2. Sleep and dreaming have been sources of mystery and fascination.
Sleep comprises an inevitable recurring episodes of reversible
disengagement from sensory and motor interaction with the environment.
Apnea is a Greek word for “without breath”.
Asok kumar RS OMFS
3. Normal sleep cycle includes
1. Quiet sleep (non– rapid eye movement
[non-rem] sleep) and
2. Active sleep (rapid eye movement [REM]
sleep).
Non-REM sleep consists of four stages,
accounts for 45% to 50% of total sleep time
REM sleep occupies 20% to 25% of total sleep
time in healthy young adult
Asok kumar RS OMFS
4. In non-REM sleep breathing is slow and regular
In REM sleep the breathing pattern is erratic, with rapid, shallow respirations.
During sleep, respiratory controls are influenced by metabolic control system and behavioral
control system.
Metabolic control system – Influences of hypoxia and hypercarbia. Controls respiration
during non-REM sleep.
Behavioral control system governs respiration during voluntary activities suppress the
ventilatory response to metabolic stimuli.
Controls respiration during REM Sleep.
Asok kumar RS OMFS
5. Generalized skeletal muscle atonia (except for the ocular muscles) and absence of reflexive
activity are other features unique to REM sleep
During REM sleep, an episode of partial or complete airway obstruction with apnea or
hypopnea may occur.
Collapse of the airway in OSA is primarily a result of high intraluminal negative pressures
associated with hypotonic pharyngeal wall musculature and disproportionate anatomy
Exaggerated in sleep because of the posterior and downward displacement of the tongue and
the soft palate.
Asok kumar RS OMFS
6. Characterized by abnormal breathing in sleep and sleep fragmentation.
At least 30 episodes of apnea occur during 7 hours of nocturnal sleep in these patients
Sleep disorders characterized by repeated pauses in breathing during sleep, which lead to
the fragmentation of sleep and decreases in oxyhemoglobin saturation.
Manifested as loud snoring and episodes of hypopnea, to complete airway collapse and
prolonged episodes of apnea.
Asok kumar RS OMFS
7. Apnea is defined as the cessation of airflow from the nostrils and mouth for at least
10 seconds.(American Academy of Sleep Medicine [AASM])
Hypopnea is defined as a recognizable transient reduction (but not complete
cessation) of breathing for 10 seconds or longer
These episodes can result in hypoxemia, hypercarbia, systemic and pulmonary
hypertension, polycythemia, cor pulmonale, bradycardia, and cardiac dysrhythmias.
50% these episodes occur in night’s sleep.
Asok kumar RS OMFS
8. 1. Central Sleep Apnea
2. Obstructive Sleep Apnea and
3. Mixed Sleep Apnea
Central sleep apnea - respiratory muscle activity ceases simultaneously with airflow
at the mouth and nostrils.
OSA- Respiratory control is normal, but the obstruction is at the level of the
pharynx. Asok kumar RS OMFS
9. Breathing disorder that occurs during sleep
Characterized by a partial or complete blockage of the upper airway
with a consequent cessation/reduction of the airflow [Guilleminault
et al. 1976; and Quo, 2001]
Second most common sleep disorder that can be potentially fatal.
Caused by the collapse of soft tissue and muscles in the upper
airway between the hard palate and the larynx.
Occurrence of at least five apneas or hypo apneas per hour,
resulting in sleep fragmentation and decreased oxygen saturation.
Asok kumar RS OMFS
10. First described by Charles Dickens as Pickwickian syndrome in 1837.
Sir William Osler described relationship between obesity and OSA
1956 - First description of the syndrome was published by Burwell and coworkers.
1966 - Gastaut and associates demonstrated repeated apneas in pickwickian patients
during sleep.
Asok kumar RS OMFS
11. OSA increases substantially with age.
More common in men (24% ) than women (9%).
Prevalence in children aged 2 to 8 years is only 2%
Age : 40 to 65 years.
Highest prevalence - Middle-aged men [Young et al. 1993]
60%-70% of patients with OSA are obese
Post-menopausal women are at higher risk for OSA.
Gender differences in the prevalence of OSA may be related to the body fat distribution.
Asok kumar RS OMFS
12. Lee JE; Lee CH; Lee SJ; Ryu Y; Lee WH; Yoon IY; Rhee CS; Kim JW. Mortality of
patients with obstructive sleep apnea in Korea. J Clin Sleep Med 2013;9(10):997 1002
OSA- Major risk factor for cardiovascular disability in terms of morbidity and mortality
[Mcnicholas et al (2007)]
Median age of death was 66.8 year (range 42-86 years)
Female OSA patients had a lower mortality than males
Asok kumar RS OMFS
13. Anatomic upper airway risk factors for OSA
1. Obesity (Increased upper airway submucosal adipose tissue deposition)
2. Retrusive maxillomandibular skeleton (Hypoplasia of the maxilla or
mandible)
3. Alterations in the intranasal cavity (Septal deviations, hypertrophic inferior
turbinates, tight nasal aperture, elevated nasal floor, adenoid
hypertrophy)
4. Enlargement of upper-airway soft-tissue visceral structures (Soft palate,
tonsils, tongue) and
5. Inadequate pharyngeal muscular tone Asok kumar RS OMFS
14. Alcohol, narcotics, sedatives, muscle relaxants negatively influence the neuromuscular
tone of chest wall
Chan MA, Kim J,Woods CA. Obstructive sleep apnea: A review.US Pharm
2019;44(7):16-19. Asok kumar RS OMFS
16. OSA is characterized by recurrent sleep-associated collapse of the pharyngeal airway leading
to hypoxemia, hypercapnia, and fluctuations in intrathoracic pressure.
Protective mechanisms increase the activity of the pharyngeal dilator muscles, while awake.
Patency of the upper airway maintained by balance between the pharyngeal musculature
and the negative oropharyngeal pressures generated from resistance to airflow in the
nasopharynx
In sleep, the mechanisms fail and collapses the pharyngeal airway.
Conditions worsened by supine sleep position
Collapse of airway occurs in behind the soft palate and tongue
Asok kumar RS OMFS
17. Schwab and colleagues documented an increase in adipose
hypertrophy within the floor of the mouth, the soft palate, the
pharyngeal fat pads, and the lateral pharyngeal walls in individuals
with OSA.
Fogel and colleagues the pharyngeal muscles of primary importance
fall into three groups:
1. The muscles that influence the hyoid bone position (geniohyoid,
sternohyoid)
2. The muscles of the tongue (genioglossus)
3. The muscles of the soft palate (tensor palatine
and levator palatine)
Asok kumar RS OMFS
18. During inspiration these muscles expand the upper airway.
During expiration, the muscles relax except tensor palatine.
Tensor palatine maintain a constant muscle tone throughout the
respiratory cycle to preserve a patent airway.
To prevent apnea in individuals with an anatomically “small-
volume” airway, there will be an increased the functioning of the
pharyngeal muscles
This reflex is diminished in apnea-prone individuals.
Asok kumar RS OMFS
19. Snoring
Excessive day time sleepiness
Morning tiredness
Morning head ache
Fatigue
Lack of refreshing sleep
Intellectual deterioration
Depression
Body-mass index greater than 25 kg/m2.
Neck circumference greater than 40 cm
Asok kumar RS OMFS
20. Sleep walking
Enuresis
Feeling of chocking,
Restless and unrefreshing sleep,
Behavioral changes
Nocturia
Systemic hypertension
OSA is associated with hypertension,cardiovascular disease, metabolic syndrome, stroke and possible
premature Death
Asok kumar RS OMFS
22. Diagnostic evaluation includes:
1. History
2. Physical examination
3. Radiologic evaluation and
4. Polysomnography
Asok kumar RS OMFS
23. Nose - Deviated nasal septum and enlargement of the turbinates.
Oral cavity- Micrognathia, retrognathia, and macroglossia
Tumors in the nasopharynx or hypopharynx may be noted.
Pharynx - adenotonsillary hypertrophy, long soft palate,
large base of the tongue, and excess pharyngeal mucosa
Larynx - vocal cord webs and paralysis of the vocal cords.
Asok kumar RS OMFS
24. Palate Tonsil
Friedman M, Ibrahim H, Joseph NJ. Staging of obstructive sleep apnea/hypopnea syndrome: a guide to
appropriate treatment. Laryngoscope. Mar 2004;114(3):455
Asok kumar RS OMFS
26. Evaluation of respiratory, and central nervous system.
CVS: Elevated blood pressure, cor pulmonale are prominent sinus
dysrhythmia
Body mass index: above 30 kg/m2 is a risk factor for OSA
Neck circumference: above 17 inches in men, or 16 inches in women,
Asok kumar RS OMFS
27. 0 – would never doze
1 – Slight chance of dozing
2 – Moderate chance of dozing
3 – High chance of dozing
A value above 10 is considered abnormal
Situation Score
Sitting and reading
Watching Tv
Sitting inactive in public place
As a passenger in a car without
break
Sitting and talking to someone
Sitting quiety after lunch
In a car, while stopped for a few
minutes in traffic
Asok kumar RS OMFS
28. LATERAL CEPHALOGRAM
Cephalometric analysis -Identify skeletal and soft tissue abnormalities
that may exist.
ADVANTAGES:
1. Easy access
2. Low cost
3. Minimal radiation exposure
Maxillary position - SNA (sella-nasion–A point)
Mandibular position -SNB (sella-nasion–B point)
Asok kumar RS OMFS
29. Hyoid bone position – Perpendicular line from the mandibular
plane (MP) through the hyoid bone (H).
MP-H distance =15.4 ± 3 mm
Soft palate length - Distance between posterior nasal spine
(PNS) to the tip of the soft palate shadow (P).
PNS-P distance = 37 ± 3 mm.
Posterior airway space (PAS) = 11 ± 1 mm.
Asok kumar RS OMFS
30. Dynamic study
Allows the visualization of the head and neck
including bony and soft structures and upper airway
Videofluoroscopy - used to investigate
1. Assessment of pharyngeal airway in both the A-P and
transverse planes
2. Upper airway dynamics during speech and
3. OSA during sleep
Ama Johal, Zahra Sheriteh, Joanna Battagel and Claire Marshall..The use of
videofluoroscopy in the assessment of the pharyngeal airway in obstructive sleep apnoea
European Journal of Orthodontics 33 (2011) 212–219
Asok kumar RS OMFS
32. First reported by Holland (1974)
Gold standard for diagnosing sleep apnea, quantitating its
severity and determining the success of treatment modalities.
Performed in a sleep laboratory and the patient’s sleep is
monitored overnight.
Evaluates sleep-disordered breathing, sleep architecture, and
oxygen desaturations.
Episodes of apnea and hypopnea are determined from a
reduction in airflow in combination with oxygen desaturation
during a 4- to 8-hour time frame. Asok kumar RS OMFS
33. COMPONENTS:
Electroencephalogram (EEG),
Electrooculogram (EOG),
Electromyogram (EMG), and
ECG (lead V2).
Oxygen saturation is measured by oximetry.
Respiratory effort and breathing pattern -Respiratory inductive
plethysmography or by measuring intrathoracic pressure
changes with an esophageal balloon catheter.
Distinction between episode of central apnea and obstructive
apnea is made by correlating airflow with movement of
respiratory muscles. Asok kumar RS OMFS
34. Central apnea occurs if both airflow and respiratory muscle movement stop
simultaneously.
Obstructive apnea occurs when airflow at the mouth and nose ceases but respiratory
muscles in the abdomen and thorax continue to move dysfunctionally.
Apneas and hypopnea with oxygen desaturation below 85%
Watch-PAT 200 - Provides comprehensive evidence of sleep architecture.
RDI and AHI, sleep time, ODI (oxygen level), sleep stages and architecture, heart rate,
body position, and snoring intensity (dB) can be determined
Prabhat K. C., Lata Goyal, Afshan Bey, Sandhya Maheshwari. Recent advances in the management of obstructive
sleep apnea: The dental perspective.Journal of Natural Science, Biology and Medicine July 2012 Vol 3 Issue 2.
Asok kumar RS OMFS
35. Apnea Hypopnea Index (AHI) - Number
of apneas and hypopneas per hour of
sleep.
Respiratory disturbance index (RDI) -
Number of apneas, hypopneas, and
respiratory-effort–related arousals
(RERA) per hour of sleep
RDI = (RERA +hypopnea +apnea) x 60
Total sleep time (minutes)
AHI = Apnea + Hypopnea x60
Total sleep time (minutes)
Asok kumar RS OMFS
36. Other diagnostic tests
1. Complete blood count (CBC),
2. Serum electrolytes, and
3. Thyroid function tests.
4. Estimation of blood glucose and
5. Serum lipid profile
Asok kumar RS OMFS
37. AIM:
1. Increase the life expectancy
2. Decrease the disease problems and
3. Improve the quality-of-life.
Less invasive treatment options should be selected whenever possible.
TREATMENT MODALITIES:
1. Behavior modification
2. Diet and medication
3. Continuous positive airway pressure (CPAP) devices
4. Oral appliances
5. Surgery
Asok kumar RS OMFS
39. BEHAVIOR MODIFICATION
Changing the sleep position from the supine to lateral / prone position
Sleeping laterally against a full body pillow, or wearing an anti-supine belt
‘Tennis ball technique’, consisting of a tennis ball strapped to the back to discourage
supine position, supine alarm devices and a number of positional pillows [Oksenberg,
2005; Frank et al. 2015].
Avoidance of alcohol, and sedatives for 3 hr before the sleep
Reduce the day time sleepiness
DIET AND MEDICATION
Weight loss and maintaining a healthy diet.
1% change in weight is associated with a 3% change in AHI
Topical intranasal application of corticosteroids
Leukotriene receptor antagonist Asok kumar RS OMFS
40. PROTRYPTYLINE
Suppress the REM sleep
Increase the tone of the upper airway muscles, thus stabilizing the airway
Amphetamines, Methylphenidate, and Modafinil – CNS stimulant increases alertness.
Used in the treatment of Excessive Daytime Sleepiness (EDS)
PROGESTERONE
Increases alveolar ventilation
Improves oxygenation
Several other drugs like Acetazolamide, Medroxyprogesterone, Theophylline, Doxapram and Almitrine are
under investigation.
Asok kumar RS OMFS
41. First reported in 1981 by Sullivan
Non-invasive gold standard treatment for moderate-to-severe OSA.
First-line treatment for OSA in adults
Continuous inhalation of air under positive pressure through a sealed face mask or nose
mask into upper airway or lung.
Counteracts the collapsing force and provide a pneumatic splint
Decreases daytime sleepiness and improve the patient’s quality of life.
DISCOMFORT AND DIFFICULTY
1. Drying of the nasal and oral mucous membranes
2. Dislodgment during sleep,
3. Noise
4. Inconvenience when transporting the unit,
5. Claustrophobia
Complexity limits its acceptance by patients and leads to suboptimal treatment adherence.
Asok kumar RS OMFS
42. Also known as Mandibular advancement splints (MAS).
American Sleep Disorders Association recommends that
oral appliances used in patients with primary snoring, mild
OSA, or in those with moderate to severe OSA who are
intolerant of nasal CPAP.
OBJECTIVE:
Prevent the sealing of the tongue to the posteriorpharyngeal
mucosa by mechanical repositioning and holding the
mandible in a protruded (forward) location.
Asok kumar RS OMFS
44. ADVERSE EFFECTS:
1. Tooth movement with changes in occlusion
2. Injury to the periodontium
3. Excessive salivation or dry mouth
4. Temporomandibular disorders
5. Masticatory muscle discomfort.
Asok kumar RS OMFS
45. Spicuzza L, Caruso D and Maria GD.Obstructive sleep apnoea syndrome and its
management.Ther Adv Chronic Dis (2015).Vol.6(5) 273-385
Asok kumar RS OMFS
46. INDICATION:
1. Excessive daytime sleepiness as a result of OSA
2. RDI of more than 20 events/hour
3. Oxygen desaturations of less than 90% with apnea events
4. Documented hypertension, arrhythmia, or both believed to be triggered by OSA
5. Negative esophageal pressures (i.e., >−10 cm of water)
6. Anatomic abnormalities of the upper airway (i.e., jaw deformity, fixed intranasal
obstructions, chronically enlarged tonsils, enlarged floppy soft palate)
Asok kumar RS OMFS
47. ADENOTONSILLECTOMY- first-line therapy for children with OSA and cures
approximately 80 % of pediatric cases of pediatric OSA.
POSITIVE AIRWAY PRESSURE THERAPY – For patients with minimal adenotonsillar
tissue or a strong preference for a nonsurgical approach
RAPID MAXILLARY EXPANSION – Prepubertal children with OSA and a narrow palate
(crossbite) and little adenotonsillar tissue are ideal candidates
Widens the palate and nasal passages, thereby increasing airway patency.
CORTICOSTEROIDS OR MONTELUKAST – For children with mild or moderate OSA
and nasal obstruction due to adenoidal hypertrophy/allergic rhinitis.
DISTRACTION OSTEOGENESIS (DO)- Bilateral mandibular DO in children with
craniofacial abnormalities can improve OSA
Shalini parudi.Management of obstructive sleep apnea in children – UpToDate (2020)
Asok kumar RS OMFS
49. NON SURGICAL MANAGEMENT:
1. Prone positioning
2. Supplemental oxygen therapy
3. Nasal CPAP
SURGICAL:
1. TONGUE LIPADHESION:
Douglas in 1946 described the Tongue Lip Adhesion technique for
the management of Pierre Robin patients.
Procedure in which the tongue is attached anteriorly to the lower
lip.
Opens the oropharyngeal airway space as the tongue base is
pulled forward
2. MANDIBULAR DISTRACTION OSTEOGENESIS
Mandibular distraction osteogenesis with glossopexy provides
relief of severe upper airway obstruction for infants with Robin
sequence.
Distraction osteogenesis and glossopexy for Robin sequence with airway obstructionans_5588 320..325 Alan T. L. Cheng, Michelle
Corke, Alison Loughran-Fowlds. ANZ J Surg 81 (2011) 320–325
Asok kumar RS OMFS
51. In 1969, Kuhlo and coworkers performed first efficacious surgical procedure
for treating OSA.
Bypasses all the potential obstructive sites in the upper airway.
Rapid and striking reduction in daytime somnolence and a marked
improvement in sleep architecture.
Used as an interim treatment until adjunctive procedure to reconstruct the
upper airway are completed.
Asok kumar RS OMFS
52. Standard first-line treatment for a child
Overall cure rate - 82.9%.
If a children with OSA had a preoperative RDI of
less than 19 events/ hour
Reduce the RDI to less than 5 events/hour
Other anatomic causes for the child’s OSA should
be considered (e.g., maxillomandibular hypoplasia).
Asok kumar RS OMFS
53. Originally described by Fujita.(1980)
Involves removal of the tonsils, uvula, removing
redundant lateral pharyngeal wall mucosa, and resecting
8 to 15 mm along the posterior margin of the soft palate
Basic goal is to shorten the palate and widen the PAS
In all cases, symptomatic improvement and elimination of
habitual snoring is achieved.
Success rate –ranges from 30%, if performed alone to 60%
if performed with tonsillectomy.
Reports show that significant improvement on the
postoperative polysomnogram ranges only from 41% to
66% Asok kumar RS OMFS
54. 1980 - Dr. Yves-Victor Kamami designed a procedure to reshape
and recontour the soft palate under local anesthesia with a CO2
laser to treat snoring and OSA.
Originally named the procedure “laser resection of the
palatopharynx” (LRPP).
RDI improved from 41.5 to 16.9.
1990- Dr. Yosef Krespi modified the procedure and renamed it
“laser-assisted uvulopalatoplasty” (LAUP).
Asok kumar RS OMFS
55. Minimally invasive management for snoring and mild
cases of OSA.
Also known as the Pillar procedure
Three polyester rods are placed in the soft palate
initiate an inflammatory response in the surrounding
soft tissues.
Resulting fibrosis leads to stiffening of the soft palate.
35% reduction in AHI an improved ESS scores.
Asok kumar RS OMFS
56. First described by Riley in 1984.
Advancement of the genial tubercle/genioglossus
muscle for the treatment of hypopharyngeal obstruction
in OSA
A rectangular osteotomy apical to the teeth.
Maintaining the inferior border of the mandible allows
the genial tubercles with their muscular attachments to
be maximally advanced with minimal cosmetic change
Asok kumar RS OMFS
57. 1984 - Riley and associates described an alternative technique in
which an inferior mandibular osteotomy and an associated hyoid
myotomy and suspension
The osteotomy is designed to include the genial tubercle on the inner
cortex of the anterior mandible.
Repositioning the anteroinferior segment of the mandible forward
with genioglossus muscle pulls the tongue forward and improves the
hypopharyngeal airway.
Hyoid bone to be pulled anteriorly and superiorly suture are passed
around the body of the hyoid and attached to the intact portion of the
anterior mandible.
Asok kumar RS OMFS
58. 1994 - Riley and colleagues reported on a new modified technique for hyoid
suspension.
Hyoid is fixed to the thyroid cartilage instead of the anterior margin of the
mandible.
Patients with normal pulmonary function, normal skeletal mandibular
development, the absence of obesity, and moderate OSA are candidates for
treatment with inferior mandibular osteotomy with hyoid myotomy and
suspension.
90% of the hyoid suspensions were performed in conjunction with or
following other upper airway procedures such as uvulopalatopharyngoplasty
(UPPP), nasal septoplasty, tonsillectomy and/or laser lingual tonsillectomy
Follow-up polysomnographic studies revealed significant improvement in
the apnea-hypopnea index (AHI), ranging from 30 to 90% correction.
Yosef P. Krespi, MD, Ashutosh Kacker hyoid suspension for obstructive sleep apnea. Operative techniques in
otolaryngology--head and neck surgery, vol 13, no 2 (jun), 2002: pp 144-149
Asok kumar RS OMFS
59. Most efficacious procedure for expanding the pharyngeal airway
and improving or eliminating OSA.
Best current alternative to tracheostomy
Effective for patients who have obstruction at the base of the
tongue.
Surgical facial advancement through concomitant maxillary and
mandibular osteotomies (Le fort I osteotomy in combination with
a mandibular Sagittal split osteotomy)
Addresses multiple levels of obstruction, decreasing airway
collapsibility by advancing the skeletal framework.
Scott B. Boyd, DDS, PhD. Management of Obstructive Sleep Apnea by Maxillomandibular
Advancement .Oral Maxillofacial Surg Clin N Am 21 (2009) 447–457
Asok kumar RS OMFS
60. INDICATIONS
1. Severe maxillary and mandibular deficiency (SNB < 74 degrees),
2. Morbid obesity, severe OSA (RDI > 50,
3. Oxygen desaturations < 70%),
4. Hypopharyngeal narrowing, and
5. Failure of other forms of treatment.
Riley advocated MMA as phase II surgery for those who failed to improve after phase I surgery, which
included UPPP and genioglossal advancement with hyoid myotomy.
Riley reported that 50% reduction in the RDI compared with the preoperative in MMA.
Mean reduction in AHI of 87% has been reported and represents the most effective surgical approach after
tracheotomy [Prinsell, 2002; Randerath et al. 2011]
The success rate of MMA appears to increase when adjunctive procedures such as UPPP, partial glossectomy,
septoplasty, or turbinectomies performed
Asok kumar RS OMFS
61. Fujita was the first to describe removal of tongue tissue for
OSA.
Midline glossectomy and lingual plasty are partial
glossectomies to enlarge the lower pharyngeal airway
Midline glossectomy (MLG) done by removing the anterior
and a portion of the middle third of the tongue
Lingual plasty extends tissue removal from MLG posteriorly
and laterally.
Asok kumar RS OMFS
62. Advances the dorsal profile of the tongue base
Reduces AHI to fewer than 20 events per hour.
As a standalone procedure, success rate is 36.6% [Handler
et al. 2014].
Partial glossectomy is performed medial to the tonsillar
folds and posterior to the circumvallate papillae
Transoral robotic surgery (TORS) for OSAHS was 2008.
Robotically assisted transoral version of Chabolle’s
operation (Tongue Base Reduction and supra glottoplasty)
for moderate to severe obstructive sleep apnea.
Genioglossal Advancement, Hyoid Suspension, Tongue Base Radiofrequency, and Endoscopic
Partial Midline Glossectomy for Obstructive Sleep Apnea Jeffrey Dorrity, Nicholas Wirtz
Otolaryngol Clin N Am - (2016) Asok kumar RS OMFS
64. Reliable surgical method to alleviate the narrow upper airway in growing OSA
patients with severe craniomaxillomandibular deformities
ADVANTAGE:
1. Greater advancement possible
2. Lesser chances of relapse and
3. Correction of the deformity at the same time.
INDICATION - OSA include infants and children with airway obstruction as a
result of congenital micrognathia or midface hypoplasia
Allows large advancements without the need for bone grafting and with less risk
of relapse.
Carl Bouchard, DMD,MSc, FRCD (C)*, MariaJ.Troulis, DDS,MSc, Leonard B. Kaban, DMD, MD.
Obstructive Sleep Apnea: Role of Distraction Osteogenesis.Oral Maxillofacial Surg Clin N Am 21
(2009) 459–475
Asok kumar RS OMFS
65. Introduced in 1997.
Volumetric reduction of the soft palate and tongue for the treatment
of mild sleep disordered breathing and snoring using Radiofrequency
Employs an insulated needle which delivers high-frequency (300–1000
kHz) energy.
Delivery of heat results in thermocoagulation which results in fibrosis
Genioglossal Advancement, Hyoid Suspension, Tongue Base Radiofrequency, and Endoscopic Partial Midline
Glossectomy for Obstructive Sleep Apnea Jeffrey Dorrity, Nicholas Wirtz Otolaryngol Clin N Am - (2016)
Asok kumar RS OMFS
66. Neurostimulation for stability of the upper airway during sleep
was introduced.
Stimulation of the hypoglossal nerve activates airway dilators
Less invasive and more effective
Implantable stimulators are recent advances in OSA and
received U.S. Food and Drug Administration (FDA) approval in
2014.
Used for moderate or severe OSA in adults.
Hypoglossal nerve stimulation seems to be more successful in
patients with a lower BMI Asok kumar RS OMFS
67. HGNS system (Inspire, Maple Grove, MN, USA) is comprised of:
1. Stimulation cuff electrode,
2. Pleural pressure sensing lead, and
3. Implantable pulse generator (IPG).
The stimulator device is implanted under the chest skin with an electrode
placed on the hypoglossal nerve and is activated during sleep time.
Overnight treatment with the stimulator produced a 68% reduction in the
median AHI score with a subjective improvement in daytime sleepiness
and quality of life over a period of 12 months [Strollo et al. 2014].
Hypoglossal nerve stimulation for treatment of obstructive sleep apnea (OSA): a primer for oral and
maxillofacial surgeons .Sung ok Hong, Yu-Feng Chen, Junho Jung, Yong-Dae Kwon and Stanley Yung
Chuan Liu. Maxillofacial Plastic and Reconstructive Surgery (2017) 39:27
Asok kumar RS OMFS
69. 70% of patients with OSA have obesity
Correlation between body mass index (BMI) and AHI were
documented.
Gastric bypass for the management of obesity
Reduction in intra-abdominal pressure following surgery leads to
clinically significant improvement in blood oxygenation, resulting in
favorable effects on the cerebral respiration pathways.
Indicated for patients with a BMI ≥40 , or with a BMI ≥35 with
significant comorbidities
Bariatric surgery offers a significantly greater improvement than
nonsurgical alternatives [Ashrafian et al. 2015]
Kourosh Sarkhosh ,Noah J. Switzer, Mustafa El-Hadi et al. The Impact of Bariatric Surgery
on Obstructive Sleep Apnea: A Systematic Review. Obes surg (2013) 23:414–423
Asok kumar RS OMFS
70. First 24 hours after surgery is the most critical time for complications,
Postoperative deaths have occurred later, most commonly due to the
accumulated effects of sleep deprivation, narcotic agents, and rapid eye
movement rebound.
Continuous pulse oximetry with an audible alarm is the easiest and most
reliable method for early detection of postoperative hypoventilation.
After surgery, elevation of the head of the bed reduces soft tissue edema and
turbinate swelling and reduces nasal airway resistance
Opioid-sparing analgesia is employed to minimize narcotic use
Once patients are able to maintain good oxygen saturation on room air
overnight, ambulate with minimal assistance, tolerate a non-chew diet, perform
good oral hygiene, and achieve adequate pain control with oral analgesics, they
may be discharged home
Samuel A Michelson.Anaethesia and post operative management of Obstructive sleep apnea patient. Oral Maxillofacial Surg Clin N Am 21 (2009) 425–434
Asok kumar RS OMFS
71. Bilevel PAP :
Provides two different levels of pressure (higher during inhalation and
lower during expiration) and can potentially treat OSA at a lower mean
pressure than CPAP
More expensive and a valid alternative in patients intolerant to CPAP
and in patients with associated hypoventilation or chronic obstructive
pulmonary disease [Kolla et al. 2014]
Autotitrating CPAP (Auto-CPAP):
Provides an alternative to traditional CPAP.
Asok kumar RS OMFS
72. nasal Expiratory PAP (nEPAP) :
Mild to moderate OSA,
Disposable adhesive device placed over each nostril to increase the
airflow resistance during the exhalation with a consequent
improvement in the upper airway patency.
significantly reduces snoring and the AHI score and improves
subjective daytime sleepiness with an excellent adherence after 12
months of treatment [Kryger et al. 2011,Freedman, 2014].
Oral negative pressure:
Creates oral vacuum intended to move the soft palate anteriorly to
decrease obstruction of the airway during sleep
Negative pressure system (Winx Sleep Therapy System, ApniCure,
Redwood City, USA) consists of an oral interface, a vacuum pump and
a connection tube
Asok kumar RS OMFS
73. Peterson’s principles of oral and maxillofacial surgery - Third edition
Orthognathic surgery: Principles & practice- Jeffrey c. Posnick
Fonseca Oral and maxillofacial surgery- 3 edition
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