re- quiring FNPSG are referred to Bologna Sleep Laboratory of Prof. Montagna PSG Patients Stratification: i Normal Simple l Pi Primary Snoring UARS Mild OSAHS Medium OSAHS Severe OSAHS Stridor other

18 PSYCHOMETRICS MEASURE AND PROCEDURE THE PSYCHOMETRIC BATTERY PERFORME PT (Pre Treatment) AND AT (After Treatment) includes: 1) EPWORTH SLEEPINESS SCALE (E.S.S.): a self report scale to evaluate the subjective daytime somnolence 2) CENTER FOR EPIDEMIOLOGICAL STUDIES DEPRESSION SCALE (CES-D): a self report scale (16 items), to evaluate depressive symptoms 3) PERCEIVED STRESS QUESTIONNAIRE (PSQ): aself report scale (30 items) to evaluate the perceived stress level

19 MEASURE AND PROCEDURE SF-36 ITEM SHORT FORM MENTAL HEALTH SURVEY (quality of life questionnaire; a self-reported scale to evaluated 8 demains: physical functioning, role-phisical, bodily pain, general health, vitality, social functioning, role-emotional, emotional mental health) POST-OPERATIVE PAIN: VERBAL NUMERIC SCALE (VNS) (only at post-op) op) a standard 0 (no pain) to 10 (severe pain) scale used to subjective evaluate pain and suffering after surgery. This scale is compilated every day during the hospitalization A QUESTIONNAIRE CONCERNING SELF-PERCEIVED OF SYMPTOMS (sleepiness, work performances, attention, concentration, manual dexterity, social problems, family s problems, sexual difficulties), stimulants consumption (cigarettes, coffee, the, coca cola), accidents in the last six months. SLEEP ENDOSCOPY

20 Now we have the SDB Patient Identity Card and we can perform the most appropriate p treatment

21