11/19/2012 ก! " Varies 5-86% in men 2-57% in women. Thailand 26.4% (Neruntarut et al, Sleep Breath (2011) 15: )

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1 Snoring ก Respiratory sound generated in the upper airway during sleep that typically occurs during inspiration but may occur during expiration ICSD-2, ก ก! Prevalence of snoring Varies 5-86% in men 2-57% in women Thailand 26.4% (Neruntarut et al, Sleep Breath (2011) 15: ) Obstructive sleep apnea (OSA) ก! " Definition Apnea: airflow 90% of baseline >10 sec Hypopnea: airflow 30% desat 4% of baseline >10 sec Apnea index: no. apnea episodes per hour Apnea-hypopnea index (AHI): Apnea + hypopnea events per hour Respiratory disturbance index (RDI): = AHI or AHI + Respiratory-Effort-Related Arousal index 6 1

2 Disease severity Mild AHI 5-15 Moderate AHI Severe AHI >30 Spectrum of disease No obstruction Snoring Airway resistance Sleep apnea Prevalence US vs Thailand Wisconsin Sleep Cohort study, 1993 Men 4% Women 2% Prevalence of OSA (AHI >5) 11.4% OSAS (+EDS) 4.4%. Men OSA 15.4% and OSAS 4.8% Women was 6.3% and 1.9%, (Neruntarut et al, Sleep Breath (2011) 15: ) Pickwickian syndrome 7 PLoS Med Aug;6(8 ):e Risk factors SLEEP 2012;35(9): Male gender Post menopausal women Obesity Structural deficits 2

3 Evaluation Snoring Excessive day time sleepiness (EDS) Comorbidities: DM HT Heart disease History Physical examination Nasopharyngoscopy Polysomnography Sedated endoscopy Nocturnal Symptoms Daytime Symptoms Snoring Witnessed apneas Choking/Gasping Drooling Dry mouth Bruxism Restless sleep/ frequent arousals Gastroesophageal reflux Nocturia Excessive daytime sleepiness Morning headaches Neurocognitive impairment Quality of life Mood and personality Sexual dysfunction Sleep History Sleep duration Day time sleepiness Epworth sleepiness scale, VAS vs. Fatigue Caffeine intake: coffee, tea esp. green tea, carbonated drinks, energy drinks Medication: TCA, BZP, Opioid Pain: CA, Bone and joint pain Sleep History(2) Nocturia: w/o DM, BPH Snoring severity Comorbidities: DM, HT, heart disease esp. AF. CVA, obesity, COPD Motor vehicle accidents or near misses Family history Parasomnias: sleep talking, hallucination, sleep paralysis, RLS 3

4 Physical examination Facial Proportion Maxilla-Mandible Distance from hyoid to mandibular plane (MPH) ENT I-SAN Nasal obstruction Septal deviation Dental Occlusion Angle s classification Inferior turbinate hypertrophy Allergic rhinitis Non-allergic rhinitis Nasal polyps Modified from lookfordiagnosis.com Tonsil size Friedman Tongue Position Hypopharyngeal obstruction 4

5 Upper airway endoscopy Awake in clinic Upright Supine Sedated Endoscopy Propofol vs Midazolam Palate Anatomy Endoscope Back of Tongue and Lingual Tonsils Vertical Circular Sagittal Polysomnography (PSG-Sleep Sleep study) Full attended PSG Home sleep study Level I - Full attended PSG (Gold standard) Level II - Mobile Full PSG Level III - (unattended) Home sleep study (4-5 channels) Level IV - less than 4 channels (oximetry, apnea link, etc) Level I Level III 29 ENT I-SAN

6 32 ENT I-SAN 2009 Behavioral modification Weight reduction Sleep position therapy Side sleeping vs elevate head of bed Nasal obstruction treatment Avoidance of sedatives, alcohol 33 Oral appliances PAP therapy Standard medical treatment Continuous Positive Airway Pressure (CPAP) AutoPAP, BiPAP Mandibular repositioning device (MRD or MAD) Simple snorer and mild apnea moderate OSA Herbst appliance Not recommended for TMJ disorders Edentulous patients

7 Snoring Surgeries Potential complication TMJ disorder Occlusion change Radiofrequency Ablation Radiofrequency Office based palate procedures Turbinates, soft palate, base of tongue Less invasive, under LA Multiple sites May require multiple treatment Injection snoreplasty 100% ethyl alcohol injection Pillar Implants Surgery in OSA Curative A site of pathology that is correctable Ancillary Assist in other treatments; enable CPAP use Majority of patients Surgery Surgery procedures to improve PAP use Nasal surgery Tonsillectomy Upper airway surgery for OSA Salvage after other therapies have failed Goal to correct or cure but success varies 42 7

8 Expansion sphincteroplasty Nasal procedures Success of single level ~20% Acta Otolaryngol Apr;124(3): Otolaryngol Head Neck Surg Jan;122(1):71-4. Before Septoplasty Turbinate reduction Microdebridement RF Turbinoplasty Endoscopic Turbinoplasty Pang & BT.Woodson, Oto-HNS, Vol 137, No 1, July 2007 After Palatal advancement Tongue base Lingual tonsillectomy Partial glossectomy Tongue Suspension or Advancemnt NonNon-upper airway surgery for OSA Tracheostomy Bariatric surgery(bmi>40 or >35 w/ morbidities) From 8

9 Provent NOVEL DEVICES Nasal Expiratory Positive Airway Pressure (EPAP) Provent Hypoglossal nerve stimulation Inspire II system (Inspire Medical Systems) Apnex Hypoglossal Nerve Stimulation (HGNS ) System aura6000 system (ImThera Medical) Conclusion Thank you for your attention Snoring is a sign of partial airway obstruction, warning sign of OSA Treatment are: 1. Continuous positive airway pressure 2. Oral appliances 3. Surgical procedures 9