Obstructive Sleep Apnea

Shashidhar Reddy, MD, MPH

Faculty Advisor: Matthew W. Ryan, MD

The University of Texas Medical Branch

Department of 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

REM

Sleep Latency, REM Latency

Arousal

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

Evaluation of Sleep

Polysomnography

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

Shares pathophysiology with OSA

No desaturation, continuous ventilatory effort

Snoring

Prevalence of OSA

Study Location

n Age Range

Prevalence of AHI>5 (95%CI)

Prevalence of AHI15 (95%CI)

Men Women Men Women

Wisconsin 626 30-60 24

(19-28)

9

(6-12)

9

(6-11)

4

(2-7)

Penn 1741 20-99 17

(15-20)

Not given 7

(6-9)

2

(2-3)

Spain 400 30-70 26

(20-32)

28

(20-35)

14

(10-18)

7

(3-11)

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

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

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 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

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 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

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

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

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:

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

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

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:

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.

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. 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;16–25. 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):919-30, 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 Quinn’s 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):979-1012, 1998 Dec. Walker RP. Snoring and obstructive sleep apnea. In Bailey BJ, ed. Head and Neck Surgery – Otolaryngology. Philadelphia: Lippincott-Raven, 1998.