Snoring and Sleep ApneaSnoring and Sleep ApneaManagementManagement

Dr.K.O.Paulose FRCS.DLODr.K.O.Paulose FRCS.DLOConsultant ENT SurgeonConsultant ENT Surgeon

Jubilee Hospital TrivandrumJubilee Hospital Trivandrumweb:www.drpaulose.comweb:www.drpaulose.com

About meAbout me

2010-Consultant ENT Surgeon Jubilee 2010-Consultant ENT Surgeon Jubilee Hospital, TrivandrumHospital, Trivandrum

2004-2010-Consultant ENT Surgeon SUT 2004-2010-Consultant ENT Surgeon SUT Hospital, TrivandrumHospital, Trivandrum

1987-2003-Consultant ENT Surgeon Bahrain 1987-2003-Consultant ENT Surgeon Bahrain Military HospitalMilitary Hospital

1978-1987-UK NHS Teaching Hospitals1978-1987-UK NHS Teaching Hospitals 1973-MBBS Trivandrum Medical College1973-MBBS Trivandrum Medical College 1980-DLO RCS London UK1980-DLO RCS London UK 1982-FRCS RCS Glasgow UK1982-FRCS RCS Glasgow UK

35 years of ENT Experience35 years of ENT Experience

Kumbhakarna and snoringKumbhakarna and snoring

snoring snoring kumbhakarna.jpgkumbhakarna.jpg

How Snoring and OSAHow Snoring and OSA

Causes of SnoringCauses of Snoring

Nasal ObstructionNasal Obstruction Enlarged, Uvula, Soft Palate, TongueEnlarged, Uvula, Soft Palate, Tongue Narrow retroplalatal, retrolingual Narrow retroplalatal, retrolingual

areaarea Enlarged Ts Ads in childrenEnlarged Ts Ads in children Lack of Muscle tone upper airwayLack of Muscle tone upper airway Air Turbulence in the oropharynxAir Turbulence in the oropharynx Vibration of soft palate and uvulaVibration of soft palate and uvula Venturi Effect-Bernoulli principleVenturi Effect-Bernoulli principle

Causes of SnoringCauses of Snoring

Causes of Snoring -NasalCauses of Snoring -Nasal

About Sleep ApneaAbout Sleep ApneaWhat is Sleep apnea?What is Sleep apnea?

Stoppage of breathing while asleepStoppage of breathing while asleep More than 10 secondsMore than 10 seconds 100-500 episode of apneas in one night100-500 episode of apneas in one night Plus HypopneasPlus Hypopneas Cause Hypoxia and HypercarbiaCause Hypoxia and Hypercarbia

Types of sleep apnea?Types of sleep apnea? Obstructive Sleep Apnea (OSA)Obstructive Sleep Apnea (OSA) Most common-loud snoringMost common-loud snoring Obstruction of upper airwayObstruction of upper airway Central Sleep Apnea (CSA) Central Sleep Apnea (CSA) Brain stem lesion, stroke, polio, tumorsBrain stem lesion, stroke, polio, tumors No snoringNo snoring Mixed sleep apnea (OSA+CSA)Mixed sleep apnea (OSA+CSA) Chronic respiratory failure>centralChronic respiratory failure>central

Signs and symptoms of sleep apneaSigns and symptoms of sleep apnea

Choking or gasping during sleep Choking or gasping during sleep Loud snoring Loud snoring Sudden awakenings to restart breathing Sudden awakenings to restart breathing Waking up in a sweat during the night Waking up in a sweat during the night Feeling tired in the morning Feeling tired in the morning HeadachesHeadaches Daytime sleepinessDaytime sleepiness Lack of concentration,fatigue,irritableLack of concentration,fatigue,irritable Low O2- Brain and HeartLow O2- Brain and Heart

Diagnosis of Sleep ApneaDiagnosis of Sleep Apnea

Good History from spouse or parentsGood History from spouse or parents Physical examination-Nose and ThroatPhysical examination-Nose and Throat Voice recordingVoice recording Flexible EndoscopyFlexible Endoscopy CT imaging or MRI retropalatal and CT imaging or MRI retropalatal and

pharyngeal airwaypharyngeal airway Sleep study-Polysomnogram-Home Sleep Sleep study-Polysomnogram-Home Sleep

StudyStudy Cardiac evaluationCardiac evaluation

Stop snoring and save your marriageStop snoring and save your marriage

Day time sleepinessDay time sleepiness

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Broken marriages-Divorce !!!!Broken marriages-Divorce !!!!

Car accidentsCar accidents

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Flexible EndoscopyFlexible Endoscopy

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CT Scan Retroplatal Airway-PN RatioCT Scan Retroplatal Airway-PN Ratio

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CT ImagingCT Imaging

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Sagital CT-PN ratioSagital CT-PN ratio Pharyngeal Narrowing Ratio-Its significancePharyngeal Narrowing Ratio-Its significance Soft palate-tongue contact and automatically Soft palate-tongue contact and automatically

calculated pharyngeal narrowing ratio (PNR), calculated pharyngeal narrowing ratio (PNR), defined as a ratio between the airway cross-defined as a ratio between the airway cross-section at the hard palate level and the narrowest section at the hard palate level and the narrowest cross-section from the hard palate to the cross-section from the hard palate to the epiglottis epiglottis

Soft palate should therefore be the target for Soft palate should therefore be the target for causal treatment of snoring, LAUP, CAUP, RF causal treatment of snoring, LAUP, CAUP, RF somnoplasty all aimed at the soft palate in OSA somnoplasty all aimed at the soft palate in OSA surgery. surgery.

Dynamic Sleep MRI ?Dynamic Sleep MRI ?

Polysomnography - Sleep lab studyPolysomnography - Sleep lab study

Brain electrical activity –EEGBrain electrical activity –EEG ECGECG Eye and jaw muscle movement Eye and jaw muscle movement Leg muscle movement Leg muscle movement Airflow Airflow Respiratory effort (chest and Respiratory effort (chest and

abdominal excursion) abdominal excursion) EKG EKG Oxygen saturationOxygen saturation

Home Sleep studyHome Sleep study

PolysomnogramPolysomnogram

Treatment of Snoring and Sleep ApneaTreatment of Snoring and Sleep Apnea

ConservativeConservative Weight LossWeight Loss Avoid AlcoholAvoid Alcohol Dental devices, dilatorsDental devices, dilators Avoid sleeping pillsAvoid sleeping pills or narcoticsor narcotics before bedbefore bed Stop SmokingStop Smoking Don't sleep on your backDon't sleep on your back

Surgical TreatmentSurgical Treatment GlossectomyGlossectomy Mandibular osteotomyMandibular osteotomy Hyod advancementHyod advancement Nasal surgery, Septal surgery,LAPTNasal surgery, Septal surgery,LAPT RF SomnoplastyRF Somnoplasty UPPP-LAUP+Coblator surgeryUPPP-LAUP+Coblator surgery Ts AdsTs Ads Tracheostomy-last optionTracheostomy-last option

Other Non surgical treatmentOther Non surgical treatment

Dental splintDental splint Nasal dilatorNasal dilator Nasal dropsNasal drops Treatment of allergyTreatment of allergy CPAP MachineCPAP Machine Yoga breathingYoga breathing Tennis ball on pyjama!!!Tennis ball on pyjama!!!

CPAPCPAP

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LASER TYPESLASER TYPES

Laser is an acronym that stands for Light Amplification by Stimulated Emission Laser is an acronym that stands for Light Amplification by Stimulated Emission of Radiation. of Radiation. The first concept of the laser was initiated by Albert Einstein in 1917.The first concept of the laser was initiated by Albert Einstein in 1917.

CO2 Laser CO2 Laser

Argon laser Argon laser

The Nd:YAG The Nd:YAG (Neodymium:Yttrium-aluminum-garnet) (Neodymium:Yttrium-aluminum-garnet)

The potassium-titanyl-phosphate (KTP) The potassium-titanyl-phosphate (KTP)

Diode LaserDiode Laser

Co2 LaserCo2 Laser CO2Laser CO2Laser The CO2 laser is the most versatile laser in otolaryngology. The carbon dioxide (CO2) laser The CO2 laser is the most versatile laser in otolaryngology. The carbon dioxide (CO2) laser

emits a colorless, infrared light at a specific wavelength of 10,600 microns, which has an emits a colorless, infrared light at a specific wavelength of 10,600 microns, which has an extremely high affinity for the intercellular water of cells.extremely high affinity for the intercellular water of cells.

A second, built-in, coaxial helium neon laser is necessary to indicate with its red color the A second, built-in, coaxial helium neon laser is necessary to indicate with its red color the site where the invisible CO2 laser beam will impact the target tissue. This laser, then, site where the invisible CO2 laser beam will impact the target tissue. This laser, then, acts as an aiming beam for the invisible CO2 laser beam.acts as an aiming beam for the invisible CO2 laser beam.

Advantages of Laser SurgeryAdvantages of Laser Surgery FastFast Painless Painless Bleeding-nilBleeding-nil Fast recovery Fast recovery No hospitalization if done under LANo hospitalization if done under LA GA for difficult casesGA for difficult cases

Disadvantages of LaserDisadvantages of Laser Cost of equipment and maintenanceCost of equipment and maintenance Special surgical skills Special surgical skills Increased setup time of equipment Increased setup time of equipment Need of safety eyewear Need of safety eyewear Increased care for patient safety - explosion or fire hazard.Increased care for patient safety - explosion or fire hazard. smoke smoke

Laser surgery for snoring and OSALaser surgery for snoring and OSA

LAUP LAUP (Laser Assisted Uvulopalatopharyngoplasty)(Laser Assisted Uvulopalatopharyngoplasty) involves removal of the uvula, shorten the soft palate and involves removal of the uvula, shorten the soft palate and reduce the volume of the tonsils using CO2 laser done reduce the volume of the tonsils using CO2 laser done under-LA / GAunder-LA / GA

LAPTLAPT-Laser assisted Partial -Laser assisted Partial turbinectomyturbinectomy

LASLAS-Laser assisted Septoplasty-Laser assisted Septoplasty LATLAT-Laser assisted Tonsillectomy-Laser assisted Tonsillectomy

LAUP LALAUP LA

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LAUP in OPDLAUP in OPD

After LAUP-LAAfter LAUP-LA

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Intubation-GAIntubation-GA

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Intubation ContdIntubation Contd

Laser surgery under GALaser surgery under GA

Laser Surgery for OSA in JubileeLaser Surgery for OSA in Jubilee

LAUP GALAUP GA

Tonsils,soft palate and uvulaTonsils,soft palate and uvula

LAUP and LAPTLAUP and LAPT

LAUP GALAUP GA

Laser noseLaser nose

Laser surgery NoseLaser surgery Nose

LAPT -LALAPT -LA

Septal SurgerySeptal Surgery

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Post op LAUPPost op LAUP

Oldest LAUPOldest LAUP

OSA in Children –Ts AdsOSA in Children –Ts Ads

Tonsil Adenoid Causing OSATonsil Adenoid Causing OSA

Tonsillectomy in ChildrenTonsillectomy in Children

OSA in Children-Ts Ads SurgeryOSA in Children-Ts Ads Surgery

COBLATOR SURGERYCOBLATOR SURGERY

Cold Ablation-Coblation TechnologyCold Ablation-Coblation Technology a controlled, non-heat driven process — uses a controlled, non-heat driven process — uses

radiofrequency energy to excite the electrolytes in a radiofrequency energy to excite the electrolytes in a conductive medium, such as saline conductive medium, such as saline

Temperature 40-70*C-less thermal damageTemperature 40-70*C-less thermal damage Coblator II, Arthrocare ® USA MachineCoblator II, Arthrocare ® USA Machine

Coblator Surgery Coblator Surgery RF turbinate-Turbinoplasty RF turbinate-Turbinoplasty PolypectomyPolypectomy Tonsillothomy-pediatricTonsillothomy-pediatric CAUP –Snoring and OSACAUP –Snoring and OSA Tongue base reductionTongue base reduction

Coblator MachineCoblator Machine

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Coblation TechnologyCoblation Technology

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CAUPCAUP

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Coblation SurgeryCoblation Surgery

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Coblation SurgeryCoblation Surgery

CAUP GACAUP GA

Coblation Surgery-GACoblation Surgery-GA

Coblation Soft PalateCoblation Soft Palate

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Coblator stiffening soft palateCoblator stiffening soft palate coblatorcoblator chanelingchaneling

soft palate2-nisha3. soft palate2-nisha3. coblatorcoblator chanelingchaneling soft palate2-nisha3.jpgjpg soft palate2-nisha3.jpgjpg

Diode laser surgeryDiode laser surgery

Number of OSA SurgeryNumber of OSA Surgery

1980s-UPPP1980s-UPPP 1996-2003 Laser Surgery-1000+cases (approx)1996-2003 Laser Surgery-1000+cases (approx) 2004-2010-SUT Hospital- 422 Cases 2004-2010-SUT Hospital- 422 Cases

(LAUP+LAPT+LAS+Ts+Ads+CAUP)(LAUP+LAPT+LAS+Ts+Ads+CAUP) 2010- Jubilee Hospital-86 cases 2010- Jubilee Hospital-86 cases

(LAUP+LAPT+TS+Ads etc)(LAUP+LAPT+TS+Ads etc) Result-70-80% cure OSA, 80-90% cure SnoringResult-70-80% cure OSA, 80-90% cure Snoring Redo-3-4 cases per yearRedo-3-4 cases per year Causes of Causes of Failure-Retrognathia, Large Failure-Retrognathia, Large

Tongue,Obesity,Hypothyroid, Central apnea, Hypotonia, Tongue,Obesity,Hypothyroid, Central apnea, Hypotonia, Medications etcMedications etc

Results of Laser surgeryResults of Laser surgery showed the correction of sleep apnea by an average of 70-80% showed the correction of sleep apnea by an average of 70-80%

However, the snoring sound reduction was between 80-90%. However, the snoring sound reduction was between 80-90%.

Side EffectsSide Effects post op infection -rarepost op infection -rare nasal fluid reflux –temporary nasal regurgitation for few days, but nasal fluid reflux –temporary nasal regurgitation for few days, but

rarely permanentrarely permanent no voice changes were noted no voice changes were noted Bleeding-rareBleeding-rare Dryness of throat-rareDryness of throat-rare

Causes of fauilure if anyCauses of fauilure if any mixed apnea-central componentmixed apnea-central component Inadequate excision of tissues-RedoInadequate excision of tissues-Redo Obesity,alcohol,sedativeObesity,alcohol,sedative Lack of muscle tone in the neckLack of muscle tone in the neck Base of tongue factor-coblator reductionBase of tongue factor-coblator reduction Jaw factor-need mandibular advancementJaw factor-need mandibular advancement

Happily living afterHappily living after

Thank YouThank YouFor details please visit my web site:For details please visit my web site:

www.drpaulose.comwww.drpaulose.comwww.snorefreesleep.comwww.snorefreesleep.com