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OBSTRUCTIVE SLEEP APNOEA
SYNDROME
Prof. Mohan Kameswaran
MS, FRCS, FICS, FAMS, DSc, DLO
Madras ENT Research Foundation
Chennai
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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
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• Primary snoring
• Upper Airway Resistance Syndrome (UARS)
• Obstructive sleep apnoea syndrome (OSAS)
SLEEP DISORDERED BREATHING
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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
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• 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
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• 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
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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
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• 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
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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
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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%
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OSAS
3 major levels of obstruction (Fujita)
• Retropalatal (Type1)
• Retropalatal and retrolingual (Type 2)
• Exclusively retrolingual (Type 3)
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SLEEP MRI - Type 1 obstruction
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SLEEP MRI - Type 2 obstruction
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OSAS - EFFECTS
• Oxygen desaturation causing increased
sympathetic output & peripheral vasoconstriction
• High negative intrathoracic pressures with arousal
& termination of obstructive episode
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• 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
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Commonest etiology
• Adenotonsillar hypertrophy
• Neuromuscular hypotonia
• Craniofacial and neurologic syndromes
PEDIATRIC OSAS
OBSTRUCTIVE TONSILS
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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
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• 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
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Sleep MRI - Craniosynostosis
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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
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LARYNGOPHARYNGEAL REFLUX
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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
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ENT & Head and Neck examination
• Short thick neck (Collar size > 17.5)
• Enlarged floppy uvula
• Elongated soft palate
• Tonsillar hypertrophy
• Enlarged tongue
• Micrognathia / retrognathia
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• 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
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Polysomnography
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Polysomnography
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Sleep MRI & Fiberoptic endoscopy - assessment of
the site of obstruction - retropalatal / retrolingual /
combined
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Sleep MRI
Sleep endoscopy
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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
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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)
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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
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MANDIBULAR POSITIONING DEVICE
NOZOVENT NASAL SPLINT
TONGUE RETAINING DEVICE
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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
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Continuous Positive Airway Pressure
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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
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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%
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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
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POOR SURGICAL CASES
• Extreme obesity
• Lack of physical activity
• Alcoholism
• Type 2 collapse
• Cardiac arrhythmias
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SURGICAL TREATMENT
• Nasal surgery, Adenotonsillectomy
• Uvulopalatopharyngoplasty, LAUP, RAUP, CAUP
• Hyoid advancement
• Midline Laser glossectomy
• Mandibular / Maxillary osteotomy & advancement
• Tracheostomy - gold standard
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Enlargement of retropalatal airway
• Uvulopalatopharyngoplasty (UPPP)
• Laser - LAUP
• Radiofrequency - RAUP
• Coblation - CAUP
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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
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UvulopalatopharyngoplastyUvulopalatopharyngoplasty (UPPP) (UPPP)
For successful UPPP, Mandibular - hyoid angle must be less than
25 - 30
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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%
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Sleep MRI – post UPPPshowing retrolingual obstruction
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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
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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
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Radiofrequency in OSASRadiofrequency in OSAS
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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
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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)
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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
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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
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CANDIDATE FOR GENIOGLOSSUS ADVANCEMENT
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Tongue suspension
Tongue base is pulled forward and secured anteriorly
by a titanium screw placed at the lingual cortex of genial tubercle of mandible
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MODIFIED HYOID MYOTOMY & SUSPENSION
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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
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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
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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
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Candidate for maxillomandibular
advancement
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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
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MAXILLOMANDIBULAR ADVANCEMENT PROCEDURE (Riley & Powell)(Riley & Powell)
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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
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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
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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
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• 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
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