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surgical management of OSA
- 1. SURGICAL MANAGEMENT OF OSA Dr. Abhimanyu Dept. of ENT
- 3. Surgery - Indications • AHI >5 and <14 +excessive daytime sleepiness • AHI >15 • Oxyhemoglobin desaturation <90% • Cardiac arrythmias a/w obstructions • Unsuccessful /refused medical treatment or desire for surgery • Upper airway resistance syndrome
- 5. FRIEDMAN CLASSIFICATION Tongue position Tonsil size BMI success STAGE 1 1 2 3,4 3,4 <40 <40 80% STAGE 2 1,2 3,4 0,1,2 3,4 <40 <40 37.9% STAGE 3 3,4 any 0,1,2 any <40 <40 8.1%
- 8. Three major areas of obstructionNASAL Batten/spreader grafts Septoplasty Turbinoplasty FESS Adeno- tonsillectomy RETROPALATAL Palatal implants Radiofrequency volume reduction Cautery assisted palatal stiffening UPPP Uvulopalatal flap Transpalatal advancement Laser assisted uvuloplasty RETROLINGUAL Midline Partial glossectomy Linguloplasty Radiofrequency assisted tongue base reduction Endoscopic microdebridement Lingual tonsils excision Genioglossus advancement Hyoid advancement/suspe nsion
- 9. NASAL SURGERY • Nasal obstruction - poor sleep quality, snoring, and OSA. • Septoplasty, turbinate reduction, nasal valve surgery, and sinus surgery . • However, nasal procedures are unlikely to significantly improve OSA when used alone. • Initial step in OSA management so as to facilitate better CPAP adherence.
- 11. • Friedman M, Landsberg R, Tanyeri H. Submucosal uvulopalatopharyngoplasty. Op Tech Otolaryngol Head Neck Surg 2000;11:26–9
- 13. Z - palatoplasty • Friedman M, Ibrahim H, Vidyasagar R. Z-palatoplasty (ZPP): a technique for patients without tonsils. Otolaryngol Head Neck Surg 2004;131:89–100; with permission. Copyright 2004 The American Academy of Otolaryngology– Head and Neck Surgery Foundation Inc
- 18. TONGUE BASE PROCEDURES PARTIAL MIDLINE GLOSSECTOMY (PMG) • Removal of a midline rectangular strip of the posterior half of tongue. LINGUALPLASTY • Additional tongue tissue removed posteriorly and laterally RADIOFREQUENCY TONGUE BASE ABLATION (RFA / RFT) Lingual Tonsillectomy - Laser Lingual Tonsillectomy (LLT)
- 21. GENIOGLOSSAL ADVANCEMENT • The rectangular geniotubercle osteotomy modification offers excellent tension on the genioglossus muscle with a minimal fracture risk. The geniotubercle fragment is rotated enough to allow bony overlap. A single inferiorly placed miniscrew is used to fix the fragment.
- 22. Antero-inferior advancement of hyoid
- 23. Device assisted
- 26. Surgical Treatment Success • apnea-hypopnea index less than 20 with a reduction greater than 50% and few desaturations less than 90% with improvement of subjective symptoms.
- 27. THANK YOU
Editor's Notes
- 1923-pierre robin french surgeon 2014 AADSM american association for dental sleep medicine Position report defining effective oral appliance Dual arch design,adjustable >5mm,lifespan -3yrs,optimum fit and comfort Efficacy – CPAP >MAD but compliance MAD>CPAP Combination therapy
- Uars--- not meeting criteria of OSA but pt have respiratory effort related arousals and excessive day time somnolence
- An anatomically-based staging system is made to identify areas of obstruction, and helps in tailoring the appropriate surgical treatment for each individual. • The severity of disease is a secondary factor, which plays a role in determining the need for treatment. • TS 0 - post-tonsillectomy patients. • TS 1 implies tonsils hidden within the pillars. • TS 2 represents tonsils that extend to the pillars. • TS 3 refers to tonsils that extend beyond the pillars, but not all the way to the midline, • TS 4 tonsils (‘‘kissing tonsils’’) reach the midline. FTP I - the entire uvula, tonsils, and tonsillar pillars. • FTP II allows visualization of the uvula, but not the tonsils. • FTP III allows visualization of the soft palate, but not the uvula • FTP IV allows visualization of the hard palate only
- body-mass index (BMI) >40 kg/m(2) or with BMI >35 kg/m(2) and 1 or more significant comorbid conditions type II diabetes (T2DM),hypertension, sleep apnea and other respiratory disorders, non-alcoholic fatty liver disease,osteoarthritis, lipid abnormalities, gastrointestinal disorders, or heart disease.
- Fujita classification –type 1 – retro palatal 2- retro palatal and retro lingual 3- exclusive retro lingual
- Ikematsu – snoring 1964 Fujita popularised in 1980s
- Complications – initially –nasal regurg due to velopharyngeal insufficiency,dryness, discomfort,speech prob, late – permanent vp insuff, nasopharyngeal stenosis The techinique of uppp has changed over the time . Radical uppp is not more effective than conservative (preserve velar muscles ) instead has more complication rate.
- Friedman 2,3 Goal is to change the scar contracture tension line in a anterolateral vector By splitting the soft palate and retracting it anterolaterally, an effective anterolateral pull is created, which actually continues to widen the airway as healing and contracture occur. None of the palatal musculature is resected, in spite of the aggressive palatal shortening, thereby addressing and minimizing the risk for permanent velopharyngeal insufficiency (VPI)
- 1.Exposure of the palatopharyngeus (vertical fibers). 2. Elevation of the palatopharyngeus. 3. Rotation and tunnelling of the palatopharyngeus toward the hamulus. Or sutures are put from velar muscles and palatopharyngeus 4.Suture suspension and approximation.
- Grade 2, 3 …or if uppp and z plasty fails 1-cm portion of the hard palate is removed, and the soft palate is then advanced and secured medially and laterally in the tensor aponeurosis, which enlarges the retropalatal region.
- minimally invasive, single-step procedure • useful for mild OSA. • Polyethylenterephthalat (PET) • Three rod-shaped implants are inserted in the soft palate. • The implants themselves and the surrounding scarring induce a stiffening of the soft palate, reduce snoring sounds. Developed to reduce pain, cost & morbidity of UPPP , in mild OSA • Complication – partial implant extrusion • Advantage – single office visit, minimal morbidity, reduce snoring.
- SUBMUCOSAL PARTIAL GLOSSECTOMY TECHNIQUES • PERCUTANEOUS SUBMUCOSAL TONGUE BASE EXCISION • SMILE submucosal minimally invasive lingual excision • SMELL Submucosal midline endoscopic lingual base lysis
- RADIOFREQUENCY TONGUE BASE ABLATION (RFA) volumetric reduction in tonguebase Tissue 465 KHz coagulation necrosis and healing by scar. OP setting under LA • Require multiple treatments to achieve the desired results.
- Repose , encore -brands Permanent 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. • It is then anchored to the screw to pull the tongue base anteriorly.
- Result in an enlarged retrolingual airway by fixing the major dilators of the pharyngeal airway forward. • Usually done along with GA
- Medtronic AIRvance Siesta medical – encore device Titanium screws near canine on post aspect of mandible with a special drill
- Mobilizing the maxilla and mandible to achieve anterior displacement, after intraoral osteotomy. • The maxilla and mandible are stabilized with titanium plates in the advanced position. Lefort 1 maxillary osteotomy with bilateral saggital split mandibular osteotomy with minimum 1cm advancement
- strategies that increase activity in the pharyngeal dilator muscles should be effective for patients who have dysfunction in these muscles.8 Thus, a concept is emerging that personalized medicine may be applied to obstructive sleep apnea on the basis of underlying mechanisms Results equal to cpap with better adherance. randomized, therapy-withdrawal trial provide reassurance that the benefits from hypoglossal-nerve stimulation observed by Strollo et al. were real.
- Includes a wide variety of procedures that vary in their invasiveness and success rates. t/t philosophy – 1.site specific surgery 2.treat to cure 3. staged surgical procedures 4. full pt disclosure of options and risks 5.follow up