Ken Falci, Ph.D.,Director, OSAS Center for Food Safety and Applied Nutrition (CFSAN)
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OBSTRUCTIVE SLEEP APNOEA
SYNDROME
Prof. Mohan Kameswaran
MS, FRCS, FICS, FAMS, DSc, DLO
Madras ENT Research Foundation
Chennai
OBSTRUCTIVE SLEEP APNOEA SYNDROME
• OSA is a common disorder resulting from collapse of
the pharyngeal airway during sleep
• Significant advances have been made in the
evaluation and treatment of OSAS over the past
several years
• Primary snoring
• Upper Airway Resistance Syndrome (UARS)
• Obstructive sleep apnoea syndrome (OSAS)
SLEEP DISORDERED BREATHING
RDI O2
desaturationDay time
sleepiness
Primary snoring
< 5 / hr SaO2 > 90% No
UARS < 5 / hr SaO2 > or = 90%
Yes
OSAS > 5 / hr SaO2 < 90% Yes
SLEEP-RELATED UPPER AIRWAY OBSTRUCTION
• Apnoea - cessation of airflow at the nostrils and mouth
for atleast 10 seconds
• SAS - 30 or more apnoeic episodes during a
7-hour period of sleep or an apnoea index (number of
apnoeas per hour of sleep) equal to or greater than 5
SLEEP APNOEA SYNDROME - Semantics
• Hypopnoea (reduction in tidal volume) - 50% reduction
in airflow, lasting for 10 seconds in the presence of
continued respiratory effort
• Respiratory Disturbance Index (RDI) or Apnoea
Hypopnoea index (AHI) - number of apnoeas and
hypopnoeas per hour of sleep
• In OSAS, RDI is greater than 10
SLEEP APNOEA - TYPES
• Obstructive sleep apnoea - cessation of airflow in the
presence of continued respiratory effort
• Central sleep apnoea - no airflow at the nose or mouth
associated with a cessation of all respiratory effort
• Mixed apnoea - begins initially as central apnoea, then
becomes obstructive
• Intrinsic dyssomnia characterized by recurrent episodes
of upper airway collapse and obstruction during sleep
• Associated with recurrent oxyhemoglobin desaturation
and arousal from sleep
• Both anatomic and neuromuscular factors are important
OBSTRUCTIVE SLEEP APNOEA
Abnormal neuromuscular control of pharyngeal dilators (genioglossus, geniohyoid, palatoglossus, medial pterygoids)
during sleep
Airway narrowing (space occupying lesion from the nasal vestibule to glottis)
OSA - PATHOPHYSIOLOGY
Venturi effect Increased intraluminal negative pressure
UPPER AIRWAY OBSTRUCTION
How many people have sleep apnea?
Older guidelines (AHI > 10) - 2 - 4% of the population Older guidelines (AHI > 10) - 2 - 4% of the population
Newer guidelines (AHI > 5 with symptoms) - 9 - 24% Newer guidelines (AHI > 5 with symptoms) - 9 - 24%
Children: 1- 3%
OSAS
3 major levels of obstruction (Fujita)
• Retropalatal (Type1)
• Retropalatal and retrolingual (Type 2)
• Exclusively retrolingual (Type 3)
SLEEP MRI - Type 1 obstruction
SLEEP MRI - Type 2 obstruction
OSAS - EFFECTS
• Oxygen desaturation causing increased
sympathetic output & peripheral vasoconstriction
• High negative intrathoracic pressures with arousal
& termination of obstructive episode
• Nose - nasal polyps, DNS,
rhinitis, nasal packing
• Pharynx - nasopharyngeal
tumor, enlarged adenoids,
palatal & lingual tonsils,
retropharyngeal mass,
enlarged tongue,
micro/retrognathia
• Larynx – tumors, oedema
Shy- Drager syndrome laryngotracheomalacia vascular ring
OBSTRUCTIVE SLEEP APNOEA CAUSES
Male sex Obesity
Increasing age
Commonest etiology
• Adenotonsillar hypertrophy
• Neuromuscular hypotonia
• Craniofacial and neurologic syndromes
PEDIATRIC OSAS
OBSTRUCTIVE TONSILS
Common
• Snoring
• Excessive daytime sleepiness
• Obstructive episodes
Less common
• Morning headaches
• Personality change
• Intellectual deterioration
• Depression
• Abnormal body movements
• Frequent waking
• Nocturnal choking
• Impotence
OBSTRUCTIVE SLEEP APNOEA Clinical features
• Loud snoring
• Noisy breathing during sleep
• Mouth breathing
• Growth retardation
• Repetitive upper airway
infection
• Abnormal shyness
• Nocturnal enuresis
• Poor growth problems
• Rebellious and aggressive
behavior
• Attention deficit disorder
PEDIATRIC OSAS
Sleep MRI - Craniosynostosis
OSAS - common associations
• LPR
• Systemic hypertension
(50 - 70%)
• Coronary artery disease
• Pulmonary hypertension
• Right heart failure
• Cardiac arrhythmias
• Left ventricular hypertrophy
• MI
• Depression
• Sudden death?
• Vehicular and work-related
accidents
LARYNGOPHARYNGEAL REFLUX
OSAS - HISTORY & EXAMINATION
• General appearance, weight, height, blood pressure
• H/O alcohol, drugs e.g. sedatives
• Thyroid evaluation
• ENT & Head and Neck examination - nasal airway, tongue
size, soft palate, uvula, tonsils, naso / hypopharynx, larynx
• Craniofacial morphology
Snoring / OSAS
If OSAS, the site of obstruction
Associated problems
ENT & Head and Neck examination
• Short thick neck (Collar size > 17.5)
• Enlarged floppy uvula
• Elongated soft palate
• Tonsillar hypertrophy
• Enlarged tongue
• Micrognathia / retrognathia
• FBC, ECG, chest X-ray, Lung function tests
• Polysomnography (Holland, Dement, Raynall, 1974)
- Level 1 PSG - gold standard investigation
- Overnight monitoring of pulse oximetry, End tidal CO2, ECG, EEG, anterior
tibialis EMG, EOG, nasal & oral airflow, chest & abdominal movements &
sleeping position
- Differentiates obstructive from central sleep apnoea
- Evaluates the severity
INVESTIGATIONS
Polysomnography
Polysomnography
Sleep MRI & Fiberoptic endoscopy - assessment of
the site of obstruction - retropalatal / retrolingual /
combined
Sleep MRI
Sleep endoscopy
OSAS - TREATMENT• Medical
• Appliances - nasal splint, mandibular positioning device, tongue retaining device
• Surgical
• If anatomic obstruction is present, corrective surgery should be done
NONSURGICAL TREATMENT
• Weight loss
• Treatment of systemic disorders
• Alcohol advice
• Drugs review
NONSURGICAL TREATMENT
Drug treatment
• Protryptiline (increases the neuromuscular activity of upper
airway & decreases REM sleep)
• Theophylline
• Progesterone
• Modafinil (improves wakefulness by decreasing GABA
mediated neurotransmission)
NONSURGICAL TREATMENT• Mandibular positioning device – in non obese patients with
micrognathia / retrognathia, advances the mandible and increases
posterior airway space, has success rate of 50 % & compliance rate
of 25%
• Tongue retaining device
• Positional devices
• Nasal splints
• Nasal CPAP, Nasal BiPAP & Demand PAP
MANDIBULAR POSITIONING DEVICE
NOZOVENT NASAL SPLINT
TONGUE RETAINING DEVICE
Nasal Continuous Positive Airway Pressure (Colin Sullivan, 1981)
• Noninvasive and highly effective primary treatment
modality
• Delivers a continuous flow of air & provides a pneumatic
splint to the upper airway during inspiration preventing
collapse during sleep by increasing airway volume, area and
lateral dimensions in retropalatal and retroglossal regions
Continuous Positive Airway Pressure
Nasal CPAP
• Problems: dermal irritation, dryness, sneezing,
rhinorrhoea, claustrophobia, panic attacks leading to
noncompliance
• Auto-CPAP is as effective as constant CPAP
• The auto-CPAP is characterized by its ability to
modify the positive-pressure level applied
Nasal CPAP
• Restores normal respiration during sleep, normalizes
sleep organization
• Improves day time alertness, neuropsychiatric function,
right heart function, and systemic blood pressure
• Success rate - 90%
• Compliance - 50%
SURGICAL TREATMENT
Indications
• Primary snoring
• AHI > 15
• O2 desaturation < 90%
• AHI > 5 or < 14, with excessive daytime sleepiness
• UARS
• Unsuccessful medical treatment
• Type 1 collapse (mainly retropalatal)
• Failure of compliance for CPAP
POOR SURGICAL CASES
• Extreme obesity
• Lack of physical activity
• Alcoholism
• Type 2 collapse
• Cardiac arrhythmias
SURGICAL TREATMENT
• Nasal surgery, Adenotonsillectomy
• Uvulopalatopharyngoplasty, LAUP, RAUP, CAUP
• Hyoid advancement
• Midline Laser glossectomy
• Mandibular / Maxillary osteotomy & advancement
• Tracheostomy - gold standard
Enlargement of retropalatal airway
• Uvulopalatopharyngoplasty (UPPP)
• Laser - LAUP
• Radiofrequency - RAUP
• Coblation - CAUP
UVULOPALATOPHARYNGOPLASTY Dr. Ikematsu (1964), Dr. Fujita (1981)
• Removal of excessive redundant tissue in the oropharynx
with increased cross-sectional area
• Success rates in curing snoring: 85 - 90%
• Success rates in reducing apnoeic index: 23 - 77%
• Complications: bleeding, velopharyngeal insufficiency, dry
throat, nasopharyngeal stenosis, airway compromise,
hypernasal speech & taste disturbances
UvulopalatopharyngoplastyUvulopalatopharyngoplasty (UPPP) (UPPP)
For successful UPPP, Mandibular - hyoid angle must be less than
25 - 30
LASER ASSISTED UVULOPALATOPHARYNGOPLASTY
(Dr. Kamami, 1993)
• Effective and has the advantage of a bloodless field
• Success rates: short term - 77 - 89%
long term - 75%
no snoring - 52%
Sleep MRI – post UPPPshowing retrolingual obstruction
UPPP / LAUP - Anesthetic considerations• Pre-op evaluation
• Avoid sedatives, narcotics
• Difficult intubation (FO intubation may be required)
• After extubation - nasopharyngeal airway, pulse oximetry and
avoidance of narcotic analgesia, monitoring for post obstructive
pulmonary edema
NASOPHARYNGEAL AIRWAY
RADIOFREQUENCY IN OSAS
• Radiofrequency thermal ablation uses low levels of RF
energy to create targeted tissue ablation resulting in
tissue volume reduction
• The procedure is quick, painless and is associated with
minimal edema
Radiofrequency in OSASRadiofrequency in OSAS
COBLATION
• Voltages applied to convert conductive fluid between
electrodes and tissue into ionized vapor layer (plasma)
• Ionized layer contains excited particles which, when in
contact with tissue, break tissues molecular bonds with
minimal thermal penetration
• Energy used - up to 8 eV
Enlargement of retrolingual space
• Tongue base reduction procedures
• Mandibular osteotomy with genioglossal advancement
• Repose tongue suspension intraoral approach
• Hyoid Myotomy and suspension
• Genioglossal advancement and hyoid suspension (GAHM)
• Maxillofacial techniques
• Uvulopalatopharyngoglossoplasty (UPPGP)
(UPPP with limited resection of the tongue base)
Tongue base reduction proceduresType 3 (Riley)
• Tracheostomy required
• Midline Laser glossectomy - laser is used to extirpate a rectangular strip
(2.5 into 5 cms) of the posterior portion of tongue, useful in Down’s
syndrome, Mucopolysaccharidosis
• Lingualplasty - modification of LMG, involves additional excision of
lateral tongue tissue
• Radiofrequency tissue ablation of tongue base - RF probe with 465 KHZ
GENIOGLOSSUS ADVANCEMENT PROCEDURE
Osteotomies in the mandible at the geniotubercle advancing the insertion of genioglossus or geniohyoid by 10-14 mm & rotating it by 90%. This increases the tension placed on the tongue
CANDIDATE FOR GENIOGLOSSUS ADVANCEMENT
Tongue suspension
Tongue base is pulled forward and secured anteriorly
by a titanium screw placed at the lingual cortex of genial tubercle of mandible
MODIFIED HYOID MYOTOMY & SUSPENSION
Genioglossal advancement and hyoid suspension (GAHM)
• Combined procedure of inferior mandibular osteotomy with
genioglossal advancement with hyoid myotomy & suspension
• Success rates - 70%
• Complications: infection, need for root canal therapy,
permanent anesthesia, seroma, mandibular fracture, aspiration
Hyoid distraction procedure(Tucker Woodson)
The hyoid bone is split and two separate loops of suture
are used to pull the bone not only anteriorly and
superiorly, but also laterally
MAXILLOFACIAL TECHNIQUES
• Used in severe OSAS where the tongue base is the cause
of obstruction
• Advances the skeletal support of soft tissues (tongue and
pharynx) that collapse during sleep
Candidate for maxillomandibular
advancement
MAXILLOMANDIBULAR OSTEOTOMY & ADVANCEMENT (Riley & Powell)
• Phase 2 surgery
• Improves retropalatal and retrolingual space and increases airway
caliber in an anteroposterior direction
• Success rates: 95%
• Complications: malocclusion, inferior alveolar, lingual or
infraorbital paresthesia, nonunion/malunion, relapse of
advancement, TMJ complications, need for restorative dental work
MAXILLOMANDIBULAR ADVANCEMENT PROCEDURE (Riley & Powell)(Riley & Powell)
Presurgical evaluation
Phase I (site of obstruction)
UPPPType I oropharynx
UPPP + MOHMType 2 oro - hypopharynx
MOHMType 3 hypopharynx
Postop polysomnogram (6 months)Failure
Phase II - MMO
Riley-Powell-Stanford surgical protocol
TracheostomyTracheostomy
Bypasses airway obstruction Bypasses airway obstruction
Indications - severe OSAS with Indications - severe OSAS with • RDI above 50RDI above 50
• Lowest OLowest O22 saturation below 60% saturation below 60%
• Cardiac arrhythmiasCardiac arrhythmias
CONCLUSION
• OSA is a common disease of adult & pediatric age groups
with a myriad of presentations
• Often the patient is unaware of his condition
• A detailed history, clinical examination & simple
overnight observation will help to clinch the diagnosis
• Sleep MRI ( dynamic MRI ) with F.O.nasendoscopy
has obviated the need for cumbersome cephalometric
measures to establish the site of obstruction
• A comprehensive presurgical evaluation to identify the
site of airway obstruction improves surgical success
rates