Obstructive Sleep Apnea

1. Obstructive Sleep Apnea Melanie Giesler, DO

4. Patient Evaluation • History • Spousal/Parental complaint of snoring • Morning headache • Daytime Somnolence • Insomnia • Dry Mouth

5. 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

6. Physiology of Sleep • REM • Sleep Latency, REM Latency • Arousal Woodson, Tucker “Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment” SIPAC 1996

7. Evaluation of Sleep • Polysomnography • EMG – submental & ant. tibialis • Nasal and oral airflow • EEG, EOG • Oxygen Saturation • Thoracic/abdominal movements • Sleep position • Blood pressure • Cardiac Rhythm • Leg Movements • AI (cessation of airflow for 10 seconds leading to an arousal), HI (reduction of airflow by at least 50% for at least 10 seconds), AHI, RDI – sum of events per hour

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

9. Evaluation of Sleep • Standard Polysomnogram • Split-Night Polysomnography (1-2 hours of data then start CPAP) • Epworth Sleepiness Scale • Multiple Sleep Latency Test

10. Epworth Sleepiness Scale • Score of 10 or more – further study

11. Multiple Sleep Latency Test • Documents Sleepiness • The MSLT is a series of 5 naps taken at 2 hour intervals, starting at approximately 9:00 A.M. • This is done the following day after a polysomnogram (PSG) • The MSLT determines how long it takes a person to fall asleep at preset times throughout the day.

12. Definition of OSA • AHI>5 • AHI > 20 increases risk of mortality • AHI 5-14=mild;15-29=moderate; >30=severe (apneas + hyponeas/#hours of sleep) • Upper Airway Resistance Syndrome • Shares pathophysiology with OSA • No desaturation, continuous ventilatory effort

13. Prevalence of OSA – up to 4% of middle aged adults

14. Pathophysiology of OSA • Airway size:

15. Bernouli’s Principle • increased air velocity produces decreased pressure

16. Pathophysiology of OSA • Sites of Obstruction: • Obstruction tends to propagate

17. Pathophysiology of OSA • Sites of Obstruction:

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

19. 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

20. Physical Exam Obstructive Sleep Apnea

21. Pathophysiology of OSA • Tests to determine site of obstruction: • Muller’s Maneuver – palate vs BOT/hypopharynx; inspire against closed nasal and oral airway • Sleep endoscopy • Fluoroscopy • Manometry • Cephalometrics • Dynamic CT scanning and MRI scanning

22. Muller’s Manuver

23. Medical Management • Weight Loss • CPAP • Nasal Obstruction • Sleep Hygiene - Sedative Avoidance • Smoking cessation

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

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

26. CPAP/BiPAP

27. CPAP/BiPaP

28. Nonsurgical Management • Oral appliance • Mandibular advancement device • Tongue retaining device

29. Nonsurgical Management • Oral Appliances • May be as effective as surgical options, especially with symptoms worse with patient supine • 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 obstructivesleep apnea: a randomized study. Chest. 121(3):739-46, 2002 Mar.

30. 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

31. 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

32. 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 obstructivesleep apnea. [Journal Article] Laryngoscope. 113(2):201-4, 2003 Feb.

33. 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

34. Surgical Management • Uvulopalatopharyngoplasty • Fujita (1981) • 10-50% effective at 5 years

35. 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.

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

37. Surgical Management • Cahali, 2003 proposed the Lateral Pharyngoplasty for patients with significant lateral narrowing: Cahali MB. Lateral pharyngoplasty: a new treatment for obstructivesleep apnea hypopnea syndrome. Laryngoscope. 113(11):1961-8, 2003 Nov.

38. Surgical Management • Lateral Pharyngoplasty

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

40. 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

41. Surgical Management • Soft palate implants • Stiffens soft palate – makes palate more stiff and (hopefully) less likely to collapse

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

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

44. Surgical Management • Lingual Suspension:

45. Surgical Management • Lingual Suspension:

46. 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

47. 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

48. Surgical Management • Maxillary-Mandibular Advancement • Performed in conjunction with oral surgeons

49. 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