Obstructive Sleep Apnea

Shashidhar Reddy, MD, MPH Matthew W. Ryan, MD UTMB - 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

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

{ { {

REM Sleep Latency, REM Latency Arousal

Evaluation of Sleep
{

Polysomnography
z z z z z z z

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
z z

Shares pathophysiology with OSA No desaturation, continuous ventilatory effort

Snoring

Prevalence of OSA

Study Location Wisconsin Penn Spain

Age Prevalence of Range AHI>5 (95%CI) Men Women

9 (6-12) Not given 28 (20-35) 30-60 24 (19-28) 17 (15-20) 26 (20-32)

Prevalence of AHI15 (95%CI) Men

9 (6-11) 7 (6-9) 14 (10-18)

Women
4 (2-7) 2 (2-3) 7 (3-11)

626

1741 20-99 400

30-70

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
z

z z

Snoring (most commonly noted complaint) Daytime Sleepiness Hypertension and Cardiovascular Disease are Associated Pulmonary Disease

Pathophysiology of OSA
{

Findings in Obstruction:
z z z z z z z z z

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:

z z z z z z

Mullers 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
z

Pressure must be individually titrated Compliance is as low as 50% { Air leakage, eustachian tube dysfunction, noise, mask discomfort, claustrophobia

Medical Management
{

BiPAP
z

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

Nonsurgical Management
{

Oral appliance
z

Mandibular advancement device Tongue retaining device

Nonsurgical Management
{

Oral Appliances
z

May be as effective as surgical options, especially with sx worse on patients 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
z

z z z

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
z

z z z

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
z z z

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
z z

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
z z z

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 M, Ibrahim H, Bass L. Clinical staging selected patients Friedman for sleep-disordered breathing. Otolaryngol Head
Neck Surg 2002; 127: 1321.

Surgical Management
{

UP3 Complications
z

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
z

z z

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

z

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
z

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

z

Lingual Tonsillectomy
{

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

Surgical Management
{

Tongue Base Procedures

z
{

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
z

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

z

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
z z

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
{

MaxillaryMandibular Advancement
z

Performed in conjunction with oral surgeons

Surgical Management
{

Algorithms
z z

Studies efficacy of various algorithms Therapy should be directed toward presumed site of obstruction
{

This does not always guarantee results

Surgical Management
{

Algorithms
z

Riley et al 1992
{

Studied 2 phase approach for multilevel site of obstruction (Stanford Protocol):

z z z z z

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
z

Friedman et al developed a staging system for type of operation:

Surgical Management
{

Algorithms:
z

Friedman et al:

Surgical Management
{

Algorithms:
z

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 apneahypopnea 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: 1321. 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;1625. 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):91930, 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 Quinns 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):9791012, 1998 Dec. Walker RP. Snoring and obstructive sleep apnea. In Bailey BJ, ed. Head and Neck Surgery Otolaryngology. Philadelphia: Lippincott-Raven, 1998.