1. Plastic and Reconstructive Surgery
The Management of Snoring and Obstructive Sleep Apnea Rex Moulton-Barrett, MD
Plastic and Reconstructive Surgery
Otolaryngology & Head and Head Surgery
Alameda Hospital
June 2005

2. Spectrum of Sleep Disordered Breathing

4. Definitions Upper Airway Resistance Syndrome ( UARS )
• Daytime somnolence
• No significant apnea or O2 desaturation
• Habitual loud snoring (crescendo)
• they wake from their own noise of snoring
Guillaminault C, Stoohs R, Duncan S. Chest 99:40-48;1991
Guilleminault C, Stoohs R, Clerk A et al. Chest 104: ;1993

5. Definitions Hypopnoea: ‘ Chicago Criteria’
1. Fall in average tidal volume by > 50%
but < 10 second apnoea
or < 50% tidal volume reduction and
2. at least 4% in oxyhemoglobin desaturation
3. EEG evidence of arousal

6. Definitions Apnea Cessation of airflow for at least 10 seconds
Obstructive / Central / Mixed
based on presence or absence of respiratory movement
Obstructive - cessation of airflow in the presence of continued inspiratory effort
Central - absence of both airflow and inspiratory effort
Mixed - combination of both, beginning as central apnea followed by the onset of inspiratory effort without airfolow.
UARS - characterized by complaints of daytime fatigue and/or sleepiness, increased upper airway resistance during sleep, frequent transient arousals, and no significant hypoxemia.
Laryngoscope 106:9 pt , 1996
-normal RDI
-sleep fragmented by very short alpha EEG arousals throughout the sleeping period - usually ignored in sleep analyses.
-mean sleep latency was 5.1 min.
-arousals directly related to an abnormal increase in respiratory effort during sleep (mean peak insp esophageal pressure just preceding a transient arousal was 33 +/-7 cm H2O.
-nasal CPAP eliminates the dayitme sleepiness

7. Prevalence of Sleep Apnea
AHI = RDI
= apnoea+hyponoea / hour
>5 : 24% Males & 9% Females
4 - 6 times more common in men
20 million Americans
Young T, Palta M, Dempsey J. N Engl J Med : ;1993

8. Pathophysiology Scale
RDI / AHI
UARS <5
Mild
Moderate
Severe >40

9. What is Significant RDI?
A RDI of events per hour is close to what adults seem to be able to tolerate with no clinical consequence. Hosselet JJ, Ayappa I, Norman RG et al. Classificatin of sleep-disordered breathing. Am J Respir Crit Care Med 163: ;2001

10. 10x > risk, VAMV UCLA 2000

11. Somnolence Induced MVAs
3 fold increase in motor vehicle accidents if RDI> 5
Why is obstructive sleep apnea important to diagnose and treat? As I’ll go into later, it is associated with cardiovascular disease, hypertension, stroke, depression, and other illnesses, but most worrisome is the very high rate of motor vehicle collisions among patients with this disorder. Unfortunately, when one of these patients gets behind the wheel, they don’t only risk their own life, but also the lives of other motorists and pedestrians, just as if they had a few beers.
Reaction times worse than with alcohol impairment.
risk of MVA 2.6x greater for untreated sleep apneics AHI<15,
7X risk with AHI>15
-50% of long haul truck drivers have sleep disordered breathing
-30% have severe OSAS (202 drivers studied)
-fatigue contributing factor in 42-54%of auto accidents and 32% of fatal auto accidents (est cost of billion in 1988)
So think about that the next time you see one of these big boys on your tail, and make some space.

12. Morbidity and Mortality
Risk factor for cardiovascular disease
Hypertension
MI –polycythemia, platelet aggregation
Stroke
Mortality
AI>20 = 37% mortality over 8 yrs compared with 4% for AI<20 (Chest 94:9-14, 1988)
Snoring
-can impair and restrict normal social interactions
-These associated morbidity may argue for snoring as a relevant health concern in the heroic snorer irrespective of the airflow limitation and increased upper airway resistance that may also disrupt sleep.
Excessive Sleepiness
- risk of MVA 2.6x greater for untreated sleep apneics
-50% of long haul truck drivers have sleep disordered breathing
-30% have severe OSAS (202 drivers studied)
-fatigue contributing factor in 42-54%of auto accidents and 32% of fatal auto accidents (est cost of billion in 1988)
Cardiovascular Disease
-HTN due to inc. sympathetic tone during sleep from arousal, hypercarbia and hypoxia---”non-dippers”.
-OSAS identified as an independent risk factor for HTN(Hla. Ann Int Med 120: , 1994).
-Use of CPAP reduces HTN.
-HTN leads to LV dysfunction.
-inc. platelet aggregation (prob f/ elevated catecholamines and chronic intermittent hypoxia)------inc. embolic events (stroke)
Association vs. causation

13. History Heroic snoring Observed apneas or choking Excessive sleepiness
Cardinal symptom of OSAS
Observed apneas or choking
Excessive sleepiness
Witnessed apnoeas
Change in personality – depression, anxiety
Cognitive dysfunction – memory, concentration
Morning headaches
Decreased libido or impotence
Car or work accidents
History alone is only 60% specific and 60% sensitive
Need objective testing
Spouse usually gives more accurate description of symptoms
Women are more likely to have subtle symptoms.
Snoring - energy from neg. inspiratory pressure is dissipated across pharyngeal tissues.
80-90% of snores originate in vibration of the palate, uvula, and lateral pharyngeal wall tissues.
Usually noise >50 dB before it is considered snoring
Legend of men protecting their women
Inability to concentrate, inattentive
Falling asleep while driving a vehicle is not uncommon
Some symptoms are rarely volunteered, but frequently elicited:
intermittent nocturnal enuresis and impotence.
Not everyone who snores has OSAS, but virtually all patients with OSAS have significant snoring problems.
History of recent weight gain.

14. Sleep Apnea Risk Factors
•Obesity
•Increasing age
•Male gender
•Anatomical abnormalities of upper airway
•Family history
•Alcohol or sedative use
•Smoking

15. Diagnosis: Physical Exam
Upper body obesity / thick neck
>17” males
>16” females
Airway abnormality
Nasal
Oropharyngeal
Hypopharyngeal

16. Differential Diagnosis of OSAS
• Narcolepsy
REM sleep within 10 minutes
• Excessive daytime sleepiness associated with psychosocial and psychiatric disorders
• Drug related syndromes
• Restless Legs / Periodic limb movement disorder
• Idiopathic hypersomnolence
Narcolepsy
-xs daytime sleepiness with “sleep attacks” even while engaging in activities including sexual relations, conversations
-cataplectic attacks - loss of muscle tone and complete postural collapse
-sleep paralysis at entry or emergence from sleep - with conciousness
-hypnogogic hallucinations- dream like experiences
-Usually begin 20’s
-REM sleep within 10 minutes , MSLT- 2/5 naps with REM
-Treated with amphetamines
Excessive daytime sleepiness assoc with psychosocial and psychiatric disorders
-daytime naps, prolonged periods spent in bed, deprssion, short REM latency (<60 min)
Drug related syndromes
-sustained use of CNS depressants
-tolerance or withdrawl from CNS stimulants
Restless Legs…
-repetetive muscle contractions in legs

17. Evaluation of Upper Airway
No consistent characteristic in OSA
Quantitative measures depend on state
Methods of Evaluation
Cephalometric radiographs
Cephalometric raiographs -
Evaluate skeletal and facial contour
Results may be distorted by technique, position, wakefulness
Advantages : noninvasive, objective, low cost, easily accessible
There are craniofacial differences between pts with OSAS and those without
Skeletal subtypes - difined by relationship of mandible to maxilla
-OSAS w/ nl maxillo-mandibular relationships - more likely to have obstruction secondary to soft tissue abnormality (palate,tongue)
-OSAS w/o nl maxillo-mandibular relationship - ex:retrognathicare more likely to be helped by a mandibular advancement procedure ordevice.
-measurements vary according to skeletal subtype, obesity, race
Overall - cephalometric analysis is inconsistent (various research results)
Sleeping pharyngeal manometry - general measurement of the segment of obstruction - does not describe airflow changes.
Acoustic reflection - measures cross sectional airway changes
-must be performed during wakefulness, in sitting position
-requires oral mouth piece--alters pharyngeal anatomy
CT scanning - measures cross sectional size
-too slow to measure changes in airway size with resp. cycle
-fast CT scanners too expensive, unavailable
Endoscopic methods - variable success (Mueller’s maneuver - inspiratory effort against closed nares) -measurement during sleep may provide better results
goal- exclude patients for isolated UPPP with tongue base or hypopharyngeal collapse or obstruction (50% with these features are nonresponders, 5% are responders (therefore 95% with these features are not responders)

18. Anatomic Factors in Airway Obstruction
•Increased nasal resistance.
•Excessive palatal length.
•Increased tongue size.
•Increased vertical airway length
•Enlarged tonsils.
•Mandibular retrusion.
Although there is no single anatomic predictor of OSA, the more anatomic points of obstruction, the higher the likelihood that there is more severe OSA.
During wakefulness, patients with OSDB exhibit augmented motor activity in the pharynx that serves to prevent airway collapse. During Sleep this activity is lost resulting in obstruction.

19. Impact of nose on snoring and OSAS
• Obstruction increases airway resistance
• Anterior rhinomanometric volume has an inverse relationship with RDI p<0.05
• Nasal obstruction is an important cause of OSA
Virkkula, P et al. Acta Otolaryngol, 2003
(Finland)
Nose accounts for >50% of airway resistance.
Obstruction…increased resistance…dec flow… inc neg insp pressure…inc tissue collapse…inc snoring and OSA
Fairbanks - 77% snoring cessation with septoplasty and turbinate surgery
Patient selection
-Afrin Test
3 sprays each nostril 30 min before bedtime every other night and compare snoring on spray vs no pray nights.

20. Malampatti I-IV: Airway Classification
Visualize
I:Soft palate, tonsils, uvula
II:No tonsils seen
III:Soft palate only seen
IV:Hard palate only seen IV

21. Maximal inspiratory movement
Muller Maneuver
Maximal inspiratory movement

22. Velopharyngeal Closure Patterns
A. Coronal %
B. Circular %
C. Circular +Passavant’s Ridge 7%
D. Sagittal %
Finkelstein , Talmi , Nachman .Plastic Rec Surg 1992;89:

23. Snoring: “a marker for airway resistance during sleep”
Hofffstein V, Mateika S, Nash S. Comparing Perceptions and Measurements of Snoring. Sleep 19: ;1996

24. Balance of forces affecting airway
Kuna ST, Sant’Ambrogio G. JAMA 266: ;1991

25. Pathophysiology of OSAS
• Collapse of pharyngeal airway
• Increased upper airway resistance
• Diaphragm movement increases negative airway pressure
• Increased airway collapse
• Hypopnea and apnea – increase vagal tone
• Hypoxia, Hypercarbia – catacholamine rise
• Increased ventilatory effort
• Sleep fragmentation and arousal
collapse due to structurally small pharyngeal upper airway and a sleep-related loss of muscle tone.
In OSAS upper airway is structurally small and requires muscle tone (wakefulness) to maintain patency due to its structural vulnerability.
apneic events >60 seconds will generally decrease the PaO2 concentration by as much as mm Hg.
Hypoxemia increases catacholamine release increasing BP
Pulmonary and systemic arterial pressures increase in response to nocturnal oxygen desaturation. This may lead to LVH.
Apneas associated with sinus arrythmias - bradycardia mediated by increased vagal efferent activity.

26. Who to order a Sleep Study On ?

29. RDI EPWORTH 0 8.0+/-3.5 Mild 12.1 11.0+/-4.2 Mod 34.8 13.0+/-4.7
Epworth v. RDI
RDI EPWORTH
/-3.5
Mild /-4.2
Mod /-4.7
Severe /-3.3
T. Woodson - Monograph

30. Why Get a Sleep Study ?
Documentation
Quantification
Determine Therapy

31. Polysomnography • Establish diagnosis of sleep apnea
• Assess disease severity
• Rule out other disorders of sleep
• CPAP titration
• Components:
EEG
EOG
EMG
EKG
Chest wall and abdominal wall impedance
Intercostal EMG
Body position
Pulse Oximetry
PSG - recognized to be the standard for diagnosing OSAS
EEG - to determine stages of sleep
identification of the types of apneic events

32. In-Laboratory Polysomnography
Pros
“Full” set of variables recorded
Technician for patient & equipment problems
Able to determine success of C-Pap
Cons
Cost
Accessibility
Patient sleeps away from home
Fails to localize site of obstruction

33. “The Polysomnographic Age …. has ended”
Unattended ambulatory monitoring is “biologically plausible and technologically feasible”
Strohl KP. When, Where and How to Test for Sleep apnea. Sleep 2000;23:S99-S101

34. SNAP Testing • PSG: polysomnograpghy “considered gold standard”
inherant variability,
problems of reproducibility
• SNAP testing: out-patient, localizes site of obstruction, inexpensive
• Direct and solid correlation between both for measurement of RDI
• For RDI >= 5 : % positive predictive value,
96% specificity
75% sensitivity
Allan, P, Chaney, J, Mair, E. Otolaryngol HNSurg, 2004

35. SNAP Testing Acoustic Analysis of Oro-Nasal Respiration
• Sound & Airflow Detection
• Pulse Oximetry & Pulse rate
• Apnea & Hypopnea Indices
• Snoring Analysis
• 6 hours+ continuous recording

37. SNAP Data Collection Cannula

38. Effort & Movement Transducer

39. Why SNAP ?
Patient Selection
OSA detection
Snoring Localization & Quantification
Outcome Monitoring

40. SNAP - Apnea

41. SNAP - Oximetry

42. SNAP - Snoring

44. OSA in Children History
Shyness
Developmental Delay
Aggressive Behavior
Symptoms of ADD
Witnessed apneas: positive predictive value of 86%
T&A are usual source of obstruction
Several studies show improvement in behavior and school performance after T+A
Children may not be sleepy. Daytime napping.
95% have improved QOL after tonsillectomy.

45. Treatment for OSA Medical Surgical Reduction of Risk factors
CPAP - Most common treatment
Drugs
Airway appliances
Surgical
Some of these methods are experimental or have been shown to be not effective in treating OSAS.
Many modalities work with some success in some patients, but no single modality succeeds in all pts.

46. Reduction of Risk Factors
Obesity
Sleep hygiene
Nasal obstruction
Body position
Sedative and alcohol use
These are Factors contributing to apnea severity.
Obesity
Important risk factor for OSAS.
Increased risk of oxyhemoglobin desaturation and hypoventilation during sleep and wakefulness
Significant independent contributor to CV morbidity and mortality
Weight loss associated with reduction in RDI and OSAS severity
(Thorax 48: , 1983)
Why is RDI and OSAS severity decreased with wt loss?
?Enlargement of pharyngeal and parapharyngeal fatty deposits -MRIstudies do not substantiate this.
Central obesity associated with increased neck size.
?altered metabolism
Wt loss reduces severity of OSA in morbidly obese.
OSA recurrs in some patients despite maintenance of wt reduction.
Wt gain worsens apnea in successfully treated surgical patients
Inadequate Sleep Duration - poor sleep quality worsens upper airway collapssibility
Nasal Obstruction -Does not independently contribute to OSAS
Improving nasal patency reduces both snoring and OSAS in some patients
nasal dialators, steroids, decongestants, allergy therapy.
Isolated nasal treatment of clinically sig OSAS is rarely successful in eliminating disease.
Alcohol - depresses hypoglossus greater than phrenic nerve.

47. Drugs Oxygen - most widely used Protriptyline Theophyline Progesterone
Nicotine
Serotonin antagonists
Modafinil (Provigil)
None have proved to be highly effective.
Some benefit may occur in individual patients.
Protriptyline - dec REM sleep, stim hypoglossus with minimal effect on phrenic nerve.
Oxygen - initial increase in apnea time, shortened over therapeutic period
-net dec in apnea time, inc in O2 sat
Proposed mechanisms:
maintainence of nl O2 sat may prevent hypoxia induced ventillatory depression
-sustained hyperoxia may augment ventilation by dec cerebral blood flow thus inc cerebral CO2 tension
-may prevent CNS dysfunction from apnea related hypoxia
-stabalizes ventilatory control system
-some pts experience worsening apnia with hypercarbia and acidosis.
Serotonin Antagonists - augment activity of upper airway dialator muscles. May offer real hope
(Am J Respir Crit Care Med 153: , 1996)

48. Pharmacologic Treatment
Modafinil in obstructive sleep apnea-hypopnea syndrome: a pilot study in 6 patients by Arnulf I, Homeyer P, Garma L, Whitelaw WA, Derenne JP. Service de Pneumologie et Laboratoire du Sommeil, Hopital Pitie-Salpetriere, Paris, France. Respiration 1997; 64(2): ABSTRACT
We studied the effects of modafinil, a vigilance-enhancing drug, on excessive daytime sleepiness, memory, night sleep and respiration in 6 patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) using a double-blind random cross-over design with 24-hour polysomnography, verbal memory test and a 5-week sleep-wake diary kept by the patients. There were two 2-week treatment periods in which either modafinil or placebo was used; they were separated by a 1-week wash-out period. Our results show that modafinil reduces daytime sleep duration, lengthens the duration of subjective daytime vigilance and improves long-term memory in patients with OSAHS without modifying night sleep and respiration events.

49. CPAP Splints the Upper Airway
Collapsing forces
Tissue pressure and mass
Constrictor muscle tone
Negative inspiratory pressure
Dilating forces
Dilating muscle tone
Tissue pressures that stabilize the airway
CPAP augments dilating forces
muscles that retract tongue - hyoglossus and styloglossus
muscles that protrude tongue - genioglossus
Transmural pressure - describes size of the airway at any moment
equals pressure difference between dilating and collapsing forces
Airway closing pressure - the transmural pressure at which complete airway obstruction occurs.
CPAP - augments the dilating pressures, thereby keeping the airway pressure above the closing pressure.
with increased splinting of airway there is a progression from
apneas…. hypopneas….increased uppere airway resistance…. non-obstructed ventilation

50. CPAP Has Poor Compliance
CPAP is effective
Not a cure
Pattern of use established early
Drop out rate > 25%
50% effective use
Treatment of OSAS has been most affected by the development of CPAP
pneumatically splints - Sullivan. Lancet I:
pressure setting tittrated to the individual - variations secondary to differences in anatomy and physiology.
Effective - dec in SBP and heart rate, improved sleepiness and psychosocial functioning, decreased sympathetic nervous sys activity, normalization of growth hormone, insulin and glucose profiles.mortality risk less than controls and equal to tracheostomy
Not a cure, but a daily form of treatment that requires patient compliance to remain effective
pattern of use established within the first weeks of use.
effective dropout rate 15-25%, with hrs/night use in the remaining patients
50% use for greater than 4hrs/night for 5-7 nights per week
New girl friend, can’t be intimate with wife, clausterphobic, nasal dryness

51. Bi-level Applied Pressure
• CPAP forces patients to produce high expiratory pressures – uncomfortable
• Collapsing pressures are increased during inspiration
• Bi-level pressure applies lower pressures during expiration and higher levels during inspiration
Increased initial patient acceptance
Increased compliance?
Collapsing pressures greater during inspiration secondary to negative inspiratory pressure
Bi-level pressure - independent titration of pressure during inspiration and expiration
May have increased compliance in patient subgroups who have large differences between their inpiratory and expiratory pressures.
Longterm - no difference in compliance or patient complaints

52. Side Effects of CPAP Dry nose and mouth (65%) Mask discomfort (50%)
Sneezing and rhinitis (25-35%)
Claustrophobia
Social impediment
Alleviating side effects increases compliance
Warmed humidity
Eliminating air leaks
More comfortable masks
Humidity - relieves dryness
Warmed - Reduces CPAP rhinitis and intolerance
Eliminating Leaks - allows flow rates to be decreased which decreases dryness

53. Airway Appliances Nasal Appliances Oral appliances Breath Rite Strips
Mandible repositioning
Some devices reduce RDI
Patient compliance
TMJ and teeth problems
Tongue repositioning
Patient selection
Follow up PSG to test efficacy
Nasal Appliances - acute reduction of nasal resistance may decrease snoring in some patients.
Devices to dilate the nasal valve using internal or external splints
No evidence to date supports treatment of clinically significant OSAS only with these devices.
Oral Appliances - increase airway size or alter the effects of muscular function on the upper airway.
A variety of appliances (Sleep 18: , 1995)
OA vs CPAP (Chest 109: , 1996)
Patient selection - retrognathic, enlarged tongue

54. Surgical Treatment of Snoring & OSAS
Types of procedures
Prevent obstruction
Bypass obstruction
Key to success is to localize site of obstruction
Indications determined by:
Severity of medical complications (asystole, bradycardia with apnea, vtach O2 sat below 50%, severe hypercarbia, cor pulmonale, socioeconomic compromise secondary to daytime sleepiness(MSLT normal is >7 min)
Indications
Correct upper airway pathology
Treat snoring
Treat OSAS
socially disturbing debilitating loud snoring
pt should be informed of nonsurgical options
Surgery - goal is definitive treatment
- May require several stages
-Stage I - less complex, less morbidity
-Stage II- more complexity and morbidity
Bypass obstruction - tracheostomy (cure but with high morbidity)
- Surgical gold standard (CPAP is de facto gold standard (treatment, not cure) - secondary to low morbidity)
Prevent obstruction - alter airway
- Soft tissue techniques - directly enlarge airway (UPPP)
- Skeletal advancement techniques - enlage airway by moving
muscle insertions

55. Nasal Surgery Nasal airway resistance
Increased nasal airway resistance leads to increased negative inspiratory pressures
Addition of nasal surgery may improve surgical success and increase CPAP use
Rarely definitive treatment for OSAS alone
nasal packs increase nasal airway resistance - worsening OSAS

56. Maurer, J, et al. Otolaryngol HNSurg 2005
Pillar Procedure
Mannheim, Germany
• 3 plate palate implants placed in the office
• 1% extrusion rate
• 78% response rate with 51% reduction of snoring
Maurer, J, et al. Otolaryngol HNSurg 2005

57. Tonsillectomy Should be removed if enlarged in OSAS Reduces RDI
Rarely curative alone (Except in Children)

58. Weingarten, C. Laryngoscope, 1995
Snare Uvulectomy
Weingarten, C. Laryngoscope, 1995
• In office procedure
• Topical anesthesia
• Local anesthesia with epinephrine
• Wire snare 1-1.5cm above tip uvula
• If redundant palatal folds:
• 1-1.5cmVertical wedges in soft palate

59. Injection Somnoplasty
5 days post procedure
• SNAP Test
• sitting position
• 20% benzocaine jel on Q tip: 20 minutes
• 3 cc syringe with 27g 3/4 inch needle:
• 1cc 99% ETOH & 1cc with 1cc Lidocaine 2%
• or Thromboject ( sodium tetradecyl sulfate )
men: 2cc 3%, women 2cc 1%
• inject :mid pharynx point (not base of uvula)just below mucosa
• 2 minutes later will turn purple
• expected complications: gag on bubble, swelling, mucosal ulcer
• f/u 6 weeks later,
• if still snoring: repeat just lateral to site: 1cc each side

60. Injection Somnoplasty
Vital statistics:
• Indicated if RDI< 5
• 1.2 inject/ per patient ( 86% benefit )
• 3/29 palatal fistula: more likely if-larger inject in small pt.
inject into muscle
• Not effective in sleep apnoea
Brietzke, S & Mair, E. Otolaryngol HNSurg, 2001.

61. Laser Assisted Uvulopalatoplasty

63. Radiofrequency Partial Uvulopalatoplasty
• 460 kHz 10mmlength, 10mm insulated 22 g needle
• Target temperature between C
• 20% benzocaine topical
• 4 sites submucosal delivery for seconds:
< 750 J superior midline
<350 J paramedian
May amputate long uvula and place within muscle
• 70% snoring improvement at 1 yr
• mean number of treatments was 3.6
Troell,R. Otolaryngol Clin N Am 2003

64. Uvulopalatoplasty Treatment of snoring Treatment of OSA
80% effective
Treatment of OSA
- previously reported 50% effective
- when combined with nasal and or base of tongue surgery higher success
Multiple methods available
Laser
Cautery
Radiofrequency
Removal of distal palate and uvula
LAUP - Paris 1980
Effective treatment of snoring
May be effective in treating mild OSAS
Serial excision or sculpting with laser / electrocautery / radiofrequency
Endpoint:
-pt happy
-snoring gone
-pt unable to make a snoring sound - if still has noisy breathing then snoring from elsewhere.
Results suggest stability if weight remains constant.
Applied in younger patients so that ther may be increase in risk of OSAS over time
Decreased snoring may delay diagnosis of OSAS

65. Uvulopalatopharyngoplasty (UPPP)
Reduction of snoring (90%)
Decreased sleepiness (84%)
Objective reduction in OSAS (50%)
50% decrease in RDI - (50%)
RDI < 20 events/hr or AI < 10 events/hr (42%)
Determinants of success
Location of airway obstruction
Severity of OSAS
Risks of UPPP
Miljeteig h, Am J Respir Cri Care Med 150: , 1994
Sher AE. Sleep 19:
Success rates vary by criteria used.
At RDI < 20 events/hr or AI < 10 events/hr - mortality = CPAP, normalization of driving simulator performance tests and improved cardiovascular function.
Determinants of success - Only location of airway collapse (UPPP may only relieve one area of airway obstruction) and severity of OSAS (RDI)
Not age, BMI, baseline AI, lowest oxyhemoglobin desaturation, presence or abscence of tonsil

66. History • William Osler (1906): Pickwickian
• Simmons and Hill (1974): Hypersomnia caused by upper airway obstruction
• Ikematsu (1952): First UPPP
• Fujita (1979):
• Sullivan (1981): CPAP
1895
Pickwickian Syndrome= obesity, hypersomnolence, and resp failure.
Assoc with daytime waking hypoventilation.
“an extraordainary phenomenon in excessively fat young persons is uncontrollable tendency to sleep - like the fat boy in Pickwick” - referring to Joe- a character in Charles Dickens famous novels “the posthumous papers of the Pickwick Club”
Ikematsu 1952 Japan - 23 you female c/o snoring disturbing her marriage - on exam had a redundant soft palate and elongated uvula - improved after UPPP
Fujita pts - 9 symptomatic relief
1985

67. UVPP Contraindications
Velopharyngeal inadequacy
Submucous cleft palate
Non-palatal level of obstruction

68. Uvulopalatopharyngoplasty (UPPP)

70. Comparison of Treatment Methods
Pillar CPAP LAUP UPPP RF Sclerotherapy
Multiple visits  No Yes   Yes   No Yes Yes
  Pain   Low Low   Very high   Very high Low Medium
SE’s  Partial extrusion (1%)
Nocturnal awakenings (46%),
Nasal congestion and dryness (44%)  
Transient VPI (27%)3  
Transient VPI(20–100%)   Ulceration (22%)   Mucosal loss(22%)
  Sedation  Local None Local General Local Local
  Recovery time  < 24 HRS None 7 days 10 days   < 24 HRS <24 HRS    
Reimbursement In process Yes (apnea) No Yes (apnea) No No
                             

71. EFFICACY Snoring Yes Yes Yes Yes Yes Yes
Pillar CPAP LAUP UPPP RF Sclerotherapy
 OSA   Yes Yes  Yes  Yes No No
 Snoring   Yes Yes  Yes  Yes Yes Yes
 Reversible procedure Yes Yes  No  No No No
                             

72. PHYSICIAN EXPERIENCE Type of physician ENT Pulmon ENT ENT ENT ENT
Pillar CPAP LAUP UPPP RF Anlation Sclerotherapy
 Type of physician ENT  Pulmon  ENT  ENT  ENT   ENT
 Patient visits One  Multiple  Multiple  One  Multiple   Multiple
 Physician time Low  Low  High  High  Medium   Medium
 Hospital   No  No  Yes  Yes  Yes   No
 FDA clearance Snoring and OSA OSA only Not req  Not req  Snoring only No

73. Surgery of Lower Pharynx
• Radiofrequency Base of Tongue volumetric reduction
• Hyoid Suspension
• Epiglottectomy
• Lingual tonsillectomy
• Midline glossectomy
• Lingualplasty
Directly modigy soft tissues of the lower pharynx
Data on all of these procedures is sparse
Indicated when the involved tissues are disproportionate and obstructive
Linguaplasty and MLG are partial glossectomies of the tongue base
MLG following UPPP failure - 40% success rate
Lingualplasty following UPPP failure in severe OSAS - 70% short-term success (RDI<20
(Woodson. Oto-HNS 107:40-48, 1992) (?Levine. Laryngoscope 104: , 1994)
Complications:25% early complication rate - bleeding, severe odynophagia, tongue edema, and taste changes (low rate of long term complications)
Linguaplasty - indicated in macrglossia or disproportionate tonge base
Potential of worsening airway instability
CPAP or tracheostomy manadotory perioperatively
Epiglottectomy - if omega-shaped epiglottis and prolapsing redundant arytenoids
- prolonged odynophagia and edema post operatively
- successfully treated with CPAP

74. Base of Tongue RFVTR

75. Prominent Lingual Tonsils

76. Maxillofacial Surgery
Limited mandibular osteotomies & genioglossus advancement
Hyoid myotomy
Airway stabilized when hyoid pulled anterior and inferior
Mandibular advancement
May require pre-op orthodontics
Malocclusion may be surgically acquired
Most successful in non-obese retrognathic patients
Bimaxillary advancement
MFS enlarges airway by advancing the skeletal support of the soft tissues that surround the airway
Many of these techniques involve limited or segmental mandibular advancement.
Indicated in pts with abnormalities of the lower pharynx, tongue base, and retrohyoid airway segments.
MFS combined with ancillary soft-tissue surgeries have the highhest surgical success rates (60-67%).(Riley. OHNS 108: , 1993)
Limited mandibular osteotomis and genioglossus advancement
-Bicortical rectangular osteotomy at the geniotubercle . The rectangular osteotomy and LMO-GGA advances the genioglossus attachment at the geniotuburcle. The window is placed below the apices of the teeth, and above the inferior mandibular border. The bone is advanced anteriorly and then turned 90 deg.
-incisor tooth paresthesia is a common occurrence that resolves in most patients. Tooth damage is rare.
Hyoid myotomy -hyoid advanced anteriorly with attached tongue and pharyngeal tissues.
Airway stabalized when hyoid pulled anterior and inferior
Achieved by suspending the hyoid onto the superior margin of the thyroid cartilage
Mandibular advancement mm advancement in non-obese retrognathic patient have high success rates
malocclusion, pre-op orthdontics may be required
Bimaxillary advancement - indicated in sig maxillomandibular deficiency, morbid obesity, severe OSAS
-May retain pre-op dentition and may not require extensive orthodotic tx
->90% success rate when part of a staged protocol
-Complications - change in aesthetic appearance, facial paresthesia, change in occlusion, TMJ dysfunction - These often resolve over time.

77. Maxillofacial Surgery
Limited mandibular osteotomies and genioglossus advancement
Hyoid myotomy
Airway stabilized when hyoid pulled anterior and inferior
Mandibular advancement
May require pre-op orthodontics
Malocclusion may be surgically acquired
Most successful in non-obese retrognathic patients
Bimaxillary advancement
MFS enlarges airway by advancing the skeletal support of the soft tissues that surround the airway
Many of these techniques involve limited or segmental mandibular advancement.
Indicated in pts with abnormalities of the lower pharynx, tongue base, and retrohyoid airway segments.
MFS combined with ancillary soft-tissue surgeries have the highhest surgical success rates (60-67%).(Riley. OHNS 108: , 1993)
Limited mandibular osteotomis and genioglossus advancement
-Bicortical rectangular osteotomy at the geniotubercle . The rectangular osteotomy and LMO-GGA advances the genioglossus attachment at the geniotuburcle. The window is placed below the apices of the teeth, and above the inferior mandibular border. The bone is advanced anteriorly and then turned 90 deg.
-incisor tooth paresthesia is a common occurrence that resolves in most patients. Tooth damage is rare.
Hyoid myotomy -hyoid advanced anteriorly with attached tongue and pharyngeal tissues.
Airway stabalized when hyoid pulled anterior and inferior
Achieved by suspending the hyoid onto the superior margin of the thyroid cartilage
Mandibular advancement mm advancement in non-obese retrognathic patient have high success rates
malocclusion, pre-op orthdontics may be required
Bimaxillary advancement - indicated in sig maxillomandibular deficiency, morbid obesity, severe OSAS
-May retain pre-op dentition and may not require extensive orthodotic tx
->90% success rate when part of a staged protocol
-Complications - change in aesthetic appearance, facial paresthesia, change in occlusion, TMJ dysfunction - These often resolve over time.

78. Probably less effective than genioglossus advancement
Hyoid Suspension
Probably less effective than genioglossus advancement

79. Electrical Stimulation
Eisle, D, et al, 2003
Genioglossus muscle - dilator
Transcutaneous stimulation
Poorly tolerated
Implantable electrodes
Variable success
Arousal from sleep from the stimulus
genioglossus protrudes the tongue
May increase muscle tone and airway size
May be effective in treating OSAS (Chest 107:67-73, 1995)
Jury is still out on the effectiveness and practicality of this approach
Experimental: relies on trans-sternal transducer to
induce genioglossus activity

80. Tracheostomy Bypasses upper airway obstruction Indications Morbidity
Effective in decreasing M&M associated with OSAS
Indications
Severe OSAS or obesity hypoventilation
Perioperative airway management
Morbidity
tracheal stenosis
Infection
Effects on appearance and voice
Only 100% cure of OSAS
After healing, may be occluded during wakefulness and opened during sleep
Technical Considerations
More difficult tracheostomy - obesity, short neck, low larynx, inability to extend neck
“skin flap” permenant tracheostomy with lipectomy (to reduce tension on theskin flaps) may reduce complications by providing an epithelialized stoma and allowing better exposure and care of stoma
These patients prone to more complications

81. Tube Free Tracheostomy (Isaac Eliachar, MD)
Bypasses upper airway obstruction
Effective in decreasing M&M associated with OSAS
Indications
Severe OSAS or obesity hypoventilation
Perioperative airway management
Morbidity
tracheal stenosis
Infection
Effects on appearance and voice
100% successful