Sleep Apnea Syndromes

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2 Treatment of Obstructive Sleep Apnea Syndrome Laugh and the world laughs with you, Snore, snore, snore and you sleep alone Ali Tawfik Abdel wahab Mouhamed Elsharawy Kamal Hazem Emam Waleed Radwan Ahmed Mosad Mansoura,Egypt

3 Political economic signification of Sleep disorders Direct costs of sleep disorders 15,9 Mill US $ Hospitalization costs of non-treated patients with Sleep-Apnoe-syndrome 42 Mill US $ Traffic and industrial accidents in cause of tiredness 50 Mill US $ cardivascular cases of death due to Sleep Apnoea Syndrome in the USA Prevalence of 87% in a study on 159 american truck-drivers

4 Sleep Physiology Five phases of sleep: stages 1, 2, 3, 4, (NREM) and REM (rapid eye movement). These stages progress in a cycle from stage 1 to REM sleep. Then the cycle starts over again with stage 1. We spend almost :- 50 % of our total sleep time in stage 2 sleep. 20 % in REM sleep. 30 % in the remaining the other stages. Infants, by contrast, spend about half of their sleep time in REM sleep.

5 NonREM sleep Sleep Apnea Syndromes superficial sleep (phase I and II) -sleeper can be easy waked up by little influences deep sleep (phase III and IV) REM sleep (dream sleep) Sleep Physiology -brain waves similar to those when you`re awaken, rapid eye-movement, raised muscle-tension

6 Snoring Definition: Sounds generated by the loose redundant soft tissue of the upper airway in the during sleeping. Social effects of snoring: Snoring may be the family life. disruptive to

7 Incidence of Snoring 53% of the adult male population snore intermittently 31% snore regularly. 38% of adult female snore intermittently. 19% snore regularly.

8 Snoring Different grading scales for snoring have been developed. An easy grading system was developed by Pelausaand Trashis(1989). o Grade I No snoring. o Grade 11 Occasional snoring o Grade III Persistent snoring. o Grade IV Persistent loud snoring.

9 Snoring Camilleri et al (1995), have adopted this technique and proposed a simplified grading for patients with simple snoring : Grade 1: Palatal snoring. Grade 2: Mixed snoring. Grade 3: Non-palatal (tongue base) snoring.

10 Should everyone who snores undergo a sleep study? q When the snoring is accompanied by symptoms of OSA, such as morning headache, and restless sleep.. q When snoring is socially disruptive but not accompanied by symptoms of sleep apnea, the picture is not so clear. q Unfortunately, even "apneas" witnessed by bedpartners are not predictive of OSA. q The only reasonably accurate method of detecting OSA remains the sleep study. q Therefore, current recommendations suggest obtaining a sleep study before to any surgery for sleep apnea or snoring.

11 What questions should you ask for a patient with suspected SAS? q Does your snoring ever awaken you from sleep? q Do you ever awaken suddenly, gasping for air? q Do family members complain about your snoring? q Does your spouse notice periods in which breathing temporarily stops? q Do you feel rested (sleepy) after a night's sleep? q Do you feel drowsy at work. q Do you fall asleep at inappropriate times (such as at work, while driving, or while on the telephone)? q Do you have morning headaches?

12 q Epworth Are there Sleepiness special Scale tests is a sensitive to evaluate screening for tool SAS? for OSA. q It is a series of questions about daytime somnolence. q A numerical score is assigned that correlates well to the eventual diagnosis of OSA. q Polysomnography is the most sensitive and specific test in the evaluation of SAS:- q The patient needs to spend a night in sleep lab. q Gives an apnea index (AI), respiratory disturbance index (RDI), and oxygen desaturations q differentiate between pure OSA, and central sleep apnea and can characterize the severity of the apnea.

13 Are there special tests to evaluate for SAS? q Home sleep studies have recently been implemented in an effort to reduce cost. q These studies range from simple continuous pulse oximetry recordings to multi-channel recordings using devices similar to those used in a sleep laboratory. q Although these tests are gaining popularity, none is as sensitive or specific as a sleep laboratory study. q The multiple sleep latency test is also performed in a sleep laboratory, but it is done during the day. q The subject is given the chance to take naps, and this test assesses the time it takes for the subject to fall asleep. q An average sleep onset of < 5 minutes is generally considered pathologic and suggests excessive daytime sleepiness.

14 Are there special tests to evaluate for SAS? q Muller's maneuver is performed as part of an extensive physical examination and involves passing the flexible fiberoptic scope into the hypopharynxto obtain a view of the entire hypopharynxand larynx. q The examiner then pinches the nostrils closed, and the patient closes his or her lips while attempting to inhale. q If the hypopharynxand/or larynx collapse, then the test is positive. q A positive test means that the site of upper airway obstruction is very likely below the level of the soft palate, and the patient will probably not benefit from a uvulopalatopharyngoplastyalone. q Tongue base procedures may be necessary

15 Are there special tests to evaluate for SAS? q Sleep flexible fiberoptic endoscopy is occasionally perfored for apnea. q A flexible fiberoptic endoscope is passed into the hypopharynx to watch the patient breathe while under a light general anesthetic. q This can help to evaluate the site of obstruction and may encourage the physician to do some type of tongue base procedure.

16 Sleep Apnea Obstructive Central Mixed Hypopnea Obesity-hypoventlation (Pick wickian syndr.) Upper-airway Resistance syndr. Neurological Narcolepsy Insomnia Periodic leg movement(plm) (Restless legs) Bruxism, Sleep walking, Hypersomnia, Sleep terrors

17 Sleep Apnea Syndrome Definition: Apnea:- Cessation of airflow from the mouth and nose during sleeping period for 10 seconds or more, for 5 times or more per hour. Apnea Index (AI): The total number of apneas per hour of sleep. Hypopnea: 50% or more reduction in the amplitude of a validated measure of breathing or a less than 50% amplitude reduction that is associated with either an arousal or more than 3% drop in oxygen saturation Apnea Hypopnea Index (AHl): Summation of apneas and hypopneasper hour sleep.

18 Sleep Apnea Syndrome Desaturation: Drop of oxygen saturation of at least 4% or more from baseline and maintained for at least 10 seconds. Desaturation Index: The number of desaturation events per hour, averaged over all hours of sleep Arousal Index: The number of times per hour a patient is aroused from sleep.

19 Types of SAS Obstructive Sleep Apnea Central Sleep Apnea Mixed Sleep Apnea Upper-airway Resistance syndr.

20 Types of SAS Obstructive apnea Cessation of airflow for at least 10 seconds with respiratory effort Central apnea Cessation of airflow and without respiratory effort for at least 10 seconds Mixed apnea Characteristics of both for at least 10 seconds Hypopnea Hypoventilation secondary to partial obstruction

21 Evaluation of Sleep Polysomnography EMG Airflow EEG EOG Oxygen Saturation Cardiac Rhythm Leg Movements Chest & abdominal motion Types of SAS Obstructive Sleep Apnea Central Sleep Apnea Mixed Sleep Apnea Upper-airway Resistance syndr.

22 Polysomnogram Polysomnography EMG Airflow EEG EOG Oxygen Saturation Cardiac Rhythm Leg Movements Chest & abdominal motion

23 Polysomnography 1. Inpatient (sleep lab) 2. Patients home 3. Split night study

24 What are the polysomnographiccharacteristics of OSA? Apnea: Apnea:- Temporary cessation of air exchange due to obstruction of the upper airway while normal or extraordinary respiratory efforts are being made. Hypopnea a reduction of air exchange associated with oxygen desaturation. It can be obstructive or central. q Mixed sleep apnea Exhibits components of both central and obstructive apnea but is considered a variant of OSA. Treatment is similar to treatment for OSA. q q q Sleep Apnea Syndromes Apnea Index (AI) number of apnea events per hour. Respiratory Disturbance Index (RDI) number of apnea events plus number of hypop nea events per hour. "Pickwickian Charles Dickens, in The Posthumous Papers of the Pickwickian Club (1837), described the obese and somnolent Joe." Pickwickian syndrome is characterized by obesity and hypoventilation who "goes on errands fast asleep and snores.

25 Polysomnogram Obstructive apnea Cessation of airflow for at least 10 seconds with respiratory effort Central apnea Cessation of both airflow and respiratory effort for at least 10 seconds Mixed apnea Characteristics of both for at least 10 seconds Hypopnea Sleep Apnea Syndromes Hypoventilation secondary to partial obstruction

26 Polysomnogram Apnea index Apnea-Hypopnea index = respiratory disturbance index Arousal index

27 Grading of Sleep Apneas Mild 5-20 *AI (per hour) Moderate AI (per hour) Severe >40 AI (per hour) **(American Sleep Association) *AI =Apnea Index

28 Upper airway resistance syndrome (UARS) This is considered as a mild variant of OSA, Patients present with complaints of excessive daytime sleepiness and snoring, but not have apneas or hypopneas when evaluated by polysomnography. Esophageal pressure manometry demonstrates progressive negative pressure followed by frequent arousals. It is diagnosed by esophageal pressure measurement using an esophageal catheter.

29 Types of SAS Obstructive Sleep Apnea Central Sleep Apnea Mixed Sleep Apnea

30 Central Sleep Apnea

31 Central Sleep Apnea CSA is much less common than OSA and must be distinguished from it. CSA occurs when the neural drive to the respiratory muscles is temporarily abolished, resulting in an absence of respiratory effort (Chest & abdominal motion).

32 Central Sleep Apnea During sleep respiration is controlled by:- Automatic feedback system. Sensory signals from multiple receptors are relayed to the brain stem, where they are integrated, and the brain stem sends signals, which stimulate the muscles of respiration and lungs. Any condition affecting this feedback system may cause CSA.

33 Central Sleep Apnea Respiration During Sleep by Automatic feed back system Receptors in respiratory muscles and lungs Sensory Signals Stimulatory Signals Brainstem Any causes affect this automatic feed back system

34 Central Sleep Apnea Causes of CSA:- Any condition affect this automatic feed back system Congenital central alveolar hypoventilation, which results from a very low sensitivity to increased PCO2. Chronic neuropathies mayalso impair the sensory component. Bilateral brainstem lesions:- vascular conditions. Infections, and degenerative and metabolic diseases affect integrative function. Neuromuscular disease, such as:- Polio, amyotrophic lateral sclerosis, and muscular dystrophies,impair motor function. Chronic obstructive pulmonary disease and congestive heart failure.

35 Central Sleep Apnea With polysomnography (Sleep Lab.):- CSA can be diagnosed and its degree of severity and can be determined. CSA can also be confirmed by measuring :- Esophageal pressure. Respiratory efforts during sleep.

36 Central Sleep Apnea The primary treatment for CSA: Nasal mask ventilation using CPAP, intermittent positive pressure ventilation. Medication to stimulate respiration and to increase the tone of the genioglossus and geniohyoid muscles have had limited success. In the most severe cases tracheostomy.

37 Obstruction Sleep Apnea Syndrome (OSAS)

38 Pathophysiology of OSA Sites of Obstruction Obstruction tends to propagate

39 Pathophysiology of OSA Sites of Obstruction: Fujita,etal, 1981

40 Pathophysiology of OSA Pharyngeal collapse Decreased airway patency Increase in negative pressure Becomes a vicious cycle

41 What is the pathophysiology of OSA? q OSA can be caused by an obstruction at any level of the upper airway (i.e., above the true vocal cords or glottis). q Respiratory physiology dictates that during inspiration, there is a negative pressure within the upper airway. q Sleep physiology reveals that during the deeper stages of sleep (NREM:-_ stages III, IV, and REM), there is muscle relaxation of the entire body, including the muscles of the upper airway. q Most patients with OSA have redundant tissue or an abnormally small air passage.

42 What is the pathophysiology of OSA? q In the presence of these anatomic variants, these two physiologic events combine to result in collapse of the upper airway, with resulting obstruction to airflow. q Oxyhemoglobin desaturation eventually leads to an arousal to a lighter level of sleep, and the airway is re-established with the characteristic loud snorting respiration. q Any factor that adds to upper airway obstruction can cause or exacerbate OSA, including:- q Bulky soft palate or uvula, q Fullness in the base of the tongue, q Adenotonsillar hypertrophy, q Low lying hyoid bone q Obstructive laryngeal masses, q Nasal obstruction????????.

43 Pathophysiology-complications Desaturation with compensatory polycythemia Hypercapniawith pulmonary hypertension Systemic hypertension Arrythmias

44 Polysomnogram Apnea index Apnea-Hypopnea index = respiratory disturbance index Arousal index

45 Obstruction Sleep Apnea DIAGNOSIS History Examination Investigations

46 Obstruction Sleep Apnea Symptoms of OSA Snoring (most commonly noted complaint) Cessation of breathing during the sleep Daytime Sleepiness Hypertension and Cardiovascular Disease are Associated Pulmonary Disease

47 Obstruction Sleep Apnea Findings in Obstruction: Nasal Obstruction????? Long, thick soft palate Narrowed oropharynx Redundant pharyngeal tissues Large lingual tonsil Large tongue Retrodisplaced Mandible Retro-displaced hyoid complex Large or floppy Epiglottis???

48 SYMPTOMS and SIGNS OF OSA Snoring Pauses in breathing Gasping or choking Restless sleep Excessive sleepiness or fatigue during the day Poor judgment or concentration Irritability Memory loss High blood pressure Depression Obesity Large neck size (>17" in men; >16" in women) Crowded airway Morning headache Sexual dysfunction Frequent urination at night

49 Evaluation -history restless sleep personality change impaired cognitive skills weight gain morning headache nocturia/enuresis sexual dysfunction sedative use

50 What should you look for on the physical examination of a patient with suspected OSA? qretrognathia and/or macroglossia can also contribute to OSA. Full, thick necks may also predispose patients to OSA, especially in the setting of an overall "pickwickian" patient. qlaryngeal examination should be performed to rule out any obstructing lesion.

51 Oral cavity and oropharynx Careful examination of the oral cavity and oropharynx is of principal importance. Because many of the surgical procedures performed to improve OSA are performed on this area. The examination should take special notes of the potentially correctable anatomy or deformities. The oropharynx can be assessed using the modified Mallampati stechnique :- The patient is evaluated with the mouth open and without protrusion of the tongue. The patient is asked to open the mouth widely with the tongue left in place and oropharyngealcrowding is graded as follows.

52 The modified Mallampatitechnique is highly predictive of the severity of obstractivcsleep apnea The oropharynx can be assessed using the modified Mallampati s technique ):- The patient is evaluated with the mouth open and without protrusion of the tongue. The patient is asked to open the mouth widely with the tongue left in place and oropharyngeal crowding is graded as follows` Mallampati oropharyngeal grades A.Grade I The tonsils, pillars, and soft palate are clearly visible A. B. Grade II The uvula, pillars and upper pole are visible. C. Grade III Only part of the soft palate is visible; the tonsils, pillars, mid base of the uvula cannot be seen. D. Grade IV Only the hard palate is visible. (Friedman Metal, 1999)

53 The Tonsils can be graded as follows 0 I II III IV o Grade 0 : The patient had a tonsillectomy. o Grade I : Tonsils are in tonsillarfossa, barely seen behind the anterior pillars. o Grade II: The Tonsils are visible behind the anterior pillars. o Grade III :The Tonsils are extending three quarters oft he way to the midline. o Grade IV : The Tonsils are completely obstructing the airway, also knownas kissing tonsils Normal nose and pharynx on one side. Abnormalities associated with snoring on the other side: long soft palate and uvula, large tongue and lingual tonsil, large palatine tonsil and deviated nasal septum. The tonsil grading was found to be both predictive of the presence of OSA and significantly related to the severity of OSA Friedman et al, 1999

54 Pathophysiology of OSA Tests to determine site of obstruction: Muller s Maneuver Sleep nasoendoscopy Fluoroscopy Manometry Cephalometrics Dynamic CT scanning and MRI scanning A Sleep nasendoscopy. (a) The palatal closure is viewed, (b) The tongue base and larynx are viewed. B

55 Muller s Maneuver Fibro optic nasoendoscopy a b A B Flexible fiberopticview of the retropalatalregion at rest and with Muller Maneuver A 90 % collapse of the retropalatalregion is noted here. (Courtesy of Richard J. Schwab,MD Philadelphia, PA.) Sleep nasendoscopy. (a) The palatal closure is viewed, (b) The tongue base and larynx are viewed.

56 DIAGNOSIS History Examination Investigations

57 Oximetery In Sleep Apnea

58 Oximetery

59 Oximetery In Sleep Apnea

60 Oximetery In Sleep Apnea

61 DIAGNOSIS

62 DIAGNOSIS

63 DIAGNOSIS

64 Complications of OSAS Related to excessive daytime sleepiness. Related to cardiovascular system Systemic Hypertension Pulmonary Hypertension Arrhythmia Right Heart Failure Myocardial Infarction Complete Heart Block

65 Causes of Death in OSAS Cardiovascular Heart Failure Myocardial Infarction Complete Heart Block Motor Car Accidents

66 Treatment of OSAS Findings in Obstruction: Nasal Obstruction????? Long, thick soft palate Narrowed oropharynx Redundant pharyngeal tissues Large lingual tonsil Large tongue Retrodisplaced Mandible Retro-displaced hyoid complex Large or floppy Epiglottis???

67 Treatment of OSAS Nonsurgical Treatment Surgical Treatment

68 Treatment of SAS

69 Treatment of OSAS Nonsurgical Treatment Surgical Treatment

70 Treatment of OSAS NonsurgicalTreatment 1. Weight loss 2. Drug review( Sedative, Hypnotics) 3. Nasal medication 4. Nasal Dilators 5. Positional advice 6. Oral device a. Mandibular positioning device b. Tongue retaining device 7. Continuous Positive Airway Pressure (CPAP) 8. Drug treatment (e.g. protriptyline)

71 Treatment of OSAS NonsurgicalTreatment 1. Weight loss 2. Drug review( Sedative, Hypnotics) 3. Nasal medication 4. Nasal Dilators 5. Positional advice 6. Oral device a) Mandibular positioning device b) Tongue retaining device 7. Continuous Positive Airway Pressure (CPAP) 8. Drug treatment (e.g. protriptyline)

72 Treatment of OSAS Nonsurgical Treatment Weight loss Should be recommended for OSAS Decrease the severity of OSAS Unfortunately, is difficult to achieve and to maintain for these patients of OSAS.

73 Nonsurgical Treatment Weight loss Get below trigger weight Diet, exercise, bariatric surgery, medications Sleep hygiene Avoidance of sedatives Positional changes

74 Treatment of OSAS Nonsurgical Treatment 1. Weight loss 2. Drug review( Sedative, Hypnotics) 3. Nasal medication 4. Nasal Dilators 5. Positional advice 6. Oral device a) Mandibular positioning device b) Tongue retaining device 7. Continuous Positive Airway Pressure (CPAP) 8. Drug treatment (e.g. protriptyline)

75 Treatment of OSAS Nonsurgical Treatment Drug review Avoidance of Sedatives, hypnotics and alcohol because they increase the severity of OSAS.

76 Treatment of OSAS Medical Treatment 1. Weight loss 2. Drug review( Sedative, Hypnotics) 3. Nasal medication 4. Nasal Dilators 5. Positional advice 6. Oral device a) Mandibular positioning device b) Tongue retaining device 7. Continuous Positive Airway Pressure (CPAP) 8. Drug treatment (e.g. protriptyline)

77 Nasal medication

78 Treatment of OSAS Nonsurgical Treatment 1. Weight loss 2. Drug review( Sedative, Hypnotics) 3. Nasal medication 4. Nasal Dilators 5. Positional advice 6. Oral device a) Mandibular positioning device b) Tongue retaining device 7. Continuous Positive Airway Pressure (CPAP) 8. Drug treatment (e.g. protriptyline)

79 Nasal Dilators

80 Treatment of OSAS Nonsurgical Treatment 1. Weight loss 2. Drug review( Sedative, Hypnotics) 3. Nasal medication 4. Nasal Dilators 5. Positional advice 6. Oral device a) Mandibular positioning device b) Tongue retaining device 7. Continuous Positive Airway Pressure (CPAP) 8. Drug treatment (e.g. protriptyline)

81 Treatment of OSAS NonsurgicalTreatment Positional advice:- Mild and Moderate OSAS may be improved by sleeping in the lateral position by using night shirt with tennis balls in the back

82 Positional advice

83 Treatment of OSAS Nonsurgical Treatment 1. Weight loss 2. Drug review( Sedative, Hypnotics) 3. Nasal medication 4. Nasal Dilators 5. Positional advice 6. Oral device a) Mandibular positioning device b) Tongue retaining device 7. Continuous Positive Airway Pressure (CPAP) 8. Drug treatment (e.g. protriptyline)

84 Nonsurgical Treatment Treatment of OSAS Oral device Advances the mandible Retains the tongue anteriorly

85 Treatment of OSAS Nonsurgical Treatment 1. Weight loss 2. Drug review( Sedative, Hypnotics) 3. Nasal medication 4. Nasal Dilators 5. Positional advice 6. Oral device a) Mandibular positioning device b) Tongue retaining device 7. Continuous Positive Airway Pressure (CPAP) 8. Drug treatment (e.g. protriptyline)

86 Nonsurgical Treatment Continuous Positive Airway Pressure( CPAP) 1981 Very effective Can be modified and used on a trial basis

87 Nonsurgical Treatment Continuous Positive Airway Pressure( CPAP) Function of the CPAP-therapy During inspiration air will be sucked in: low pressure Patients with sleep apnea have a high collapsibility of the upper airways: it comes to a collapse or to a complette occlusion The CPAP device opens the upper airways with a possitive pressure

88 Treatment of OSAS Nonsurgical Treatment Continuous Positive Airway Pressure( CPAP)

89 Nonsurgical Treatment Continuous Positive Airway Pressure( CPAP) Act as a pneumatic splint of the collapsed pharynx

90 Nonsurgical Treatment Continuous Positive Airway Pressure( CPAP) Titrated to limit all respiratory events 50-90% acceptance better if daytime symptoms improved Side effects in 40-50%

91 Nonsurgical Treatment Continuous Positive Airway Pressure( CPAP)

92 Nonsurgical Treatment Continuous Positive Airway Pressure( CPAP)

93 Nonsurgical Treatment q q q q q q q Continuous Positive Airway Pressure( CPAP) Nasal continuous positive airway pressure (CPAP) is the most effective nonsurgical treatment of OSA. An airtight mask is held over the nose by a strap wrapped around the patient's head. CPAP is maintained by a machine that is similar to a ventilator. Although nasal CPAP is nearly 100% effective in relieving OSA, compliance is a problem. The masks and positive pressure are uncomfortable for many people. Longterm compliance is 50% to 75%, depending on the level of support the patients are given by the medical staff. Bilevel positive airway pressure (BiPAP) is often tolerated better by decreasing the expiratory pressure.

94 Treatment of OSAS Medical Treatment 1. Weight loss 2. Drug review( Sedative, Hypnotics) 3. Nasal medication 4. Nasal Dilators 5. Positional advice 6. Oral device a) Mandibular positioning device b) Tongue retaining device 7. Continuous Positive Airway Pressure (CPAP) 8. Drug treatment (e.g. protriptyline)

95 Treatment of OSAS Medical Treatment Drug treatment (e.g. protriptyline)

96 Surgical Treatment of OSAS Surgical Treatment Philosophy 1. Treatment to cure 2. Site-specific surgical therapy 3. Staged surgical management (if necessary) 4. Full patient disclosure of options and risks 5. Follow-up all treatment

97 Surgical Treatment of OSAS Surgical Indications for Treatment 1. Apnea-hypopnea index of >15 2. Oxyhemoglobin desaturation of <90% 3. Excessive daytime sleepiness 4. Upper airway resistance syndrome, preferably with objective improvement of neurocognitive dysfunction using medical therapy 5. Significant cardiac arrhythmias associated with obstructions 6. Unsuccessful or refused medical therapy and desire for surgery 7. Medically stable enough to undergo the recommended procedure (s)

98 Surgical Treatment of OSAS The success depends on proper diagnosis. After failure of medical treatment. Presence of specific surgically correctable abnormality. The aim is widening the upper airway by:- Reduction of the soft tissues of the oroph. Advancement of the tongue or jaws Types of Surgery depend on :- The site of obst. Grade of obst. Cause of obstruction. Mild 5-20 AI (per hour) Moderate AI (per hour) Severe >40 AI (per hour) **(American Sleep Association)

99 Surgical Treatment of OSAS Two phases Phase I * Nasal, UPPP, mandibular advancement and GAHM Phase II * Bimaxillaryadvancement. * Base of the Tongue Surgery. (Powell et al.,) 1998

100 Surgical Treatment of OSAS Nasal Surgery Laser-assisted uvulopalatoplasty (LAUP)** Electrocautery-assisted uvulopalatoplasty (EAUP)** Radioferquency assisted uvulopalatoplasty (RAUP)** Adeno-tonsillectomy in children Uvulo-palato-pharyngoplasty (UPPP) Genio-glossus advancement with hyoid myotomy (GAHM) Linguoplasty Mandibular advancement Maxillo-mandibularadvancement Tracheostomy

101 Surgical Treatment of OSAS Nasal Surgery Limited efficacy when used alone Verse et al 2002 showed 15.8% success rate when used alone in patients with OSA and day-time nasal congestion with snoring (RDI<20 and 50% reduction) Adenoidectomy

102 Surgical Treatment of OSAS Nasal Surgery Laser-assisted uvulo-palatoplasty (LAUP)** Electrocautery-assisted uvulopalatoplasty (EAUP)** Radioferquency assisted uvulopalatoplasty (RAUP)** Adeno-tonsillectomy in children Uvulo-palato-pharyngoplasty (UPPP) Genio-glossus advancement with hyoid myotomy (GAHM) Linguoplasty Mandibular advancement Maxillo-mandibularadvancement Tracheostomy

103 Surgical Treatment of OSAS Laser-assisted uvulo-palatoplasty (LAUP)** Electrocautery-assisted uvulopalatoplasty (EAUP)** Radioferquency assisted uvulopalatoplasty (RAUP)** Recommended for snorers without OSA.

104 What are the surgical treatments of snoring and OSA? Palate q Palate reduction can be achieved by laser-assisted uvulopalatoplasty (LAUP), submucosal radiofrequency device, electrocautery(termed Bovieassisted uvulopalatoplastyor BAUP), or uvulopalatopharyngoplasty. q For snoring, LAUP, BAUP, and the radiofrequency procedures are usually performed. For each of these procedures, as healing occurs the soft palate elevates, shortens, and stiffens, reducing the tendency to vibrate. q Electrocautery is less expensive and more widely available.

105 What are the surgical treatments of snoring and OSA? Palate q q q q q Sleep Apnea Syndromes These procedures are performed in a doctor's office or in an outpatient setting under local anesthesia. They often require two to four stages, each separated by about 1 month, titrating the procedures to resolve the snoring without causing velopharyngeal insufficiency. Radiofrequency procedures usually help about 80% of the patients achieve significant improvement in their snoring. It is only minimally uncomfortable for the patients. LAUP, BAUP, and UPPP improve snoring in 90% of patients but cause severe pain for days. LAUP and radiofrequency palate procedures for the treatment of true OSA have not been widely accepted, although they appear to have some positive effect in mild to moderate OSA.

106 Surgical Treatment of OSAS Laser Assisted Uvulopalatoplasty High initial success rate for snoring Rates decrease, as for UP at twelve months Performed awake Kamami Technihue 1997

107 Surgical Treatment of OSAS Radioferquency assisted uvulopalatoplasty (RAUP)*

108 Surgical Treatment of OSAS Radiosurgically-Assisted Uvulopalaplasty (RAUP) The steps of Radiosurgically-Assisted Uvulopalatoplasty (RAUP). (a) Before the operation (A) Pa/ata/incision on the right side (c) Bilateral palatal incisions (d) The final view after partial uvulectomy.

109 Surgical Treatment of OSAS Laser-assisted uvulo-palatoplasty (LAUP)** Electrocautery-assisted uvulopalatoplasty (EAUP)** Radioferquency assisted uvulopalatoplasty (RAUP)** Silent apneics Where the snoring is controlled but undiagnosed life threatening OSA may persist. Must be considered.

110 Surgical Treatment of OSAS Nasal Surgery Laser-assisted uvulopalatoplasty (LAUP)** Adeno-tonsillectomy in children Uvulo-palato-pharyngoplasty (UPPP) Genio-glossusadvancement with hyoid myotomy (GAHM) Linguoplasty Mandibular advancement Maxillo-mandibularadvancement Tracheostomy

111 Surgical Treatment of OSAS Adeno-tonsillectomy in children

112 Surgical Treatment of OSAS Nasal Surgery Laser-assisted uvulopalatoplasty (LAUP)** Adeno-tonsillectomy in children Uvulo-palato-pharyngoplasty (UPPP) Genio-glossusadvancement with hyoid myotomy (GAHM) Linguoplasty Mandibular advancement (MA) Maxillo-mandibularadvancement (MMA) Tracheostomy

113 Pathophysiology of OSA Sites of Obstruction: Fujita,etal, 1981

114 Surgical Treatment of OSAS Riley-Powell-Stanford Protocol Fujita,etal, 1981 Riley-Powell,1998

115 Surgical Treatment of OSAS Two phases Phase I * Nasal, UPPP, mandibular advancement and GAHM Phase II * Bimaxillaryadvancement. * Base of the Tongue Surgery. (Powell et al.,) 1998

116 Surgical Treatment of OSAS Uvulo-palato-pharyngoplasty(UPPP) Indications of UPPP Socially disruptive snoring. OSAS at the velopharyngealor upper oropharyngeal level.

117 Surgical Treatment of OSAS Uvulo-palato-pharyngoplasty(UPPP) The Aim is to enlarge the retro-palatal airway by:- 1- Excision of the tonsils if present. 2- Excise uvula and posterior portion of the soft palate. 3- Trim or reorient the anterior and posterior pillars

118 Surgical Treatment of OSAS General anaesthesia 1-Very difficult intubation. 2-Ready to use an alternative technique of intubation. 3-No preop. Sedation. 4-Ready for emergency tracheostomy. 5-Extubatedwhen fully awake. 6-Post operative CPAP. 7-IV steroid during and post op. 8-No post op. sedative or Hypnotics. 9-Post op. ICU especially for cardiac patients

119 Surgical Treatment of OSAS Uvulo-palato-pharyngoplasty(UPPP) Judging the amount of soft palate to be resected.

120 Surgical Treatment of OSAS Uvulo-palato-pharyngoplasty(UPPP) Ikematsu, 1964 Fujita,etal, 1981 Simmons et al 1983 Many modifications

121 Surgical Treatment of OSAS Uvulo-palato-pharyngoplasty(UPPP) A box-like resection. Reconstruction. Deep sutures pulling.forwardsthe posterior pillar

122 Surgical Treatment of OSAS Uvulo-palato-pharyngoplasty (UPPP) Fujita et al 1987

123 Surgical Treatment of OSAS Uvulo-palato-pharyngoplasty(UPPP)

124 Surgical Treatment of OSAS Uvulopalatopharyngoplasty The most commonly performed surgery for OSA Severity of disease is poor outcome predictor Levin and Becker (1994) successedup to 80% initial success, but decreased to 46% success rate at 12 months Friedman et al (1999 ) showed a success rate of 80% at 6 months in carefully selected patients Friedman M, Ibrahim H, Bass L. Clinical staging for sleep-disordered breathing. Otolaryngol Head Neck Surg 2002; 127:

125 Surgical Treatment of OSAS Results of UPPP Curing snoring 85-90% Reduce apnea index 77% Improving excessive daytime sleepiness and performance

126 Surgical Treatment of OSAS Side Effects of UPPP Extremely painful op. Postop. Bleeding up to 3% Nasal regurgitation Dry throat Disturbance of the taste Hypernasal speech Velopharyngeal stenosis

127 UPPP Sleep Apnea Syndromes Surgical Treatment of OSAS Still not fully defined, although may eliminate snoring but it has been not shown to improve long-term mortality. This reinforces the importance of patient selection and late postoperative reassessment. (Charles & Michael 1997)

128 Surgical Treatment of OSAS UPPS Complications Minor Transient VPI Hemorrhage<1% Major NP stenosis VPI Death Emergent Tracheotomy

129 Surgical Treatment of OSAS The reversible uvulopalatal flap ( A), Preoperative palate anatomy. (B), Uvula is grasped with a forceps and reflected back toward the soft-hard palate junction; note the muscular crease.( C), The mucosa of the oral aspect of the uvula and soft palate in a diamond shape is removed with cold knife dissection; the uvular tip is amputated and the uvular muscle thinned, if necessary. (D), Trimmed and sutured flap, with the shaded area indicating the location of the tissue before it is repositioned. E, Postoperative appearance, with closure up on the soft palate ( Powell,1996.)

130 Surgical Treatment of OSAS Hypopharyngeal and Base-of-Tongue Procedures In the early 1980s, Fujita and colleagues recognized that many patients with OSA have obstruction at multiple levels of the pharynx. Riley and colleagues (1985 ) assessed UPPP failures with cephalometric analysis and concluded that the base of the tongue was the cause of the persistent obstruction. Schwab, Gefter, and Hoffman (1995) examined the upper airways of patients with OSA using magnetic resonance imaging and determined that collapse of the lateral pharyngeal wall was a significant component of sleep-related airway obstruction. Addressing hypopharyngeal obstruction has substantially improved surgical success rates and motivated the search for surgical procedures to improve reconstruction in this anatomic area.

131 Surgical Treatment of OSAS Nasal Surgery Laser-assisted uvulopalatoplasty (LAUP)** Adeno-tonsillectomy in children Uvulo-palato-pharyngoplasty (UPPP) Genio-glossusadvancement with hyoid myotomy (GAHM) Linguoplasty Mandibular advancement Maxillo-mandibularadvancement Tracheostomy

132 Surgical Treatment of OSAS Nasal Surgery Laser-assisted uvulopalatoplasty (LAUP)** Adeno-tonsillectomy in children Uvulo-palato-pharyngoplasty (UPPP) Genio-glossusadvancement with hyoid myotomy (GAHM) Linguoplasty Mandibular advancement Maxillo-mandibularadvancement Tracheostomy

133 Surgical Treatment of OSAS Nasal Surgery Laser-assisted uvulopalatoplasty (LAUP)** Adeno-tonsillectomy in children Uvulo-palato-pharyngoplasty (UPPP) Genio-glossusadvancement with hyoid myotomy (GAHM) Linguoplasty Mandibular advancement Maxillo-mandibularadvancement Tracheostomy

134 Surgical Treatment of OSAS Genio-glossus advancement with hyoid myotomy (GAHM) The aim is to widen the hypopharynx by advancing the tongue base. Usually is combined with UPPP.

135 Surgical Treatment of OSAS Genioglossus Advancement Rarely performed alone. Increases rate of efficacy of other procedures. Usually is combined with UPPP

136 Surgical Treatment of OSAS Hyoid Myotomy and Suspension Advances hyoid bone anteriorly and inferiorly. Advances epiglottis and base of tongue. Performed in conjunction with other procedures. Dysphagia may result.

137 Surgical Treatment of OSAS Nasal Surgery Laser-assisted uvulopalatoplasty (LAUP)** Adeno-tonsillectomy in children Uvulo-palato-pharyngoplasty (UPPP) Genio-glossusadvancement with hyoid myotomy (GAHM) Linguoplasty Mandibular advancement Maxillo-mandibularadvancement Tracheostomy

138 Surgical Treatment of OSAS Linguoplasty 1-Failed UPPP. 2-Hypopharyngealcollapse. 3-Major retro-glossalnarrowing. 4- By surgery or laser.

139 Surgical Treatment of OSAS Tongue Base Procedures Lingual Tonsillectomy may be useful in patients with hypertrophy, but usually in conjunction with other procedures

140 Surgical Treatment of OSAS Tongue Base Procedures Lingualplasty Chabolle, et al success rate of 77% (RDI<20, 50% reduction) in 22 patients in conjunction with UPPP Complication rate of 25% -bleeding, altered taste, odynophagia, edema Can be combined with epiglottectomy Lingual Suspension:

141 Surgical Treatment of OSAS Nasal Surgery Laser-assisted uvulopalatoplasty (LAUP)** Adeno-tonsillectomy in children Uvulo-palato-pharyngoplasty (UPPP) Genio-glossusadvancement with hyoid myotomy (GAHM) Linguoplasty Mandibular advancement Maxillo-mandibularadvancement Tracheostomy

142 Surgical Treatment of OSAS Mandibular advancement

143 Surgical Treatment of OSAS Mandibular advancement

144 Surgical Treatment of OSAS Nasal Surgery Laser-assisted uvulopalatoplasty (LAUP)** Adeno-tonsillectomy in children Uvulo-palato-pharyngoplasty (UPPP) Genio-glossusadvancement with hyoid myotomy (GAHM) Linguoplasty Mandibular advancement Maxillo-mandibularadvancement Tracheostomy

145 Surgical Treatment of OSAS Maxillo-mandibularadvancement RESERVED FOR PATIENTS WITH SEVERE OSAS

146 Surgical Treatment of OSAS Maxillo-mandibular advancement

147 What are the surgical treatments of snoring and OSA Tongue base q Radiofrequency tongue base reduction, lag screw and suture suspension of the tongue and hyoid, advancement genioplasty combined with a hyoid suspension, distraction osteogenesis, partial midline glossectomy, and maxillomandibular advancement are used to reduce obstruction at the tongue base. q Radiofrequency tongue base reduction can obtain a 17% reduction in tongue base volume and has been shown to decrease RDI from 40 to 8, but it can require four to eight staged procedures, with a month between each one. q Patients should be in a monitored setting for the night after the procedure.

148 What are the surgical treatments of snoring and OSA? Tongue base q q q q q q Sleep Apnea Syndromes Lag screw and suture suspension of the tongue and hyoid are procedures that pull the tongue forward. Lag screws with preloaded sutures are driven into the inner cortex of the anterior mandible below the level of the teeth. A floor of mouth incision is made for the tongue suture. Submental incisions are made for the hyoid suspension. Sutures are then passed around the hyoid and through the tongue base to pull the tongue forward. The best data presented showed a 60% average decrease in RDI from 74 to about 30. Although this is a painful procedure, it is less morbid than some of the other options.

149 What are the surgical treatments of snoring and OSA Tongue base q Partial midline glossectomy, using either a laser or electrocautery, can be performed. q It requires a tracheotomy because significant bleeding and swelling can occur. q It is highly effective, with average decreases in RDI from 59 to 8. Because of the tracheotomy this procedure has not gained wide acceptance. q Maxillo-mandibular advancement is highly effective in a select group of relatively young, healthy, thin patients with retrusive midfaces and retrognathic mandibles. q Success in this select group of patients is essentially 100%. q This is a much larger operation than the UPPP, but it does successfully alter the anatomic anomalies that cause OSA. q Maxillo mandibular advancement is achieved using bilateral sagittal split osteotomies in the mandible and LeFort I osteotomies in the midface.

150 Surgical Treatment of OSAS Surgical complications The risks of UPPP include postoperative ;- Bleeding (196-5%). Infection (2%). Transient nasal reflux (12%-15%). Nasopharyngeal stenosis(<1%). Altered speech (rare). The complications associated with the genioglossusadvancement and hyoid suspen sion include:- Infection (2%-5%). Need for root canal therapy (4%). Permanent anesthesia (6%). Seroma (2%). There are also small risks of mandibular frac-ture, aspiration, and death. Edelman RR et al, 1990.

151 Surgical Treatment of OSAS Surgical Results Three to four months after upper airway reconstruction, patients should undergo a postoperative polysomnogram to determine the response to surgical therapy. The success of surgical intervention has been defined in a number of ways.

152 Surgical Treatment of OSAS Defining Surgical Success 50% reduction in the AHI or a 50% reduction in the AI Polysomnographicimprovement. Patients should experience relief from their snoring and improved sleep hygiene. The elimination. Excessive daytime somnolence. Better-quality sleep. Improved ability to concentrate. Elimination of the necessity of naps. Improved work performance. If neurocognitivedysfunction exists even with mild obstructive objective sleep parameters additional treatment should be considered.

153 Surgical Treatment of OSAS Nasal Surgery Laser-assisted uvulopalatoplasty (LAUP)** Adeno-tonsillectomy in children Uvulo-palato-pharyngoplasty (UPPP) Genio-glossusadvancement with hyoid myotomy (GAHM) Linguoplasty Mandibular advancement Maxillo-mandibularadvancement Tracheostomy

154 Surgical Treatment of OSAS Tracheostomy Bypasses all areas of obstruction Virtually 100% effective Two indications 1- Temporary procedure during airway reconstruction. 2- Severe OSA when CPAP refused, ineffective, or not tolerated or if other conditions exacerbated by the apneas. 3- OSA associated with serious complications as cardiac arrhythmias or cor-pulmonale Line the tract with skin flaps Lack of social acceptance Tracheostomy

155 Surgical Treatment of OSAS Tracheostomy for treatment of OSAS Cures 100% of OSAS Indications Severe OSAS Failure of medical and surgical treatment Associated complications Life-saving for serious cardiac arrhythmias A Tracheostomy will allow many patients to return to a near normal lifestyle Tracheostomy

156 Surgical Treatment of OSAS Tracheostomy q q q q q q q Tracheotomy remains the gold standard in the treatment of OSA. It bypasses the upper air way entirely and is effective in almost all patients, including those with severe disease. In patients with very severe disease, those who are markedly obese, or those who are debilitated, it is probably the initial procedure of choice. Effectiveness in this group of patients is in the high 90% range. The other methods that have been described realistically have little chance of benefit. However, the patient must live with and care for the tracheotomy on a daily basis, which is undesirable to most patients. For children with craniofacial abnormalities, such as Pierre Robin syn drome, a tracheotomy is a good intervention until the child grows enough to undergo mandibular advancement procedures.

157 Sleep Apnea Syndromes Conclusions SAS is extremely common medical disorder in the past 30 years. 4 to 5% of the population complain of SAS. 2 to 4% of the population complain of OSAS. SAS plays a large part of the road traffic and industrial accidents due to sleepiness.

158 Sleep Apnea Syndromes Conclusions (Cont.) Proper diagnosis and treatment needs Team work consists of :-Chest physicians, ENT surgeons, Cardiologists, Neurologists and Anaesthetists. Sleep lab. Searching for a simple, safe, cheap, objective and reliable methods for diagnosis and treatment of OSAS.

159 Sleep Apnea Syndromes What does the future hold for OSA? q Improvement in weight control may be available in the near future with advances in behavioral, pharmacologic, nutritional, and possibly genetic treatments. q Continued improvement of CPAP and BiPAPmachines. q Surgical advances, such as radiofrequency reduction of parapharyngeal fat pads, are being investigated. q Phrenic nerve to hypoglossal nerve has been studied in animal models. q When a breath is taken, the phrenic nerve would stimulate the hypoglossal nerve to move the tongue forward.

160 Thank You Laugh and the world laughs with you, Snore, snore, snore and you sleep alone

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