1. Obstructive Sleep Apnea
İlhan TOPALOĞLU M.D
Otolaryngology Department
Yeditepe University, School of Medicine

2. Apnea:Temporary absence or cessation of breathing for 10 seconds.
Oxygen desaturation:the condition of a low blood oxygen(< %90) concentration.
Hypopnea: is a disorder which involves episodes of overly shallow breathing or an abnormally low respiratory flow more than %50. This differs from apnea in that there remains some flow of air.
Respiratory disturbance index: Respiratory Disturbance Index (RDI) is the number of apnoea and hypopnea events per hour during sleep
RDI upto 5 per hour is considered normal

3. 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

4. Evaluation of Sleep Polysomnography EMG Airflow EEG, EOG
Oxygen Saturation
Cardiac Rhythm
Leg Movements
AI, HI, AHI, RDI

5. Evaluation of Sleep Polysomnography
Woodson, Tucker “Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment” SIPAC 1996

6. Pathophysiology of OSA
Sites of Obstruction:
Obstruction tends to propagate

7. Pathophysiology of OSA
Sites of Obstruction:

8. Pathophysiology of OSA
Symptoms of OSA
Snoring (most commonly noted complaint)
Daytime Sleepiness
Hypertension and Cardiovascular Disease are Associated
Pulmonary Disease

9. 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

10. Pathophysiology of OSA
Tests to determine site of obstruction:
Muller’s Maneuver
Sleep endoscopy
Fluoroscopy
Manometry
Cephalometrics
Dynamic CT scanning and MRI scanning

11. Medical Management Weight Loss/Exercise
Nasal Obstruction/Allergy Treatment
Sedative Avoidance
Smoking cessation
Sleep hygiene
Consistent sleep/wake times
Avoid alcohol, heavy meals before bedtime
Position on side
Avoid caffeine, TV, reading in bed

12. Medical Management CPAP Pressure must be individually titrated
Compliance is as low as 50%
Air leakage, eustachian tube dysfunction, noise, mask discomfort, claustrophobia

13. Medical Management BiPAP
Useful when > 6 cm H2O difference in inspiratory and expiratory pressures
No objective evidence demonstrates improved compliance over CPAP

14. Nonsurgical Management
Oral appliance
Mandibular advancement device
Tongue retaining device

15. 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.

16. 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

17. 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

18. Surgical Management Nasal Surgery Adenoidectomy (children)
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 (children)

19. 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.

20. Surgical Management
Uvulopalatopharyngoplasty

21. Surgical Management UP3 Complications Minor Major Transient VPI
Hemorrhage<1%
Major
NP stenosis
VPI

22. 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.

23. Surgical Management
Lateral Pharyngoplasty

24. 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

25. Surgical Management Laser Assisted Uvulopalatoplasty
High initial success rate for snoring
Rates decrease, as for UP3, at twelve months
Performed awake

26. 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
Radiofrequency Ablation – Fischer et al 2003

27. 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

28. Pillar™ Palatal Implant System
Three Implants Per Patient
Implants are made of Dacron®
Implants are 18 mm in length and 1.8 mm
in diameter
Implants are meant to be Permanent
Implants “can be removed”
FDA Approved for SNORING
FDA Approved for mild to moderate
SLEEP APNEA - AHI UNDER 30

29. Anesthesia Mouth Rinse (chlorhexidine gluconate or equivalent)
Antibiotic 1 hour pre-op or as directed
Mouth Rinse (chlorhexidine gluconate or equivalent)
Hurricane or Equivalent Topical Spray
Ponticane or Equivalent
Topical Jelly Anesthetic, optional.
Local Anesthetic Infiltration: 2 to 3 cc. Beginning at the junction of the Hard and Soft Palate inject entire “Target Zone”. (lidocaine with epinephrine or equivalent)
Have available: Flexible Scope, Angled Tonsil Forceps

30. Placement of Implants
2 m.m. apart
Minimum
Palate Length
25 mm

31. Placement of Implants
Insert the needle through the mucosa layer into the muscle. The insertion site should be as close to the junction of the hard and soft palate as possible. Continue needle advancement in an arcing motion until the “Full insertion depth marker” is no longer visible.
Insertion point

32. Placement of Implants INSPECTION
Inspect the needle insertion site. If a portion of the implant is exposed, it must be removed with a hemostat.
Inspect the nasal side of the soft palate using a Flexible Naso Scope. If the implant is exposed, it must be removed. An angled tonsil forceps is recommended.
Hard palate
Muscle
Implant
Glandular tissue

33. Patient Selection “The Preferred Patient”
BMI less than 32
AHI Less than 30
No Obvious Nasal Obstruction
Small to Medium Sized Tonsils
Mallampati Class І or Class ΙΙ
Friedman Tongue Position I and II
Minimum 25mm Palate to treat

34. Surgical Management Tongue Base Procedures Lingual Tonsillectomy
may be useful in patients with hypertrophy, but usually in conjunction with other procedures

35. 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

36. Surgical Management Mandibular Procedures Genioglossus Advancement
Rarely performed alone
Increases rate of efficacy of other procedures
Transient incisor paresthesia

37. Surgical Management
Lingual Suspension

38. Surgical Management
Lingual Suspension

40. 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

41. 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

42. Surgical Management Maxillary-Mandibular Advancement
Performed in conjunction with oral surgeons
Temporary or permanent paresthesia
Change in facial structure

43. Surgical Management Algorithms Studies efficacy of various algorithms
Therapy should be directed toward presumed site of obstruction
This does not always guarantee results

44. 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

45. Surgical Management Algorithms
Friedman et al developed a staging system for type of operation:

47. Surgical Management
Chance of success with surgical management decreases with increasing Friedman stage
Stage I and II patients have good success with UPPP and tongue base procedures
Stage III and IV patients have much lower rates of success following UPPP/tongue base

48. Ultimate Surgical Management
Tracheotomy
Morbid obesity
Significant anesthetic/surgical risks
Obvious disadvantages
Trach care
Supplies, equipment
aesthetics

49. 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.

50. CONCLUSIONS Surgical management provides effective management for OSA
Can be safely performed in most patients with proper preoperative preparation
Significant perioperative risks in some patients
Surgery should be considered for patients unable to utilize nonsurgical management