1. Obstructive Sleep Apnea Hyponea Syndrome

2. Overview  Physiology of Sleep  Evaluation of Sleep  Definition of Obstructive Sleep Apnea Hyponea Syndrome(OSAHS)  Pathophysiology of OSAHS  Medical Treatment of OSAHS  Surgical Treatment of OSAHS

3. Physiology of Sleep  REM ( rapid eye movements Sleep) more likely to occur more likely to occur  Arousal Woodson, Tucker “Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment” SIPAC 1996

4. Evaluation of Sleep  Polysomnography  EMG  Airflow  EEG, EOG  Oxygen Saturation  Cardiac Rhythm  Leg Movements

5. Evaluation of Sleep  Polysomnography(PSG) Woodson, Tucker “Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment” SIPAC 1996

6. Evaluation of Sleep  Polysomnography(PSG) ---- Gold standard ---- Gold standard  Epworth Sleepiness Scale  Multiple Sleep Latency Test

7. Definition of OSAHS  Apnea is defined as cessation of airflow for ten seconds which results in an arousal. If the chest wall continues to mechanically move during this time, then it is an obstructive apnea. If the chest wall does not attempt to ventilate, then it is presumably due to a neurologic etiology and is termed a central apnea. Sometimes there are characteristics of both an obstructive and a central apnea, and this is termed a mixed apnea.  Hypopnea is considered a diminution in airflow which results in hypoxemia and results in an arousal.

8. Definition of OSAHS  the apnea-hypopnea index (AHI): the sum of apneas and hypopneas per hour  AHI: 5 — 20 = mild  AHI: 20 — 40 = moderate > 20 increases risk of mortality > 20 increases risk of mortality  AHI: >40 = severe

9. Definition of OSAHS  Snoring Patients with snoring who have an apnea- hypopnea index (AHI) of fewer than 5 and no complaints of excessive daytime sleepiness fall into this category  OSAHS : AHI>5 Difference : AHI

10. Hypoxia  The lowest SaO 2 ＞ 85% : mild  The lowest SaO 2 65 - 84% : moderate  The lowest SaO 2 ＜ 65%: severe one of the indicator for risk of surgery one of the indicator for risk of surgery

11. Pathophysiology of OSAHS  Sites of Obstruction:  Related to airway collapses

12. Pathophysiology of OSAHS  Symptoms of OSAHS  Snoring (most commonly noted complaint)  Daytime Sleepiness  Hypertension and Cardiovascular Disease are Associated  Pulmonary Disease

13. Pathophysiology of OSAHS  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

14. Pathophysiology of OSA  Tests to determine site of obstruction:  Muller ’ s Maneuver  Endoscopy  Fluoroscopy  Manometry  Cephalometrics  Dynamic CT scanning and MRI scanning

15. Medical Management  Weight Loss  Nasal Obstruction  Alcohol and Sedative Avoidance  Smoking cessation

16. Medical Management  CPAP Continuous positive airway pressure Continuous positive airway pressure  Pressure must be individually titrated  Compliance is as low as 50%  Air leakage, eustachian tube dysfunction, noise, mask discomfort, claustrophobia

17. Nonsurgical Management  Oral appliance  Mandibular advancement device  Tongue retaining device

18. Nonsurgical Management  Oral Appliances  mechanically moving the jaw or tongue forward and opening the airway.  May be as effective as surgical options

19. Surgical Management  Measures of success –  No further need for medical or surgical therapy  Response = 50% reduction in AHII  Reduction of AHI to < 20  Reduction in arousals and daytime sleepiness

20. Surgical Management  Perioperative Issues  High risk in patients with severe symptoms  Nasal CPAP often required after surgery  Nasal CPAP before surgery improves postoperative course  Risk of pulmonary edema after relief of obstruction

21. Surgical Management  Tracheostomy  Primary treatment modality  Temporary treatment while other surgery is done  Thatcher GW. et al: tracheostomy leads to quick reduction in sequelae of OSA, few complications. Once placed, uncommon to decannulate

22. Surgical Management  Nasal Surgery  Limited efficacy when used alone  Verse et al 2002 showed 15.8% success rate when used alone in patients with OSAHS and day-time nasal congestion with snoring (AHI<20 and 50% reduction)  Adenoidectomy

23. Surgical Management  Uvulopalatopharyngoplasty

24. Surgical Management  Uvulopalatopharyngoplasty(UPPP)  The most commonly performed surgery for OSAHS  Severity of disease is poor outcome predictor  Levin and Becker (1994) up to 80% initial success decreased to 46% success rate at 12 months  Friedman et al showed a success rate of 80% at 6 months in carefully selected patients

25. Surgical Management  UPPP Complications

26. Surgical Management  Cahali, 2003 proposed the Lateral Pharyngoplasty for patients with significant lateral narrowing:

27. Surgical Management  Lateral Pharyngoplasty

28. Surgical Management  Laser Assisted Uvulopalatoplasty  High initial success rate for snoring  Rates decrease, as for UP3 at twelve months  Performed awake

29. Surgical Management  Radiofrequency Ablation – Fischer et al 2003 Radiofrequency device is inserted into various parts of palate, tonsils and tongue base at various thermal energies

30. Surgical Management  Fischer et al 2003  At 6 months Showed significant reduction of:  AHI (but not to below 20)  Arousals  Daytime sleepiness by the Epworth Sleepiness Scale

31. Surgical Management  Tongue Base Procedures  Lingual Tonsillectomy  may be useful in patients with hypertrophy, but usually in conjunction with other procedures

32. Surgical Management  Tongue Base Procedures  Lingualplasty  Chabolle, et al success rate of 77% (RDI<20, 50% reduction) in 22 patients in conjunction with UPPP  Complication rate of 25% - bleeding, altered taste, odynophagia, edema  Can be combined with epiglottectomy

33. Surgical Management  Mandibular Procedures  Genioglossus Advancement  Rarely performed alone  Increases rate of efficacy of other procedures  Transient incisor paresthesia

34. Surgical Management  Lingual Suspension:

35. Surgical Management  Lingual Suspension:

36. Surgical Management  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

37. Surgical Management  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

38. Surgical Management  Maxillary-Mandibular Advancement  Performed in conjunction with oral surgeons

39. Surgical Management  Algorithms  Friedman et al developed a staging system for type of operation:

40. Surgical Management  Algorithms:  Friedman et al:

41. Surgical Management  Algorithms:  Friedman et al:  Success = AHI<20 and AHI reduced 50%

42. Important keys  The complete description of OSAHS Obstructive Sleep Apnea Hyponea Syndrome Obstructive Sleep Apnea Hyponea Syndrome  The gold standard for diagnose of OSAHS: Polysomnography (PSG) Polysomnography (PSG)  The difference between snoring and OSAHS : Apnea-hypopnea index (AHI) Apnea-hypopnea index (AHI)  The most commonly performed surgery for OSAHS Uvulopalatopharyngoplasty (UPPP) Uvulopalatopharyngoplasty (UPPP)

43. Conclusions  Sleep medicine is an exciting, relatively new field that has emerged. The otolaryngologist has become a key figure in the diagnosis and management of sleep disorders due to his or her familiarity with the airway and the ability to intervene surgically. An understanding of the medical and surgical issues involved is necessary for the otolaryngologist to deal with this field which is rapidly evolving.