It is the most common sleep apnea. It is characterized by repeated episodes of complete or partial obstructions of the upper airway during sleep.

1. OBSTRUCTIVE SLEEP APNEA

2. WHAT IS
OSA?
Obstructive Sleep Apnea (OSA) is the most common
type of sleep apnea and characterized by repeated
episodes of complete or partial obstructions of the
upper airway during sleep , despite the effort to breathe
, and is usually associated with a reduction in blood
oxygen saturation.
It is classified amongst the SLEEP RELATED
BREATHING DISORDERS. Frequent episodes of
Apnea and Hypoapnea as well as symptoms of
Functional impairment. Cessation of breathing for 10
seconds or more.
It is a major cause of morbidity and significant cause of
mortality worldwide , including developed and
developing nations.

3. PATHO
PHYSIOLOGY

4. SIGNS
&
SYMPTOMS
EXCESS WEIGHT : Weighing more than 120%
of the predicted normal or having Body Mass
Index greater than 25 kg/m2. – 70% patients.
NECK CIRCUMFERENCE greater than 40 cm
predicts OSA with a sensitivity of 61% and
specificity of 93% , regardless of gender.
OVERT ANATOMICAL ABNORMALITIES
which cause narrowing of the nasal or
pharyngeal airway.
SMALL MOUTH , BULKY UVULA – resting
on base of the tongue even during Phonation.

5. DIAGNOSTIC
CRITERION
Individuals must fulfil criterion A OR B , plus criterion C to be
diagnosed with OSA.
A. EXCESSIVE DAYTIME SLEEPINESS that is not explained by
other factors.
B. Two or more of the following that are not explained by other factors:
Choking or Gasping during sleep, Recurrent awakenings from sleep,
Unrefreshing sleep, Daytime Fatigue, Impaired concentration.
C. Overnight monitoring demonstrates 5-10 or more obstructive
breathing events per hour during sleep or greater than 30 events per 6
hours of sleep. These events may include any combination of
obstructive sleep apnea, hypopnoea or respiratory effort related
arousals (RERAs).

6. DIAGNOSIS
The main diagnostic test
for OSA is an overnight
sleep study carried out
in a sleep laboratory.
The usual parameters
recorded continuously
throughout the duration
of sleep are:
ELECTROENCEPHA
LOGRAM (EEG) to
monitor sleep states.
ELECTROMYOGRA
M (EMG) for muscle
tone ,
Respiratory airflow by
nasal probes
Respiratory effort by
bands placed around
chest and abdomen.
Arterial oxygen
saturation , and
EMG of Anterior
tibialis muscle to
monitor for the
presence of periodic leg
movements.
In lab
POLYSOMNOGRAP
HY represents the
GOLD STANDARD
for diagnosing sleep
apnea.
CT SCANNING of the
Pharynx and Larynx and
Radiographic imaging
of Pharyngeal and
Laryngeal Airway.

7. TREATMENT
The treatment of OSA
may be divided into 5
modalities:
AVOIDANCE OF
FACTORS which
aggravate or precipitate
apnea.
WEIGHT LOSS MEDICATIONS NOCTURNAL
CONTINUOUS
POSITIVE AIRWAY
PRESSURE (CPAP)
SURGERY

8. CPAP

9. SURGICAL TREATMENT
TracheostomyMaxilla-Mandibular Advancement

10. SURGICAL TREATMENT
MAXILLO-MANDIBULAR ADVANCEMENT : Maxillary or Mandibular deficiency or both can result in
diminished airway dimension and lead to nocturnal obstruction. MMA expands the skeletal framework in
the pharyngeal and hypopharyngeal regions, leading to improvement of the upper airway from the
velopharynx to the hypopharynx.
TRACHEOSTOMY : In this surgery, a permanent opening in the neck to the windpipe (TRACHEA) and
the tube is put into the opening to let air in. A VALVE keeps the opening of the tube closed during day
and open so that the air can go around the blockage into throat and then lungs while asleep. It is done only
in SEVERE OSA and other treatments have failed.
NASAL PROCEDURES : The treatment of Nasal Obstruction plays an important role in sleep apnea
surgery
3 anatomic areas of the nose that may contribute to obstruction are the septum , the turbinates and the
nasal valve.

11. SURGICAL TREATMENT
Nasal Procedure., Turbinectomy, Polypectomy, Septoplasty

12. SURGICAL TREATMENT
UVULOPALATOPHARYNGOPLASTY : This surgery consists of tissue rearrangement at the Uvula ,
Palate and Throat walls in order to increase the airway size and decrease tissue collapse.
PALATAL SURGERY : Tonsils and the Palate are intimately associated with obstructive sleep apnea
(OSA) as the area behind the palate is usually the throat's narrowest point. Patients with OSA usually
have an excessive amount of flaccid tissue in the Oropharynx area that blocks the airway during sleep
and cause snoring. Surgery aims to stiffen this flaccidness and decrease tissue redundancy.
LASER ASSISTED UVULOPALATOPHARYNGOPLASTY : LASER is used to remove parts or all
of the UVULA at the rear of the mouth.

13. SURGICAL TREATMENT
Laser assisted uvulopalatoplasty
UvulopalatopharyngoplastyLaser Assisted Uvulopalatopharyngoplasty

14. SURGICAL TREATMENT
GENIOGLOSSUS ADVANCEMENT: A Surgical Procedure where the tongue muscle that is attached to lower
jaw is pulled forward, making tongue firmer and less collapsible during sleep. It is usually performed with UPPP
OR MMA.
RADIOFREQUENCY ABLATION : The procedure can be performed in the ambulatory setting and needs
only local anesthesia. It is recommended as the second line treatment for mild to moderate OSA If CPAP
therapy is not adhered.
HYOID MYOTOMY AND SUSPENSION :The hyoid bone and muscle attachments to the tongue and airway
are pulled forward with the aim of increasing airway size and improving airway stability in the retrolingual and
hypopharyngeal airway.
PALATAL IMPLANT SYSTEM : Minimally invasive surgery and it is an alternative for LAUP and patients who
refuse CPAP therapy.

15. SURGICAL TREATMENT
Mandibular Osteotomy
with Genioglossus
Advancement
Hyoid Myotomy and
Suspension
Palatal Implant System Radiofrequency
Ablation (RFA)

16. ARTICLE REVIEW

17. CPAP Vs SURGERY
A Closer look at the evidence however reveals that surgery may indeed play a primary role in patients with
OSA. Several published RCT have documented that at least a minimum level of CPAP use of 5-6 hours per
night is required to reap benefits from it. Patients on CPAP FAIL to use it enough hours per night. CPAP has
many complications such as chronic lung disease, Infection to skin and eyes, nasal congestion, hypotension,
gastric distension ,etc. The issue of adherence is generally a non-issue with surgery, especially beyond the
initial recovery period. MAXILLO-MANDIBULAR ADVANCEMENT procedure had an especially high
success. SURGERY appears to clinically successful long term in at least half of OSA patients.

18. CONCLUSION
CPAP is often documented as the gold standard or mandatory first line therapy for patients with OSA, A careful
assessment of the outcomes provided by the literature does not support this assertion , especially when the concept
of CPAP ADHERENCE is taken into account.
In many patients beneficial surgical results may supplant the role of the CPAP machine when considering First
Line Therapy. SURGERY IS THE NEW GOLD STANDARD THERAPY FOR OBSRUCTIVE SLEEP
APNEA.
REFERENCE
ROTENBERG et al. Journal of Otolaryngology – Head and Neck Surgery (2016). Reference article : OBSTRUCTIVE
SLEEP APNEA : A CLINICAL REVIEW. Guileminault C, Abad VC OSA Syndrome . Med Clin North Am 2004.
Marshall NS , Neil AM , Campbell AJ Randomized trial of adherence of CPAP in OSA.