1. Surgical Management of Obstructive Sleep Apnea Marilene B. Wang, MD Chief of Otolaryngology, VAGLAHS Professor UCLA Division of Head and Neck Surgery

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

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

4. Definition of OSA RDI>5 RDI>5 RDI > 20 increases risk of mortality RDI > 20 increases risk of mortality RDI 20-40=moderate, >40=severe RDI 20-40=moderate, >40=severe Upper Airway Resistance Syndrome Upper Airway Resistance Syndrome Shares pathophysiology with OSA Shares pathophysiology with OSA No desaturation, continuous ventilatory effort No desaturation, continuous ventilatory effort Snoring Snoring

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

6. Pathophysiology of OSA Sites of Obstruction: Sites of Obstruction:

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

8. Pathophysiology of OSA Findings in Obstruction: Findings in Obstruction: Nasal Obstruction Nasal Obstruction Long, thick soft palate Long, thick soft palate Retrodisplaced Mandible Retrodisplaced Mandible Narrowed oropharynx Narrowed oropharynx Redundant pharyngeal tissues Redundant pharyngeal tissues Large lingual tonsil Large lingual tonsil Large tongue Large tongue Large or floppy Epiglottis Large or floppy Epiglottis Retro-displaced hyoid complex Retro-displaced hyoid complex

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

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

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

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

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

14. Nonsurgical Management Oral Appliances Oral Appliances May be as effective as surgical options, especially with sx worse on patient’s back 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 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.

15. Surgical Management Measures of success – Measures of success – No further need for medical or surgical therapy No further need for medical or surgical therapy Response = 50% reduction in RDI Response = 50% reduction in RDI Reduction of RDI to < 20 Reduction of RDI to < 20 Reduction in arousals and daytime sleepiness Reduction in arousals and daytime sleepiness

16. Surgical Management Perioperative Issues Perioperative Issues High risk in patients with severe symptoms High risk in patients with severe symptoms Associated conditions of HTN, CVD Associated conditions of HTN, CVD Nasal CPAP often required after surgery Nasal CPAP often required after surgery Nasal CPAP before surgery improves postoperative course Nasal CPAP before surgery improves postoperative course Risk of pulmonary edema after relief of obstruction Risk of pulmonary edema after relief of obstruction

17. Surgical Management Nasal Surgery Nasal Surgery Limited efficacy when used alone 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) 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) Adenoidectomy (children)

18. Surgical Management Uvulopalatopharyngoplasty Uvulopalatopharyngoplasty The most commonly performed surgery for OSA The most commonly performed surgery for OSA Severity of disease is poor outcome predictor Severity of disease is poor outcome predictor Levin and Becker (1994) up to 80% initial success decreased to 46% success rate at 12 months 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 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.

19. Surgical Management Uvulopalatopharyngoplasty Uvulopalatopharyngoplasty

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

21. Surgical Management Cahali, 2003 proposed the Lateral Pharyngoplasty for patients with significant lateral narrowing: 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.

22. Surgical Management Lateral Pharyngoplasty Lateral Pharyngoplasty

23. Surgical Managment Lateral Pharyngoplasty Lateral Pharyngoplasty Median apnea-hypopnea index decreased from 41.2 to 9.5 (P =.009) Median apnea-hypopnea index decreased from 41.2 to 9.5 (P =.009) No control group No control group No evaluation at 12 months No evaluation at 12 months

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

25. Surgical Management Radiofrequency Ablation – Fischer et al 2003 Radiofrequency Ablation – Fischer et al 2003 Radiofrequency device is inserted into various parts of palate, tonsils and tongue base at various thermal energies

26. Surgical Management Fischer et al 2003 Fischer et al 2003 At 6 months Showed significant reduction of: At 6 months Showed significant reduction of: RDI (but not to below 20) RDI (but not to below 20) Arousals Arousals Daytime sleepiness by the Epworth Sleepiness Scale Daytime sleepiness by the Epworth Sleepiness Scale

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

28. Anesthesia Anesthesia Antibiotic 1 hour pre-op or as directed Antibiotic 1 hour pre-op or as directed Mouth Rinse (chlorhexidine gluconate or equivalent) Mouth Rinse (chlorhexidine gluconate or equivalent) Hurricane or Equivalent Topical Spray Hurricane or Equivalent Topical Spray Ponticane or Equivalent Ponticane or Equivalent Topical Jelly Anesthetic, optional. 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) 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 Have available: Flexible Scope, Angled Tonsil Forceps

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

30. 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

31. 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 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 Implant Muscle Glandular tissue

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

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

34. Surgical Management Tongue Base Procedures Tongue Base Procedures Lingualplasty Lingualplasty Chabolle, et al success rate of 77% (RDI<20, 50% reduction) in 22 patients in conjunction with UPPP 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 Complication rate of 25% - bleeding, altered taste, odynophagia, edema Can be combined with epiglottectomy Can be combined with epiglottectomy

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

36. Surgical Management Lingual Suspension Lingual Suspension

37. Surgical Management Lingual Suspension Lingual Suspension

39. Surgical Management Hyoid Myotomy and Suspension Hyoid Myotomy and Suspension Advances hyoid bone anteriorly and inferiorly Advances hyoid bone anteriorly and inferiorly Advances epiglottis and base of tongue Advances epiglottis and base of tongue Performed in conjunction with other procedures Performed in conjunction with other procedures Dysphagia may result Dysphagia may result

40. Surgical Management Maxillary-Mandibular Advancement Maxillary-Mandibular Advancement Severe disease Severe disease Failure with more conservative measures Failure with more conservative measures Midface, palate, and mandible advanced anteriorly Midface, palate, and mandible advanced anteriorly Limited by ability to stabilize the segments and aesthetic facial changes Limited by ability to stabilize the segments and aesthetic facial changes

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

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

43. Surgical Management Algorithms Algorithms Riley et al 1992 Riley et al 1992 Studied 2 phase approach for multilevel site of obstruction (Stanford Protocol): Studied 2 phase approach for multilevel site of obstruction (Stanford Protocol): Phase 1: Genioglossal advancement, hyoid myotomy and advancement, UP3 Phase 1: Genioglossal advancement, hyoid myotomy and advancement, UP3 Phase 2: Maxillary-Mandibular advancement in 6 months if phase 1 failed Phase 2: Maxillary-Mandibular advancement in 6 months if phase 1 failed Reported >90% success rate in patients who completed both phases Reported >90% success rate in patients who completed both phases Other studies have lowered this number Other studies have lowered this number Testing is done at 6 months Testing is done at 6 months

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

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

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

48. Surgical Management Tracheostomy Tracheostomy Primary treatment modality Primary treatment modality Temporary treatment while other surgery is done 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) Thatcher GW. et al: tracheostomy leads to quick reduction in sequelae of OSA, few complications (see table II) Once placed, uncommon to decannulate 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.

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