KHAIRALLAH AOUCAR M.D PGYIII ENT

Holy Spirit University -kaslik

Grand round ENT Sat /12/14

• mild for AHI or RDI ≥ 5 and < 15

• moderate for AHI or RDI ≥ 15 and ≤ 30

• severe for AHI or RDI > 30/hr

July 2011

CPAP vs control Only 1 study evaluated a clinical outcome(heart failure

symptomatology)=> no significant effect after 3 months.

CPAP vs control statistically and clinically significant improvement in

sleepiness as measured by ESS

Inconsistent effects on other sleepiness tests, quality of life tests, neurocognitive tests, and blood pressure

Conclusion:CPAP vs control Despite no evidence or weak evidence on clinical

outcomes

given the large magnitude of effect on the important intermediate outcomes:AHI, ESS, and other sleep study measures=>

the strength of evidence is moderate that CPAP is an effective treatment for OSA.

strength of evidence is insufficient to determine which patients might benefit most from treatment

OSA treatmentsMAD vs. control

No study evaluated clinical outcomes.

In 2 studies about 5% of patients had tooth damage (or loosening).

Substantial jaw pain was reported in about 2–4% of patients

no study reported on the long-term consequences of any adverse events

same conclusion as CPAP

Surgery vs.control No study evaluated clinical outcomes.

Of these 7 studies, 4 found statistically significant improvements in AHI, other sleep study measures, and/or sleepiness measures.

The remaining studies found no differences in these outcomes or quality of life or neurocognitive function.

Conclusion :surgery vs control the strength of evidence is insufficient to evaluate

the relative efficacy of surgical interventions for the treatment of OSA.

OSA treatmentsSurgery vs CPAP

Of 12 eligible studies comparing surgery with CPAP (1 quality A, 11 qualityC), only 2 were RCTs.

There were 2 retrospective studies that evaluated mortality in UPPP vs. CPAP.

Of these: 1 study found higher mortality over 6 years among patients using CPAP

1 study found no difference in 5-year survival.

Both trials found no difference in outcomes either between RFA and CPAP after 2 months or between maxillomandibular advancement osteotomy and CPAPat after 12 months.

Conclusion: The strength of evidence is insufficient to determine the relative merits of surgical treatments versus CPAP.

OSA treatmentsSurgery vs. MAD

A single trial (quality B) compared UPPP and MAD treatment.

more patients using MAD achieved 50% reductions in AHI at 1 year and significantly lower AHI at 4 years.

Conclusion: The strength of evidence is insufficient to determine the relative merits of surgical treatments versus MAD

Weight loss Conclusion: The strength of evidence is low to

show that some intensive weight loss programs are effective treatment for OSA in obese patients.

MEDICAL AND SURGICAL EVALUATION

comprehensive medical history

head and neck examination

polysomnography

Fiberoptic nasopharyngolaryngoscopy

lateral cephalometric analysis

Physical exam Vital signs

BMI

neck size

Face-retrognathia,micrognathia

Nose(sd,valve collapse)

Oral cavity- palate, uvula, tonsils/pillars, tongue, occlusion

Success of UPPP was defined as a reduction of the postoperative(RDI) to< 50%

In addition, the postoperative RDI must have <20.

type II and III predict bad outcomes for UPPP

Tests to determine site of obstruction

Muller’s Maneuver

Sleep endoscopy

Fluoroscopy

Manometry

Cephalometrics

Dynamic CT scanning and MRI scanning

Muller’s maneuver

Katsnatonis etal:prediction efficacy only 33%

Doghramgi et al:no benefit of MM in predictive value for UPPP

Sleep endoscopy Advantage: Dynamic assessment of sleeping patient

– Directly visualize location of obstruction and structures

Major disadvantages

– Difficult to fall asleep with fiberoptic scope held in place manually or otherwise secured externally

– Difficult to move scope without awakening (to visualize multiple potential regions of obstruction)

Drug-Induced Sleep Endoscopy

Developed in UK in 1991

Used in several centers around the world but less commonly in U.S.

Fiberoptic endoscopy of sedated, sleeping patient

Not easy: requires sedation, somewhat time consuming

– Sedatives decrease muscle tone and decrease respiratory drive

May artificially worsen OSA and alter pattern of collapse

Key is avoidance of oversedation (Eastwood 2005: decreases muscle tone)

Propofol has less decrease in respiratory drive

CEPHALOMETRIC ANALYSIS Patient is awake upright

and static

2 D=>may underestimate the degree of obstruction

significant correlation between an increase of the apnea index (AI)

PAS-epipharynx <7 mm

MP-H distance >27.4 mm

Useful for genioglossus advacement and MMA

Naganuma H, Okamoto M, Woodson BT, Hirose H. Cephalometric and fiberopticevaluation as a case-selection technique for obstructive sleep apnea syndrome (OSAS). Acta Otolaryngol Suppl. 2002;57-63.

CT and MRI Advantage: Assessment during sleep possible

Disadvantages

– CT and MRI can be static (although cine-CT)

– Time-consuming and not inexpensive

– Specific equipment and technical assistance

– Radiation exposure (CT and fluoroscopy)

Surgery The presence and severity of obstructive sleep

apnea must be determined before initiating surgical therapy (Standard).

The patient should be advised about potential surgical success rates and complications, the availability of alternative treatment options such as nasal positive airway pressure and oral appliances, and the levels of effectiveness and success rates of these alternative treatments (Standard).

Aurora RN; Casey KR; Kristo D; Auerbach S; Bista SR; Chowdhuri S; Karippot A; Lamm C; Ramar K; Zak R; Morgenthaler TI. Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults. SLEEP 2010;33(10):1408-1413.

SURGICAL PREPARATION—RISK MANAGEMENT

appropriate laboratory

cardiopulmonary, and radiographic tests in patients with existing comorbid medical conditions (diabetes, hypothyroidism, cardiovascular disease, and pulmonary disease)

consultation with the appropriate medical specialist should be sought

SURGICAL TREATMENT PHILOSOPHY

Since multilevel obstruction may exist, it may be necessary to treat more than one site.

Failure to recognize or treat all anatomical levels will lead to persistent obstruction.

Powell NB, Riley RW, Guilleminault C. Surgical management of sleep-disordered breathing. In: Kryger MH, Roth T, Dement WC, eds. Principles and Practices of Sleep Medicine. 4th ed. Philadelphia: Elsevier Saunders, 2005:1081–1097.

Powell NB, Riley RW, Guilleminault C. Surgical management of sleep-disordered breathing. In: Kryger MH, Roth T, Dement WC, eds. Principles and Practices of Sleep Medicine. 4th ed. Philadelphia: Elsevier Saunders, 2005:1081–1097.

Conservative surgery (phase I) is therefore recommended initially with the plan to perform postoperative PSG to assess response to surgery.

Those patients who are incompletely treated would then be considered for phase II surgery.

phase II surgery may be the appropriate first step=>in non obese patients with marked mandibulardeficiency and normal palates

Powell NB, Riley RW. A surgical protocol for sleep disordered breathing. Oral MaxillofacSurg ClinNorth Am 1995; 7(2):345–356.

SURGICAL PROTOCOL OUTCOMES Clinical response to phase I surgery ranges from 42%

to 75%

Riley R, Powell N, Guilleminault C. Obstructive sleep apnea syndrome: a review of 306consecutively treated surgical patients. Otolaryngol Head Neck Surg 1993; 108(2):117–125.

Lee N, Givens C, Wilson J, et al. Staged surgical treatment of obstructive sleep apneasyndrome: areview of 35 patients. J Oral Maxillofac Surg 1999; 57(4):382–385. with sleep apnea. Arch Otolaryngol Head Neck Surg 1996; 122(9):953–957.

Factors for less succ outcome

RDI>60

oxygen desaturation <70%

mandibular deficiency :sella nasion pointB<75’

BMI> 33 kg/m2

Preoperative CPAP can alleviate the issues associated with sleep deprivation and may reduce the risk of postobstructive pulmonary edema.

Consequently, all patients who are tolerant of CPAP are encouraged to use this modality for at least two weeks prior to surgery

Nasal Reconstruction Nasal reconstruction can improve quality of life and

may improve OSA in select patients

improve a patient’s tolerance of nasal CPAP

Rarely, however, will alleviating nasal obstruction cure OSA.

Olsen K. The role of nasal surgery in the treatment of obstructive sleep apnea. OtolaryngolHeadNeck Surg 1991; 2(5):63–68.Hoijer U, Ejnell H, Hedner J, et al. The effects of nasal dilatation on snoring and obstructive sleepapnea. Arch Otolaryngol Head Neck Surg 1992; 118(3):281–284.

Uvulopalatopharyngoplasty/Uvulopalatal Flap

UPPP is an excellent technique to alleviate isolated retropalatalobstruction (Fujita type I)

UPPP was found to have a success rate of 39% for curing OSA

Sher AE, Schechtman KB, Piccirillo JF. The efficacy of surgical modifications of the upper airway inadults with obstructive sleep apnea syndrome. Sleep 1996; 19(2):156–177.

Uvulopalatopharyngoplasty (UPPP) as a single surgical procedure: UPPP as a sole procedure, with or without tonsillectomy, does not reliably normalize the AHI when treating moderate to severe obstructive sleep apnea syndrome. Therefore, patients with severe OSA should initially be offered positive airway pressure therapy, while those with moderate OSA should initially be offered either PAP therapy or oral appliances. (Option).

Mandibular Osteotomy with Genioglossus Advancement

The rationale of this surgery is to enlarge the PAS by preventing prolapse of the tongue during sleep

no study to determine the compliance of the genioglossus muscle preoperatively

limitation :no additional room is created for the tongue in contrast to maxillomandibularadvancement.

Meticulous hemostasis+aggressive antihypertensive management are critical to prevent hematoma formation.

Mild postoperative floor of mouth edema or ecchymosisis common and is usually self-limiting

Hyoid Myotomy and Suspensionadjunctive procedure to treat tongue base obstruction for those who previously underwent genioglossus advancement and have evidence of a posteriorly displaced epiglottis.

MMA In 1990, Riley et al.

demonstrated no statistical difference between nasal CPAP and surgery in improving sleep architecture and SRBD

Maxillo-Mandibular Advancement (MMA): MMA is indicated for surgical treatment of severe OSA in patients who cannot tolerate or who are unwilling to adhere to positive airway pressure therapy, or in whom oral appliances, which are more often appropriate in mild and moderate OSA patients, have been considered and found ineffective or undesirable (Option).

Multi-Level or Stepwise Surgery (MLS): Use of MLS, as a combined procedure or as stepwise multiple operations, is acceptable in patients with narrowing of multiple sites in the upper airway, particularly if they have failed UPPP as a sole treatment (Option).

Radiofrequency ablation (RFA mild to moderate

obstructive sleep apneawho cannot tolerate or who are unwilling to adhere to positive airway pressure therapy, or in whom oral appliances have been considered and found ineffective or undesirable (Option).

PALATAL IMPLANT SYSTEM mild OSA who cannot

tolerate or who are unwilling to adhere to positive airway pressure therapy, or in whom oral appliances have been considered and found ineffective or undesirable (Option).

Injection Snoreplasty 3% sodium tetradecyl sulfate (sotradecol) and 50%

Ethanol

Complete cessation or a significant reduction in snoring was reported by 92% of patients or bed partners.

snoring relapse was 18% at long-term follow-up

not shown to significantly reduce the RDI

The genial bone advancement trephine system (GBAT)

long-term objective studies have not documented the success rate of the GBAT technique when used as primary treatment for SRBD.

Repose GenioglossusAdvancement Hyoid Myotomy

Subjective improvements in snoring and daytime fatigue.

Reduction of the RDI and apnea index with improvement of oxygen saturation was observed.

Unfortunately, the overall cure rate was approximately 20% in several studies

Tracheostomy Effective single intervention to treat obstructive

sleep apnea. This operation should be considered only when other options do not exist, have failed, are refused, or when this operation is deemed necessary by clinical urgency (Option).

Conclusion Identifying the site(s) of airway obstruction in

OSA is critical

No single ideal method of identifying site of obstruction, although there are some options

Improving our assessment of the airway may enable targeted, more-effective treatment of OSA with surgery and oral appliances