S LEEP A PNEA

SLEEP APNEAStephen A. Schendel, M.D., D.D.S.Richard L. Jacobson, D.M.D., M.S.Joseph A. Broujerdi, M.D., D.M.D.

Prepared by Jenny R. Armstrong, B.A.

STEPHEN A. SCHENDEL, M.D., D.D.S.

Surgical interests are craniofacial and maxillofacial surgery, including sleep apnea and orthognathic surgery Professor of Surgery Emeritus at Stanford University Medical Center and Lucile Packard Children’s Hospital

EDUCATION AND TRAINING: Graduate of University of Minnesota Dental School in 1973 Residency at Parkland Memorial Hospital in Dallas Studied as a Fulbright Fellow at the University of Nantes in France

Emphasis of cleft lip & palate surgery and dentofacial orthopedics under the tutelage of Dr. Jean Delaire Graduate of University of Hawaii Medical School in 1983 Assistant to Dr. Paul Tessier 1987 to 1988 in Paris, France General Surgery internship at Baylor University Medical Center, Dallas General Surgery and Plastic Surgery training at Stanford University Medical Center

ACHIEVEMENTS: Recipient of a Chateaubriand French Research Fellowship Full-time faculty of the Division of Plastic and Reconstructive Surgery at Stanford University Medical School from 1989 until 2007 Leader in the field of distraction osteogenesis for the correction of facial deformities. Board-certified in Oral and Maxillofacial Surgery and Plastic Surgery Fellow of the American College of Surgeons Fellow in the American Academy of Pediatrics Former President of the American Society of Maxillofacial Surgeons Former board member of the American Society of Plastic Surgeons from 1992 to 2002 Former Chief of Plastic Surgery at Stanford University Medical Center and Chief of Pediatric Surgery Chairman of the Department of Functional Restoration from 1994 to 2001 Director of The Craniofacial Anomalies Center at Lucile Packard Children’s Hospital from 1994-2007 Full-time faculty of the Division of Plastic and Reconstructive Surgery at Stanford University Medical School from 1989 until 2007

PUBLICATIONS He has published over 100 articles and chapters including a textbook on maxillofacial surgery.

RICHARD L. JACOBSON, D.M.D., M.S.

Board certified orthodontist practicing in Pacific Palisades for 30 years Additional areas of interest and expertise include orthognathic surgery and temporomandibular joint disorders Part-time instructor at UCLA School of Dentistry Department of Orthodontics

EDUCATION AND TRAINING: UCLA School of Dentistry Department of Orthodontics 1981 M.S. in Oral Biology UCLA 1979-1983 TMJ Department American Institute of Bioprogressive Education Mentored by Robert M. Ricketts, D.D.S., M.S., and Tom Graber, D.D.S., M.S, PhD.

SERVICE Director of the Foundation for Orthodontic Research and Education 1990-2000, elected President in 2000 Director of the Western Orthogmorphic Diagnostic team Service on the UCLA/St. John's Cleft Palate and Craniofacial Team President of the UCLA Orthodontics Alumni Association 1985, 2001 Reviewer for the American Journal of Orthodontics and World Journal of Orthodontics (2011) International Review Board approval for an airway study on 1300 patients (May 2011)

PUBLICATIONS Textbook: Radiographic Cephalometry: From Basics to 3-D (Quintessence) American Journal of Orthodontics, Journal of Clinical Orthodontics, Journal of Oral and Maxillofacial Surgery

JOSEPH A. BROUJERDI, M.D., D.M.D.

Dual training in Plastic & Reconstructive surgery and Oral & Maxillofacial Surgery Sub-specialty and surgical interests: Cranio-Maxillofacial Surgery and Surgical Treatment of Sleep

Disorders

EDUCATION AND TRAINING: Graduate of the University of Pennsylvania School of Dental Medicine Craniofacial/Pediatric Plastic Surgery fellowship at Stanford University Medical Center, Lucile

Packard Children’s Hospital Plastic & Reconstructive Surgery at Wayne State University/Detroit University Medical Center General Surgery and Oral & Maxillofacial Surgery at SUNY Downstate/Kings County Hospital Center

ACHIEVEMENTS: Recipient of Henry M. Goldman award from the University of Pennsylvania

PUBLICATIONS: Dr. Broujerdi has written many papers covering new developments in the field of Plastic &

Reconstructive Surgery, contributed to peer-reviewed journals, and co-authored a book chapter on Maxillofacial Surgery. He has given presentations and spoken at national and international conferences.

RELEVANT TERMINOLOGY•All encompassing term for abnormal sleep patterns and disturbances• Includes OSA and UARSSleep-Disordered Breathing (SDB)

•Re-occuring partial or complete collapse of the upper airway during sleep, resulting in arterial desaturation

•Occurs 5 or more times per hour in sleep (AHI>5)•Patients symptomatic

Obstructive Sleep Apnea (OSA)

•Patients symptomatic•Evidence of nocturnal sleep fragmentation•AHI <5•No oxygen desaturation

Upper Airway Resistance Syndrome(UARS)

•Cessation of breathing during sleepApnea

•Reduction of airflow, abnormally low respiratory rate, shallow breathing lasting for 10 or more secondsHypoapnea

• Indication that airway is partially obstructedSnoring

EPIDEMIOLOGY

EPIDEMIOLOGY OF SNORING

Affects 90 million adults in the USA

37% of adults self-report snoring a few nights a week in previous year

27% of adults self-report snoring every night

Studies indicate that a more reasonable estimate is 50% of adults snore

Men slightly more likely to snore than women

National Sleep Foundation, 2002. Sleep in America. www.sleepfoundation.org, 4 May 2011Powell N., Riley R., Schendel S. California Sleep Institute, 2009. www.calsleep.com, Snoring. 4 May 2011

http://www.sleepfoundation.org/

http://www.calsleep.com/

EPIDEMIOLOGY OF UARS

No gender bias Non-obese (BMI <25) Younger patient

Mean age 37.5 years

Guilleminault C., Takaoka S. 2009, Signs and Symptoms of Obstructive Sleep Apnea And Upper Airway Resistance Syndrome. Friedman M., ed. Sleep Apnea and Snoring: Surgical and Non-Surgical Therapy, Saunders Elsevier, Chicago, p 3-8.

EPIDEMIOLOGY OF SLEEP APNEA

2-5% of the population18 million people in the USA More males than females until

menopause 25% of adult men 9% of adult women

Typically presents between ages of 40-60

1/3 of those with OSA have cases severe enough to warrant immediate treatment

Stevens, Damien R. Sleep Medicine Secrets. Hanley & Belfus, Inc.: Philadelphia, 3004. p 3Powell N., Riley R., Schendel S. California Sleep Institute, 2009. www.calsleep.com, Snoring. 4 May 2011

http://www.calsleep.com/


Worsens with increasing age

2 men with OSA for each woman

(4% men vs. 2% women

Obesity with BMI greater than 25(60%-90% of

OSA are obese)

Neck size greater than 17 inches

Family history of sleep apnea

Dentofacial deformities• High narrow palate• Elongated soft palate• Small or deficient jaw

Enlarged tonsils and adenoids

Friedman et al, 2009. pp 3, 51.

More ‘vigilant’ sleepers (more concerned about bed-partners sleep)

More likely to have REM-related apneas and therefore tougher to diagnose

Tend to be more obese and have lower AHI than men

Some studies suggest women with OSA may have higher mortality

Post-menopausal women are 3x more likely to have OSA than pre-menopausal women

Increased risk of sleep apnea during pregnancy

EPIDEMIOLOGY OF SLEEP APNEA: WOMEN

National Sleep Foundation, Women and Sleep. http://www.sleepfoundation.org/article/sleep-topics/women-and-sleep 4 May 2011

http://www.sleepfoundation.org/article/sleep-topics/women-and-sleep

http://www.sleepfoundation.org/article/sleep-topics/women-and-sleep

SYMPTOMS

Excessive daytime sleepiness

Apneas or loud snoring observed

by bed partner

Choking sensations upon

awakening

Gastroesophageal reflux

Reduced ability to concentrate Memory loss Personality

changes Mood swings

NocturiaDry mouth

upon awakeningMorning

headacheImpotence

Friedman et al, pp 1

NON-SPECIFIC SYMPTOMS: WOMEN

Insomnia Disrupted sleep

Chronic fatigue

Depression Anemia Fatigue

Fibromyalgia Menopausal changes

Friedman et al, pp 8


An individual with untreated apnea is up to 4 times more

likely to have a stroke & 3 times

more likely to have heart disease

(National Sleep Foundation)

Treatment with CPAP was found to

lower blood pressure and reduce risk of

stroke by 20%

(The Lancet 2002, 359: 204-210)

People suffering from sleep apnea are 6 times

more likely to be involved in a car crash

(as a result of drowsiness) than those without sleep disorders.

(New England Journal of Medicine, March 18, 1999)

The NHTSA estimates that each year drowsy

driving is responsible for at least 100,000

automobile crashes, 40,000 injuries, and

1550 fatalities

(National Sleep Foundation)

EPIDEMIOLOGY OF SLEEP APNEA: MEDICAL COMPLICATIONS

• Heart problems • CHF• cardiac arrest

• stroke• high blood pressure• type II diabetes• constant fatigue• personality changes• headaches• decrease in sexual desire/impotance• increased risk of accidents

Increased risk of:

ANATOMY

AIRWAY ANATOMY

• Posterior of post-nasal spine (PNS) to superior point of hyoid bone• Retropalatal Space (RP)• Posterior of PNS to edge of the soft palate

• Retroglossal Space (RG)• Edge of soft palate to superior point of hyoid bone

• Epiglottis

Upper Airway Space (UAS)

• Internal Nasal Valve• External Nasal Valve• Pharynx• Hard palate• Uvula• Turbinates• Septum

Nasal Airway Space (NAS)

AIRWAY ANATOMY

Friedman et.al, 2009. pp 96

ANATOMY: NASOPHARYNX

ANATOMY: NASOPHARYNX

Airflow of Inspiration Parabolic curve directed superiorly through

the nostril Up through the nasal cavity

passing the turbinates Posteriorly passes through

the nasopharynx

ANATOMY: INTERNAL NASAL VALVE

4 structures SUPERIOR: Upper lateral cartilage MEDIAL: Nasal septum INFERIOR: Pyriform aperture POSTERIOR: Head of inferior turbinate

Narrowest part of the nasal passage Source of nasal resistance

Narrowest portion of IV is region between septum and near the posterior border of the upper lateral cartilage 10-15 degrees in Caucasians Wider in African Americans and Asians IV angles < 10 degrees more prone to

nasal valve collapse


Filter and heat air from 0 to 36 and humidify it Special air flow receptor cells on surface of inferior turbinates Secretes mucous that keeps nose moist and limits drying

ANATOMY: TURBINATES


ANATOMY: EXTERNAL NASAL VALVE

Nares Alar margin Soft tissue triangle Columella Nasal sill

Nasal vestibule Inside the external naris Septum and Columella are located

medially Alar sidewalls are lateral to the vestibule

Vibrissae Located within vestibule Filter air Direct air posteriorly into nasal cavity Limit rate of inspired air


ANATOMY: NASAL MUSCULATURE

Elevator muscles Procerus Levator labii superioris alaeque nasi Anomalus nasi

Depressor muscles Alar nasalis Depressor septi nasi

Compressor muscles Transverse nasalis Compressor narium mino

Dilator muscles Alar muscles

Dilate the IV to keep the lumen open

AIRFLOW: NASAL STRUCTURES

IV and EV function together to deliver smooth air current

Inspiration: Nostrils flare EV is increased

Bernoulli Principle Intraluminal pressure in the IV

decreases when airflow is increased

cartilage in nose counterbalances tendency towards IV collapse

IV area should remain unchanged during normal nasal function

CAUSES FOR NASAL OBSTRUCTION

• Normal nose contributes to 50% of upper airway resistance

Structural

• Septal deviation• Hypertrophy of the inferior or

middle turbinates• Inspiratory or fixed nasal

valve collapse• 13% of adults with chronic

nasal obstruction• Polyps

Mucosal• Allergic rhinitis• Vasomotor rhinitis• Chronic sinusitis• Upper respiratory infections

Neuromuscular

3 Causes

STRUCTURES OF THE NOSE OFTEN INDICATING NASAL OBSTRUCTION

Narrow or Weak Upper Cartilaginous Vault or weak lateral nasal walls

Narrow IV

Collapse in the resting state

Small decreases in cross-sectional area of IV can be substantial Pouseille’s Law

EV collapse due to insufficient support of the alar rim and alar lobule

Short nasal bones and long upper cartilagious ault

Narrow, projecting nose

Slit-like or small nostrils

Pinching of the lateral wall with inspiration

Thin cartilage

Nasal obstruction may result in mouth breathing

Tongue gets pushed back

Limited growth of mandible

Adenoid Face Syndrome

ANATOMY: OROPHARYNX & HYPOPHARYNX

ANATOMY: RETROPALATAL SPACE

Hard Palate Bony structure Separates nasal and oral cavities Occupies 2/3 of total oral palate

Soft Palate Occupies 1/3 of total oral palate

Uvula Prevents air escape into nasal cavity during

speech secretes mucus for swallowing and

digestion prevents choking and regurgitation of liquids controls gag reflex prevents passage of food/liquids into nasal

passages Tongue

ANATOMY: PALATE Soft Palate

Fibromuscular tissue Separates oral and nasal cavities Ends posteriorly with the uvula

Musculature: Levator veli palatini Tensor veli palatini Palatopharyngeus Musculus uvulae Palatoglossus

Nerve Pharyngeal Plexus CN V2

Function: Mucous secretion Prevents regurgitation of food into

nasal cavity

ANATOMY: RETROGLOSSAL SPACE

Epiglottis Base of Tongue Hyoid

Genioglossus, geniohyoid, and middle pharyngeal constrictor muscles insert on hyoid bone

Tonsils Mandible Genioglossus

CAUSES OF POTENTIAL AIRWAY OBSTRUCTION

Causes:

Relaxation of the throat muscles

Anatomical abnormalities of the nose and throat

Sleep position

Alcohol

Muscle relaxers and

other medications

Obesity

MOST COMMON CAUSE IS ANATOMIC ABNORMALITY LEADING TO OBSTRUCTION

MAJOR SITES OF POTENTIAL AIRWAY OBSTRUCTION

Nose Septum Nasal valve Turbinate Polyp

Palate Oropharynx

Tonsils Lateral pharynx Tongue Mandible Hyoid Epiglottis

SLEEP ARCHITECTURE Sleep Stages:

REM – Rapid Eye Movement 20-25% of total sleep time Memorable dreaming occurs as well as atonia

NREM – Non-Rapid Eye Movement 3 Stages:

N1 Somnolence Sudden twitches/jerks can occur with onset of sleep Loss of muscle tone

N2 Muscular activity decreases Awareness of external environment disappears 45-55% of total sleep in adults

N3 – Delta Sleep or Slow-Wave Sleep Parasomnias occur

NREM-REM Cycle N1 N2 N3 N2 REM Each cycle lasts from 90 to 110 minutes on average Deep sleep is stage N3 and occurs earlier in cycle REM is later in sleep cycle before awakening

DIAGNOSTICS

DIAGNOSING SLEEP APNEA IN OUR PRACTICE

Clinical examination and patient symptoms

Excessive daytime sleepiness

Decreased concentration and work performance

Loud snoring

Dentofacial abnormalities

Epworth Sleep Scale

Airway analysis

Identify region of abnormality and obstruction• Upper Airway Space• Nasal Passages

Polysomnogram

AHI

Oxygen Desaturation

EKG

Sleep Architecture

Nasal Endoscopy

Identify region of abnormality and

obstruction

Meuller’s Manuever

Identify region of abnormality and

obstruction

CLINICAL EXAMINATIONHt., Wt., BMI, Neck Circ.•greater than 17 inches

Nose•Cottle test, septum, turbinate

Palate•U vs. V shape

Uvula •Thickness & Length

Tonsil size•Size 0, 1, 2, 3, 4

Lateral Pharyngeal tissue•Ant. & Post. tonsil pillars U vs. V shape

Tongue size•Mallampati classification I, II, III, IV

CLINICAL EXAMINATION: BMI

Grade 0 - < 20

• Underweight

Grade 1 – 20-25

• Normal

Grade 2 – 25-30

• Overweight

Grade 3 – 30-40

• Obese

Grade 4 - >40

• Morbidly Obese

CLINICAL EXAMINATION: NASOPHARYNX

Cottle Test• cheek is retracted laterally and patient breathes quietly• determines if should correct septum or valve• positive result if Cottle test improves breathing and indicates valve problem

Septum• image of normal vs. deviation • Cause airflow turbulance and dryness/bleeding if deviated

Turbinate• Enlarged vs. normal image

Alar collapse

Polyps

CLINICAL EXAMINATION: NASOPHARYNX

CLINICAL EXAMINATION: OROPHARYNX AND HYPOPHARYNX

Palate• U vs. V Shape

Lateral Pharyngeal Tissue• anterior and posterior tonsil pillars• U vs. V shape

Uvula• thickness and size

Epiglottis • position and character

Laryngeal view• I Full view of VC• II Partial View of VC• III Epiglottis only• IV No epiglottis

Hyoid• position

Dentofacial Characteristics• periodontal condition• dental occlusion• skeletal proportions

CLINICAL EXAMINATION: TONGUE SIZE

Mallampati Position of Tongue Based upon patient sticking tongue out 3 grades

Friedman Tongue Postions (FTP) Method to approximate obstruction at

hypopharyngeal level Evaluate tongue in neutral, natural position

inside mouth Repeat procedure 5 times

5 Positions I – Tonsils, Uvula, Pillars IIa – Uvula IIb – Most of soft palate, base of uvula III – Some of soft palate IV – Only hard palate

Friedman et al., 2009, pp 106

CLINICAL EXAMINATION: TONSIL SIZE

0 – surgically absent 1 – less than 25%

hidden within pillars 2 – 25-50%

extending to pillars 3 – 50-75%

Extending beyond pillars 4 – 75-100%

Extending to midline

CLINICAL EXAMINATION: OSAHS SCORE

FTP (O-IV)

Tonsil Size

(O-4)

BMI Grade (0-4)

OSAHS Score

INTERPRETING RESULTS

• >8 Positive OSAHS• 74% effective in predicting severe OSAHS (AHI >45)

• <4 Negative OSAHS• 67% effective in predicting AHI <20


CLINICAL EXAMINATION: CRANIOFACIAL CHARACTERISTICS

Short anterior cranial base

Less obtuse cranial base flexure angle

Mandibular retrusion,

hypoplasia

Maxillary retrusion,

hypoplasia

Steep mandibular plane,

dolicocephalic facial pattern

Long soft palate Decreased airway space

Lowered position of hyoid bone

Increased anterior facial height

Adenoid face syndrome

CLINICAL EXAMINATION: EPWORTH SLEEPINESS SCALE (ESS)

Scaled questionnaire intended to measure daytime sleepiness• Developed in 1991 by

Dr. Murray Johns of Epworth Hospital in Melbourne, Australia

Requires patient to rate probability of falling asleep on a scale of increasing probability between 0-3 for 8 situations

The sum of the scores for each question is the

patients total score

SCORE INTERPRETATION:• 0-9 Normal• 10-24 Expert medical

advice should be sought

CLINICAL EXAMINATION: EPWORTH SLEEPINESS SCALE (ESS)

CLINICAL EXAMINATION: MUELLER MANEUVER

Forced inspiratory effort against obstructed airway with fiberoptic endoscopic visualization of airway•Exposes UAS to negative intraluminal pressure

Evaluate pharynx 4 degrees of airway obstruction defined

Describe any visible obstruction linked to

the epiglottis

• THERE IS SOME EVIDENCE THAT MUELLER MANEUVER DOES NOT REFLECT ACTUAL

SITES OF OBSTRUCTION DURING SLEEPFriedman et al., 2009, pp 104, 224

UPPER AIRWAY ANALYSIS

Volumetric (cm3)• UAS• RP• RG• NAS

Surface Area (mm2)• Choke points

• Area of smallest surface area

• Identify independently in Retropalatal Space and in Retroglossal Space

Length (mm)• 2-dimensional length

parameters of the choke points• Transverse

dimension• Anterior-posterior

dimension

Height (mm)• 2-dimensional height

of the airway• Retropalatal height• Retroglossal height

HISTORICALLY: 2-D CEPHAMALOMETRIC ANALYSIS

Standardized lateral x-ray of H&N for skeletal and soft tissue assessment

Multiple bony and soft tissue measurements

Skeletal Class I, II, III Good estimate of A-P dimension No estimate of transverse dimension Performed upright when patient is

awake muscles are active Head position is different than when

resting may underestimate degree tissue falls

HISTORICALLY:2-D CEPHALOMETRIC ANALYSIS

SNA 82 SNB 80 Posterior airway space (PAS)

11mm Soft palate length (35 mm) Mandibular plane to hyoid (MP-

H) 15

Patients with OSA have decreased SNB, narrow PAS, and high MP-H

AIRWAY ANALYSIS: 2-D VS. 3-DPATIENT WITH NORMAL AIRWAY

AIRWAY ANALYSIS: 2-D VS. 3-DPATIENT WITH SDB

AIRWAY ANALYSIS: 2-D VS. 3-DPATIENT WITH OSAHS

ANATOMICALLY NORMAL PATIENT RESEARCH:CLINICAL EXPERIENCE

390 patients total

13 age groups, 30 patients per group

Any malocclusion could be corrected with

orthodontics alone

203 females, 187 males

TOTAL UPPER AIRWAY VOLUME (CM3)

6-8 9-11 12-14 15-17 18-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56+0

5

10

15

20

25

30

35

Min Outlier Max Outlier

Age

Upp

er A

irway

Vol

ume

(cm

3)

AVERAGE UPPER AIRWAY VOLUME (CM3) BY SEX

0.00 10.00 20.00 30.00 40.00 50.00 60.00 70.000.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

18.00

Female UAS (cm^3)

Age (Average)

Aver

age

Volu

me

(cm

3)

Male UA volume is generally

greater than female UA

volume

INDEX (TOTAL VOLUME CM3/HEIGHT MM) BY SEX

Female index is greater than male

index between the ages of 20

and 40

0.00 10.00 20.00 30.00 40.00 50.00 60.00 70.000

0.05

0.1

0.15

0.2

0.25

0.3

0.35

Male IndexPolynomial (Male Index)Female IndexPolynomial (Female Index)

Age (Average)

Inde

x (c

m3/

mm

)

Average UAS (cm3) Average Index (cm3/mm)

TABLE OF DATA

Age Female Index Male Index

6-8 0.12 0.14

9-11 0.15 0.15

12-14 0.20 0.18

15-17 0.23 0.25

18-20 0.25 0.23

21-25 0.27 0.21

26-30 0.29 0.21

31-35 0.26 0.21

36-40 0.26 0.22

41-45 0.23 0.22

46-50 0.22 0.22

51-55 0.21 0.17

56+ 0.20 0.20

Age Female Male6-8 5.29 6.33

9-11 6.75 7.20

12-14 10.21 9.98

15-17 12.47 15.57

18-20 13.75 14.97

21-25 13.83 14.18

26-30 15.74 14.97

31-35 14.41 13.80

36-40 15.23 15.34

41-45 12.91 15.58

46-50 13.29 14.94

51-55 11.87 12.15

56+ 11.57 13.37

RETROPALATAL VS. RETROGLOSSAL SPACE AS AGE INCREASES

0.00 10.00 20.00 30.00 40.00 50.00 60.00 70.000.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

10.00

Retropalatal Space (v cm^3)Polynomial (Retropalatal Space (v cm^3))Retroglossal Space (V) cm^3Polynomial (Retroglossal Space (V) cm^3)

Age (average)

Volu

me

(cm

3)

Retropalatal space is greater

in volume on average than retroglossal

space in normal patients

CHOKE POINT RETROPALATAL VS. RETROGLOSSAL

The choke point (smallest surface

area) of the airway generally

lies in the retroglossal

space

0.00 10.00 20.00 30.00 40.00 50.00 60.00 70.000.00

50.00

100.00

150.00

200.00

250.00

Choke point retropalatal (mm^2)Polynomial (Choke point retropalatal (mm^2))Choke point retroglossal (mm^2)Polynomial (Choke point retroglossal (mm^2))

Age (Average)

Surfa

ce A

rea

(mm

2)

CHOKE POINTS MALE VS. FEMALE

0.00 10.00 20.00 30.00 40.00 50.00 60.00 70.000.00

50.00

100.00

150.00

200.00

250.00

300.00

Female Choke Pt Retropalatal (mm^2)Female Choke Pt Retroglossal (mm^2)Male Choke Pt Retropalatal (mm^2)Male Choke Pt Retroglossal (mm^2)

Age (Average)

Chok

e Po

ints

(mm

2)

Female choke points are greater in

surface area than males

between ages 20-40

OSA PATIENT PRE-TREATMENT DATA VS.

NORMAL PATIENT DATAUAS (cm3) OSA: 8.64 cm3

Normal: 13.67 cm3 Percent Difference: 36.8%

Retropalatal Space (cm3)

OSA: 3.92 cm3


Retroglossal Space (cm3)

OSA: 4.59 cm3


Choke-Point Retropalatal (mm2)

OSA: 78.04 mm2

Normal: 166.8 mm2 Percent Difference: 53.2%

Choke-Point Retropalatal Transverse (mm)

OSA: 18.19 mm

Normal: 23.37 mm Percent Difference: 22.2%

Choke-Point Retropalatal A-P (mm)

OSA: 3.94 mm


Choke-Point Retroglossal (mm2)

OSA: 84.8 mm2

Normal: 152.89 mm2 Percent Difference:44.5%

Choke-Point Retroglossal Transverse (mm)

OSA: 18.01 mm


Choke-Point Retroglossal A-P (mm)

OSA: 5.41 mm


POLYSOMNOGRAM

The gold standard in diagnosing apneas

No patient should undergo airway surgery without a sleep study

• OSA• Narcolepsy• Periodic Limb Movement Disorder• REM Behavior Disorder• Parasomnias

Used to diagnose or rule out sleep disorders

• Patient is woken after 2-3 hrs if demonstrating obstructive sleep apnea and CPAP is applied for remainder of study

• Aides in determining best levels for CPAP titration

Split Night Study

POLYSOMNOGRAM INTERPRETATION

Apnea/Hypoapnea Index - AHI

• <5 NORMAL• 5-15 MODERATE OSA• >15 SEVERE OSA

Oxygen Desaturation • 3% oxygen desaturation constitutes an apnea or hypoapnea

EKG

• Analyze for abnormalities that might be indicative of heart irregularities

• P Wave• QRS Complex• T Wave

Sleep Architecture

• Sleep Onset Latency• Usually less than 20 minutes

• Sleep Efficiency:• # of minutes of sleep/# of minutes in bed• Normal is 85% to 90% and higher

• Sleep Stages:• Majority of sleep is stage 2• REM sleep normally occupies 20-25% of sleep time and

decreases with age• Stage 3 deep sleep decreases with age

CONSERVATIVE MEASUREMENTS

CONSERVATIVE MEASUREMENTS

CPAP

Bipap

Nasal CPAP

Oral Devices (Dental Appliances)•Mandibular Posturing Device

Nasal Devices

Oropharyngeal Exercises

Weight loss

Behavior modification

CONSERVATIVE MEASUREMENTS: CPAP

Indications:• individuals with AHI >15 or >5 with existing co-morbidities

The “Gold Standard” of OSA Tx• Reduction of stroke by 20% • Compliance rates make success rates near 50%• Reduction in depressive symptoms • Eradication of snoring• Decreased cholesterol and blood pressure• Improvement in quality of life

Auto adjusting and fixed pressure

Disadvantages• Poor patient compliance• Loud and cumbersome• Dry nose, mouth

Friedman et al., 2009, pp 60-67

CONSERVATIVE MEASUREMENTS: BIPAP

Biphobic Continuous Airway Pressure

Two pressure levels

• One for inspiration • One for expiration

Rare – those with high CPAP pressures who have trouble breathing against the pressure

CONSERVATIVE MEASUREMENTS: NASAL CPAP

Long-term compliance rates ranging from 46%-89%

Successful if accepted by the patient


CONSERVATIVE MEASUREMENTS: MANDIBULAR POSTURING DEVICES

Indicated for use in: patients with primary snoring and mild to moderate OSA patients who do not respond to CPAP or failed tx with CPAP

Some studies indicate as being as effective as CPAP in certain patients

CONSERVATIVE MEASUREMENTS: ORAL APPLIANCES

RX for Oral Appliances: Oral examination Orthodontic evaluation Periodontal evaluation Temporomandibular joint evaluation Craniofacial skeletal evaluation

PURPOSE: Create more airway by posturing the airway

forward Adjustable screw allows variable posture (create

more space if necessary) DISADVANTAGES:

Can move teeth/create malocclusion if not properly designed and monitored

Can be bulky Success in 52% of patients

Success defined as no more than 10 apneas or hypoapneas per hour of sleep


CONSERVATIVE MEASUREMENTS: ORAL APPLIANCES

Upper and lower impressions Facebow in centric relation 2 wax bites

Normal bite Posturing edge-edge, lower jaw

forward Pour in die-keen Mount models Set occlusion in forward postured

bite Add acrylic to upper and lower

models until flat bite Add screws to adjust bite Add lateral wings Polish

CONSERVATIVE MEASUREMENTS: NASAL DEVICES

Nasal devices are a good predictor of success with IV/EV reconstruction PROVENT

Prosthetic nasal device placed in each nostril acts as a valve

Uses patients own breathing to keep nasal airway open

Breathe Right strips

CONSERVATIVE MEASUREMENTS: OROPHARYNGEAL EXERCISES

Exercises that strengthen and tone the oropharyngeal muscles

DISADVANTAGES:

• Limitations on amount can improve symptoms of OSA• Only recommended for a very select group of patients who are

also on CPAP therapy• Patient compliance• Time consuming• Referral to specialists to teach exercises

CONSERVATIVE MEASUREMENTS: WEIGHT LOSS

Improvement in: SDB Oxygen hemoglobin saturation Sleep fragmentation Daytime performance

Loss of 9-18% weight associated with AHI reduction of 30-75%

Surgical weight loss tx have shown greater improvements in AHI than dietary tx


CONSERVATIVE MEASUREMENTS: BEHAVIOR MODIFICATION

• Patient sleeps on side or stomach• Pillows, positioners

Sleep position therapy

• Reduces bulk tissue in neck• exerciseWeight loss

• Loss of muscle tone

Avoidance of sedatives,

alcohol, large meals

DISADVANTAGES:• Not a stand-alone treatment• Only mitigates the effects of OSA

HISTORICAL TX OF OSA

HISTORICAL TREATMENT OF OSA

CPAP and Traecheostomy are gold-standard of OSA Treatment

50% reduction of AHI is standard of success

Two-phase surgical protocol Powell-Riley Protocol Avoid unnecessary surgery Objective is to alleviate obstruction

equivalent to CPAP management

Fujita Classification Type I Palate – Mild OSA Type II Combined – Severe OSA Type III Hypopharynx – Moderate to Severe

OSA

TRAECHEOSTOMY

1st modality used to treat OSA Eliminates sleep apnea

permanently Is sometimes used temporarily

pre-surgically


Indications Contraindications

SURGICAL INDICATIONS/CONTRAINDICATIONS

AHI >20 May be performed if <20 if has a

comorbidity or decreased cognition due to OSA

Oxygen desaturation <90% Esophageal Pressure (PES) more

negative than -10 cm H2O EDS Neurobehavioral symptoms CPAP/Conservative Treatment Failure Anatomical sites of obstruction

Severe pulmonary disease Unstable cardiovascular

disease Morbid obesity Alcohol or drug abuse Psychiatric instability Unrealistic Expectations


PRE-OPERATIVE PLANNING

Physical evaluation by PMD and optimization

for surgery

Pre-Operative CPAP• Reduce risk of

postobstructive pulmonary edema

• Reduce sleep deprivation

PHASE I SURGERY

Surgery directed at site of obstruction Conservative surgery targeting the soft-tissues

Nasal Reconstruction Soft Palate Base of tongue Epiglottis

60% of all patients are cured with phase I surgery Less than successful outcome predicted by AHI greater than

60, oxygen desaturation below 70%, and morbid obesity Re-evaluate patient with polysomnogram 3-4 months post-

operatively


PHASE II SURGERY

Maxillo-mandibular advancement Enlarges the hypopharyngeal and

pharyngeal airway by advancing the skeleton

Creates more space for tongue anteriorly

Documented success rates >90%


SURGICAL INTERVENTION

NASAL RECONSTRUCTION

CPAP TITRATION LEVELSBEFORE AND AFTER

NASAL SURGERY FOR OSA

Mean CPAP (cm H2O)

OSAHS Patients Pre-Op Post-Op

Total (n=22) 9.3 6.7

Severe (n=13) 10.07 7.42

Moderate (n=4) 9.5 6.5

Mild(n=5) 7.2 5

• Reduce nasal obstruction

• Reduce severity of or eliminate SDB

• Facilitate SDB treatment by allowing nose to be used in positive airway therapies

3 Goal

s



Septoplasty

Turbinectomy

Radiofrequency reduction

Internal nasal valve reconstruction

External nasal valve reconstruction

Spreader grafts

NASAL RECONSTRUCTION: SEPTOPLASTY

TARGET: deviated septum PROCEDURE:

Incisions are made in the lining of the septum

Repositioning of the cartilage and/or bone of the nasal cavity

May be stabilized with splints or sutures internally

NASAL RECONSTRUCTION: TURBINECTOMY

GOAL:

• Partial or complete removal of enlarged turbinates

DISADVANTAGES:

• Can cause dryness

• High post-operative bleeding rates

• “Empty Nose” Syndrome

NASAL RECONSTRUCTION: RADIOFREQUENCY REDUCTION

GOAL: Turbinate reduction to increase airflow

PROCEDURE: Uses RF energy to create

submucosal tissue controlled shrinkage leading to reduction of tissue volume

ADVANTAGES: Performed in office with topical

anesthetic Procedure duration is 2-4 minutes Improvement 10-14 days following

treatment


NASAL RECONSTRUCTION: INTERNAL NASAL VALVE RECONSTRUCTION

Nasal Valve Suspension Spreader Graft

GOAL: correct internal nasal valve collapse by lateralizing superior segment of upper lateral cartilage

Cartilage Spanning Graft Splay Conchal Graft


NASAL RECONSTRUCTION: EXTERNAL NASAL VALVE RECONSTRUCTION

Alar Batten Graft Columelloplasty Nasal Valve Suspension


Age: 27 Diagnosis:

Nasal Obstruction and Snoring Procedures:

Nasal Reconstruction Septoplasty Radiofrequency Inferior

Turbinates Spreader Grafts

Palatopharyngoplasty

Pre-UAS

Post – UAS

Pre-RP

Post-RP

Pre-RG

Post -RG

Pre-Choke Pt RP

Post Choke Pt RP

Pre-Choke Pt RG

Post-Choke Pt RG

EM 10.37 11.39 5.05 5.66 4.72 4.93 115.2 126.72 128.43 123.57

NASAL RECONSTRUCTION: CASE I

Before After




Isolated correction of the nasal passages does not always improve OSA Study performed by Friedman

50 patients with nasal airway obstruction 98% subjective improvement in nasal breathing 66% did not notice significant change in snoring PSG results did not show significant change in AHI or LSAT CPAP levels decreased

Medical tx resolved OSA in 9% Surgical tx resolved OSA in 18%


SOFT PALATE RECONSTRUCTION: RADIOFREQUENCY SOFT PALATE

GOAL: Reduce tissue volume of soft palate and

stiffen remaining tissue leading to the reduction of snoring and sleep apnea without surgery

ADVANTAGES: In-office procedure Local anesthesia Minimal patient discomfort

RESULTS: Significant improvement in ESS Significant reduction in snoring by

patient and bed partner Immediate reduction in palatal tissue

volume Continual symptomatic improvement

over time due to tissue shrinkage and stiffening


SOFT PALATE RECONSTRUCTION: BASE OF TONGUE

GOAL: Reduce volume of the tongue to

increase airway volume ADVANTAGES:

In-office procedure Local anesthesia procedure duration is 15-20 minutes Results in 3-6 weeks

DISADVANTAGE: Treatment often needs to be

repeated over multiple sessions to achieve desired results due to tongue size and limited RF energy that can be applied to tongue


SOFT PALATE RECONSTRUCTION: RADIOFREQUENCY SUCCESS RATES

Steward: Combined reduction of palate and base of tongue Success Rate: 59%

Fischer et al: Palate, Tonsil, Tongue Base AHI changed from 32.6 +/- 17.4 Pre-Op to 22 +/- 15 Post-Op Success Rate: 33%

Stuck: Palate and Base of Tongue Success rate 33.3% Success was AHI reduction of 50% and value <15


SOFT PALATE RECONSTRUCTION

Radiofrequency

Uvulopalatopharyngoplasty (UPPP)

Tonsilectomy

Lateral Pharyngoplasty

Palatal Pharyngoplasty

Pillar Procedure

SOFT PALATE RECONSTRUCTION: UPPP Historic procedure TARGET:

Retropalatal soft tissue obstruction Uvula Pharyngeal Walls Tonsils, Adenoids if present

GOALS: Creates more space in the width of the airway at the throat’s opening, improving the ability of the airway to remain open,

and the movement and closure of the soft palate PROCEDURE:

Removes uvula, (tonsils, and adenoids if present), positions soft tissues of the palate and lateral pharyngeal walls SUCCESS RATE: 39%

Success defined by: AHI reduction of 50%and postoperative AHI <20 Or AI reduced by 50% and postoperative AI <10

DISADVANTAGES: Aggressive procedure Throat dryness Velopharyngeal Insufficiency (VPI)

Hypernasal speech Changes in voice

Regurgitation of fluids through the nose or mouth Does not address other sites of obstruction in the airway Impaired sense of smell Failure and recurrence of apnea Friedman et al., 2009, pp 83, 180

SOFT PALATE RECONSTRUCTION: UPPP

Friedman et al., 2009, pp 151, 178-180

SOFT PALATE RECONSTRUCTION: TONSILECTOMY

GOAL: Create more lateral airway

space through removal of the tonsils and adenoids if necessary

DISADVANTAGES: Failure to improve nasal

airway or resolve snoring, sleep apnea or breathing

VPI Painful procedure Bleeding

SOFT PALATE RECONSTRUCTION: LATERAL AND PALATAL PHARYNGOPLASTY

GOAL: Widening of the airway by placing the lateral throat walls in tension

and reducing the soft palate ADVANTAGES:

Higher degree of success and lesser degree of complications in comparison to UPPP

Produces greater radius of opening in soft palate and throat providing a wider area for air exchange than UPPP

Preserves much of the soft palate and uvula function so less chance of VPI or regurgitation of fluids into nasal cavity in comparison to UPPP

DISADVANTAGES: Failure and recurrence of apnea


SOFT PALATE RECONSTRUCTION: LATERAL AND PALATAL PHARYNGOPLASTY

Friedman et al., 2009, pp 151, 178-180

SOFT PALATE RECONSTRUCTION: TRANSPALATAL ADVANCEMENT PHARYNGOPLASTY

GOAL: Enlarges upper oropharyngeal

airway to improve respiratory function through advancement of the hard palate

Soft palate is mobilized, not removed

SUCCESS RATES: 5.77% more successful than UPPP


SOFT PALATE RECONSTRUCTION: PILLAR PROCEDURE

GOAL: Palatal implant of 3 polyester filaments into uvula to

extend hard palate and reduce vibrating parts of palate

PROCEDURE: In-office procedure Local anesthesia 30 minutes duration

DISADVANTAGES: Partial extrusions of implants in 25% complete extrusion dry mouth sensation of a foreign body sore throat Failure to improve snoring or sleep apnea

SUCCESS RATE: Snoring reduced from 7.1 to 4.8 on VAS scale, but

could still be heard 90% of patients and bed partners would

recommend the procedure to others


BASE OF TONGUE RECONSTRUCTION:

Genioglossal Suspension

Genioglossal Advancement

Tubercle Advancement

Genioplasty with Genioglossal Suspension

Hyoid Myotomy with Suspension Sutures

BASE OF TONGUE: GENIOGLOSSAL SUSPENSION

GOAL: Create more space for the

tongue in the A-P dimension and prevent tongue from falling posteriorly

PROCEDURE: Suture is passed through

tongue in an inverted triangle

Suspended to the tubercle of mandible


BASE OF TONGUE: TUBERCLE ADVANCEMENT


BASE OF TONGUE: GENIOGLOSSAL ADVANCEMENT

TARGET: Base of tongue, Retroglossal Airway Space

GOAL: Limit posterior displacement of tongue

PROCUDURE: Rectangular osteotomy in mandible Advance genial tubercle, genioglossus muscle and tongue base anteriorly

Suspension sutures LIMITATION:

Does not change dental occlusion or jaw position Does not create additional room for tongue Failure or recurrence of sleep apnea

SUCCESS RATES: 30-65% Increases to 80% when combined with soft palate procedures


BASE OF TONGUE: GENIOGLOSSAL ADVANCEMENT

GENIOPLASTY/TUBERCLE ADVANCEMENT

Class II Correct facial profile Creates more anterior space

for tongue

HYOID MYOTOMY WITH SUSPENSION SUTURES

TARGET:

• Advance Hyoid Complex, Epiglottic Reconstruction

Myotomy to:

• Thyroid cartilage

• Anterior mandible (retroglossal airway space)

Results:

• 71% of patients did not need further treatment


PHASE I SURGERY: CASE I

Pre-UAS

Post – UAS

Pre-RP

Post-RP

Pre-RG

Post -RG

Pre-Choke Pt RP

Post- Choke Pt RP

Pre-Choke Pt RG

Post-Choke Pt RG

GK 11.6 12 3.91 4.37 7.16 6.88 99.27 96.03 113.85 109.53

• Age: 54• Diagnosis:

• Loud snoring• Moderate OSA• Nasal Obstruction

• Procedure:• Nasal Reconstruction

• Septoplasty• Inf Turbinates• Spreader Grafts

• Palataopharyngoplasty• Spreader Grafts

PHASE II SURGERY: CASE I

Pre-UAS

Post – UAS

Pre-RP

Post-RP

Pre-RG

Post -RG

Pre-Choke Pt RP

Post- Choke Pt RP

Pre-Choke Pt RG

Post-Choke Pt RG

GK 12 16.44 4.37 5.77 6.88 10.67 96.06 158.5 109.53 152.01

Presented with severe OSA 1 year post-op

Phase II MMA RESULTS:

AHI <5 Normal

REASONS THE AIRWAY NARROWS

Age• Soft tissue collapses

as we age• Muscle fibers elongate

and thin• Chronic

vibration/hypoxemia result in fibrous, scarred tissue

Weight • Excess tissue,

accumulate fat as we age

NEED FOR A NEW STANDARD

50% Reduction in AHI of a patient with severe OSA, could still have

severe OSA• Example:

• PT with pre-phase I AHI of 70, reduction by 50% has AHI of 35

• PT still has severe OSA

• Surgery is considered a success

Multiple surgeries to at-risk patients with

compromised health from sleep apnea

• Phase I Success Rate:• 60%

• Phase II Success Rate:• 90%

• MMA Success Rate :• 70-100% (some

studies indicate >90% success rate)

Patients do not tolerate CPAP well

• 50% success rate• “Darth Vader mask”• “Snorkeling in my sleep”

SUMMARY: CURE RATES UPPP: 39% UPPP + Genioglossus Advancement + Hyoid Myotomy (+

Radiofrequency of the Tongue Base) Success rate: 60% (study of 223 patients)

PHASE I: 60% PHASE 2: 90%


MAXILLOMANDIBULAR ADVANCEMENT OSTEOTOMY

MAXILLOMANDIBULAR ADVANCEMENT 70-100% cure rate

Patients with AHI indicating severe OSA pre-operatively have normal AHI post-surgery

Only surgery that creates more space for tongue Expand facial framework of mandible and maxilla

CANDIDATES FOR MAXILLOMANDIBULAR ADVANCEMENT

Moderate to severe OSA indicated by high AHI during

polysomnography

Narrow or bottlenecked airway

Mandibular deficiency or retrognathia

Obesity

Patients on CPAP

Patients whom other sleep apnea procedures have

failed

POST-OPERATIVE MANAGEMENT

OSA patient is more complicated than usual orthognathic patient

1. ICU stay first night Patient’s condition may dramatically change when overly sedated or asleep Careful use of analgesics and antihypertensives Use of a patient-controlled analgesia pump is not recommended Sensitivity to respiratory depressant drugs is variable Recommend IV does by ICU nurse who is constantly evaluating respiratory rates

2. Nasal CPAP recommended maintains airway controls edema lessens use of narcotics Nasal trumpet airways must be used to apply CPAP

3. IV medication is seldom needed after first post-operative day4. Patient is encouraged to be out of bed ambulating and oral liquids on first post-op day

TOTAL HOSPITAL STAY IS 2-3 DAYS

POST-OPERATIVE FOLLOW-UP

Frequent follow up suggested

DAY 1-3 Surgical edema will peak at 72 hrs Concerns about airway swelling significant Seen in office day 3 or 4 and then weekly until healed

CPAP use is continued until 1-2 weeks before follow-up PSG

4-6 MONTHS POST-OPERATIVELY Follow-up PSG obtained Allows for weight stabilization and neurologic equilibration If post-operative PSG and EDS are resolved, follow-up is at 6 months

and then yearly as necessary

RESEARCH

Patient Demographics

• 7 Patients with Obstructive Sleep Apnea• 6 Male• 1 Female

• Age at time of Maxillomandibular Advancement • 35-56 years old• Average 46.4 years old

• Pre-Operative AHI• Ranged from 18-54.6• Average 38.27

CLINICAL EXPERIENCE

CLINICAL EXPERIENCE

Pre-Operative Work-Up

CBCT Scan

3D Ceph Analysis

3dMDVultus Airway Analysis

Sleep Study

Orthodontics•3 ortho patients with brackets

•4 non-ortho patients – archbar used

Dental Models

Virtual Treatment Objectives

Model Surgery/

Fabrication of Splints

Nasal Endoscopy

SURGICAL TECHNIQUE

LeFort I Maxillary Osteotomy Advancement Bone grafting +/- Septoplasty and/or

turbinectomy Bilateral Sagittal Split

Osteotomy of the Mandible Advancement +/- Genioglossal

Advancement

POST-OPERATIVE CARE

Sleep study obtained 3-6 months post-operatively

Post-operative CBCT scan and airway analysis obtained 3-6 months post-operatively

Surgical follow-up

Discharged

Transferred to surgical floor for +1-2 nights prn

Patients admitted to ICU for 1-2 nights

PRE- AND POST-OPERATIVE DATA: AHI

PT SEX AGE BMI PRE-AHI POST-AHI

NB M 51 27 42 3.8

CD M 36 30.5 31 0

KG M 51 29 48 0

RJ M 35 28 54.6 1.5

SD M 47 23 18 4

VE F 49 19.8 53.5 28.4

TM M 56 29.2 21 5

PRE- AND POST-OP DATA: MOVEMENT

• Average Mandibular Movement: 9.57 mm• Average Maxillary Movement: 9.86 mm• Average Genio Movement: 6 mm

PT SKELETALPATTERN

MAND MOVEMENT

(MM)

MAX MOVEMENT

(MM)

GENIO MOVEMENT

(MM)

NB II 9 9 8

CD I 9 9 0

KG II 9 9 0

RJ II 8 12 6

SD II 11 8 0

VE II 10 11 4

TM I 11 11 0

PRE- AND POST-OP VOLUMETRIC ANALYSIS

PT PRE-UAS

VOL

cm3

POST- UAS

VOL

cm3

% CHNGE

UAS

PRE-RP

VOL

cm3

POST- RP

VOL

cm3

% CHNGE

RP

PRE-RG

VOL

cm3

POST-RG

VOL

cm3

% CHNGE

RG

NB 3.35 21.46540.60%

1.33 8.46536.09%

1.89 13.00587.83%

CD 7.56 10.2235.19%

3.97 4.4913.10%

3.59 5.7359.61%

KG 11.6 16.4441.72%

3.91 5.7747.57%

7.16 10.6749.02%

RJ 3.46 30.9793.06%

1.20 20.561613.33

%

2.26 9.34313.27%

SD 10.27 14.1737.97%

4.92 8.8980.69%

5.41 5.532.22%

VE 12.39 29.48137.93%

7.44 16.04115.59%

4.82 8.0266.39%

TM 11.88 20.4972.47%

4.70 10.69127.45%

7.00 12.1573.57%

Average % Change UAS 236.99%

Average % Change RP 361.97%

Average % Change RG 164.56%

PRE- AND POST-OP SURFACE AREA ANALYSIS

PT Pre-Choke PointRetro-palatal mm2

Post-Choke Point Retro-palatal mm2

% Chng

e

Pre-Choke Point Retro-gloss

al mm2

Post-Choke Point Retro-gloss

al mm2

% Chng

e

Pre- Loc-ation

of Chke

Pt

Post-Location of Chke

Pt

NB 19.71 191.87873.47%

49.68 155.34212.68%

P G

CD 74.52 61.83-17.03%

88.65 116.0130.86%

P P

KG 103.80 158.8553.03%

109.89 152.0138.33%

P G

RJ 8.37 273.53167.62%

44.28 156.60253.66%

P G

SD 104.84 187.8379.16%

107.46 161.1049.92%

P G

VE 139.70 400.58186.74%

133.65 268.46100.87%

G G

TM 95.36 387.69306.55%

60.00 72.3220.53%

G G

Average Choke Point RP Pre 78.04 mm2

Average Choke Point RP Post 237.45 mm2

Average % Change RP 664.22%

Average Choke Point RG Pre 84.80 mm2

Average Choke Point RG Post 154.55 mm2

Average % Change RG 100.98%

Location of Choke Pt Pre-Operatively 5 Patients Retropalatal, 2 Patients Retroglossal

Location of Choke Pt Post-Operatively 6 Patients Retroglossal, 1 Patient retropalatal

PRE- AND POST- OP TRANSVERSE ANALYSIS

Average change in the transverse dimension Retropalatal: 11.64 mm Retroglossal: 7.11 mm

PT Pre-Choke Pt RPTrans-verse (mm)

Post-Choke Pt

RPTrans-verse (mm)

Mm differ-ence

Pre-Choke Pt

RGTrans-verse (mm)

Post-Choke Pt

RG Trans-verse (mm)

Mm differ-ence

NB 8.1 30.6 22.5 10.2 23.4 13.2

CD 16.5 16.8 0.3 19.8 19.2 -0.6

KG 24.0 29.7 5.7 21.9 27.3 5.4

RJ 1.8 28.2 26.4 12 30 18

SD 28.5 34.8 6.3 23.7 32.4 8.7

VE 26.4 37.5 11.1 26.1 28.8 2.7

TM 22.0 31.2 9.2 12.4 14.8 2.4

PRE- AND POST-OP A-P ANALYSIS

PT Pre-Choke Pt RPA-P

(mm)

Post-ChokePt RPA-P

(mm)

Mm differ-ence

Pre-Choke Pt RGA-P

(mm)

Post-Choke Pt RG

A-P (mm)

Mm differ-ence

NB 2 5.7 3.7 5.4 6.9 1.5

CD 5.7 6.6 0.9 6 9 3

KG 3 4.5 1.5 6.9 8.7 1.8

RJ 6 25.2 19.2 4.2 6.6 2.4

SD 2.1 6.9 4.8 5.1 6 0.9

VE 4.8 9.6 4.8 3.9 12.6 8.7

TM 4 11.2 7.2 6.4 6.4 0

Average change in the A-P dimension Retropalatal: 6.40 mm Retroglossal: 2.61 mm

PRE- AND POST- OPERATIVE HEIGHT ANALYSIS

Average Change in UAS height 2.86 mm

Average Change in RP height 3.14 mm

Average Change in RG height 4.29 mm

PT Pre-UAS (mm)

Post-UAS (mm)

Pre-RP (mm)

Post-RP (mm)

Pre-RG (mm)

Post-RG (mm)

NB 80 74 46 44 32 30

CD 70 70 40 38 30 32

KG 74 80 38 32 36 48

RJ 68 66 38 32 30 32

SD 74 72 34 34 40 38

VE 64 62 32 34 32 28

TM 76 78 26 22 50 56

POUSEILLE’S LAWAs radius increases and height decreases,

the resistance of flow decreases

Results Volume

The UAS enlarged significantly The shape of the UAS changed from a funnel to a tube like shape The retropalatal space increases in volume more than the retroglossal space

Surface Area The surface area at the choke point in the retropalatal space increases by a greater percent change than the

retroglossal space The location of the choke point is generally pre-operatively in the retropalatal space and post-operatively in the

retroglossal space Indication of normalizing the airway and eliminating any bottlenecking/funneling

The airway enlarges in a rectangular fashion Length

The transverse dimension increases more than the A-P dimension in millimeter change The A-P dimension increases more than the transverse dimension in percent change The retropalatal space increases more in the transverse and A-P dimensions than the retroglossal space does

Height The height of the airway measured from the posterior of the post nasal spine to the superior tip of the hyoid

bone generally decreases post-operatively The height of the airway was pre-operatively shorter in the retropalatal space than the height of the retroglossal

space The height of the airway was post-operatively shorter in the retroglossal space than the retropalatal space

Case I: Volume: Pre-UAS:

3.46 cm3Post-UAS: 30.9 cm3

% Increase: 790.3

Surface Area:Pre:

8.37 mm2 RP

Post: 156.60 mm2

RG

% Increase: 177.71

Transverse Length

RetropalatalPre: 1.8 mm

Post: 28.2 mm

MM Increase: 26.4 mm

Transverse Length

RetroglossalPre: 12 mm Post: 30 mm

MM Increase:

18 mm

Anterior-Posterior Length

Retropalatal

Pre: 6 mmPost:

25.2 mm

MM Increase: 19.2 mm


Retroglossal

Pre: 4.2 mm Post: 6.6 mmMM

Increase: 2.4 mm

CASE I

CASE I

Pre-Surgical Post- Surgical

CASE I

Volume: Pre-UAS: 3.32 cm3

Post-UAS: 21.46 cm3

% Increase: 546.38

Surface Area:Pre:

19.71 mm2 RP

Post: 155.34 mm2

RG

% Increase: 688.12

Transverse Length

RetropalatalPre: 8.1 mm Post: 30.6

mmMM Increase:

22.5 mm

Transverse Length

RetroglossalPre: 10.2 mm Post: 23.4

mmMM Increase:

13.2 mm


Retropalatal

Pre: 2 mm Post: 5.7 mm MM Increase: 3.7 mm


Retroglossal

Pre: 5.4 mm Post: 6.9 mm MM Increase: 1.5 mm

CASE II

CASE II

CASE II

CONCLUSIONS3-Dimensional airway analysis indicates that

maxillomandibular advancement is an effective treatment option for patients with obstructive sleep apnea by increasing tension and changing the position of the palatal and pharyngeal muscles. As a result: Airway volume increases Shape of airway changes

Change from a funnel to cylindrical shape Height of airway decreases

Resistance decreases Radius of the airway increases Height of the airway decreases

SUMMARY MMA effective treatment option

CURES sleep apnea, doesn’t just manage The best treatment will depend on good diagnostic values

Polysomnogram Airway analysis Clinical condition and patient symptoms

SDB IN CHILDREN

EPIDEMIOLOGY OF SLEEP APNEA: CHILDREN

Affects 8% or more of children in the US True apnea commonly does not occur Symptoms:

Restless sleep Sweating during sleep Snoring Night terror Sleep walking Bed wetting Daytime fatigue Hyperactive behavior Poor academic performance and attention

span 50% of children with ADHD had signs of

sleep disordered breathing compared to only 22% of children without ADHD

Golan N, Shahar E, Ravid S, Pillar G, Sleep Disorders and Daytime Sleepiness In Children With Attention-Deficit/Hyperactive Disorder. Sleep, 2004 March 15; 27 (2):261-6

Some children may exhibit poor physical growth Dentofacial deformities

Adenoid face syndrome Long face Open bite Mouth breathing Underdeveloped lower jaw Narrow (high arch palate) Over developed upper jaw (gummy smile)

EPIDEMIOLOGY OF SLEEP APNEA: CHILDREN

CAUSES OF PEDIATRIC OSA

Enlarged tonsils and adenoids Nasal obstruction (enlarged turbinates) Dentofacial deformities (abnormal jaw growth) Congenital birth deformity

Cleft lip & palate Perre Robin sequence Hemi Facial Microsomia Treacher Collins

TREATMENT OF PEDIATRIC OSA

Target: Treatment at site of obstruction tonsils or adenoids

Procedures: Tonsilectomy Adenoidectomy Orthodontics

Rapid palatal expansion Nasal CPAP Radiofrequency Maxillofacial Surgery at full maturity prn Distraction Osteogenesis

SUCCESS RATES: 80%

INSURANCE, BILLING, AND CODING

INSURANCE: EXAMINATION AND CONSULTATION

New Patient Examination – 99201-99204 Consultation: 99214 Office visit: 99214

Panorex – 70355 Cephalometric – 70350 Frontal – 70250 TMJ Cuts – 70110 Laminographs – 70350 CBCT – use all of the above

INSURANCE: DIAGNOSTIC CODES

Sleep Apnea - 327.23

Deviated Septum - 470.0

Turbinates (hypertrophy) - 478.0

Maxillary sinusitis - 473.0

Maxillary/Mandibular prognathism – 524.00

Maxillary hyperplasia – 524.01

Mandibular hyperplasia – 524.02

Maxillary hypoplasia – 524.03

Mandibular hypoplasia – 524.04

Maxillary/Mandibular retrognathia – 524.06

INSURANCE: DIAGNOSTIC CODES

Cephalgia (head/facial pain) – 784.0

Myalgia/Myositis – 729.1

Injury to face and neck – 959.09

Accident, same level – E885

Accident, fall – E888

Struck by moving appliance – E919

Struck in sports – E917.0

INSURANCE: MANDIBULAR POSTURING DEVICES

Submit 1500 INSURANCE claim to patients provider

CODES: 21085 – Sleep Apnea Device 21076 – Custom Preparation

INSURANCE: PSG A sleep study is usually mandatory, and should be performed

regardless for proper diagnosis of OSA, for insurance coverage of CPAP or any surgical procedure for sleep apnea

HMO Must be referred for PSG by primary care physician Out of network must pay everything out of pocket

PPO Refer patient for PSG Submit patient’s insurance to sleep center 1-2 weeks turn around for results

Medicare Must be referred for PSG by primary care physician At home, unattended sleep-study may be performed to qualify for CPAP

INSURANCE: PSG CODES 95807 – Sleep study, simultaneous recording of ventilation,

respiratory effort, ECG or heart rate, and oxygen saturation attended by a technoglogist

95808 – Polysomnography, sleep staging with 1-3 additional parameters of sleep, attended by a technologist

95810 – Polysomnography, sleep staging with 4 or more additional parameters of sleep, attended by a technologist

Split-Study 95811 – Polysomnography, sleep staging with 4 or more additional

parameters of sleep, with initiation of CPAP therapy or bilevel ventilation, attended by a technologist

Unattended Study 95806 – Sleep study, unattended, simultaneous recording of heart rate,

oxgyen saturation, respiratory airflow, and respiratory effort

INSURANCE: CPAP Sleep Center will usually provide and submit this information

E0601 – CPAP Device A7027 – Combination oral/nasal mask, used with CPAP device A7030 – Full face mask used with positive airway pressure device A7034 – Nasal interface (mask or cannula type) used with PAP device, with or without

headstrap A7035 – Headgear used with PAP device A7036 – Chinstrap used with PAP device A7037 – Tubing used with PAP device A7038 – Filter, disposable, used with PAP device A7039 – Filter, nondisposable, used with PAP device

REPLACEMENTS A7028 – Oral cushion for combination oral/nasal mask, replacement only, each A7029 – Nasal pillows for combiantion oral/nasal mask, replacement only, pair A7032 – Cushion for use on nasal mask interface, replacement only, each A7033 – Pillow for use on nasal cannula type itnerface, replacement only, pair

INSURANCE: PRE-AUTHORIZATION

Contact patient’s insurance to begin pre-authorization processThey will notify you what you need to submit

Generally requests are made for: A letter documenting patient historyX-RaysEO’s IO’sDental Models

The entire pre-authorization process can take 1 week to 3 months

INSURANCE: PROCEDURE CODES Septoplasty: 30520

Turbinectomy: 30130-50

Radiofrequency: Turbinates: 30802

Soft Palate: 41530

Base of Tongue: 0088T

UPPP/Palatalpharyngoplasty: 42145

Pharyngoplasty: 42953

Tonsilectomy and adenoidectomy younger than 12: 42820

Tonsilectomy and adenoidectomy age 12 and over: 42821

Removal of foreign body from pharynx: 42809

LeFort I: 21143

LeFort I with bone grafts: 21147

BSSO: 21196

Genioplasty: 21121

Genioglossal Advancement: 21191

Mandible osteotomy with genioglossus advancement: 21199

Hyoid Myotomy and suspension: 21685

INSURANCE: PROCEDURE CODES

INSURANCE: WHAT TO DO IF DENIED

Dispute denial of benefits

Contact insurance and set up a peer-peer review

Peer-peer review is between submitting doctor and reviewing doctor and takes

place over the phone

Submit additional diagnostic material

WE HAVE NEVER HAD A PROCEDURE DENIED AFTER PEER-PEER REVIEW

IMAGE REFERENCES

Cyber Sarge’s Vietnam Veterens Information. 2006. Sleep Apnea Information. http://cybersarges.tripod.com/SleepApnea.html 4 May 2011.

Friedman M., ed. Sleep Apnea and Snoring: Surgical and Non-Surgical Therapy, Saunders Elsevier: Chicago, 2009, pp. 96, 106, 120

E-Doctor Online. Nose Anatomy. http://www.edoctoronline.com/medical-atlas.asp?c=4&id=21657&m=1&p=3&cid=1050&s= 4 May 2011

Cwynar, Justin, 2004. Mouth, Teeth, Tongue, Nose. http://www.pitt.edu/~anat/Head/Mouth/Mouth.htm 4 May 2011

Guyuron B. Soft Tissue Functional Anatomy of the Nose. Aesthetic Surgery Journal, Nov 2006 Vol. 26 No. 6 733-755.

Rhee J et al. Clinical Consensus Statement: Diagnosis and Management of Nasal Valve Compromise. Otolaryngol, Head, and Neck Surgery, July 1 2010 vol. 143. no. 1 48-59

The Snoring Centre, 2009. http://www.snoringcentre.com/images/tonsil_size_sm.gif 4 May 2011

NY Snoring and Sinus, 2010. Septoplasty. http://www.nysnoringandsinus.com/septoplasty.html 4 May 2011 Pearl A M.D. Premier Community Health – A.D.A.M., 2006. Tonsilectomy. http://

www.premiercommunityhealth.org/adam/Health%20Illustrated%20Encyclopedia/3/100122.htm 4 May 2011

http://cybersarges.tripod.com/SleepApnea.html

http://cybersarges.tripod.com/SleepApnea.html

http://www.edoctoronline.com/medical-atlas.asp?c=4&id=21657&m=1&p=3&cid=1050&s

http://www.pitt.edu/~anat/Head/Mouth/Mouth.htm

http://www.pitt.edu/~anat/Head/Mouth/Mouth.htm

http://www.snoringcentre.com/images/tonsil_size_sm.gif

http://www.snoringcentre.com/images/tonsil_size_sm.gif

http://www.nysnoringandsinus.com/septoplasty.html

http://www.nysnoringandsinus.com/septoplasty.html

http://www.premiercommunityhealth.org/adam/Health%20Illustrated%20Encyclopedia/3/100122.htm

http://www.premiercommunityhealth.org/adam/Health%20Illustrated%20Encyclopedia/3/100122.htm

Documents

S LEEP A PNEA