1. Obstructive Sleep Apnea Melanie Giesler, DO

4. Patient Evaluation  History Spousal/Parental complaint of snoring Morning headache Daytime Somnolence Insomnia Dry Mouth

5. Overview  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

6. Physiology of Sleep  REM  Sleep Latency, REM Latency  Arousal Woodson, Tucker “Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment” SIPAC 1996

7. Evaluation of Sleep  Polysomnography EMG – submental & ant. tibialis Nasal and oral airflow EEG, EOG Oxygen Saturation Thoracic/abdominal movements Sleep position Blood pressure Cardiac Rhythm Leg Movements AI (cessation of airflow for 10 seconds leading to an arousal), HI (reduction of airflow by at least 50% for at least 10 seconds), AHI, RDI – sum of events per hour

8. Evaluation of Sleep  Polysomnography Woodson, Tucker “Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment” SIPAC 1996

9. Evaluation of Sleep  Standard Polysomnogram  Split-Night Polysomnography (1-2 hours of data then start CPAP)  Epworth Sleepiness Scale  Multiple Sleep Latency Test

10. Epworth Sleepiness Scale  Score of 10 or more – further study

11. Multiple Sleep Latency Test  Documents Sleepiness  The MSLT is a series of 5 naps taken at 2 hour intervals, starting at approximately 9:00 A.M.  This is done the following day after a polysomnogram (PSG)  The MSLT determines how long it takes a person to fall asleep at preset times throughout the day.

12. Definition of OSA  AHI>5  AHI > 20 increases risk of mortality  AHI 5-14=mild;15-29=moderate; >30=severe (apneas + hyponeas/#hours of sleep)  Upper Airway Resistance Syndrome Shares pathophysiology with OSA No desaturation, continuous ventilatory effort

13. Prevalence of OSA – up to 4% of middle aged adults Study Location nAge Range Prevalence of AHI>5 (95%CI) Prevalence of AHI>15 (95%CI) MenWomenMenWomen Wisconsin626 30-6024 (19-28) 9 (6-12) 9 (6-11) 4 (2-7) Penn1741 20-9917 (15-20) Not given7 (6-9) 2 (2-3) Spain400 30-7026 (20-32) 28 (20-35) 14 (10-18) 7 (3-11)

14. Pathophysiology of OSA  Airway size:

15. Bernouli’s Principle  increased air velocity produces decreased pressure

16. Pathophysiology of OSA  Sites of Obstruction:  Obstruction tends to propagate

17. Pathophysiology of OSA  Sites of Obstruction:

18. Pathophysiology of OSA  Symptoms of OSA Snoring (most commonly noted complaint) Daytime Sleepiness Hypertension and Cardiovascular Disease are associated Pulmonary Disease

19. Pathophysiology of OSA  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

20. Physical Exam Obstructive Sleep Apnea

21. Pathophysiology of OSA  Tests to determine site of obstruction: Muller’s Maneuver – palate vs BOT/hypopharynx; inspire against closed nasal and oral airway Sleep endoscopy Fluoroscopy Manometry Cephalometrics Dynamic CT scanning and MRI scanning

22. Muller’s Manuver

23. Medical Management  Weight Loss  CPAP  Nasal Obstruction  Sleep Hygiene - Sedative Avoidance  Smoking cessation

24. Medical Management  CPAP Pressure must be individually titrated Compliance is as low as 50%  Air leakage, eustachian tube dysfunction, noise, mask discomfort, claustrophobia

25. Medical Management  BiPAP Useful when > 6 cm H2O difference in inspiratory and expiratory pressures No objective evidence demonstrates improved compliance over CPAP

26. CPAP/BiPAP

27. CPAP/BiPaP

28. Nonsurgical Management  Oral appliance Mandibular advancement device Tongue retaining device

29. Nonsurgical Management  Oral Appliances May be as effective as surgical options, especially with symptoms worse with patient supine However low compliance rate of about 60% in study by Walker et al in 2002 rendered it a worse treatment modality than surgical procedures Walker-Engstrom ML. Tegelberg A. Wilhelmsson B. Ringqvist I. 4-year follow-up of treatment with dental appliance or uvulopalatopharyngoplasty in patients with obstructive sleep apnea: a randomized study. Chest. 121(3):739-46, 2002 Mar.

30. Surgical Management  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

31. Surgical Management  Perioperative Issues High risk in patients with severe symptoms Associated conditions of HTN, CVD Nasal CPAP often required after surgery Nasal CPAP before surgery improves postoperative course Risk of pulmonary edema after relief of obstruction

32. 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 (see table II) Once placed, uncommon to decannulate Thatcher GW. Maisel RH. The long-term evaluation of tracheostomy in the management of severe obstructive sleep apnea. [Journal Article] Laryngoscope. 113(2):201-4, 2003 Feb.

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

34. Surgical Management  Uvulopalatopharyngoplasty  Fujita (1981)  10-50% effective at 5 years

35. Surgical Management  Uvulopalatopharyngoplasty The most commonly performed surgery for OSA 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 Friedman M, Ibrahim H, Bass L. Clinical staging for sleep-disordered breathing. Otolaryngol Head Neck Surg 2002; 127: 13–21.

36. Surgical Management  UP3 Complications Minor  Transient VPI  Hemorrhage <1% Major  NP stenosis  VPI

37. Surgical Management  Cahali, 2003 proposed the Lateral Pharyngoplasty for patients with significant lateral narrowing: Cahali MB. Lateral pharyngoplasty: a new treatment for obstructive sleep apnea hypopnea syndrome. Laryngoscope. 113(11):1961-8, 2003 Nov.

38. Surgical Management  Lateral Pharyngoplasty

39. Surgical Management  Lateral Pharyngoplasty Median apnea-hypopnea index decreased from 41.2 to 9.5 (P =.009) No control group No evaluation at 12 months

40. 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

41. Surgical Management  Soft palate implants Stiffens soft palate – makes palate more stiff and (hopefully) less likely to collapse

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

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

44. Surgical Management  Lingual Suspension:

45. Surgical Management  Lingual Suspension:

46. 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

47. 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

48. Surgical Management  Maxillary- Mandibular Advancement Performed in conjunction with oral surgeons

49. Conclusions  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

51. Bibliography Friedman, Michael MD; Ibrahim, Hani MD; Joseph, Ninos J. BS Staging of Obstructive Sleep Apnea/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 apnea–hypopnea syndrome. 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 hypopnea syndrome. Laryngoscope. 113(11):1961-8, 2003 Nov. Thatcher GW. Maisel RH. The long-term evaluation of tracheostomy in the management of severe obstructive sleep apnea. [Journal Article] Laryngoscope. 113(2):201-4, 2003 Feb. Friedman M, Ibrahim H, Bass L. Clinical staging for sleep-disordered breathing. Otolaryngol Head Neck Surg 2002; 127: 13–21. Walker-Engstrom ML. Tegelberg A. Wilhelmsson B. Ringqvist I. 4-year follow-up of treatment with dental appliance or uvulopalatopharyngoplasty in patients with obstructive sleep apnea: a randomized 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: position statement of the American Academy of Sleep Medicine. Sleep 23(8):1017-8, 2000 Dec. Berger G, Finkelstein Y, Stein G, et al. Laser-assisted uvulopalatoplasty for snoring: medium- to long-term subjective and objective analysis. Archives of Otolaryngology - Head & Neck Surgery 127(4):412-7, 2001 Apr. Carskadon MA, Dement WC. Normal human sleep: an overview. In: Kryer MH, Roth T, Dement WC, eds. Principles and practice of sleep medicine. Philadelphia: WB Saunders. 1994;16–25. Chaudhary BA. Obstructive sleep apnea. Resident and Staff Physician 44(9) 21-34, 1998 Sep. Coleman J. Overview of sleep disorders. Otolaryngologic Clinics of North America 32(2):187-93, 1999 Apr. Coleman J. Sleep studies: current techniques and future trends. Otolaryngologic Clinics of North America 32(2):195-210, 1999 Apr. Coleman J, Rathfoot C. Oropharyngeal surgery in the management of upper airway obstruction during sleep. Otolaryngologic Clinics of North America 32(2):263-76, 1999 Apr. Goldberg AN, Schwab RJ. Identifying the patient with sleep apnea: upper airway assessment and physical examination. Otolaryngologic Clinics of North America 31(6):919- 30, 1998 Dec. He J, Kryger M, Zorick F, et al. Mortality and apnea index in obstructive sleep apnea. Chest 94:9-14, 1988. Johnson JT. Uvulopalatopharyngoplasty. In Myers, EN (ed). Operative Otolaryngology: Head and Neck Surgery. Philadelphia: WB Saunders. 1997; 208-14. Johnson JT, Braun TW. Preoperative, intraoperative, and postoperative management of patients with obstructive sleep apnea syndrome. Otolaryngologic Clinics of North America 31(6):1025-30, 1998 Dec. Millman RP, Rosenberg CL, Kramer NR. Oral appliances in the treatment of snoring and sleep apnea. Otolaryngologic Clinics of North America 31(6):1039-48, 1998 Dec. Picirrillo JF, Thawley SE. Sleep-Disordered Breathing. In Otolaryngology – Head and Neck Surgery, 3rd ed. Cummings CW, et al (eds) Mosby:St Louis, 1999. Redline S, Strohl KP. Recognition and consequences of obstructive sleep apnea hypopnea syndrome. Otolaryngologic Clinics of North America 32(2):303-31, 1999 Apr. Sanders M, Black J, Constantino J, et al. Diagnosis of sleep disordered breathing by half-night polysomnography. Am Rev Respir Dis 144:1256-61, 1991. Scharf S, Garshick E, Brown R, et al. A screening for subclinical sleep disordered breathing. Sleep 13:344-53, 1990. Schwab RJ, Goldberg AN. Upper airway assessment: radiographic and other imaging techniques. Otolaryngologic Clinics of North America 31(6):931-68, 1998 Dec. Schwartz AR, Eisele DW, Smith PL. Pharyngeal airway obstruction in obstructive sleep apnea. Otolaryngologic Clinics of North America 31(6):911-8, 1998 Dec. Stroud R, Quinn FB. Obstructive sleep apnea syndrome. In Dr Quinn’s Online Textbook available at www.utmb.edu/oto, 1998 Feb.www.utmb.edu/oto Troell RJ, Riley RW, Powell NB, Li K. Surgical management of the hypopharyngeal airway in sleep disordered breathing. Otolaryngologic Clinics of North America 31(6):979- 1012, 1998 Dec. Walker RP. Snoring and obstructive sleep apnea. In Bailey BJ, ed. Head and Neck Surgery – Otolaryngology. Philadelphia: Lippincott-Raven, 1998.