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Dr.Sherif Bugnah
ENT Resident
Armed Forces Hospitals Southern Region
Khamis Mushayt - Saudi Arabia
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` Physiology of Sleep
` Evaluation of Sleep
` Definition of Obstructive Sleep Apnea (OSA)` Prevalence of OSA
` Pathophysiology of OSA
` Medical Treatment of OSA
` Surgical Treatment of OSA
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` Sleep is characterized by two distinct states,
non-REM sleep and REM sleep. Non-REM
and REM sleep alternate in 90- to 110-minute
cycles. A normal sleep pattern has 4-5 cycles.
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` Non-REM Sleep
` Non-REM sleep consists of
four stages ,Approximately
75% of the sleep cycle isspent in non-REM sleep.
` (muscle activity is still
functional, breathing is low,
and brain activity is
minimal. )
` REM Sleep` Most dreaming takes place
during REM (Rapid EyeMovement) sleep. Periodic
eyelid fluttering, muscleparalysis, and irregularbreathing, body temperature,heart rate, and bloodpressure distinguish REM
from non-REM sleep stages.
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Woodson, Tucker Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment SIPAC 1996
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` Polysomnography
EMG
Airflow
EEG, EOG
Oxygen Saturation
Cardiac Rhythm
Leg Movements AI, HI, AHI, RDI
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` Polysomnography
Woodson, Tucker Obstructive Sleep Apnea Syndrome,
Diagnosis and Treatment SIPAC 1996
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` Obstructive sleep apnea (OSA) is a sleep disorder that
involves cessation or significant decrease in airflow in the
presence of breathing effort. characterized by recurrent
episodes of upper airway (UA) collapse during sleep.
` By definition, apnea episodes last 10 seconds or longer and
commonly last 30 seconds or longer. Apnea may occur
hundreds of times nightly, 1-2 times per minute in severe OSA
patients, and is often accompanied by wide swings in heart
rate, precipitous decrease in oxygen saturation,
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` RDI>5
` RDI > 20 increases risk of mortality
` RDI 20-40=moderate, >40=severe` Upper Airway Resistance Syndrome
Shares pathophysiology with OSA
No desaturation, continuous ventilatory effort
` Snoring
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The prevalence of OSAS in children (2%) is
similar to the prevalence in adults (2%-9%)
(American Academy of Pediatrics [AAP], 2002;
Young et al., 1993
approx 1 in 15 or 6.62% or 18 million people
in USA [Source statistic for calcuation:
"estimated 18 million Americans (NHLBI)"
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` Sites of Obstruction:
` Conclusion: Although there was
considerable variability in the
techniques and the results, themost common site of obstruction
detected by these studies was at
the level of the oropharynx, with
extension to the laryngopharynx
commonly observed.
Stanford University Center of Excellence for Sleep Disorders, 401 Quarry Road,Suite 3301, Stanford, CA 94305-5730, USA
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` Symptoms of OSA Snoring (most commonly noted complaint)
Daytime Sleepiness
Hypertension and Cardiovascular Disease are
Associated
Pulmonary Disease
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` Findings in Obstruction: Nasal Obstruction
Long, thick soft palate
Retrodisplaced Mandible Narrowed oropharynx
Redundant pharyngeal tissues
Large lingual tonsil
Large tongue
Large or floppy Epiglottis
Retro-displaced hyoid complex
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` Tests to determine site of obstruction: Mullers Maneuver
` an inspiratory effort against a closed airway or glottis. The effort
decreases intrapulmonary and intrathoracic pressures and expandspulmonary gas
Sleep endoscopy
Fluoroscopy
Manometry
Cephalometrics
Dynamic CT scanning and MRI scanning
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` Weight Loss
` Nasal Obstruction
` Sedative Avoidance
` Smoking cessation
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` CPAP
Pressure must be
individually titrated
Compliance is as low as50%
x Air leakage, eustachian
tube dysfunction, noise,
mask discomfort,
claustrophobia
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` BiPAP
Useful when > 6 cm H2O difference in inspiratoryand expiratory pressures
No objective evidence demonstrates improved
compliance over CPAP
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` Oral appliance
Mandibular
advancement device
Tongue retainingdevice
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` Oral Appliances May be as effective as surgical options, especially
with sx worse
Howeverlow compliance rate of about 60%,
it a worse treatment modality than surgical
procedures (in study by Walkeret alin 2002 )
Walker-Engstrom ML. Tegelberg A. Wilhelmsson B. Ringqvist I. 4-year follow-up oftreatment with dental appliance or uvulopalatopharyngoplasty in patients withobstructive sleep apnea: a randomized study. Chest. 121(3):739-46, 2002 Mar.
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` Measures of success No further need for medical or surgical therapy
Response = 50% reduction in RDI
Reduction of RDI to < 20
Reduction in arousals and daytime sleepiness
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` Perioperative Issues High risk in patients with severe symptoms
Associated conditions ofHTN, CVD
Nasal CPAPoften required after surgery
Nasal CPAPbefore surgery improves
postoperative course
Risk of pulmonary edema after relief of
obstruction
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` Tracheostomy Primary treatment modality
Temporary treatment while other surgery is done
(leads to quick reduction in sequelae of OSA, few complications)Laryngoscope. 113(2):201-4, 2003 Feb. Study
D\A Once placed, uncommon to decannulate
Thatcher GW. Maisel RH. The long-term evaluation oftracheostomy in the
management of severe obstructive sleep apnea. [Journal Article]Laryngoscope. 113(2):201-4, 2003 Feb.
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` Nasal Surgery Limited efficacy when used alone
15.8% success rate when used alone in patients with
OSA and day-time nasal congestion with snoring
(RDI
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` Uvulopalatopharyngoplasty
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` Uvulopalatopharyngoplasty The most commonly performed surgery for OSA
Severity of disease is poor outcome predictor
up to 80% initial success decreased to 46%
success rate at 12 months - Levin and Becker(1994)
success rate of 80% at 6 months in Friedman et alshowed a carefully selected patients
Friedman M, Ibrahim H, Bass L. Clinical stagingfor sleep-disordered breathing. Otolaryngol HeadNeck Surg 2002; 127: 1321.
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` UP3 Complications
Minor
x Transient VPI
x
Hemorrhage
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` Lateral
Pharyngoplasty for
patients with
significant lateralnarrowing (Cahali,
2003 )
Cahali MB. Lateral pharyngoplasty: anew treatment for obstructive sleepapnea hypopnea syndrome.Laryngoscope. 113(11):1961-8, 2003Nov.
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` Lateral Pharyngoplasty
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` Laser Assisted
Uvulopalatoplasty
High initial success rate
for snoring
Rates decrease, as for
UP3 at twelve months
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` Radiofrequency
Ablation Fischeret
al 2003
Radiofrequency device isinserted into various partsof palate, tonsils andtongue base at variousthermal energies
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` Tongue Base Procedures Lingual Tonsillectomy
x
may be useful in patients withhypertrophy, but usually in conjunction
with other procedures
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` Tongue Base Procedures
Lingualplasty
x success rate of 77% (RDI
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` MandibularProcedures
Genioglossus
Advancement
x Rarely performedalone
x Increases rate of
efficacy of other
procedurers
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` Lingual
Suspension:
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LingualSuspension:
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` Hyoid Myotomy and
Suspension Advances hyoid bone
anteriorly and inferiorly
Advances epiglottis and
base of tongue
Performed in conjunction
with other procedures
Dysphagia may result
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` Maxillary-Mandibular Advancement Severe disease
Failure with more conservative measures
Midface, palate, and mandible advanced
anteriorly
Limited by ability to stabilize the segments and
aesthetic facial changes
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` Maxillary-
Mandibular
Advancement
Performed inconjunction with oral
surgeons
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Friedman, Michael MD; Ibrahim, Hani MD; Joseph, Ninos J. BS Staging ofObstructive SleepApnea/Hypopnea Syndrome: A Guide to Appropriate Treatment. Laryngoscope. 114(3):454-459,March 2004.
Riley RW, Powell NB, Li KK, Guilleminault C. Surgical therapy for obstructive sleep apneahypopneasyndrome. In: Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine.Philadelphia, Pa: WB Saunders Co; 2000:913-928.
Cahali MB. Lateral pharyngoplasty: a new treatment for obstructive sleep apnea hypopneasyndrome. Laryngoscope. 113(11):1961-8, 2003 Nov.
Thatcher GW. Maisel RH. The long-term evaluation oftracheostomy in the management of severeobstructive sleep apnea. [Journal Article] Laryngoscope. 113(2):201-4, 2003 Feb.
Friedman M, Ibrahim H, Bass L. Clinical staging for sleep-disordered breathing. Otolaryngol HeadNeck Surg 2002; 127: 1321.
Walker-Engstrom ML. Tegelberg A. Wilhelmsson B. Ringqvist I. 4-year follow-up of treatment withdental appliance or uvulopalatopharyngoplasty in patients with obstructive sleep apnea: arandomized study. Chest. 121(3):739-46, 2002 Mar.Woodson, Tucker Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment SIPAC 1996
Anonymous. Cost justification for diagnosis and treatment of obstructive sleep apnea: positionstatement of the American Academy of Sleep Medicine. Sleep 23(8):1017-8, 2000 Dec.
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