obstructive sleep apnea hyponea syndrome. overview physiology of sleep evaluation of sleep ...
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Obstructive Sleep Obstructive Sleep Apnea Hyponea Apnea Hyponea SyndromeSyndrome
OverviewOverview
Physiology of SleepPhysiology of Sleep Evaluation of SleepEvaluation of Sleep Definition of Obstructive Sleep Apnea Definition of Obstructive Sleep Apnea
Hyponea Syndrome(OSAHS)Hyponea Syndrome(OSAHS) Pathophysiology of OSAHSPathophysiology of OSAHS Medical Treatment of OSAHSMedical Treatment of OSAHS Surgical Treatment of OSAHSSurgical Treatment of OSAHS
Physiology of SleepPhysiology of Sleep
REM ( rapid eye movements Sleep)REM ( rapid eye movements Sleep)
more likely to occurmore likely to occur
ArousalArousal
Woodson, Tucker “Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment” SIPAC 1996
Evaluation of SleepEvaluation of Sleep
PolysomnographyPolysomnography EMGEMG AirflowAirflow EEG, EOGEEG, EOG Oxygen SaturationOxygen Saturation Cardiac RhythmCardiac Rhythm Leg MovementsLeg Movements
Evaluation of SleepEvaluation of Sleep
Polysomnography(PSG)Polysomnography(PSG)
Woodson, Tucker “Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment” SIPAC 1996
Evaluation of SleepEvaluation of Sleep
Polysomnography(PSG)Polysomnography(PSG)
---- ---- Gold standardGold standard Epworth Sleepiness ScaleEpworth Sleepiness Scale
Multiple Sleep Latency TestMultiple Sleep Latency Test
Definition of OSAHSDefinition of OSAHS
ApneaApnea is defined as cessation of airflow for ten is defined as cessation of airflow for ten seconds which results in an arousal. If the chest seconds which results in an arousal. If the chest wall continues to mechanically move during this wall continues to mechanically move during this time, then it is an time, then it is an obstructive apneaobstructive apnea. If the chest . If the chest wall does not attempt to ventilate, then it is wall does not attempt to ventilate, then it is presumably due to a neurologic etiology and is presumably due to a neurologic etiology and is termed a termed a central apneacentral apnea. Sometimes there are . Sometimes there are characteristics of both an obstructive and a characteristics of both an obstructive and a central apnea, and this is termed a central apnea, and this is termed a mixed apneamixed apnea. .
HypopneaHypopnea is considered a diminution in airflow is considered a diminution in airflow which results in hypoxemia and results in an which results in hypoxemia and results in an arousal. arousal.
Definition of OSAHSDefinition of OSAHS
the the apnea-hypopnea indexapnea-hypopnea index (AHI): the (AHI): the sum of apneas and hypopneas per hour sum of apneas and hypopneas per hour
AHI: 5 — 20 = mildAHI: 5 — 20 = mild AHI: 20 — 40 = moderate AHI: 20 — 40 = moderate
> 20 increases risk of mortality> 20 increases risk of mortality AHI: >40 = severeAHI: >40 = severe
Definition of OSAHSDefinition of OSAHS
SnoringSnoring 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 OSAHS : AHI>5
Difference : AHI
HypoxiaHypoxia
The lowest SaOThe lowest SaO22 >> 885% : mild5% : mild
The lowest SaOThe lowest SaO22 65 - 65 - 884% : moderate4% : moderate
The lowest SaOThe lowest SaO22 << 65%: severe65%: severe
one of the indicator for risk of surgery one of the indicator for risk of surgery
Pathophysiology of Pathophysiology of OSAHSOSAHS
Sites of Sites of Obstruction:Obstruction:
Related to Related to airway airway collapsescollapses
Pathophysiology of Pathophysiology of OSAHSOSAHS
Symptoms of OSAHSSymptoms of OSAHS Snoring (most commonly noted complaint)Snoring (most commonly noted complaint) Daytime SleepinessDaytime Sleepiness Hypertension and Cardiovascular Disease Hypertension and Cardiovascular Disease
are Associatedare Associated Pulmonary DiseasePulmonary Disease
Pathophysiology of Pathophysiology of OSAHSOSAHS
Findings in Obstruction:Findings in Obstruction: Nasal ObstructionNasal Obstruction Long, thick soft palateLong, thick soft palate Retrodisplaced MandibleRetrodisplaced Mandible Narrowed oropharynxNarrowed oropharynx Redundant pharyngeal tissuesRedundant pharyngeal tissues Large lingual tonsilLarge lingual tonsil Large tongueLarge tongue Large or floppy EpiglottisLarge or floppy Epiglottis Retro-displaced hyoid complexRetro-displaced hyoid complex
Pathophysiology of OSAPathophysiology of OSA
Tests to determine site of obstruction:Tests to determine site of obstruction: Muller’s ManeuverMuller’s Maneuver EndoscopyEndoscopy FluoroscopyFluoroscopy ManometryManometry CephalometricsCephalometrics Dynamic CT scanning and MRI scanningDynamic CT scanning and MRI scanning
Medical ManagementMedical Management
Weight LossWeight Loss Nasal ObstructionNasal Obstruction Alcohol and Sedative AvoidanceAlcohol and Sedative Avoidance Smoking cessationSmoking cessation
Medical ManagementMedical Management
CPAPCPAP Continuous positive airway pressureContinuous positive airway pressure
Pressure must be Pressure must be individually titratedindividually titrated
Compliance is as low Compliance is as low as 50%as 50% Air leakage, Air leakage,
eustachian tube eustachian tube dysfunction, noise, dysfunction, noise, mask discomfort, mask discomfort, claustrophobiaclaustrophobia
Nonsurgical ManagementNonsurgical Management
Oral applianceOral appliance Mandibular Mandibular
advancement deviceadvancement device Tongue retaining Tongue retaining
devicedevice
Nonsurgical ManagementNonsurgical Management
Oral AppliancesOral Appliances mechanically moving the jaw or tongue mechanically moving the jaw or tongue
forward and opening the airway. forward and opening the airway. May be as effective as surgical optionsMay be as effective as surgical options
Surgical ManagementSurgical Management
Measures of success –Measures of success – No further need for medical or surgical No further need for medical or surgical
therapytherapy Response = 50% reduction in AHIIResponse = 50% reduction in AHII Reduction of AHI to < 20Reduction of AHI to < 20 Reduction in arousals and daytime Reduction in arousals and daytime
sleepinesssleepiness
Surgical ManagementSurgical Management
Perioperative IssuesPerioperative Issues High risk in patients with severe symptomsHigh risk in patients with severe symptoms Nasal CPAP often required after surgeryNasal CPAP often required after surgery Nasal CPAP before surgery improves Nasal CPAP before surgery improves
postoperative coursepostoperative course Risk of pulmonary edema after relief of Risk of pulmonary edema after relief of
obstructionobstruction
Surgical ManagementSurgical Management
TracheostomyTracheostomy Primary treatment modalityPrimary treatment modality Temporary treatment while other surgery is doneTemporary treatment while other surgery is done Thatcher GW. Thatcher GW. et alet al: tracheostomy leads to quick : tracheostomy leads to quick
reduction in sequelae of OSA, few complications . reduction in sequelae of OSA, few complications . Once placed, uncommon to decannulateOnce placed, uncommon to decannulate
Surgical ManagementSurgical Management
Nasal SurgeryNasal Surgery Limited efficacy when used aloneLimited efficacy when used alone Verse Verse et alet al 2002 showed 15.8% success 2002 showed 15.8% success
rate when used alone in patients with rate when used alone in patients with OSAHS and day-time nasal congestion with OSAHS and day-time nasal congestion with snoring (AHI<20 and 50% reduction)snoring (AHI<20 and 50% reduction)
AdenoidectomyAdenoidectomy
Surgical ManagementSurgical Management
UvulopalatopharyngoplastyUvulopalatopharyngoplasty
Surgical ManagementSurgical Management
Uvulopalatopharyngoplasty(UPPP)Uvulopalatopharyngoplasty(UPPP) The most commonly performed surgery for The most commonly performed surgery for
OSAHSOSAHS Severity of disease is poor outcome predictorSeverity of disease is poor outcome predictor Levin and Becker (1994) up to 80% initial Levin and Becker (1994) up to 80% initial
success decreased to 46% success rate at success decreased to 46% success rate at 12 months12 months
Friedman Friedman et alet al showed a success rate of showed a success rate of 80% at 6 months in carefully selected 80% at 6 months in carefully selected patientspatients
Surgical ManagementSurgical Management
UPPP UPPP ComplicationsComplications
Surgical ManagementSurgical Management
Cahali, 2003 Cahali, 2003 proposed the Lateral proposed the Lateral Pharyngoplasty for Pharyngoplasty for patients with patients with significant lateral significant lateral narrowing:narrowing:
Surgical ManagementSurgical Management
Lateral PharyngoplastyLateral Pharyngoplasty
Surgical ManagementSurgical Management
Laser Assisted Laser Assisted UvulopalatoplastyUvulopalatoplasty High initial success High initial success
rate for snoringrate for snoring Rates decrease, as Rates decrease, as
for UP3 at twelve for UP3 at twelve monthsmonths
Performed awakePerformed awake
Surgical ManagementSurgical Management
Radiofrequency Radiofrequency Ablation – Fischer Ablation – Fischer et et al 2003al 2003
Radiofrequency device is inserted into various parts of palate, tonsils and tongue base at various thermal energies
Surgical ManagementSurgical Management
Fischer Fischer et al et al 20032003 At 6 months Showed significant reduction of:At 6 months Showed significant reduction of:
AHI (but not to below 20)AHI (but not to below 20) ArousalsArousals Daytime sleepiness by the Epworth Sleepiness ScaleDaytime sleepiness by the Epworth Sleepiness Scale
Surgical ManagementSurgical Management
Tongue Base ProceduresTongue Base Procedures Lingual TonsillectomyLingual Tonsillectomy
may be useful in patients with hypertrophy, but may be useful in patients with hypertrophy, but usually in conjunction with other proceduresusually in conjunction with other procedures
Surgical ManagementSurgical Management
Tongue Base Tongue Base ProceduresProcedures LingualplastyLingualplasty
Chabolle, Chabolle, et alet al success rate of 77% success rate of 77% (RDI<20, 50% (RDI<20, 50% reduction) in 22 reduction) in 22 patients in conjunction patients in conjunction with UPPPwith UPPP
Complication rate of Complication rate of 25% - bleeding, 25% - bleeding, altered taste, altered taste, odynophagia, edemaodynophagia, edema
Can be combined with Can be combined with epiglottectomyepiglottectomy
Surgical ManagementSurgical Management
Mandibular Mandibular ProceduresProcedures Genioglossus Genioglossus
AdvancementAdvancement Rarely performed Rarely performed
alonealone Increases rate of Increases rate of
efficacy of other efficacy of other proceduresprocedures
Transient incisor Transient incisor paresthesiaparesthesia
Surgical ManagementSurgical Management
Lingual Lingual Suspension:Suspension:
Surgical ManagementSurgical Management
Lingual Lingual Suspension:Suspension:
Surgical ManagementSurgical Management
Hyoid Myotomy and Hyoid Myotomy and SuspensionSuspension Advances hyoid bone Advances hyoid bone
anteriorly and inferiorlyanteriorly and inferiorly Advances epiglottis and Advances epiglottis and
base of tonguebase of tongue Performed in Performed in
conjunction with other conjunction with other proceduresprocedures
Dysphagia may resultDysphagia may result
Surgical ManagementSurgical Management
Maxillary-Mandibular AdvancementMaxillary-Mandibular Advancement Severe diseaseSevere disease Failure with more conservative measuresFailure with more conservative measures Midface, palate, and mandible advanced Midface, palate, and mandible advanced
anteriorlyanteriorly Limited by ability to stabilize the segments Limited by ability to stabilize the segments
and aesthetic facial changesand aesthetic facial changes
Surgical ManagementSurgical Management
Maxillary-Mandibular Maxillary-Mandibular AdvancementAdvancement Performed in Performed in
conjunction with oral conjunction with oral surgeonssurgeons
Surgical ManagementSurgical Management
AlgorithmsAlgorithms Friedman Friedman et alet al
developed a staging developed a staging system for type of system for type of operation:operation:
Surgical ManagementSurgical Management
Algorithms:Algorithms: Friedman Friedman et et
alal::
Surgical ManagementSurgical Management
Algorithms:Algorithms: Friedman Friedman et alet al::
Success = AHI<20 Success = AHI<20 and AHI reduced and AHI reduced 50%50%
Important keysImportant keys
The complete description of OSAHSThe complete description of OSAHS
Obstructive Sleep Apnea Hyponea SyndromeObstructive Sleep Apnea Hyponea Syndrome
The gold standard for diagnose of OSAHS:The gold standard for diagnose of OSAHS: Polysomnography (PSG) Polysomnography (PSG)
The difference between snoring and OSAHSThe difference between snoring and OSAHS ::
Apnea-hypopnea index (AHI)Apnea-hypopnea index (AHI)
The most commonly performed surgery for The most commonly performed surgery for OSAHSOSAHS
Uvulopalatopharyngoplasty (UPPP)Uvulopalatopharyngoplasty (UPPP)
ConclusionsConclusions
Sleep medicine is an exciting, relatively new Sleep medicine is an exciting, relatively new field that has emerged. The otolaryngologist field that has emerged. The otolaryngologist has become a key figure in the diagnosis and has become a key figure in the diagnosis and management of sleep disorders due to his or management of sleep disorders due to his or her familiarity with the airway and the ability to her familiarity with the airway and the ability to intervene surgically. An understanding of the intervene surgically. An understanding of the medical and surgical issues involved is medical and surgical issues involved is necessary for the otolaryngologist to deal with necessary for the otolaryngologist to deal with this field which is rapidly evolving. this field which is rapidly evolving.