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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

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

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

REM Sleep Latency, REM Latency Arousal

Evaluation of Sleep

Polysomnography

EMG Airflow EEG, EOG Oxygen Saturation Cardiac Rhythm Leg Movements AI, HI, AHI, RDI

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

Evaluation of Sleep

Polysomnography

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

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

Shares pathophysiology with OSA No desaturation, continuous ventilatory effort

Snoring

Prevalence of OSA

Study

n

Age

Prevalence of

Prevalence of

Location

Range

AHI>5 (95%CI)

AHI15 (95%CI)

     

Men

Women

Men

Women

Wisconsin

626

30-60

24

9

9

4

(19-28)

(6-12)

(6-11)

(2-7)

Penn

1741

20-99

17

Not given

7

2

(15-20)

(6-9)

(2-3)

Spain

400

30-70

26

28

14

7

(20-32)

(20-35)

(10-18)

(3-11)

Pathophysiology of OSA

Airway size:

Pathophysiology of OSA Airway size:

Pathophysiology of OSA

Sites of Obstruction:

Obstruction tends to propagate

Pathophysiology of OSA Sites of Obstruction: Obstruction tends to propagate

Pathophysiology of OSA

Sites of Obstruction:

Pathophysiology of OSA Sites of Obstruction:

Pathophysiology of OSA

Symptoms of OSA

Snoring (most commonly noted complaint)

Daytime Sleepiness

Hypertension and Cardiovascular Disease are Associated

Pulmonary Disease

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

Pathophysiology of OSA

Tests to determine site of obstruction:

Muller’s 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

Pressure must be individually titrated

Compliance is as low as 50%

Air leakage, eustachian tube dysfunction, noise, mask discomfort, claustrophobia

Medical Management CPAP Pressure must be individually titrated Compliance is as low as 50% Air leakage,

Medical Management

BiPAP

Useful when > 6 cm H2O difference in inspiratory and expiratory pressures

No objective evidence demonstrates improved compliance over CPAP

Nonsurgical Management

Oral appliance

Mandibular advancement device

Tongue retaining device

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

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.

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

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

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

Surgical Management Tracheostomy Primary treatment modality Temporary treatment while other surgery is done Thatcher GW. et

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

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

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.

Surgical Management

UP3 Complications

Minor

Transient VPI

Hemorrhage

<1%

Major

NP stenosis VPI

Surgical Management UP3 Complications 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 Cahali, 2003 proposed the Lateral Pharyngoplasty for patients with significant lateral narrowing: Cahali MB.
Surgical Management Cahali, 2003 proposed the Lateral Pharyngoplasty for patients with significant lateral narrowing: Cahali MB.

Surgical Management

Lateral Pharyngoplasty

Surgical Management Lateral Pharyngoplasty
Surgical Management Lateral Pharyngoplasty
Surgical Management Lateral Pharyngoplasty
Surgical Management Lateral Pharyngoplasty

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

Surgical Management

Laser Assisted Uvulopalatoplasty

High initial success rate for snoring

Rates decrease, as for UP3 at twelve months

Performed awake

Surgical Management Laser Assisted Uvulopalatoplasty High initial success rate for snoring Rates decrease, as for UP3

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 Radiofrequency Ablation – Fischer et al 2003 Radiofrequency device is inserted into various parts

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

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 Tongue Base Procedures Lingualplasty Chabolle, et al success rate of 77% (RDI<20, 50% reduction)

Surgical Management

Mandibular Procedures

Genioglossus Advancement

Rarely performed alone

Increases rate of efficacy of other procedures

Transient incisor paresthesia

Surgical Management Mandibular Procedures Genioglossus Advancement Rarely performed alone Increases rate of efficacy of other procedures

Surgical Management

Lingual Suspension:

Surgical Management Lingual Suspension:

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 Hyoid Myotomy and Suspension Advances hyoid bone anteriorly and inferiorly Advances epiglottis and base

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 Maxillary- Mandibular Advancement Performed in conjunction with oral surgeons

Surgical Management

Algorithms

Studies efficacy of various algorithms

Therapy should be directed toward presumed site of obstruction

This does not always guarantee results

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

Surgical Management

Algorithms

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

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 :

Surgical Management

Algorithms:

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.

Surgical Management Algorithms: Friedman et al : Success = RDI<20 and RDI reduced 50% Friedman, Michael

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 apnea–hypopnea 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: 13–21.

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.

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