Surgical Options for the Successful Treatment of Obstructive Sleep Apnea

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1 Surgical Options for the Successful Treatment of Obstructive Sleep Apnea Benjamin J. Teitelbaum, MD, FACS Otolaryngology Head and Neck Surgery Saint Agnes Medical Center Fresno, California

2 Terms Apnea Hypopnea Apnea-Hypopnea Index (AHI) Respiratory Disturbance Index (RDI) Sleep Disordered Breathing (SDB) Obstructive Sleep Apnea Syndrome (OSA)

3 Spectrum of Sleep Disordered Snoring Breathing Upper Airway Resistance Syndrome Obstructive Sleep Apnea Obesity hypoventilation syndrome

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5 Epidemiology (from Young, et al 1993) Women Men Habitual snoring SDB (RDI > 5) Sleep apnea w/hypersomnolence 28% 44% 9% 24% 2% 4%

6 Prevalance of OSA in the US is estimated to be 7-18 million

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9 Symptoms of Sleep Apnea Snoring Daytime sleepiness/fatigue Witnessed apnea Nocturnal choking/gasping Morning headaches Restless, fragmented sleep Add snoring and excessive daytime somnolence to your ROS!

10 Measuring Daytime Somnolence: the Epworth Sleepiness Scale SITUATION Sitting and reading CHANCE OF DOZING (0-3) Watching TV Sitting inactive in public Passenger in car Lying down in afternoon Sitting and talking Sitting after lunch In a car while stopped

11 Signs of Sleep Apnea Pharyngeal narrowing Macroglossia Retrognathia Obesity Large neck circumference

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19 Treatment for OSA CPAP Surgery Oral Appliance Combination

20 CPAP Most effective treatment option Compliance remains a problem

21 CPAP Compliance (from Kribbs,, et al 1993) 35 OSA patients on CPAP with covert compliance monitor for total 3743 days Criteria for regular use defined as >4 hrs on 70% of days monitored Only 46% of patients met criteria for regular use Patients self reports of CPAP use overestimated actual use

22 Improving CPAP compliance?

23 Role of Surgery for Obstructive Sleep Apnea cure sleep apnea and eliminate the need for CPAP (in properly selected patients) decrease the severity of obstructive sleep apnea enhance CPAP compliance reducing CPAP pressure alleviating nasal obstruction

24 Uvulopalatopharyngoplasty (Fujita, 1981)

25 Results of UPPP (Sher,, et al. 1996) Meta-analysis of 37 articles/992 subjects For patients with all sites of collapse, only 40.7% of patients achieved a sufficient response Site of pharyngeal narrowing affects the probability of UPPP success Ideal UPPP candidate has pharyngeal narrowing/collapse limited to the retropalatal region

26 Results of UPPP

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28 Staging for SDB:Palate Position

29 Staging for SDB:Tonsil Size

30 Staging For SDB (Friedman, 2002) palate tonsil BMI Stage I 1,2 3,4 <40 Stage II 1,2 0,1,2 <40 3,4 3,4 <40 Stage III 3,4 0,1,2 Any Stage IV any any >40

31 Success rate of UPPP (Friedman, et al. 2002) Stage I Stage II Stage III % success

32 Points of Obstruction

33 Who suffers from multi-level level obstruction? The vast majority of these patients (87% of 415) had multi-level obstruction. Robert Riley, MD AAO-HNS, Denver 2001, Surgery for Tongue-based OSA

34 Lower Pharyngeal Airway Surgery Genioglossus advancement Hyoid suspension Radiofrequency reduction of tongue Tongue suspension Partial midline tongue resection Maxillomandibular advancement

35 Genioglossus Advancement/Hyoid Suspension

36 Tongue base reduction

37 Tongue Suspension

38 Surgery for OSA Cochrane review, randomized controlled studies (RCS) assessing different surgical techniques with inactive and active control treatments were identified Conclusion: no RCS supported surgery for sleep apnea (no level 1 evidence)

39 Results of multilevel surgery

40 Maxillomandibular Advancement

41 Results of Maxillomandibular Advancement

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46 Conclusions Analysis of a patient s airway and the use of an anatomically based staging system should guide the selection of treatment options for patients with OSA Surgical techniques which address multiple levels of the upper airway are evolving OSA patients who are noncompliant with CPAP should be evaluated for surgery