OSA part 3

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Dr. Supreet Singh Nayyar, AFMC 2012

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SLEEP DISORDERED BREATHING (PART 3)

Treatment for more topics, visitwww.nayyarENT.com

Non-Surgical therapy for OSAHS

Address co-existent, predisposing conditions

Obesity Documented reduction in symptom after weight reduction Degree of improvement has no linear correlation with weight Few may not benefit if co-existent craniofacial abnormalities

Life style modification Avoid tobacco /smoking Dietary modification

Sleep deprivation Avoiding agents affecting sleep Treat hypothyroidism

Mechanical devices (positive airway pressure)

Body posture modification Sleeping with head and trunk elevated to 30-60 degree angle to

horizontal reduces OSA

Lateral decubitus is also effective in reducing episodes (sleep ball)Pharmacological therapy

Protriptyline

Non-sedating tricyclic antidepressant Increasing tone of airway muscle Statistically significant improvement

Side effects : dry mouth, urinary hesitancy, constipation, confusion, ataxia Dose: 30 mg/day

Agents with uncertain limited role

Serotonin agonists Affects dilators
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Busiprone Data insufficient

Stimulants Amphetamines

CVS complication Insufficient data

Continuous Positive Airway Pressure (CPAP)Indications

Mild OSA with EDS Moderate to severe OSA Co-morbidities

Many consider it to be mainstay of OSA treatment

Mechanism:

Acts as pneumatic splintEquipment:

Machine provides fixed pressure or vary pressure depending on thepresence of apnoeas (Auto CPAP)

Mask is nasal or full face, kept in place by Velcro straps Port of exhalation Newer machine small and light so portable Humidifier also available as an optional mode

Compliance

By 3 years 25-40% stop using CPAP Treatment failure Cost factor

o Regular service and maintenanceo Change of mask

Side effects

Claustrophobia Nasal stuffiness Skin abrasions, nasal bridge abrasions Leaks are uncomfortable for eyes Air swallowing if pressure more than esophageal sphincter pressure Pulmonary baro trauma ( very rare) Treatment Failure

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Surgical managementSURGICAL TREATMENT OPTIONS

Nasal Surgery

1. Nasal septoplasty

2. Inferior turbinectomy

3. Adenoidectomy

4. Nasal tumor or polyp excision

5. Nasal valve reconstruction

Palatal Surgery

1. Uvulopalatopharyngoplasty

2. Uvulopalatal flap

3. Tonsillectomy

4. Transpalatal advancement pharyngoplasty

5. Laser-assisted uvulopalatoplasty

6. Palatal radiofrequency

Hypopharyngeal Surgery

1. Maxillomandibular osteotomy and advancement

2. Mandibular osteotomy with genioglossus advancement

3. Hyoid myotomy and suspension

4. Tongue base radiofrequency

5. Partial glossectomy

6. Lingual tonsillectomy

7. Repose tongue suspension

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Indications for surgery

Uvulopalatopharyngoplasty(UPPP)

First described by Ikematsu(1950), Fugita popularized in 1985

Principle:

Stiffen the soft palate by scarring Increase space behind soft palate

Consists of

Tonsillectomy Reorientation of the anterior and posterior tonsillar pillars Excision of the uvula and posterior rim of the soft palate.

Complications:

Nasal regurgitation Swallowing & voice problems Severe post op pain Hemorrhage Laryngospasm

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Pulmonary edema, hypoxia Not satisfied post surgery

75-95% short term success

Long term

45%Modification:

Preserve uvula

Laser-assisted Uvulopalatoplasty(LAUP)

Described by Kamami in France in 1993

Principle

Stiffen the soft palate Prevent palatal flutter

Surgery

Local anesthesia on soft palate B/l vertical incision in soft palate followed by partial vaporization of

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uvula with CO2 Laser

Various modification doneComplications

Low Globus like symptom common Post operative pain

Uvulopalatoplasty

Reversible uvulopalatal flap

A, Preoperative palate anatomy B, Uvula is grasped with a forceps and reflected back toward the soft-

hard palate junction; note the muscular crease.

C, The mucosa of the oral aspect of the uvula and soft palate in adiamond shape is removed with cold knife dissection; the uvular tip is

amputated and the uvular muscle thinned, if necessary

D, Trimmed and sutured flap, with the shaded area indicating thelocation of the tissue before it is repositioned.

E, Postoperative appearance, with closure up on the soft palateRadiofrequency tissue volume reduction/Thermal ablation(RFTVR)

Principle

Similar to diathermy Lower temperature, lower current and voltage

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Insulated probe delivering radiofrequency energy at a frequency of465 KHz

Thermal injury to specific submucosal sites in soft palate causingfibrosis and contraction

Introduced into the base-of-tongue tissue under local anesthesiaAdvantage

Day care, LA Less post operative pain Significant improvement reported Good for multi level obstruction Low relapse rate

Mandibular osteotomy and genioglossal advancementIntraoral approach

To enlarge the retrolingual area.

The genial tubercle, which is the anterior attachment of the genioglossus

muscle, is mobilized by osteotomy

The segment is

advanced and

rotated to allow

bony overlap to

lock the inner

(lingual) surface

of the mandible

and the

geniotubercle at the outer (labial) surface

The fragment is fixed at the inferior aspect of the osteotomy with a

titanium screw

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Other ProceduresPalatal: Z-pharyngoplasty, palatal implants

Tongue base

RFTVR Laser midline glossectomy

to enlarge the retrolingual airway excision of approximately 2.5 5 cm of midline tongue tissue intraoral approach may also require

lingual tonsillectomy reduction of the aryepiglottic folds partial epiglottectomy

usually combined with a tracheotomy for airway protection Tongue suspension suture Hypoglossal nerve stimulation

Lingualplasty.

Same procedure as the LMG (laser midline glossectomy) Except that additional tongue tissue is extirpated posteriorly and

laterally to the portion removed by LMG

Epiglottis

epiglottectomyTemporary tracheostomy

Repose tongue suspension.Intraoral incision is made in the frenulum

Titanium screw is placed at the lingual cortex of the geniotubercle of the mandiblePermanent suture is passed through the paramedian tongue musculature along the

length of the tongue, through the tongue base, and then back through the length of the

tongue musculature

Then anchored to the screw, pulling the tongue base anteriorlyHyoid myotomy and suspension

Addresses retrolingual area

Can alleviate obstruction caused by redundant lateral pharyngeal tissue or aretrodisplaced epiglottis

Horizontal cervical incision over the hyoid bone is preferred

Dissection is carried down to the suprahyoid musculature

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Midline hyoid bone is isolated and then advanced over the thyroid ala

Secured with two medial and two lateral permanent sutures

Maxillomandibular osteotomy and advancement

Improves retropalatal collapse by stabilizing the superior pharyngeal muscles and

widening the nasopharyngeal inletAlso improves retrolingual obstruction by placing the genioglossus muscle under

tension, thereby providing more room in the oral cavity for soft tissues and also

stabilizing the lateral pharyngeal wall

Outer-table cranial bone graft may be necessary, along with arch bar placement (ororthodontic banding) before the osteotomies

Usually performed if previous upper airway procedures have not completely relieved

the sleep-related obstruction.

Clinical OutcomesOverall success rate for UPPP 40%

With multilevel surgical strategy have achieved60% when applying strict response criteria

80% have been reported when applying commonly accepted measures of

improvementHowever, the results may be reduced in morbidly obese patients

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Johnson and Chinnachieved a mean reduction of 44.1 points on the RDI (from a

preoperative value of 58.7 to a mean postoperative value of 10.5) in patients

undergoing UPPP and genioglossal advancement without HMWhen defining success as a RDI of less than 10, seven out of nine patients (78%)

were successfully treatedTroell and colleagues[57]

reported that seven of 11 patients (63.6%) who underwent a

palatopharyngoplasty combined with genioglossus advancement and HM were cured,

with cure defined as a postoperative RDI of less than 10, with resolution of EDS

Oral AppliancesTwo basic types of appliancesMandibular advancement devices

Popular

Positioning the lower jaw and tongue downward and forward The airway passage is increased Comfortable More effective

Tongue repositioners

Pulling only the tongue forward and not the entire lower jaw. Teeth, jaw muscles and joints are less affected Less studied

A period of consistent nightly wear is required

Patient motivation and cooperation essential

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Documents

OSA part 3