1. Obstructive Sleep Apnea Syndrome Robert H. Stroud, M.D. Francis B. Quinn, M.D. February 4, 1998

2. History u Charles Dickens - The Pickwick Papers u William Osler - Pickwickian Syndrome 1918 u Guilleminault - OSAS - 1973 u Fujita - UPPP - 1981 u Sullivan - CPAP - 1981

3. Epidemiology u 85% men u Prevalence - 2% in women, 4% in men u two thirds are obese u elderly u African-American

4. Pathophysiology u Bernoulli principle and Venturi effect u snoring u tissue laxity and redundant mucosa u anatomic abnormalities u decreased muscle tone with REM sleep u airway collapse

5. Pathophysiology u desaturation u arousal with restoration of airway u sleep fragmentation leading to hypersomnolence

6. Pathophysiology - complications u desaturation with compensatory polycythemia u hypercapnia with pulmonary hypertension u systemic hypertension u arrythmias

7. Evaluation u complete H&P u snoring - characteristics u daytime sleepiness

8. Evaluation - history u restless sleep u personality change u impaired cognitive skills u weight gain u morning headache u nocturia/enuresis u sexual dysfunction u sedative use

9. Evaluation - history u adenotonsillar hypertrophy u nasal obstruction u hypothyroidism u acromegaly u Down syndrome u micrognathia u retrognathia u obesity u vocal cord paralysis u H&N masses

10. Evaluation - physical exam u retrognathia u mouth-breathing u “tired” appearance

11. Evaluation - physical exam u Nasal obstruction - turbinate hypertrophy, polyposis, septal deviation u oral cavity and oropharynx –redundant mucosa –beefy red –elongated uvula –macroglossia –AT hypertrophy

12. Evaluation - physical exam u fiberoptic examination u Mueller’s maneuver u examine in supine position u usually difficult to localize one site of obstruction

13. Evaluation u Polysomnography –EEG –EOG –submental EMG –nasal and oral airflow –respiratory muscle effort –oxygen saturation –ECG –anterior tibialis EMG –sleep position

14. Evaluation - polysomnography u central, obstructive, mixed apneas u apnea - cessation of flow for 10 secs u hyponea - 50% decrease in flow or EEG arousal

15. Evaluation - polysomnography u respiratory disturbance index (RDI) - apneas + hyponeas per hour u apnea duration u degree of desaturation u sleep disturbance index - arousals per hour

16. Evaluation - radiography u lateral neck film in children u CT and MRI of limited benefit u somnofluoroscopy u cephalometrics

17. Evaluation - other studies u thyroid function tests u arterial blood gas u complete blood count u audio tape u rhinomanometry u multi sleep latency test (MSLT)

18. Treatment u raise intra-pharyngeal pressure u decrease pharyngeal closing pressure u increase muscular activity

19. Treatment u weight loss u avoid sedatives u pharmacotherapy u orthodontic devices u continuous positive airway pressure

20. Treatment - CPAP u 100% effective u titrate pressure u poor compliance - 50-80%

21. Treatment - surgical u adenotonsillectomy - preferred treatment in children u tracheostomy - cure for OSAS –used for failure of more conservative treatment –life threatening cardiopulmonary complications –alternative techniques to lessen complications

22. Treatment - surgical u Uvulopalatopharyngoplasty (UPPP) –excise excess tissue from free margin of soft palate –+/- tracheostomy –variable response - approximately 50% –+/- nasal surgery

23. Treatment - surgical u laser midline glossectomy u mandibular advancement u maxillary advancement - LeFort I osteotomy u hyoid suspension and inferior sagittal mandibular osteotomy u hyoid expansion

24. Treatment - complications u failure to achieve relief u difficult airway, anesthetic risk u decreased respiratory drive u bleeding, infection, pain u velopharyngeal incompetence u nasopharyngeal stenosis u post-obstructive pulmonary edema

25. Conclusion u life threatening complications u suboptimal treatment either due to poor response or limited compliance u good patient selection and long-term follow- up