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7/30/2019 OSA part 3
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Dr. Supreet Singh Nayyar, AFMC 2012
www.nayyarENT.com 1
SLEEP DISORDERED BREATHING (PART 3)
Treatment for more topics, visitwww.nayyarENT.com
Non-Surgical therapy for OSAHS
Address co-existent, predisposing conditions
Obesity Documented reduction in symptom after weight reduction Degree of improvement has no linear correlation with weight Few may not benefit if co-existent craniofacial abnormalities
Life style modification Avoid tobacco /smoking Dietary modification
Sleep deprivation Avoiding agents affecting sleep Treat hypothyroidism
Mechanical devices (positive airway pressure)
Body posture modification Sleeping with head and trunk elevated to 30-60 degree angle to
horizontal reduces OSA
Lateral decubitus is also effective in reducing episodes (sleep ball)Pharmacological therapy
Protriptyline
Non-sedating tricyclic antidepressant Increasing tone of airway muscle Statistically significant improvement
Side effects : dry mouth, urinary hesitancy, constipation, confusion, ataxia Dose: 30 mg/day
Agents with uncertain limited role
Serotonin agonists Affects dilators
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Busiprone Data insufficient
Stimulants Amphetamines
CVS complication Insufficient data
Continuous Positive Airway Pressure (CPAP)Indications
Mild OSA with EDS Moderate to severe OSA Co-morbidities
Many consider it to be mainstay of OSA treatment
Mechanism:
Acts as pneumatic splintEquipment:
Machine provides fixed pressure or vary pressure depending on thepresence of apnoeas (Auto CPAP)
Mask is nasal or full face, kept in place by Velcro straps Port of exhalation Newer machine small and light so portable Humidifier also available as an optional mode
Compliance
By 3 years 25-40% stop using CPAP Treatment failure Cost factor
o Regular service and maintenanceo Change of mask
Side effects
Claustrophobia Nasal stuffiness Skin abrasions, nasal bridge abrasions Leaks are uncomfortable for eyes Air swallowing if pressure more than esophageal sphincter pressure Pulmonary baro trauma ( very rare) Treatment Failure
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Dr. Supreet Singh Nayyar, AFMC 2012
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Surgical managementSURGICAL TREATMENT OPTIONS
Nasal Surgery
1. Nasal septoplasty
2. Inferior turbinectomy
3. Adenoidectomy
4. Nasal tumor or polyp excision
5. Nasal valve reconstruction
Palatal Surgery
1. Uvulopalatopharyngoplasty
2. Uvulopalatal flap
3. Tonsillectomy
4. Transpalatal advancement pharyngoplasty
5. Laser-assisted uvulopalatoplasty
6. Palatal radiofrequency
Hypopharyngeal Surgery
1. Maxillomandibular osteotomy and advancement
2. Mandibular osteotomy with genioglossus advancement
3. Hyoid myotomy and suspension
4. Tongue base radiofrequency
5. Partial glossectomy
6. Lingual tonsillectomy
7. Repose tongue suspension
for more topics, visitwww.nayyarENT.com
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Dr. Supreet Singh Nayyar, AFMC 2012
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Indications for surgery
Uvulopalatopharyngoplasty(UPPP)
First described by Ikematsu(1950), Fugita popularized in 1985
Principle:
Stiffen the soft palate by scarring Increase space behind soft palate
Consists of
Tonsillectomy Reorientation of the anterior and posterior tonsillar pillars Excision of the uvula and posterior rim of the soft palate.
Complications:
Nasal regurgitation Swallowing & voice problems Severe post op pain Hemorrhage Laryngospasm
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Dr. Supreet Singh Nayyar, AFMC 2012
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Pulmonary edema, hypoxia Not satisfied post surgery
75-95% short term success
Long term
45%Modification:
Preserve uvula
Laser-assisted Uvulopalatoplasty(LAUP)
Described by Kamami in France in 1993
Principle
Stiffen the soft palate Prevent palatal flutter
Surgery
Local anesthesia on soft palate B/l vertical incision in soft palate followed by partial vaporization of
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Dr. Supreet Singh Nayyar, AFMC 2012
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uvula with CO2 Laser
Various modification doneComplications
Low Globus like symptom common Post operative pain
Uvulopalatoplasty
Reversible uvulopalatal flap
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 adiamond 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 thelocation of the tissue before it is repositioned.
E, Postoperative appearance, with closure up on the soft palateRadiofrequency tissue volume reduction/Thermal ablation(RFTVR)
Principle
Similar to diathermy Lower temperature, lower current and voltage
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Dr. Supreet Singh Nayyar, AFMC 2012
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Insulated probe delivering radiofrequency energy at a frequency of465 KHz
Thermal injury to specific submucosal sites in soft palate causingfibrosis and contraction
Introduced into the base-of-tongue tissue under local anesthesiaAdvantage
Day care, LA Less post operative pain Significant improvement reported Good for multi level obstruction Low relapse rate
Mandibular osteotomy and genioglossal advancementIntraoral approach
To enlarge the retrolingual area.
The genial tubercle, which is the anterior attachment of the genioglossus
muscle, is mobilized by osteotomy
The segment is
advanced and
rotated to allow
bony overlap to
lock the inner
(lingual) surface
of the mandible
and the
geniotubercle at the outer (labial) surface
The fragment is fixed at the inferior aspect of the osteotomy with a
titanium screw
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Dr. Supreet Singh Nayyar, AFMC 2012
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Other ProceduresPalatal: Z-pharyngoplasty, palatal implants
Tongue base
RFTVR Laser midline glossectomy
to enlarge the retrolingual airway excision of approximately 2.5 5 cm of midline tongue tissue intraoral approach may also require
lingual tonsillectomy reduction of the aryepiglottic folds partial epiglottectomy
usually combined with a tracheotomy for airway protection Tongue suspension suture Hypoglossal nerve stimulation
Lingualplasty.
Same procedure as the LMG (laser midline glossectomy) Except that additional tongue tissue is extirpated posteriorly and
laterally to the portion removed by LMG
Epiglottis
epiglottectomyTemporary tracheostomy
Repose tongue suspension.Intraoral incision is made in the frenulum
Titanium screw is placed at the lingual cortex of the geniotubercle of the mandiblePermanent suture is passed through the paramedian tongue musculature along the
length of the tongue, through the tongue base, and then back through the length of the
tongue musculature
Then anchored to the screw, pulling the tongue base anteriorlyHyoid myotomy and suspension
Addresses retrolingual area
Can alleviate obstruction caused by redundant lateral pharyngeal tissue or aretrodisplaced epiglottis
Horizontal cervical incision over the hyoid bone is preferred
Dissection is carried down to the suprahyoid musculature
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Dr. Supreet Singh Nayyar, AFMC 2012
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Midline hyoid bone is isolated and then advanced over the thyroid ala
Secured with two medial and two lateral permanent sutures
Maxillomandibular osteotomy and advancement
Improves retropalatal collapse by stabilizing the superior pharyngeal muscles and
widening the nasopharyngeal inletAlso improves retrolingual obstruction by placing the genioglossus muscle under
tension, thereby providing more room in the oral cavity for soft tissues and also
stabilizing the lateral pharyngeal wall
Outer-table cranial bone graft may be necessary, along with arch bar placement (ororthodontic banding) before the osteotomies
Usually performed if previous upper airway procedures have not completely relieved
the sleep-related obstruction.
Clinical OutcomesOverall success rate for UPPP 40%
With multilevel surgical strategy have achieved60% when applying strict response criteria
80% have been reported when applying commonly accepted measures of
improvementHowever, the results may be reduced in morbidly obese patients
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Dr. Supreet Singh Nayyar, AFMC 2012
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Johnson and Chinnachieved a mean reduction of 44.1 points on the RDI (from a
preoperative value of 58.7 to a mean postoperative value of 10.5) in patients
undergoing UPPP and genioglossal advancement without HMWhen defining success as a RDI of less than 10, seven out of nine patients (78%)
were successfully treatedTroell and colleagues[57]
reported that seven of 11 patients (63.6%) who underwent a
palatopharyngoplasty combined with genioglossus advancement and HM were cured,
with cure defined as a postoperative RDI of less than 10, with resolution of EDS
Oral AppliancesTwo basic types of appliancesMandibular advancement devices
Popular
Positioning the lower jaw and tongue downward and forward The airway passage is increased Comfortable More effective
Tongue repositioners
Pulling only the tongue forward and not the entire lower jaw. Teeth, jaw muscles and joints are less affected Less studied
A period of consistent nightly wear is required
Patient motivation and cooperation essential
for more topics, visitwww.nayyarENT.com
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