Obstructive Sleep Apnea- Hypopnea Syndrome and Snoring: Surgical Options

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1 Obstructive Sleep Apnea- Hypopnea Syndrome and Snoring: Surgical Options Joshua L. Kessler, MD, FACS Boston ENT Associates Clinical Instructor, Otology and Laryngology Harvard Medical School

2 Why Consider Surgery? Failure to respond or partial response to CPAP Underlying anatomic abnormality Failure to tolerate CPAP Unable to habituate Refusal to try Increased morbidity known with an AI of over 20

3 Every Snorer Gets a Sleep Study! Important to Identify OSAH Over 50% of typical snorers will have OSAH (AHI>10) Dictates treatment and insurance coverage CPAP and more Oral Appliance Snoring procedure

4 Otolaryngology Assessment History/Physical Looking for anatomic factors contributing to OSAH Fiberoptic Examination Mueller s Maneuver Tonsils & Adenoids Base of Tongue Nasal Obstruction Labs/Imaging PSG if not already obtained Consider thyroid Cephalometrics

5 Surgical Options for OSAH Phase I : Conservative, First Option Nasal surgery Tonsillectomy +/- Adenoidectomy (pedi) Pharyngeal Surgery Uvulopalatopharyngoplasy Laser Assisted Uvulopalatoplasty (LAUP) Genioglossal Advancement and Hyoid Suspension

6 Nasal Options Septoplasty for obstructing nasal septum Endoscopic surgery for nasal polyps Inferior turbinate reduction techniques

7 Nasal Surgery Rare that procedures for nasal obstruction will significantly reduce RDI or snoring Will help with CPAP/BiPAP tolerance Symptoms may be a result of CPAP use May be performed in conjunction with pharyngeal surgery

8 Pediatric Adenotonsillectomy In general, snoring and apnea in children is due to large tonsils and adenoids History and Physical is often enough to recommend T & A Need to rule out congenital masses that could cause obstruction If there is any question in the diagnosis, would consider a pediatric sleep study

9 Pharyngeal Surgery Uvulopalatopharyngoplasty (UPPP) Laser Assisted Uvulopalatoplasy (LAUP)

10 Uvulopalatopharyngoplasty Designed to enlarge the oropharyngeal airway Performed under general anesthesia Half of patients stay overnight for observation Multiple flawed studies, but the general rule is cure in about 40%. Usually will see about a 50% decrease in RDI, but difficult to predict who will respond 75-90% have complete resolution in snoring Long term improvement variable Painful, potential complications

11 UPPP

12 Laser Assisted Uvulopalatoplasty Office procedure popularized in the 1990 s Found to be about equal to UPPP in treating RDI and reducing snoring Indicated in mild OSAH (RDI less than 20) Often requires multiple procedures Very painful Added laser complication possibilities Significant difficulties with insurance coverage

13 Laser Assisted Uvuloplasty

14 Mandibular Advancement with Hyoid Suspension Mandibular osteotomy made and advanced to pull the tongue forward Infrahyoid muscles are transected and the hyoid is suspended from the mandible Indicated in patients with little evidence of pharyngeal obstruction Rarely performed

15 Surgical Options for OSA Phase 2 : Complex, used if Phase 1 fails Midline Glossectomy Mandibular and Maxillary Advancement Tracheotomy

16 Midline Glossectomy Laser resection of the midline of the base of tongue Rarely performed indicated for patients who have failed UPPP and still have major hypopharyngeal collapse In studies, about 40% success rate (decrease in RDI of >50%) Significant risk of post op pain, bleeding, and permanent dysphagia

17 Mandibular and Maxillary Advancement Useful in retrognathic mandible with hypopharyngeal collapse When combined with previous UPPP, shown to have a >90% success rate in properly chosen population Usually performed by oromaxillofacial surgeons based on cephalometric films and failure to respond to phase I treatment

18 Mandibular and Maxillary Advancement

19 Tracheotomy 100% Cure Rate 100% Undesirable For patients with severe OSAH with cardiopulmonary complications who have not responded to typical treatment Cor pulmonale, chronic alveolar hypoventilation, serious nocturnal arrhythmias, disabling hypersomnolence

20 Newer Techniques Pillar Procedure Somnoplasty (Radiofrequency Ablation) Injection Snoreplasty ***All for patients with snoring but zero to mild OSAH*** (not covered by insurance)

21 Pillar Procedure Office procedure Three polyester 18mm implants placed at the hard and soft palate junction Limited candidacy depending on position of palate Designed to stiffen the palate and decrease vibrations

22 Pillar Procedure Short Term efficacy equal to UPPP, LAUP, Radiofrequency, and Injection Snoreplasty Long term 15% relapse snoring rate Problems with extrusion (15-25%) of unknown importance Costs patient about $1000 Preliminary data indicates lowering RDI by up to 20 points, with the mean between 5-10.

23 Radiofrequency Ablation Office based procedure using controlled lowpower radiofrequency energy to create submucosal lesions which then stiffen with scarring Useful on palate and turbinates Somnoplasty most common

24 RFA Staged procedure requiring multiple sessions, but promises of a single procedure forthcoming Possibility of mucosal sloughing Relapse more common that other procedures Cost to patient $600-$800, maybe more depending on number of treatments required

25 Injection Snoreplasty Office procedure injecting a caustic agent into the palate (1 session) 98% dehydrated alcohol or 3% Sodium Tetradecyl Sulfate (STS) : Not FDA approved Similar success rates: 75-85% reduction in snoring Potential for foreign body sensation, sloughing, and fistula formation (1-2%)

26 What is the best treatment for Snoring??? Short Term Efficacy (All 80-90%) LAUP=UPPP=RFA=Snoreplasty=Pillar Long Term Efficacy All equal all have relapses due to scar remodeling Pain LAUP=UPPP>>RFA>Pillar>Snoreplasty Cost UPPP>LAUP = Thousands Pillar>RFA = high hundreds, low thousands Snoreplasty = Low hundreds

27 Procedure Short-Term Effectiveness Long-Term Effectiveness Pain # of Sessions Cost UPPP $$$$ LAUP $$$ Pillar $$$ RFA $$ Snoreplasty $

28 Conclusions - OSAH All patients who snore should have a PSG Multiple procedures are available for patients with OSAH who fail medical therapy Surgery must be tailored to the patient s underlying anatomic factors contributing to OSAH for highest chance of success Each procedure has advantages and disadvantages that must be considered when planning intervention

29 Conclusions - Snoring Multiple options are also available for snoring without OSAH Most of these are office procedures that are not covered by insurance All procedures have a good short term snoring cure rate (90%) and a relatively poor long term cure rate (that we know of so far)

30 References Available Upon Request