Transcript Obstructive Sleep Apnea

Obstructive Sleep
Apnea Hyponea
Syndrome
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
Physiology of Sleep
Woodson, Tucker “Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment” SIPAC 1996
 REM ( rapid eye movements Sleep)
more likely to occur
 Arousal
Evaluation of Sleep
 Polysomnography






EMG
Airflow
EEG, EOG
Oxygen Saturation
Cardiac Rhythm
Leg Movements
Evaluation of Sleep
 Polysomnography(PSG)
Woodson, Tucker “Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment” SIPAC 1996
Evaluation of Sleep
 Polysomnography(PSG)
---- Gold standard
 Epworth Sleepiness Scale
 Multiple Sleep Latency Test
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.
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
 AHI: >40 = severe
Definition of OSAHS
 Snoring
Patients with snoring who have an apneahypopnea index (AHI) of fewer than 5 and no
complaints of excessive daytime sleepiness fall
into this category
 OSAHS : AHI>5
Difference : AHI
Hypoxia
 The lowest SaO2 ＞85% : mild
 The lowest SaO2 65 - 84% : moderate
 The lowest SaO2 ＜65%: severe
one of the indicator for risk of surgery
Pathophysiology of OSAHS
 Sites of
Obstruction:
 Related to
airway
collapses
Pathophysiology of OSAHS
 Symptoms of OSAHS
 Snoring (most commonly noted complaint)
 Daytime Sleepiness
 Hypertension and Cardiovascular Disease
are Associated
 Pulmonary Disease
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
Pathophysiology of OSA
 Tests to determine site of obstruction:






Muller’s Maneuver
Endoscopy
Fluoroscopy
Manometry
Cephalometrics
Dynamic CT scanning and MRI scanning
Medical Management




Weight Loss
Nasal Obstruction
Alcohol and Sedative Avoidance
Smoking cessation
Medical Management
 CPAP
Continuous positive airway pressure
 Pressure must be
individually titrated
 Compliance is as low
as 50%
 Air leakage,
eustachian tube
dysfunction, noise,
mask discomfort,
claustrophobia
Nonsurgical Management
 Oral appliance
 Mandibular
advancement device
 Tongue retaining
device
Nonsurgical Management
 Oral Appliances
 mechanically moving the jaw or tongue
forward and opening the airway.
 May be as effective as surgical options
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
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
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
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
Surgical Management
 Uvulopalatopharyngoplasty
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
Surgical Management
 UPPP
Complications
Surgical Management
 Cahali, 2003
proposed the Lateral
Pharyngoplasty for
patients with
significant lateral
narrowing:
Surgical Management
 Lateral Pharyngoplasty
Surgical Management
 Laser Assisted
Uvulopalatoplasty
 High initial success
rate for snoring
 Rates decrease, as
for UP3 at twelve
months
 Performed awake
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
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
Surgical Management
 Tongue Base Procedures
 Lingual Tonsillectomy
 may be useful in patients with hypertrophy, but
usually in conjunction with other procedures
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
Surgical Management
 Mandibular
Procedures
 Genioglossus
Advancement
 Rarely performed
alone
 Increases rate of
efficacy of other
procedures
 Transient incisor
paresthesia
Surgical Management
 Lingual
Suspension:
Surgical Management
 Lingual
Suspension:
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
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
Surgical Management
 Maxillary-Mandibular
Advancement
 Performed in
conjunction with oral
surgeons
Surgical Management
 Algorithms
 Friedman et al
developed a staging
system for type of
operation:
Surgical Management
 Algorithms:
 Friedman et
al:
Surgical Management
 Algorithms:
 Friedman et al:
 Success = AHI<20
and AHI reduced
50%
Important keys
 The complete description of OSAHS
Obstructive Sleep Apnea Hyponea Syndrome
 The gold standard for diagnose of OSAHS:
Polysomnography (PSG)
 The difference between snoring and OSAHS:
Apnea-hypopnea index (AHI)
 The most commonly performed surgery for
OSAHS
Uvulopalatopharyngoplasty (UPPP)
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.