Obstructive Sleep Apnea - Sleep Certified...Surgical Treatment of OSA . Physiology of Sleep REM Sleep Latency, REM Latency Arousal Woodson, Tucker “Obstructive Sleep Apnea Syndrome,
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Obstructive Sleep Apnea
Shashidhar Reddy, MD, MPH
Faculty Advisor: Matthew W. Ryan, MD
The University of Texas Medical Branch
Department of Otolaryngology
December 2004
Overview
Physiology of Sleep
Evaluation of Sleep
Definition of Obstructive Sleep Apnea (OSA)
Prevalence of OSA
Pathophysiology of OSA
Medical Treatment of OSA
Surgical Treatment of OSA
Physiology of Sleep
REM
Sleep Latency, REM Latency
Arousal
Woodson, Tucker “Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment” SIPAC 1996
Evaluation of Sleep
Polysomnography
EMG
Airflow
EEG, EOG
Oxygen Saturation
Cardiac Rhythm
Leg Movements
AI, HI, AHI, RDI
Evaluation of Sleep
Polysomnography
Woodson, Tucker “Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment” SIPAC 1996
Evaluation of Sleep
Split-Night Polysomnography
Epworth Sleepiness Scale
Multiple Sleep Latency Test
Definition of OSA
RDI>5
RDI > 20 increases risk of mortality
RDI 20-40=moderate, >40=severe
Upper Airway Resistance Syndrome
Shares pathophysiology with OSA
No desaturation, continuous ventilatory effort
Snoring
Prevalence of OSA
Study Location
n Age Range
Prevalence of AHI>5 (95%CI)
Prevalence of AHI15 (95%CI)
Men Women Men Women
Wisconsin 626 30-60 24
(19-28)
9
(6-12)
9
(6-11)
4
(2-7)
Penn 1741 20-99 17
(15-20)
Not given 7
(6-9)
2
(2-3)
Spain 400 30-70 26
(20-32)
28
(20-35)
14
(10-18)
7
(3-11)
Pathophysiology of OSA
Airway size:
Pathophysiology of OSA
Sites of Obstruction:
Obstruction tends to propagate
Pathophysiology of OSA
Sites of Obstruction:
Pathophysiology of OSA
Symptoms of OSA
Snoring (most commonly noted complaint)
Daytime Sleepiness
Hypertension and Cardiovascular Disease are Associated
Pulmonary Disease
Pathophysiology of OSA
Findings in Obstruction:
Nasal Obstruction
Long, thick soft palate
Retrodisplaced Mandible
Narrowed oropharynx
Redundant pharyngeal tissues
Large lingual tonsil
Large tongue
Large or floppy Epiglottis
Retro-displaced hyoid complex
Pathophysiology of OSA
Tests to determine site of obstruction:
Muller’s Maneuver
Sleep endoscopy
Fluoroscopy
Manometry
Cephalometrics
Dynamic CT scanning and MRI scanning
Medical Management
Weight Loss
Nasal Obstruction
Sedative Avoidance
Smoking cessation
Medical Management
CPAP
Pressure must be individually titrated
Compliance is as low as 50%
Air leakage, eustachian tube dysfunction, noise, mask discomfort, claustrophobia
Medical Management
BiPAP
Useful when > 6 cm H2O difference in inspiratory and expiratory pressures
No objective evidence demonstrates improved compliance over CPAP
Nonsurgical Management
Oral appliance
Mandibular advancement device
Tongue retaining device
Nonsurgical Management
Oral Appliances
May be as effective as surgical options, especially with sx worse on patient’s back
However low compliance rate of about 60% in study by Walker et al in 2002 rendered it a worse treatment modality than surgical procedures
Walker-Engstrom ML. Tegelberg A. Wilhelmsson B. Ringqvist I. 4-year follow-up of treatment with dental appliance or uvulopalatopharyngoplasty in patients with obstructive sleep apnea: a randomized study. Chest. 121(3):739-46, 2002 Mar.
Surgical Management
Measures of success –
No further need for medical or surgical therapy
Response = 50% reduction in RDI
Reduction of RDI to < 20
Reduction in arousals and daytime sleepiness
Surgical Management
Perioperative Issues
High risk in patients with severe symptoms
Associated conditions of HTN, CVD
Nasal CPAP often required after surgery
Nasal CPAP before surgery improves postoperative course
Risk of pulmonary edema after relief of obstruction
Surgical Management
Tracheostomy Primary treatment modality
Temporary treatment while other surgery is done
Thatcher GW. et al: tracheostomy leads to quick reduction in sequelae of OSA, few complications (see table II)
Once placed, uncommon to decannulate
Thatcher GW. Maisel RH. The long-term evaluation of tracheostomy in the management of severe obstructive sleep apnea. [Journal Article] Laryngoscope. 113(2):201-4, 2003 Feb.
Surgical Management
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
Surgical Management
Uvulopalatopharyngoplasty
Surgical Management
Uvulopalatopharyngoplasty The most commonly performed surgery
for OSA
Severity of disease is poor outcome predictor
Levin and Becker (1994) up to 80% initial success decreased to 46% success rate at 12 months
Friedman et al 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: 13–21.
Surgical Management
UP3 Complications
Minor
Transient VPI
Hemorrhage<1%
Major
NP stenosis
VPI
Surgical Management
Cahali, 2003 proposed the Lateral Pharyngoplasty for patients with significant lateral narrowing:
Cahali MB. Lateral pharyngoplasty: a new treatment for obstructive sleep apnea hypopnea syndrome. Laryngoscope. 113(11):1961-8, 2003 Nov.
Surgical Management
Lateral Pharyngoplasty
Surgical Managment
Lateral Pharyngoplasty
Median apnea-hypopnea index decreased from 41.2 to 9.5 (P = .009)
No control group
No evaluation at 12 months
Surgical Management
Laser Assisted Uvulopalatoplasty
High initial success rate for snoring
Rates decrease, as for UP3 at twelve months
Performed awake
Surgical Management
Radiofrequency Ablation – Fischer et al 2003
Radiofrequency device is inserted into various parts of palate, tonsils and tongue base at various thermal energies
Surgical Management
Fischer et al 2003
At 6 months Showed significant reduction of:
RDI (but not to below 20)
Arousals
Daytime sleepiness by the Epworth Sleepiness Scale
Surgical Management
Tongue Base Procedures
Lingual Tonsillectomy
may be useful in patients with hypertrophy, but usually in conjunction with other procedures
Surgical Management
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
Surgical Management
Mandibular Procedures
Genioglossus Advancement
Rarely performed alone
Increases rate of efficacy of other procedures
Transient incisor paresthesia
Surgical Management
Lingual Suspension:
Surgical Management
Lingual Suspension:
Surgical Management
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
Surgical Management
Maxillary-Mandibular Advancement
Severe disease
Failure with more conservative measures
Midface, palate, and mandible advanced anteriorly
Limited by ability to stabilize the segments and aesthetic facial changes
Surgical Management
Maxillary-Mandibular Advancement
Performed in conjunction with oral surgeons
Surgical Management
Algorithms
Studies efficacy of various algorithms
Therapy should be directed toward presumed site of obstruction
This does not always guarantee results
Surgical Management
Algorithms Riley et al 1992
Studied 2 phase approach for multilevel site of obstruction (Stanford Protocol): Phase 1: Genioglossal advancement, hyoid
myotomy and advancement, UP3
Phase 2: Maxillary-Mandibular advancement in 6 months if phase 1 failed
Reported >90% success rate in patients who completed both phases
Other studies have lowered this number
Testing is done at 6 months
Surgical Management
Algorithms
Friedman et al developed a staging system for type of operation:
Surgical Management
Algorithms:
Friedman et al:
Surgical Management
Algorithms:
Friedman et al:
Success = RDI<20 and RDI reduced 50%
Friedman, Michael MD; Ibrahim, Hani MD; Joseph, Ninos J. BS Staging of Obstructive Sleep Apnea/Hypopnea Syndrome: A Guide to Appropriate Treatment. Laryngoscope. 114(3):454-459, March 2004.
Conclusions
Physiology of Sleep
Evaluation of Sleep
Definition of Obstructive Sleep Apnea (OSA)
Prevalence of OSA
Pathophysiology of OSA
Medical Treatment of OSA
Surgical Treatment of OSA
Bibliography Friedman, Michael MD; Ibrahim, Hani MD; Joseph, Ninos J. BS Staging of Obstructive Sleep Apnea/Hypopnea Syndrome: A Guide to Appropriate Treatment. Laryngoscope. 114(3):454-459, March 2004.
Riley RW, Powell NB, Li KK, Guilleminault C. Surgical therapy for obstructive sleep apnea–hypopnea syndrome. In: Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine. Philadelphia, Pa: WB Saunders Co; 2000:913-928.
Cahali MB. Lateral pharyngoplasty: a new treatment for obstructive sleep apnea hypopnea syndrome. Laryngoscope. 113(11):1961-8, 2003 Nov.
Thatcher GW. Maisel RH. The long-term evaluation of tracheostomy in the management of severe obstructive sleep apnea. [Journal Article] Laryngoscope. 113(2):201-4, 2003 Feb.
Friedman M, Ibrahim H, Bass L. Clinical staging for sleep-disordered breathing. Otolaryngol Head Neck Surg 2002; 127: 13–21.
Walker-Engstrom ML. Tegelberg A. Wilhelmsson B. Ringqvist I. 4-year follow-up of treatment with dental appliance or uvulopalatopharyngoplasty in patients with obstructive sleep apnea: a randomized study. Chest. 121(3):739-46, 2002 Mar. Woodson, Tucker “Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment” SIPAC 1996 Anonymous. Cost justification for diagnosis and treatment of obstructive sleep apnea: position statement of the American Academy of Sleep Medicine. Sleep 23(8):1017-8, 2000 Dec. Berger G, Finkelstein Y, Stein G, et al. Laser-assisted uvulopalatoplasty for snoring: medium- to long-term subjective and objective analysis. Archives of Otolaryngology - Head & Neck Surgery 127(4):412-7, 2001 Apr. Carskadon MA, Dement WC. Normal human sleep: an overview. In: Kryer MH, Roth T, Dement WC, eds. Principles and practice of sleep medicine. Philadelphia: WB Saunders. 1994;16–25. Chaudhary BA. Obstructive sleep apnea. Resident and Staff Physician 44(9) 21-34, 1998 Sep. Coleman J. Overview of sleep disorders. Otolaryngologic Clinics of North America 32(2):187-93, 1999 Apr. Coleman J. Sleep studies: current techniques and future trends. Otolaryngologic Clinics of North America 32(2):195-210, 1999 Apr. Coleman J, Rathfoot C. Oropharyngeal surgery in the management of upper airway obstruction during sleep. Otolaryngologic Clinics of North America 32(2):263-76, 1999 Apr. Goldberg AN, Schwab RJ. Identifying the patient with sleep apnea: upper airway assessment and physical examination. Otolaryngologic Clinics of North America 31(6):919-30, 1998 Dec. He J, Kryger M, Zorick F, et al. Mortality and apnea index in obstructive sleep apnea. Chest 94:9-14, 1988. Johnson JT. Uvulopalatopharyngoplasty. In Myers, EN (ed). Operative Otolaryngology: Head and Neck Surgery. Philadelphia: WB Saunders. 1997; 208-14. Johnson JT, Braun TW. Preoperative, intraoperative, and postoperative management of patients with obstructive sleep apnea syndrome. Otolaryngologic Clinics of North America 31(6):1025-30, 1998 Dec. Millman RP, Rosenberg CL, Kramer NR. Oral appliances in the treatment of snoring and sleep apnea. Otolaryngologic Clinics of North America 31(6):1039-48, 1998 Dec. Picirrillo JF, Thawley SE. Sleep-Disordered Breathing. In Otolaryngology – Head and Neck Surgery, 3rd ed. Cummings CW, et al (eds) Mosby:St Louis, 1999. Redline S, Strohl KP. Recognition and consequences of obstructive sleep apnea hypopnea syndrome. Otolaryngologic Clinics of North America 32(2):303-31, 1999 Apr. Sanders M, Black J, Constantino J, et al. Diagnosis of sleep disordered breathing by half-night polysomnography. Am Rev Respir Dis 144:1256-61, 1991. Scharf S, Garshick E, Brown R, et al. A screening for subclinical sleep disordered breathing. Sleep 13:344-53, 1990. Schwab RJ, Goldberg AN. Upper airway assessment: radiographic and other imaging techniques. Otolaryngologic Clinics of North America 31(6):931-68, 1998 Dec. Schwartz AR, Eisele DW, Smith PL. Pharyngeal airway obstruction in obstructive sleep apnea. Otolaryngologic Clinics of North America 31(6):911-8, 1998 Dec. Stroud R, Quinn FB. Obstructive sleep apnea syndrome. In Dr Quinn’s Online Textbook available at www.utmb.edu/oto, 1998 Feb. Troell RJ, Riley RW, Powell NB, Li K. Surgical management of the hypopharyngeal airway in sleep disordered breathing. Otolaryngologic Clinics of North America 31(6):979-1012, 1998 Dec. Walker RP. Snoring and obstructive sleep apnea. In Bailey BJ, ed. Head and Neck Surgery – Otolaryngology. Philadelphia: Lippincott-Raven, 1998.
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