Obstructive Sleep Apnea Hyponea Syndrome Overview Physiology of

Obstructive Sleep Apnea Hyponea Syndrome

Overview § § § Physiology of Sleep Evaluation of Sleep Definition of Obstructive Sleep Apnea Hyponea Syndrome(OSAHS) Pathophysiology of OSAHS Medical Treatment of OSAHS Surgical Treatment of OSAHS

Physiology of Sleep Woodson, Tucker “Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment” SIPAC 1996 § REM ( rapid eye movements Sleep) more likely to occur § Arousal

Evaluation of Sleep § Polysomnography § § § EMG Airflow EEG, EOG Oxygen Saturation Cardiac Rhythm Leg Movements

Evaluation of Sleep § Polysomnography(PSG) Woodson, Tucker “Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment” SIPAC 1996

Evaluation of Sleep § Polysomnography(PSG) ---- Gold standard § Epworth Sleepiness Scale § Multiple Sleep Latency Test

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

Definition of OSAHS § the apnea-hypopnea index (AHI): the sum of apneas and hypopneas per hour § AHI: 5 — 20 = mild § AHI: 20 — 40 = moderate > 20 increases risk of mortality § AHI: >40 = severe

Definition of OSAHS § Snoring Patients with snoring who have an apneahypopnea index (AHI) of fewer than 5 and no complaints of excessive daytime sleepiness fall into this category § OSAHS : AHI>5 Difference : AHI

Hypoxia § The lowest Sa. O 2 ＞ 85% : mild § The lowest Sa. O 2 65 - 84% : moderate § The lowest Sa. O 2 ＜ 65%: severe one of the indicator for risk of surgery

Pathophysiology of OSAHS § Sites of Obstruction: § Related to airway collapses

Pathophysiology of OSAHS § Symptoms of OSAHS § Snoring (most commonly noted complaint) § Daytime Sleepiness § Hypertension and Cardiovascular Disease are Associated § Pulmonary Disease

Pathophysiology of OSAHS § 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 § Endoscopy § Fluoroscopy § Manometry § Cephalometrics § Dynamic CT scanning and MRI scanning

Medical Management § § Weight Loss Nasal Obstruction Alcohol and Sedative Avoidance Smoking cessation

Medical Management § CPAP Continuous positive airway pressure § Pressure must be individually titrated § Compliance is as low as 50% § Air leakage, eustachian tube dysfunction, noise, mask discomfort, claustrophobia

Nonsurgical Management § Oral appliance § Mandibular advancement device § Tongue retaining device

Nonsurgical Management § Oral Appliances § mechanically moving the jaw or tongue forward and opening the airway. § May be as effective as surgical options

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

Surgical Management § Perioperative Issues § High risk in patients with severe symptoms § 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. Once placed, uncommon to decannulate

Surgical Management § Nasal Surgery § Limited efficacy when used alone § Verse et al 2002 showed 15. 8% success rate when used alone in patients with OSAHS and day-time nasal congestion with snoring (AHI<20 and 50% reduction) § Adenoidectomy

Surgical Management § Uvulopalatopharyngoplasty

Surgical Management § Uvulopalatopharyngoplasty(UPPP) § The most commonly performed surgery for OSAHS § 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

Surgical Management § UPPP Complications

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

Surgical Management § Lateral Pharyngoplasty

Surgical Management § Laser Assisted Uvulopalatoplasty § High initial success rate for snoring § Rates decrease, as for UP 3 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: § § § AHI (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 § Friedman et al developed a staging system for type of operation:

Surgical Management § Algorithms: § Friedman et al:

Surgical Management § Algorithms: § Friedman et al: § Success = AHI<20 and AHI reduced 50%

Important keys § The complete description of OSAHS Obstructive Sleep Apnea Hyponea Syndrome § The gold standard for diagnose of OSAHS: Polysomnography (PSG) § The difference between snoring and OSAHS: Apnea- hypopnea index (AHI) § The most commonly performed surgery for OSAHS Uvulopalatopharyngoplasty (UPPP)

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