Obstructive Sleep Apnea Hyponea Syndrome. Overview Physiology of Sleep Evaluation of Sleep Definition of Obstructive Sleep Apnea Hyponea Syndrome(OSAHS)

Obstructive Sleep Obstructive Sleep Apnea Hyponea Apnea Hyponea SyndromeSyndrome

OverviewOverview

Physiology of SleepPhysiology of Sleep Evaluation of SleepEvaluation of Sleep Definition of Obstructive Sleep Apnea Definition of Obstructive Sleep Apnea

Hyponea Syndrome(OSAHS)Hyponea Syndrome(OSAHS) Pathophysiology of OSAHSPathophysiology of OSAHS Medical Treatment of OSAHSMedical Treatment of OSAHS Surgical Treatment of OSAHSSurgical Treatment of OSAHS

Physiology of SleepPhysiology of Sleep

REM ( rapid eye movements Sleep)REM ( rapid eye movements Sleep)

more likely to occurmore likely to occur

ArousalArousal

Woodson, Tucker “Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment” SIPAC 1996

Evaluation of SleepEvaluation of Sleep

PolysomnographyPolysomnography EMGEMG AirflowAirflow EEG, EOGEEG, EOG Oxygen SaturationOxygen Saturation Cardiac RhythmCardiac Rhythm Leg MovementsLeg Movements


Polysomnography(PSG)Polysomnography(PSG)

Woodson, Tucker “Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment” SIPAC 1996


Polysomnography(PSG)Polysomnography(PSG)

---- ---- Gold standardGold standard Epworth Sleepiness ScaleEpworth Sleepiness Scale

Multiple Sleep Latency TestMultiple Sleep Latency Test

Definition of OSAHSDefinition of OSAHS

ApneaApnea is defined as cessation of airflow for ten is defined as cessation of airflow for ten seconds which results in an arousal. If the chest seconds which results in an arousal. If the chest wall continues to mechanically move during this wall continues to mechanically move during this time, then it is an time, then it is an obstructive apneaobstructive apnea. If the chest . If the chest wall does not attempt to ventilate, then it is wall does not attempt to ventilate, then it is presumably due to a neurologic etiology and is presumably due to a neurologic etiology and is termed a termed a central apneacentral apnea. Sometimes there are . Sometimes there are characteristics of both an obstructive and a characteristics of both an obstructive and a central apnea, and this is termed a central apnea, and this is termed a mixed apneamixed apnea. .

HypopneaHypopnea is considered a diminution in airflow is considered a diminution in airflow which results in hypoxemia and results in an which results in hypoxemia and results in an arousal. arousal.


the the apnea-hypopnea indexapnea-hypopnea index (AHI): the (AHI): the sum of apneas and hypopneas per hour sum of apneas and hypopneas per hour

AHI: 5 — 20 = mildAHI: 5 — 20 = mild AHI: 20 — 40 = moderate AHI: 20 — 40 = moderate

> 20 increases risk of mortality> 20 increases risk of mortality AHI: >40 = severeAHI: >40 = severe


SnoringSnoring Patients with snoring who have an apnea-

hypopnea index (AHI) of fewer than 5 and no complaints of excessive daytime sleepiness fall into this category

OSAHS : AHI>5 OSAHS : AHI>5

Difference : AHI

HypoxiaHypoxia

The lowest SaOThe lowest SaO22 ＞＞ 885% : mild5% : mild

The lowest SaOThe lowest SaO22 65 - 65 - 884% : moderate4% : moderate

The lowest SaOThe lowest SaO22 ＜＜ 65%: severe65%: severe

one of the indicator for risk of surgery one of the indicator for risk of surgery

Pathophysiology of Pathophysiology of OSAHSOSAHS

Sites of Sites of Obstruction:Obstruction:

Related to Related to airway airway collapsescollapses


Symptoms of OSAHSSymptoms of OSAHS Snoring (most commonly noted complaint)Snoring (most commonly noted complaint) Daytime SleepinessDaytime Sleepiness Hypertension and Cardiovascular Disease Hypertension and Cardiovascular Disease

are Associatedare Associated Pulmonary DiseasePulmonary Disease


Findings in Obstruction:Findings in Obstruction: Nasal ObstructionNasal Obstruction Long, thick soft palateLong, thick soft palate Retrodisplaced MandibleRetrodisplaced Mandible Narrowed oropharynxNarrowed oropharynx Redundant pharyngeal tissuesRedundant pharyngeal tissues Large lingual tonsilLarge lingual tonsil Large tongueLarge tongue Large or floppy EpiglottisLarge or floppy Epiglottis Retro-displaced hyoid complexRetro-displaced hyoid complex

Pathophysiology of OSAPathophysiology of OSA

Tests to determine site of obstruction:Tests to determine site of obstruction: Muller’s ManeuverMuller’s Maneuver EndoscopyEndoscopy FluoroscopyFluoroscopy ManometryManometry CephalometricsCephalometrics Dynamic CT scanning and MRI scanningDynamic CT scanning and MRI scanning

Medical ManagementMedical Management

Weight LossWeight Loss Nasal ObstructionNasal Obstruction Alcohol and Sedative AvoidanceAlcohol and Sedative Avoidance Smoking cessationSmoking cessation

Medical ManagementMedical Management

CPAPCPAP Continuous positive airway pressureContinuous positive airway pressure

Pressure must be Pressure must be individually titratedindividually titrated

Compliance is as low Compliance is as low as 50%as 50% Air leakage, Air leakage,

eustachian tube eustachian tube dysfunction, noise, dysfunction, noise, mask discomfort, mask discomfort, claustrophobiaclaustrophobia

Nonsurgical ManagementNonsurgical Management

Oral applianceOral appliance Mandibular Mandibular

advancement deviceadvancement device Tongue retaining Tongue retaining

devicedevice

Nonsurgical ManagementNonsurgical Management

Oral AppliancesOral Appliances mechanically moving the jaw or tongue mechanically moving the jaw or tongue

forward and opening the airway. forward and opening the airway. May be as effective as surgical optionsMay be as effective as surgical options

Surgical ManagementSurgical Management

Measures of success –Measures of success – No further need for medical or surgical No further need for medical or surgical

therapytherapy Response = 50% reduction in AHIIResponse = 50% reduction in AHII Reduction of AHI to < 20Reduction of AHI to < 20 Reduction in arousals and daytime Reduction in arousals and daytime

sleepinesssleepiness


Perioperative IssuesPerioperative Issues High risk in patients with severe symptomsHigh risk in patients with severe symptoms Nasal CPAP often required after surgeryNasal CPAP often required after surgery Nasal CPAP before surgery improves Nasal CPAP before surgery improves

postoperative coursepostoperative course Risk of pulmonary edema after relief of Risk of pulmonary edema after relief of

obstructionobstruction


TracheostomyTracheostomy Primary treatment modalityPrimary treatment modality Temporary treatment while other surgery is doneTemporary treatment while other surgery is done Thatcher GW. Thatcher GW. et alet al: tracheostomy leads to quick : tracheostomy leads to quick

reduction in sequelae of OSA, few complications . reduction in sequelae of OSA, few complications . Once placed, uncommon to decannulateOnce placed, uncommon to decannulate


Nasal SurgeryNasal Surgery Limited efficacy when used aloneLimited efficacy when used alone Verse Verse et alet al 2002 showed 15.8% success 2002 showed 15.8% success

rate when used alone in patients with rate when used alone in patients with OSAHS and day-time nasal congestion with OSAHS and day-time nasal congestion with snoring (AHI<20 and 50% reduction)snoring (AHI<20 and 50% reduction)

AdenoidectomyAdenoidectomy


UvulopalatopharyngoplastyUvulopalatopharyngoplasty


Uvulopalatopharyngoplasty(UPPP)Uvulopalatopharyngoplasty(UPPP) The most commonly performed surgery for The most commonly performed surgery for

OSAHSOSAHS Severity of disease is poor outcome predictorSeverity of disease is poor outcome predictor Levin and Becker (1994) up to 80% initial Levin and Becker (1994) up to 80% initial

success decreased to 46% success rate at success decreased to 46% success rate at 12 months12 months

Friedman Friedman et alet al showed a success rate of showed a success rate of 80% at 6 months in carefully selected 80% at 6 months in carefully selected patientspatients


UPPP UPPP ComplicationsComplications


Cahali, 2003 Cahali, 2003 proposed the Lateral proposed the Lateral Pharyngoplasty for Pharyngoplasty for patients with patients with significant lateral significant lateral narrowing:narrowing:


Lateral PharyngoplastyLateral Pharyngoplasty


Laser Assisted Laser Assisted UvulopalatoplastyUvulopalatoplasty High initial success High initial success

rate for snoringrate for snoring Rates decrease, as Rates decrease, as

for UP3 at twelve for UP3 at twelve monthsmonths

Performed awakePerformed awake


Radiofrequency Radiofrequency Ablation – Fischer Ablation – Fischer et et al 2003al 2003

Radiofrequency device is inserted into various parts of palate, tonsils and tongue base at various thermal energies


Fischer Fischer et al et al 20032003 At 6 months Showed significant reduction of:At 6 months Showed significant reduction of:

AHI (but not to below 20)AHI (but not to below 20) ArousalsArousals Daytime sleepiness by the Epworth Sleepiness ScaleDaytime sleepiness by the Epworth Sleepiness Scale


Tongue Base ProceduresTongue Base Procedures Lingual TonsillectomyLingual Tonsillectomy

may be useful in patients with hypertrophy, but may be useful in patients with hypertrophy, but usually in conjunction with other proceduresusually in conjunction with other procedures


Tongue Base Tongue Base ProceduresProcedures LingualplastyLingualplasty

Chabolle, Chabolle, et alet al success rate of 77% success rate of 77% (RDI<20, 50% (RDI<20, 50% reduction) in 22 reduction) in 22 patients in conjunction patients in conjunction with UPPPwith UPPP

Complication rate of Complication rate of 25% - bleeding, 25% - bleeding, altered taste, altered taste, odynophagia, edemaodynophagia, edema

Can be combined with Can be combined with epiglottectomyepiglottectomy


Mandibular Mandibular ProceduresProcedures Genioglossus Genioglossus

AdvancementAdvancement Rarely performed Rarely performed

alonealone Increases rate of Increases rate of

efficacy of other efficacy of other proceduresprocedures

Transient incisor Transient incisor paresthesiaparesthesia


Lingual Lingual Suspension:Suspension:


Lingual Lingual Suspension:Suspension:


Hyoid Myotomy and Hyoid Myotomy and SuspensionSuspension Advances hyoid bone Advances hyoid bone

anteriorly and inferiorlyanteriorly and inferiorly Advances epiglottis and Advances epiglottis and

base of tonguebase of tongue Performed in Performed in

conjunction with other conjunction with other proceduresprocedures

Dysphagia may resultDysphagia may result


Maxillary-Mandibular AdvancementMaxillary-Mandibular Advancement Severe diseaseSevere disease Failure with more conservative measuresFailure with more conservative measures Midface, palate, and mandible advanced Midface, palate, and mandible advanced

anteriorlyanteriorly Limited by ability to stabilize the segments Limited by ability to stabilize the segments

and aesthetic facial changesand aesthetic facial changes


Maxillary-Mandibular Maxillary-Mandibular AdvancementAdvancement Performed in Performed in

conjunction with oral conjunction with oral surgeonssurgeons


AlgorithmsAlgorithms Friedman Friedman et alet al

developed a staging developed a staging system for type of system for type of operation:operation:


Algorithms:Algorithms: Friedman Friedman et et

alal::


Algorithms:Algorithms: Friedman Friedman et alet al::

Success = AHI<20 Success = AHI<20 and AHI reduced and AHI reduced 50%50%

Important keysImportant keys

The complete description of OSAHSThe complete description of OSAHS

Obstructive Sleep Apnea Hyponea SyndromeObstructive Sleep Apnea Hyponea Syndrome

The gold standard for diagnose of OSAHS:The gold standard for diagnose of OSAHS: Polysomnography (PSG) Polysomnography (PSG)

The difference between snoring and OSAHSThe difference between snoring and OSAHS ::

Apnea-hypopnea index (AHI)Apnea-hypopnea index (AHI)

The most commonly performed surgery for The most commonly performed surgery for OSAHSOSAHS

Uvulopalatopharyngoplasty (UPPP)Uvulopalatopharyngoplasty (UPPP)

ConclusionsConclusions

Sleep medicine is an exciting, relatively new Sleep medicine is an exciting, relatively new field that has emerged. The otolaryngologist field that has emerged. The otolaryngologist has become a key figure in the diagnosis and has become a key figure in the diagnosis and management of sleep disorders due to his or management of sleep disorders due to his or her familiarity with the airway and the ability to her familiarity with the airway and the ability to intervene surgically. An understanding of the intervene surgically. An understanding of the medical and surgical issues involved is medical and surgical issues involved is necessary for the otolaryngologist to deal with necessary for the otolaryngologist to deal with this field which is rapidly evolving. this field which is rapidly evolving.

Obstructive Sleep Apnea Hyponea Syndrome. Overview Physiology of Sleep Evaluation of Sleep Definition of Obstructive Sleep Apnea Hyponea Syndrome(OSAHS)

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