Sleep Apnea Syndromes Treatment of Obstructive Sleep Apnea Syndrome

Laugh and the world laughs with you, Snore, snore, snore and you sleep alone

AliAli Tawfik Abdel wahab Mouhamed ElsharawyKamal HazemEmam WaleedRadwan Ahmed Mosad Mansoura ,Egypt Sleep Apnea Syndromes

PPoolilittiicalcal eecconoonommiicc ssigigniniffiicacattionion ooff SSlleeeepp didissoorrddersers

• Directcosts of sleep disorders 15,9Mill US $ • Hospitalizationcosts of non-treated patientswith Sleep-Apnoe-syndrome 42 Mill US $ • Trafficand industrial accidents in cause oftiredness 50 Mill US $

• 38.000 cardivascular cases of death due toSleep Apnoea Syndromein the USA • Prevalenceof 87% in a study on 159 american truck-drivers Sleep Apnea Syndromes SSlleeeepp PhPhyyssiioollogyogy

Five phases of sleep: stages 1, 2, 3, 4, (NREM) and REM (rapid eye movement).

These stages progress in a cycle from stage 1 to REM sleep.

Then the cycle starts over again with stage 1 . We spend almost :- • 50 % of our total sleep time in stage 2 sleep. • 20 % in REM sleep. • 30 % in the remaining the other stages. Infants, by contrast, spend about half of their sleep time in REM sleep. Sleep Apnea Syndromes SSlleeeepp PPhhyyssiioolloogygy •NonREM sleep

§ superficialsleep (phase I and II) -sleeper can be easy waked up by little influences § deepsleep (phase III and IV)

§ REMsleep (dream sleep) -brain waves similar to those when you`re awaken, rapid eye-movement, raised muscle-tension Sleep Apnea Syndromes Snoring Definition: • Sounds generated by the loose redundant soft tissue of the upper airway in the during sleeping . Social effects of snoring: • Snoring may be disruptive to the family life. Sleep Apnea Syndromes Incidence of Snoring

• 53% of the adult male population snore intermittently • 31% snore regularly. • 38% of adult female snore intermittently . • 19% snore regularly. Sleep Apnea Syndromes SSnnorioringng • Different grading scales for snoring have been developed. • An easy grading system was developed by Pelausaand Trashis(1989). o Grade I No snoring. o Grade 11 Occasional snoring o Grade III Persistent snoring. o Grade IV Persistent loud snoring. Sleep Apnea Syndromes SSnnorioringng • Camilleriet al (1995), have adopted this technique and proposed a simplified grading for patients with simple snoring :

•Grade 1: Palatal snoring.

•Grade 2: Mixed snoring.

•Grade 3: Non-palatal (tongue base) snoring. Sleep Apnea Syndromes Should everyone who snores undergo a sleep study? q When the snoring is accompanied by symptoms of OSA, such as morning headache, and restless sleep…….. q When snoring is socially disruptive but not accompanied by symptoms of sleep apnea, the picture is not so clear. q Unfortunately, even "apneas" witnessed by bed- partners are not predictive of OSA. q The only reasonably accurate method of detecting OSA remains the sleep study. q Therefore, current recommendations suggest obtaining a sleep study before to any surgery for sleep apnea or snoring. Sleep Apnea Syndromes

What questions should you ask for a patient with suspected SAS? q Does your snoring ever awaken you from sleep? q Do you ever awaken suddenly, gasping for air? q Do family members complain about your snoring? q Does your spouse notice periods in which breathing temporarily stops? q Do you feel rested (sleepy) after a night's sleep? q Do you feel drowsy at work. q Do you fall asleep at inappropriate times (such as at work, while driving, or while on the telephone)? q Do you have morning headaches? Sleep Apnea Syndromes q EArpweo rtthheSrelee psipeciness Sacla tlee sist as steon seitvaivelu screeaten ifnogr t ooSAS?l for OSA. q It is a series of questions about daytime somnolence. q A numerical score is assigned that correlates well to the eventual diagnosis of OSA. q Polysomnography is the most sensitive and specific test in the evaluation of SAS:- q The patient needs to spend a night in sleep lab. q Gives an apnea index (AI), respiratory disturbance index (RDI), and oxygen desaturations q differentiate between pure OSA, and central sleep apnea and can characterize the severity of the apnea. Sleep Apnea Syndromes Are there special tests to evaluate for SAS? q Home sleep studies have recently been implemented in an effort to reduce cost. q These studies range from simple continuous pulse oximetryrecordings to multi-channel recordings using devices similar to those used in a sleep laboratory. q Although these tests are gaining popularity, none is as sensitive or specific as a sleep laboratory study. q The multiple sleep latency test is also performed in a sleep laboratory, but it is done during the day. q The subject is given the chance to take naps, and this test assesses the time it takes for the subject to fall asleep. q An average sleep onset of < 5 minutes is generally considered pathologic and suggests excessive daytime sleepiness. Sleep Apnea Syndromes

Are there special tests to evaluate for SAS?

q Muller's maneuver is performed as part of an extensive physical examination and involves passing the flexible fiberopticscope into the hypopharynxto obtain a view of the entire hypopharynxand larynx. q The examiner then pinches the nostrils closed, and the patient closes his or her lips while attempting to inhale. q If the hypopharynxand/or larynx collapse, then the test is positive. q A positive test means that the site of upper airway obstructionis very likely below the level of the soft palate, and the patient will probably not benefit from a uvulopalatopharyngoplastyalone. q Tongue base procedures may be necessary Sleep Apnea Syndromes

Are there special tests to evaluate for SAS?

q Sleep flexible fiberopticendoscopyis occasionally perforedfor apnea. q A flexible fiberopticendoscope is passed into the hypopharynxto watch the patient breathe while under a light general anesthetic. q This can help to evaluate the site of obstruction and may encourage the physician to do some type of tongue base procedure. Sleep Apnea Neurological Obstructive Narcolepsy Central Insomnia Mixed Periodic leg movement(PLM) Hypopnea (Restless legs) Obesity-hypoventlation Bruxism, (Pick wickian syndr.) Sleep walking, Upper-airway Resistance syndr. Hypersomnia, Sleep terrors Sleep Apnea Syndrome Definition: • Apnea:- Cessation of airflow from the mouth and nose during sleeping period for 10 seconds or more, for 5 times or more per hour. • Apnea Index (AI): The total number of apneas per hour of sleep. • Hypopnea: 50% or more reduction in the amplitude of a validated measure of breathing or a less than 50% amplitude reduction that is associated with either an arousal or more than 3% drop in oxygen saturation • Apnea Hypopnea Index (AHl): Summation of apneas and hypopneasper hour sleep. Sleep Apnea Syndrome

• Desaturation: Drop of oxygen saturation of at least 4% or more from baseline and maintained for at least 10 seconds . Desaturation Index: The number of desaturationevents per hour, averaged over all hours of sleep • Arousal Index: The number of times per hour a patient is aroused from sleep. Sleep Apnea Syndromes Types of SAS

• Obstructive Sleep Apnea • Central Sleep Apnea • Mixed Sleep Apnea • Upper-airway Resistance syndr. Sleep Apnea Syndromes Types of SAS • Obstructive apnea – Cessation of airflow for at least 10 seconds with respiratory effort • Central apnea – Cessation of airflow and without respiratory effort for at least 10 seconds • Mixed apnea – Characteristics of both for at least 10 seconds • Hypopnea – Hypoventilation secondary to partial obstruction Sleep Apnea Syndromes Evaluation of Sleep Polysomnography – EMG – Airflow – EEG – EOG Types of SAS

– Oxygen Saturation • Obstructive Sleep Apnea – Cardiac Rhythm • Central Sleep Apnea • Mixed Sleep Apnea – Leg Movements • Upper-airway Resistance syndr. – Chest & abdominal motion Sleep Apnea Syndromes Polysomnogram

Polysomnography – EMG – Airflow – EEG – EOG – Oxygen Saturation – Cardiac Rhythm – Leg Movements – Chest & abdominal motion Sleep Apnea Syndromes •Polysomnography

1. Inpatient (sleep lab) 2. Patients home 3. Split night study Sleep Apnea Syndromes What are the polysomnographiccharacteristics of OSA? • Apnea:- Temporary cessation of air exchange due to obstruction of the upper airway while normal or extraordinary respiratory efforts are being made. • Hypopnea a reduction of air exchange associated with oxygen desaturation. It can be obstructive or central. q Mixed sleep apnea Exhibits components of both central and obstructive apnea but is considered a variant of OSA. Treatment is similar to treatment for OSA. q Apnea Index (AI) number of apnea events per hour. q Respiratory Disturbance Index (RDI) number of apnea events plus number of hypopneaevents per hour. q "Pickwickian“ Charles Dickens, in The Posthumous Papers of the PickwickianClub (1837), described the obese and somnolent Joe ." Pickwickian syndrome is characterized by obesity and hypoventilation who "goes on errands fast asleep and snores . Sleep Apnea Syndromes Polysomnogram • Obstructive apnea – Cessation of airflow for at least 10 seconds with respiratory effort • Central apnea – Cessation of both airflow and respiratory effort for at least 10 seconds • Mixed apnea – Characteristics of both for at least 10 seconds • Hypopnea – Hypoventilation secondary to partial obstruction Sleep Apnea Syndromes Polysomnogram • Apnea index • Apnea-Hypopnea index = respiratory disturbance index • Arousal index Sleep Apnea Syndromes Grading of Sleep Apneas

• Mild 5-20 *AI (per hour) • Moderate 20-40 AI (per hour) • Severe >40 AI (per hour) **(American Sleep Association)

*AI =Apnea Index Sleep Apnea Syndromes Upper airway resistance syndrome (UARS) • This is considered as a mild variant of OSA, Patients present with complaints of excessive daytime sleepiness and snoring, but not have apneas or hypopneas when evaluated by polysomnography. • Esophageal pressure manometrydemonstrates progressive negative pressure followed by frequent arousals . • It is diagnosed by esophageal pressure measurement using an esophageal catheter. Sleep Apnea Syndromes Types of SAS

• Obstructive Sleep Apnea • Central Sleep Apnea • Mixed Sleep Apnea Sleep Apnea Syndromes CCenenttrarall SSlleepeep AApneapnea Sleep Apnea Syndromes CCeennttrraall SSlleeeepp AApnpneaea

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Obstruction Sleep Apnea Syndrome (OSAS) Sleep Apnea Syndromes Pathophysiologyof OSA

• Sites of Obstruction • Obstruction tends to propagate Sleep Apnea Syndromes Pathophysiologyof OSA • Sites of Obstruction:

Fujita,etal, 1981 Sleep Apnea Syndromes Pathophysiologyof OSA

• Pharyngeal collapse • Decreased airway patency • Increase in negative pressure • Becomes a vicious cycle Sleep Apnea Syndromes

What is the pathophysiologyof OSA? q OSA can be caused by an obstruction at any level of the upper airway (i.e., above the true vocal cords or glottis). q Respiratory physiology dictates that during inspiration, there is a negative pressure within the upper airway. q Sleep physiology reveals that during the deeper stages of sleep (NREM:-_ stages III, IV, and REM), there is muscle relaxation of the entire body, including the muscles of the upper airway. q Most patients with OSA have redundant tissue or an abnormally small air passage. Sleep Apnea Syndromes What is the pathophysiologyof OSA? q In the presence of these anatomic variants, these two physiologic events combine to result in collapse of the upper airway, with resulting obstruction to airflow. q Oxyhemoglobindesaturationeventually leads to an arousal to a lighter level of sleep, and the airway is re-established with the characteristic loud snorting respiration. q Any factor that adds to upper airway obstruction can cause or exacerbate OSA, including:- q Bulky soft palate or uvula, q Fullness in the base of the tongue, q Adenotonsillarhypertrophy, q Low lying hyoid bone q Obstructive laryngeal masses, q Nasal obstruction????????. Sleep Apnea Syndromes Pathophysiology-complications

•Desaturationwith compensatory polycythemia •Hypercapniawith pulmonary hypertension •Systemic hypertension •Arrythmias Sleep Apnea Syndromes Polysomnogram • Apnea index • Apnea-Hypopnea index = respiratory disturbance index • Arousal index Sleep Apnea Syndromes Obstruction Sleep Apnea DIAGNOSIS • History • Examination • Investigations Sleep Apnea Syndromes Obstruction Sleep Apnea

• Symptoms of OSA – Snoring (most commonly noted complaint) – Cessation of breathing during the sleep – Daytime Sleepiness – Hypertension and Cardiovascular Disease are Associated – Pulmonary Disease Sleep Apnea Syndromes Obstruction Sleep Apnea

• Findings in Obstruction: – Nasal Obstruction ????? – Long, thick soft palate – Narrowed oropharynx – Redundant pharyngeal tissues – Large lingual tonsil – Large tongue – RetrodisplacedMandible – Retro-displaced hyoid complex – Large or floppy Epiglottis ??? Sleep Apnea Syndromes SYMPTOMS and SIGNS OF OSA

Ø Snoring Ø High blood pressure Ø Pauses in breathing Ø Depression Ø Gasping or choking Ø Obesity Ø Restless sleep Ø Large neck size (>17" Ø Excessive sleepiness in men; >16" in or fatigue during the women) day Ø Crowded airway Ø Poor judgment or Ø Morning headache concentration Ø Sexual dysfunction Ø Irritability Ø Frequent urination at Ø Memory loss night Sleep Apnea Syndromes

Evaluation -history

•restless sleep •morning headache •personality change •nocturia/enuresis •impaired cognitive •sexual dysfunction skills •sedative use •weight gain Sleep Apnea Syndromes What should you look for on the physical examination of a patient with suspected OSA?

qRetrognathiaand/or macroglossiacan also contribute to OSA. Full, thick necks may also predispose patients to OSA, especially in the setting of an overall "pickwickian" patient. qLaryngeal examination should be performed to rule out any obstructing lesion. Sleep Apnea Syndromes Oral cavity and oropharynx • Careful examination of the oral cavity and oropharynxis of principal importance. • Because many of the surgical procedures performed to improve OSA are performed on this area. • The examination should take special notes of the potentially correctable anatomy or deformities . • The oropharynxcan be assessed using the modified Mallampati’stechnique :- – The patient is evaluated with the mouth open and without protrusion of the tongue. – The patient is asked to open the mouth widely with the tongue left in place and oropharyngealcrowding is graded as follows . The modified Mallampatitechnique is highly predictive of the severity of obstractivcsleep apnea

The oropharynx can be assessed using the modified Mallampati’s technique ):- The patient is evaluated with the mouth open and without protrusion of the tongue. The patient is asked to open the mouth widely with the tongue left in place and Maorollpahmarpayntigegradeal crowsd ing is graded as follows` A.A.Grade I The tonsils, pillars, and soft palate are clearly visible B. Grade II The uvula, pillars and upper pole are visible. C. Grade III Only part of the soft palate is visible; the tonsils, pillars, mid base of the uvula cannot be seen. D. Grade IV Only the hard palate is visible. (Friedman Metal, 1999) The Tonsils can be graded as follows

0 I II III IV

o Grade 0 : The patient had a tonsillectomy. o Grade I : Tonsils are in tonsillarfossa, barely seen behind the anterior pillars. o Grade II: The Tonsils are visible behind the anterior pillars. o Grade III :The Tonsils are extending three quarters oft he way to the midline. o Grade IV : The Tonsils are completely obstructing the airway, also knownas kissing tonsils Normal nose and pharynx on one side. Abnormalities associated with snoring on the other side: long soft palate and uvula, large tongue and lingual tonsil, large palatine tonsil and deviated nasal septum. The tonsil grading was found to be both predictive of the presence of OSA and significantly related to the severity of OSA

Friedman et al, 1999 Sleep Apnea Syndromes Pathophysiologyof OSA • Tests to determine site of A B obstruction: – Muller’s Maneuver – Sleep nasoendoscopy – Fluoroscopy – Manometry – Cephalometrics – Dynamic CT scanning and MRI scanning Sleep nasendoscopy. (a) The palatal closure is viewed, (b) The tongue base and larynx are viewed. Sleep Apnea Syndromes Muller’s Maneuver Fibro –optic nasoendoscopy

a b

A B

Sleep nasendoscopy. (a) The palatal closure is viewed, (b) The Flexible fiberopticview of the retropalatalregion at rest and with Muller Maneuver A 90 % collapse of the retropalatalregion is noted here . (Courtesy of Richard J. Schwab,MD tongue base and Philadelphia, PA.) larynx are viewed. Sleep Apnea Syndromes DIAGNOSIS

• History

• Examination

• Investigations OOxxiimmeetteeryry IInn SSlleeeepp AAppnneaea OOxxiimemetteryery OOxxiimmeetteeryry IInn SSlleeeepp AAppnneaea OOxxiimmeetteeryry IInn SSlleeeepp AAppnneaea Sleep Apnea Syndromes DIAGNOSIS Sleep Apnea Syndromes DIAGNOSIS Sleep Apnea Syndromes DIAGNOSIS Sleep Apnea Syndromes Complications of OSAS • Related to excessive daytime sleepiness…. • Related to cardiovascular system • Systemic Hypertension • Pulmonary Hypertension • Arrhythmia • Right Heart Failure • Myocardial Infarction • Complete Heart Block Sleep Apnea Syndromes

Causes of Death in OSAS

• Cardiovascular – Heart Failure – Myocardial Infarction – Complete Heart Block • Motor Car Accidents Sleep Apnea Syndromes TTrereaattmemenntt ooff OOSSASAS

• NonsurgicalTreatment • Surgical Treatment Treatment of SAS Sleep Apnea Syndromes TTreareatmtmenentt ooff OOSSASAS • NonsurgicalTreatment • Surgical Treatment Sleep Apnea Syndromes Treatment of OSAS • NonsurgicalTreatment 1. Weight loss 2. Drug review( Sedative, Hypnotics) 3. Nasal medication 4. Nasal Dilators 5. Positional advice 6. Oral device a. Mandibular positioning device b. Tongue retaining device 7. Continuous Positive Airway Pressure (CPAP) 8. Drug treatment (e.g. protriptyline) Treatment of OSAS NonsurgicalTreatment 1. Weight loss 2. Drug review( Sedative, Hypnotics) 3. Nasal medication 4. Nasal Dilators 5. Positional advice 6. Oral device a) Mandibular positioning device b) Tongue retaining device 7. Continuous Positive Airway Pressure (CPAP) 8. Drug treatment (e.g. protriptyline) Sleep Apnea Syndromes Treatment of OSAS

• NonsurgicalTreatment

–Weight loss Should be recommended for OSAS Decrease the severity of OSAS Unfortunately, is difficult to achieve and to maintain for these patients of OSAS . Sleep Apnea Syndromes Nonsurgical Treatment

Weight loss • Get below “trigger weight” – Diet, exercise, bariatric surgery, medications –

Sleep hygiene • Avoidance of sedatives – Positional changes – Sleep Apnea Syndromes Treatment of OSAS • NonsurgicalTreatment 1. Weight loss 2. Drug review( Sedative, Hypnotics) 3. Nasal medication 4. Nasal Dilators 5. Positional advice 6. Oral device a) Mandibular positioning device b) Tongue retaining device 7. Continuous Positive Airway Pressure (CPAP) 8. Drug treatment (e.g. protriptyline) Sleep Apnea Syndromes Treatment of OSAS • NonsurgicalTreatment

• Drug review Avoidance of Sedatives, hypnotics and alcohol because they increase the severity of OSAS. Sleep Apnea Syndromes Treatment of OSAS Medical Treatment 1. Weight loss 2. Drug review( Sedative, Hypnotics) 3. Nasal medication 4. Nasal Dilators 5. Positional advice 6. Oral device a) Mandibular positioning device b) Tongue retaining device 7. Continuous Positive Airway Pressure (CPAP) 8. Drug treatment (e.g. protriptyline) Nasal medication Sleep Apnea Syndromes Treatment of OSAS • NonsurgicalTreatment 1. Weight loss 2. Drug review( Sedative, Hypnotics) 3. Nasal medication 4. Nasal Dilators 5. Positional advice 6. Oral device a) Mandibular positioning device b) Tongue retaining device 7. Continuous Positive Airway Pressure (CPAP) 8. Drug treatment (e.g. protriptyline) Nasal Dilators Sleep Apnea Syndromes Treatment of OSAS • NonsurgicalTreatment 1. Weight loss 2. Drug review( Sedative, Hypnotics) 3. Nasal medication 4. Nasal Dilators 5. Positional advice 6. Oral device a) Mandibular positioning device b) Tongue retaining device 7. Continuous Positive Airway Pressure (CPAP) 8. Drug treatment (e.g. protriptyline) Sleep Apnea Syndromes Treatment of OSAS • NonsurgicalTreatment • Positional advice:- • Mild and Moderate OSAS may be improved by sleeping in the lateral position by using night shirt with tennis balls in the back Positional advice Sleep Apnea Syndromes Treatment of OSAS • NonsurgicalTreatment 1. Weight loss 2. Drug review( Sedative, Hypnotics) 3. Nasal medication 4. Nasal Dilators 5. Positional advice 6. Oral device a) Mandibular positioning device b) Tongue retaining device 7. Continuous Positive Airway Pressure (CPAP) 8. Drug treatment (e.g. protriptyline) Sleep Apnea Syndromes • NonsurgicalTreatment Treatment of OSAS Oral device Advances the mandible Retains the tongue anteriorly Sleep Apnea Syndromes Treatment of OSAS • NonsurgicalTreatment 1. Weight loss 2. Drug review( Sedative, Hypnotics) 3. Nasal medication 4. Nasal Dilators 5. Positional advice 6. Oral device a) Mandibular positioning device b) Tongue retaining device 7. Continuous Positive Airway Pressure (CPAP) 8. Drug treatment (e.g. protriptyline) Sleep Apnea Syndromes • NonsurgicalTreatment Continuous Positive Airway Pressure( CPAP) •1981 •Very effective •Can be modified and used on a trial basis Sleep Apnea Syndromes • NonsurgicalTreatment Continuous Positive Airway Pressure( CPAP) FunFunccttiionon ofof thethe CCPPAPAP--tthheerraapypy •Duringinspirationair will be sucked in: low pressure

•Patientswith sleep apnea have a high collapsibilityof the upper airways: itcomesto a collapse orto a completteocclusion

•TheCPAP device openstheupperairways witha possitivepressure Sleep Apnea Syndromes Treatment of OSAS • NonsurgicalTreatment Continuous Positive Airway Pressure( CPAP) Sleep Apnea Syndromes • NonsurgicalTreatment Continuous Positive Airway Pressure( CPAP)

Act as a pneumatic splint of the collapsed pharynx Sleep Apnea Syndromes • NonsurgicalTreatment

Continuous Positive Airway Pressure( CPAP) Titrated to limit all respiratory events • 50-90% acceptance –better if daytime • symptoms improved Side effects in 40-50% • Sleep Apnea Syndromes • NonsurgicalTreatment Continuous Positive Airway Pressure( CPAP) Sleep Apnea Syndromes • NonsurgicalTreatment

Continuous Positive Airway Pressure( CPAP) Sleep Apnea Syndromes • NonsurgicalTreatment Continuous Positive Airway Pressure( CPAP) q Nasal continuous positive airway pressure (CPAP) is the most effective nonsurgicaltreatment of OSA. q An airtight mask is held over the nose by a strap wrapped around the patient's head. q CPAP is maintained by a machine that is similar to a ventilator. q Although nasal CPAP is nearly 100% effective in relieving OSA, compliance is a problem. q The masks and positive pressure are uncomfortable for many people. q Longtermcompliance is 50% to 75%, depending on the level of support the patients are given by the medical staff. q Bilevelpositive airway pressure (BiPAP) is often tolerated better by decreasing the expiratory pressure. Sleep Apnea Syndromes Treatment of OSAS Medical Treatment 1. Weight loss 2. Drug review( Sedative, Hypnotics) 3. Nasal medication 4. Nasal Dilators 5. Positional advice 6. Oral device a) Mandibular positioning device b) Tongue retaining device 7. Continuous Positive Airway Pressure (CPAP) 8. Drug treatment (e.g. protriptyline) Sleep Apnea Syndromes Treatment of OSAS

Medical Treatment

Drug treatment (e.g. protriptyline) Sleep Apnea Syndromes Surgical Treatment of OSAS Surgical Treatment Philosophy

1. Treatment to cure

2. Site-specific surgical therapy

3. Staged surgical management (if necessary)

4. Full patient disclosure of options and risks

5. Follow-up all treatment Sleep Apnea Syndromes Surgical Treatment of OSAS

Surgical Indications for Treatment

1. Apnea-hypopneaindex of >15 2. Oxyhemoglobindesaturationof <90% 3. Excessive daytime sleepiness 4. Upper airway resistance syndrome, preferably with objective improvement of neurocognitivedysfunction using medical therapy 5. Significant cardiac arrhythmias associated with obstructions 6. Unsuccessful or refused medical therapy and desire for surgery 7. Medically stable enough to undergo the recommended procedure (s) Sleep Apnea Syndromes Surgical Treatment of OSAS

• The success depends on proper diagnosis. • After failure of medical treatment. • Presence of specific surgicallycorrectable abnormality.

• The aim is widening the upper airway by:- • Reduction of the soft tissues of the oroph. • Advancement of the tongue or jaws • Types of Surgery depend on :- • Mild 5-20 AI (per hour) – The site of obst. • Moderate 20-40 AI (per hour) – Grade of obst. • Severe >40 AI (per hour) – Cause of obstruction. **(American Sleep Association) Sleep Apnea Syndromes Surgical Treatment of OSAS

– Two phases Phase I * Nasal, UPPP, mandibular advancement and GAHM Phase II * Bimaxillaryadvancement. * Base of the Tongue Surgery.

(Powell et al.,) 1998 Sleep Apnea Syndromes Surgical Treatment of OSAS

• Nasal Surgery • Laser-assisted uvulopalatoplasty(LAUP)** • Electrocautery-assisted uvulopalatoplasty(EAUP)** • Radioferquencyassisted uvulopalatoplasty(RAUP)** • Adeno-tonsillectomy in children • Uvulo-palato-pharyngoplasty(UPPP) • Genio-glossusadvancement with hyoid myotomy(GAHM) • Linguoplasty • Mandibular advancement • Maxillo-mandibularadvancement • Tracheostomy Sleep Apnea Syndromes Surgical Treatment of OSAS

• 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 Sleep Apnea Syndromes Surgical Treatment of OSAS

• Nasal Surgery • Laser-assisted uvulo-palatoplasty(LAUP)** • Electrocautery-assisted uvulopalatoplasty(EAUP)** • Radioferquencyassisted uvulopalatoplasty(RAUP)** • Adeno-tonsillectomy in children • Uvulo-palato-pharyngoplasty(UPPP) • Genio-glossusadvancement with hyoid myotomy (GAHM) • Linguoplasty • Mandibular advancement • Maxillo-mandibularadvancement • Tracheostomy Sleep Apnea Syndromes Surgical Treatment of OSAS

Laser-assisted uvulo-palatoplasty(LAUP)**

Electrocautery-assisted uvulopalatoplasty(EAUP)** Radioferquencyassisted uvulopalatoplasty(RAUP)**

• Recommended for snorers without OSA. Sleep Apnea Syndromes What are the surgical treatments of snoring and OSA?

Palate q Palate reduction can be achieved by laser-assisted uvulopalatoplasty(LAUP), submucosal radiofrequency device, electrocautery(termed Bovie- assisted uvulopalatoplastyor BAUP), or uvulopalatopharyngoplasty. q For snoring, LAUP, BAUP, and the radiofrequency procedures are usually performed. For each of these procedures, as healing occurs the soft palate elevates, shortens, and stiffens, reducing the tendency to vibrate. q Electrocauteryis less expensive and more widely available. Sleep Apnea Syndromes What are the surgical treatments of snoring and OSA? Palate q These procedures are performed in a doctor's office or in an outpatient setting under local anesthesia. q They often require two to four stages, each separated by about 1 month, titrating the procedures to resolve the snoring without causing velopharyngealinsufficiency. q Radiofrequency procedures usually help about 80% of the patients achieve significant improvement in their snoring. q It is only minimally uncomfortable for the patients. LAUP, BAUP, and UPPP improve snoring in 90% of patients but cause severe pain for 10-14 days. q LAUP and radiofrequency palate procedures for the treatment of true OSA have not been widely accepted, although they appear to have some positive effect in mild to moderate OSA. Sleep Apnea Syndromes Surgical Treatment of OSAS

• Laser Assisted Uvulopalatoplasty – High initial success rate for snoring – Rates decrease, as for UP at twelve months – Performed awake

KamamiTechnihue1997 Surgical Treatment of OSAS Radioferquencyassisted uvulopalatoplasty(RAUP)* Surgical Treatment of OSAS Radiosurgically-Assisted Uvulopalaplasty(RAUP)

The steps of Radiosurgically-Assisted Uvulopalatoplasty(RAUP). (a) Before the operation (A) Pa/ata/incision on the right side (c) Bilateral palatal incisions (d) The final view after partial uvulectomy. Sleep Apnea Syndromes Surgical Treatment of OSAS

Laser-assisted uvulo-palatoplasty(LAUP)** Electrocautery-assisted uvulopalatoplasty(EAUP)** Radioferquencyassisted uvulopalatoplasty(RAUP)** Silent apneics •Where the snoring is controlled but undiagnosed life threatening OSA may persist . •Must be considered . Sleep Apnea Syndromes Surgical Treatment of OSAS

• Adeno-tonsillectomy in children Sleep Apnea Syndromes Surgical Treatment of OSAS

Pathophysiologyof OSA • Sites of Obstruction:

Fujita,etal, 1981 Surgical Treatment of OSAS Riley-Powell-Stanford Protocol

Fujita,etal, 1981

Riley-Powell,1998 Sleep Apnea Syndromes Surgical Treatment of OSAS

• Two phases Phase I * Nasal, UPPP, mandibular advancement and GAHM Phase II * Bimaxillaryadvancement. * Base of the Tongue Surgery.

(Powell et al.,) 1998 Sleep Apnea Syndromes Surgical Treatment of OSAS Uvulo-palato-pharyngoplasty(UPPP) Indications of UPPP

• Socially disruptive snoring. • OSAS at the velopharyngealor upper oropharyngeallevel. Sleep Apnea Syndromes Surgical Treatment of OSAS Uvulo-palato-pharyngoplasty(UPPP)

• The Aim is to enlarge the retro-palatal airway by:- 1-Excision of the tonsils if present. 2-Excise uvula and posterior portion of the soft palate. 3- Trim or reorient the anterior and posterior pillars Sleep Apnea Syndromes Surgical Treatment of OSAS General anaesthesia

1-Very difficult intubation. 2-Ready to use an alternative technique of intubation. 3-No preop. Sedation. 4-Ready for emergency tracheostomy. 5-Extubatedwhen fully awake. 6-Post operative CPAP. 7-IV steroid during and post op. 8-No post op. sedative or Hypnotics. 9-Post op. ICU especially for cardiac patients Sleep Apnea Syndromes Surgical Treatment of OSAS Uvulo-palato-pharyngoplasty(UPPP)

Judging the amount of soft palate to be resected. Sleep Apnea Syndromes Surgical Treatment of OSAS Uvulo-palato-pharyngoplasty(UPPP)

Ikematsu, 1964 Fujita,etal, 1981 Simmons et al 1983 Many modifications Sleep Apnea Syndromes Surgical Treatment of OSAS Uvulo-palato-pharyngoplasty(UPPP)

A box-like resection. Reconstruction. Deep sutures pulling .forwardsthe posterior pillar Sleep Apnea Syndromes Surgical Treatment of OSAS Uvulo-palato-pharyngoplasty(UPPP)

Fujita et al 1987 Sleep Apnea Syndromes Surgical Treatment of OSAS Uvulo-palato-pharyngoplasty(UPPP) Sleep Apnea Syndromes Surgical Treatment of OSAS

• Uvulopalatopharyngoplasty – The most commonly performed surgery for OSA – Severity of disease is poor outcome predictor – Levin and Becker (1994) successedup to 80% initial success, but decreased to 46% success rate at 12 months – Friedman et al (1999 ) showed a success rate of 80% at 6 months in carefully selected patients

Friedman M, IbrahimH, Bass L. Clinical staging for sleep-disordered breathing. OtolaryngolHead Neck Surg2002; 127: 13–21. Sleep Apnea Syndromes Surgical Treatment of OSAS

Results of UPPP • Curing snoring 85-90% • Reduce apnea index 77% • Improving excessive daytime sleepiness and performance Sleep Apnea Syndromes Surgical Treatment of OSAS Side Effects of UPPP

• Extremely painful op. • Postop. Bleeding up to 3% • Nasal regurgitation • Dry throat • Disturbance of the taste • Hypernasalspeech • Velopharyngeal stenosis Sleep Apnea Syndromes Surgical Treatment of OSAS UPPP

• Still not fully defined, although may eliminate snoring but it has been not shown to improve long-term mortality.

• This reinforces the importance of patient selection and late postoperative reassessment. (Charles & Michael 1997) Sleep Apnea Syndromes Surgical Treatment of OSAS

• UPPS Complications – Minor • Transient VPI • Hemorrhage<1% – Major • NP stenosis • VPI • Death • Emergent Tracheotomy Sleep Apnea Syndromes Surgical Treatment of OSAS The reversible uvulopalatalflap

( A), Preoperative palate anatomy. (B), Uvula is grasped with a forceps and reflected back toward the soft-hard palate junction; note the muscular crease.( C), The mucosa of the oral aspect of the uvula and soft palate in a diamond shape is removed with cold knife dissection; the uvular tip is amputated and the uvular muscle thinned, if necessary. (D), Trimmed and sutured flap, with the shaded area indicating the location of the tissue before it is repositioned. E, Postoperative appearance, with closure up on the soft palate

( Powell ,1996.) Sleep Apnea Syndromes Surgical Treatment of OSAS

Hypopharyngealand Base-of-Tongue Procedures In the early 1980s, Fujita and colleagues recognized that many patients with OSA have obstruction at multiple levels of the pharynx. • Riley and colleagues (1985 )assessed UPPP failures with cephalometricanalysis and concluded that the base of the tongue was the cause of the persistent obstruction. • Schwab, Gefter, and Hoffman (1995) examined the upper airways of patients with OSA using magnetic resonance imaging and determined that collapse of the lateral pharyngeal wall was a significant component of sleep-related airway obstruction. • Addressing hypopharyngealobstruction has substantially improved surgical success rates and motivated the search for surgical procedures to improve reconstruction in this anatomic area. Sleep Apnea Syndromes Surgical Treatment of OSAS

Genio-glossusadvancement with hyoid myotomy (GAHM)

The aim is to widen the hypopharynxby advancing the tongue base.

•Usually is combined with UPPP . Sleep Apnea Syndromes Surgical Treatment of OSAS

GenioglossusAdvancement

• Rarely performed alone . • Increases rate of efficacy of other procedures .

Usually is combined with UPPP Sleep Apnea Syndromes Surgical Treatment of OSAS Hyoid Myotomyand Suspension

– Advances hyoid bone anteriorlyand inferiorly. – Advances epiglottis and base of tongue. – Performed in conjunction with other procedures. – Dysphagiamay result. Sleep Apnea Syndromes Surgical Treatment of OSAS

1-Failed UPPP. 2-Hypopharyngealcollapse. 3-Major retro-glossalnarrowing. 4-By surgery or laser. Sleep Apnea Syndromes

Surgical Treatment of OSAS

• Tongue Base Procedures – Lingual Tonsillectomy • may be useful in patients with hypertrophy, but usually in conjunction with other procedures Sleep Apnea Syndromes Surgical Treatment of OSAS 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

Lingual Suspension: Sleep Apnea Syndromes Surgical Treatment of OSAS

Mandibular advancement Sleep Apnea Syndromes Surgical Treatment of OSAS • Nasal Surgery • Laser-assisted uvulopalatoplasty(LAUP)** • Adeno-tonsillectomy in children • Uvulo-palato-pharyngoplasty(UPPP) • Genio-glossusadvancement with hyoid myotomy(GAHM) • Linguoplasty • Mandibular advancement • Maxillo-mandibularadvancement • Tracheostomy Sleep Apnea Syndromes Surgical Treatment of OSAS

Maxillo-mandibularadvancement

RESERVED FOR PATIENTS WITH SEVERE OSAS Sleep Apnea Syndromes Surgical Treatment of OSAS Maxillo-mandibularadvancement Sleep Apnea Syndromes

What are the surgical treatments of snoring and OSA Tongue base q Radiofrequency tongue base reduction, lag screw and suture suspension of the tongue and hyoid, advancement genioplastycombined with a hyoid suspension, distraction osteogenesis, partial midline glossectomy, and maxillomandibular advancement are used to reduce obstruction at the tongue base. q Radiofrequency tongue base reduction can obtain a 17% reduction in tongue base volume and has been shown to decrease RDI from 40 to 8, but it can require four to eight staged procedures, with a month between each one. q Patients should be in a monitored setting for the night after the procedure. Sleep Apnea Syndromes What are the surgical treatments of snoring and OSA? Tongue base q Lag screw and suture suspension of the tongue and hyoid are procedures that pull the tongue forward. q Lag screws with preloaded sutures are driven into the inner cortex of the anterior mandible below the level of the teeth. q A floor of mouth incision is made for the tongue suture. q Submentalincisions are made for the hyoid suspension. Sutures are then passed around the hyoid and through the tongue base to pull the tongue forward. q The best data presented showed a 60% average decrease in RDI from 74 to about 30. q Although this is a painful procedure, it is less morbid than some of the other options. Sleep Apnea Syndromes What are the surgical treatments of snoring and OSA Tongue base q Partial midline glossectomy, using either a laser or electrocautery, can be performed. q It requires a tracheotomy because significant bleeding and swelling can occur. q It is highly effective, with average decreases in RDI from 59 to 8. Because of the tracheotomy this procedure has not gained wide acceptance. q Maxillo-mandibularadvancement is highly effective in a select group of relatively young, healthy, thin patients with retrusivemidfacesand retrognathic mandibles. q Success in this select group of patients is essentially 100%. q This is a much larger operation than the UPPP, but it does successfully alter the anatomic anomalies that cause OSA. q Maxillo mandibular advancement is achieved using bilateral sagittalsplit osteotomiesin the mandible and LeFortI osteotomiesin the midface. Sleep Apnea Syndromes Surgical Treatment of OSAS Surgical complications •The risks of UPPP include postoperative ;- •Bleeding (196-5%). •Infection (2%). •Transient nasal reflux (12%-15%). •Nasopharyngeal stenosis(<1%). •Altered speech (rare). •The complications associated with the genioglossusadvancement and hyoid suspension include:- •Infection (2%-5%). •Need for root canal therapy (4%). •Permanent anesthesia (6%). •Seroma(2%). •There are also small risks of mandibular frac-ture, aspiration, and death. Edelman RR et al, 1990. Sleep Apnea Syndromes Surgical Treatment of OSAS

Surgical Results Three to four months after upper airway reconstruction, patients should undergo a postoperative polysomnogramto determine the response to surgical therapy. The success of surgical intervention has been defined in a number of ways. Sleep Apnea Syndromes Surgical Treatment of OSAS Defining Surgical Success •50% reduction in the AHI or a 50% reduction in the AI •Polysomnographicimprovement. • Patients should experience relief from their snoring and improved sleep hygiene. •The elimination. •Excessive daytime somnolence. •Better-quality sleep. •Improved ability to concentrate. •Elimination of the necessity of naps. •Improved work performance. •If neurocognitivedysfunction exists—even with mild obstructive objective sleep parameters—additional treatment should be considered. Sleep Apnea Syndromes Surgical Treatment of OSAS

• Nasal Surgery • Laser-assisted uvulopalatoplasty(LAUP)** • Adeno-tonsillectomy in children • Uvulo-palato-pharyngoplasty(UPPP) • Genio-glossusadvancement with hyoid myotomy(GAHM) • Linguoplasty • Mandibular advancement • Maxillo-mandibularadvancement • Tracheostomy Sleep Apnea Syndromes Surgical Treatment of OSAS Tracheostomy • Bypasses all areas of obstruction • Virtually 100% effective Two indications 1-Temporary procedure during airway reconstruction. 2-Severe OSA when CPAP refused, ineffective, or not tolerated or if other conditions exacerbated by the apneas. 3-OSA associated with serious complications as cardiac arrhythmias or •Tracheostomy cor-pulmonale • Line the tract with skin flaps • Lack of social acceptance Sleep Apnea Syndromes Surgical Treatment of OSAS

Tracheostomyfor treatment of OSAS

• Cures 100% of OSAS • Indications • Severe OSAS • Failure of medical and surgical treatment • Associated complications • Life-saving for serious cardiac arrhythmias • A Tracheostomywill allow many patients to return to a near normal •Tracheostomy lifestyle Sleep Apnea Syndromes Surgical Treatment of OSAS Tracheostomy q Tracheotomy remains the gold standard in the treatment of OSA. q It bypasses the upper airway entirely and is effective in almost all patients, including those with severe disease. q In patients with very severe disease, those who are markedly obese, or those who are debilitated, it is probably the initial procedure of choice. q Effectiveness in this group of patients is in the high 90% range. q The other methods that have been described realistically have little chance of benefit. q However, the patient must live with and care for the tracheotomy on a daily basis, which is undesirable to most patients. q For children with craniofacial abnormalities, such as Pierre Robin syndrome, a tracheotomy is a good intervention until the child grows enough to undergo mandibular advancement procedures. Sleep Apnea Syndromes Sleep Apnea Syndromes Conclusions

• SAS is extremely common medical disorder in the past 30 years. • 4 to 5% of the population complain of SAS. • 2 to 4% of the population complain of OSAS. • SAS plays a large part of the road traffic and industrial accidents due to sleepiness. Sleep Apnea Syndromes Sleep Apnea Syndromes Conclusions (Cont.)

• Proper diagnosis and treatment needs • Team work consists of :-Chest physicians, ENT surgeons, Cardiologists, Neurologists and Anaesthetists. • Sleep lab. • Searching for a simple, safe, cheap, objective and reliable methods for diagnosis and treatment of OSAS. Sleep Apnea Syndromes Sleep Apnea Syndromes What does the future hold for OSA? q Improvement in weight control may be available in the near future with advances in behavioral, pharmacologic, nutritional, and possibly genetic treatments. q Continued improvement of CPAP and BiPAPmachines . q Surgical advances, such as radiofrequency reduction of parapharyngealfat pads, are being investigated. q Phrenicnerve to hypoglossal nerve has been studied in animal models. q When a breath is taken, the phrenicnerve would stimulate the hypoglossal nerve to move the tongue forward. ThThThaaannnkkk YYYououou

Laugh and the world laughs with you, Snore, snore, snore and you sleep alone