Obstructive sleep apnea (OSA) is a prevalent chronic disease characterized by pharyngeal collapse during sleep. Sleep disorder that involves cessation or significant decrease in airflow through the upper airway in the presence of breathing effort. Obstructive sleep apnea is the second most common sleep disorder, insomnia being the most common. Associated with recurrent oxyhemoglobin desaturations and arousals from sleep Apnea index- no. of apneas /hr of total sleep time. AHI (APNEA-HYPOPNEA INDEX)- No of apneas and hypoapneas/hr of total sleep time. RDI (Respiratory Disturbance Index) – no. of apneas, hypoapneas and respiratory effort related arousals(RERA)/hr of total sleep time.

1. GOOD MORNING

2. Obstructive Sleep
Apnea
Presented by:
Dr Kamini Dadsena

3. Content
 Introduction
 Classification of apneas
 Physiology of sleep
 Epidemiology
 Etiology
 Clinical Signs and Symptoms
 Diagnosis
 Treatment
 Non-surgical
 Surgical

4. Introduction
 Obstructive sleep apnea (OSA) is a prevalent chronic disease
characterized by pharyngeal collapse during sleep.
 Sleep disorder that involves cessation or significant
decrease in airflow through the upper airway in the
presence of breathing effort.
 Obstructive sleep apnea is the second most common
sleep disorder, insomnia being the most common.
 Associated with recurrent oxyhemoglobin desaturations and
arousals from sleep

5. Sleep Physiology
1. Slow-wave sleep (non-REM):
Stage 1 NREM 4-5% of total sleep time is
considered normal Increases to 15% by age 70
Stage 2 NREM 45 - 55% of total time
Stage 3 NREM
Stage 4 NREM
2. Rapid Eye Movement Sleep (REM): 20-25%
body paralysis - atonia
mind very active - vivid hallucinatory imagery or
dreaming
Range of total sleep: 10 - 20%
decreases with age
about 40 - 50% in children
total absence by age 40 - 50

6. Obstructive
sleep
apnea
High BP
Increase insulin
resistance
Increase work
place and road
traffic accident
Memory
problem and
inability to
think properly
Stroke
Cardiac
problem

8. Indexes for Sleep Disorder
 Apnea index- no. of apneas /hr of total sleep time.
 AHI (APNEA-HYPOPNEA INDEX)- No of apneas and
hypoapneas/hr of total sleep time.
 RDI (Respiratory Disturbance Index) – no. of apneas,
hypoapneas and respiratory effort related arousals(RERA)/hr
of total sleep time.

9. Classification
 Obstructive - cessation of air exchange as a result of upper
airway obstruction, usually at the level of the pharynx,
during sleep
 Central - cessation of breathing effort during sleep as a
result of inactivity of the respiratory muscles
 Mixed - cessation of breathing during sleep which begins
centrally, then quickly manifests into an obstructive apnea.

10. Pathophysiology
 A reduction in the dilating forces of the pharyngeal dilators.
 The negative inspiratory pressure generated by the
diaphragm.
 Abnormal upper airway anatomy.

11. Pathophysiology
 TRANSMURAL PRESSURE - difference between
intraluminal pressure and the surrounding tissue pressure.
 If transmural pressure decreases the cross-sectional
area of the pharynx decreases.
 If this pressure passes a critical point (Pcrit), pharyngeal
closing pressure is reached. The airway is obstructed.

12. Pathophysiology
Obstruction of Upper Airway
Classification
Type Level of obstruction Anatomic site
I Upper pharyngeal Upper oropharynx, Palate,
Tonsils
II Upper and lower
pharyngeal
Variable combination
III Lower pharyngeal Lower oropharynx,
Tongue Base, Epiglottis,
Hypopharyngeal

13. 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

14. Clinical Findings
 Choking or gasping during sleep
 Snoring
 Sudden awakenings to restart breathing
 Waking up in a sweat during the night
 Feeling tired in the morning
 Headaches
 Daytime sleepiness
 Lack of concentration,fatigue,irritable
 Attention Deficit Hyperactivity Disorder(ADHD) –
Children 81%
 GERD
 Sexual dysfunction

15. Clinical Findings
 Hypoxia – cyanosis (Central if severe)
 Hypercarbia – acidosis in severe cases
 Pulmonary hypertension
 Cardiac arrythmias
 Stroke
 DEATH

16. Epidemiology
 Most common in 3rd - 4th decade of age.
 Male: female ratio - 3:1
 85% of males – some form of obstruction
 2/3rd patients – obese.
 Undiagnosed in approximately 93% of affected women and
82% of affected men.

17. Diagnosis
 History – ask the relative (Most Reliable)
 Physical examination of nose, oral cavity,
oropharynx
 GOLD STANDARD – Polysomnography
 EEG
 EOG
 submental EMG
 nasal and oral airflow
 respiratory muscle effort
 oxygen saturation
 ECG
 Blood gas evaluations

18. Diagnosis
 Apnea-Hypoxia Index (AHI)
 Mild - ≥ 5 and < 15 events/hr
 Moderate - ≥ 15 and ≤ 30 events/hr
 Severe - >30 events/hr
 Epworth sleepiness scale – score > 10
 Fluoroscopy
 Endoscopy
 Radiographic investigations
 Cephalometrics
 CT scans
 MRI
 FIBEROPTIC NASOPHARYNGOSCOPY
 Multiple positions
 In awake & asleep patients

19. Drug-induced sleep endoscopy
(DISE)
 guide more effective surgical intervention.
 DISE involves the use of fiberoptic nasopharyngoscopy to
evaluate the site of airway collapse during
pharmacologically induced sleep.
 Useful tool for assessing the location, severity, and pattern
of airway obstruction during sleep.

20. Cephalometric Radiograph

21. PSG
 Electroencephalogram (EEG)
 Electrooculogram (EOG)
 Electromyogram (EMG)
 Electrocardiogram (ECG)
 Oronasal airflow
 Chest wall effort
 Snore microphone
 Oxyhemoglobin saturation

24. Management
Medical
 Weight loss
 Continuous positive
airway pressure (CPAP)
 Oral Appliances – TRD,
MPD
 Pharmacologic Theray
Surgical
 Nasal surgery (septoplasty, sinus
surgery, and others)
 Tonsillectomy ± adenoidectomy
 Uvulopalatopharyngoplasty (UPPP)
 Laser assisted uvulopalatoplasty
(LAUP)
 Linguaplasty
 Genioglossus and hyoid advancement
(GAHM)
 Sliding genioplasty
 Maxillo-mandibular advancement
osteotomy
 Tracheostomy

25. Medical management
 Weight Loss/Exercise
 Nasal Obstruction/Allergy Treatment
 Sedative Avoidance
 Smoking cessation
 Sleep hygiene
 Consistent sleep/wake times
 Avoid alcohol, heavy meals before bedtime
 Position on side
 Avoid caffeine, TV, reading in bed

26. CPAP
 Gold std for moderate to severe OSA
 Pneumatic splint – prevents collapse
 Provides constant +ve intraluminal pressure during
respiration

27. POSITIVE AIRWAYPRESSURE

28. Bilevel positive airway pressure (BiPAP)
 delivers a separately adjustable, lower expiratory positive
airway pressure and higher inspiratory positive airway
pressure.
Autoadjusting positive airway pressure (APAP)
 Autotitrate the pressure depending on the variations of
airflow to an effective level of CPAP

29. Medical Management
CPAP
Pressure must be
individually titrated
Compliance is as low
as 50%
Air leakage, eustachian
tube dysfunction, noise,
mask discomfort,

31. Guidelines for use of CPAP
 All patients with an apnea-hypopnea index (AHI) greater
than 15 regardless of symptomatology.
 For patients with an AHI of 5-14.9, CPAP is indicated if the
patient has :
 excessive daytime sleepiness (EDS),
 hypertension, or
 cardiovascular disease.

32. Nonsurgical Management
Oral appliance
Mandibular
advancement device
Tongue retaining
device

34. side effects of oral appliance therapy
include excessive salivation, xerostomia,
soft tissue irritations, transient discomfort
of the teeth and temporomandibular joint
(TMJ), and temporary minor occlusal
changes. Uncommon, more serious complications
include permanent occlusal
changes and significant TMJ discomfort.

35. Pharmacologic therapy
 Modafinil is approved by the US Food and Drug
Administration (FDA) for use in patients who have residual
daytime sleepiness despite optimal use of CPAP.
 Selective serotonin reuptake inhibitor agents such as
paroxetine (Paxil) and fluoxetine (Prozac) have been shown
to increase genioglossal muscle activity and decrease REM
sleep (apneas are more common in REM), although this has
not translated to a reduction in AHI in apnea patients

36. Surgeries for Obstructive Sleep
Apnea
 Nasal surgery (septoplasty, sinus surgery, and others)
 Tonsillectomy ± adenoidectomy
 Uvulopalatopharyngoplasty (UPPP)
 Laser assisted uvulopalatoplasty (LAUP)
 Linguaplasty
 Genioglossus and hyoid advancement (GAHM)
 Sliding genioplasty
 Maxillo-mandibular advancement osteotomy
 Tracheostomy

37. Indications for surgery
 RDI > 20
 Failure to tolerate CPAP, or CPAP is not effective
 RDI < 20 in young patient with congenital facial deformities
 Oxygen desaturation < 85%
 Cardiac arrhythmias associated with obstruction

38. Surgical protocol
RDI 5-20 UP3, Septoplasty, Geniohyoid advancement
RDI 20-40 MMA Followed by UP3 in incomplete cure
RDI > 40 MMA & UP3

39. 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.
 Improving nasal patency help to restore physiologic
breathing and may allow for the use of nasal CPAP in
patients previously unable to tolerate it.

40. Palatal surgery
 1981 – Fujita &colleagues – 1st palatal surgery – UPPP
 Stiffens the soft palate & increases the space behind the
soft palate.
 Complications : temporary nasal reflex ( 12-15%) , post
operative bleeding, infection & rare altered speech.

41.  Rose’s position
 Partial uvulectomy – excessive mucosa of uvula tip cutoff
without touching musculae uvulae. Tip sutured
 Incision into the mucosa of the anterior pillar is performed
in the oral fold of the palatoglossus muscle.
 Fibers of the M. palatoglossus are dissected from the tonsil.
Tonsillectomy follows.
 Posterior tonsilar pillar is partially incised.
 Lengthened posterior pillar edge sewed together with the
anterior pillar.

44. Semi-elliptical soft palate with a
functioning uvula.

45. Complications
 Change in voice (rhinolalia aperta)
 Pain with swallowing and pain with speech, usually for 1-2
weeks postoperatively
 Hemorrhage (2-4%)
 Swallowing difficulties, particularly regurgitation of food
 Velopharyngeal Insufficiency
 Disturbance in taste
 Numbness of tongue
 Nasopharyngeal stenosis
 Creation of silent apnea

46. Laser-Assisted
Uvulopalatoplasty
 In 1980s Dr. Yves-Victor designed a procedure to reshape
and recontour the soft palate under local anesthesia with a
CO2 laser to treat snoring and selected patients with
obstructive sleep apnea syndrome.
 It consisted of two paramedian vertical incisions placed
lateral to the uvula extending up toward the junction of
the hard and soft palates for 2 to 3 cm.
 A second horizontal incision was placed just under the
roof of the uvula leaving a small uvula to prevent
centripetal scar formation.

47.  Average successful surgical response of 52.2%.
 Main indications for LAUP
 loud habitual snoring
 upper airway resistance syndrome
 mild obstructive sleep apnea (apnea index < 20).

48. complication following LAUP
 moderate to severe sore throat
 Pain control is achieved with oral analgesics and anesthetic
gels.
 velopharyngeal insufficiency
 The procedure is frequently done in stages and the surgeon
has the opportunity to evaluate speech and soft palate
function
 Low risk for bleeding and infection.

49. Tongue base procedure
 Glossectomy and radiofrequency ablation of the tongue
base are additional strategies to address hypopharyngeal
obstruction.
 success rates- reported surgical success from 20% to 83%
 Transoral robotic surgery for OSA is less morbid than
glossectomy and appears to be more effective for treating
OSA.

50. Tongue base procedure
PARTIAL MIDLINE GLOSSECTOMY (PMG)
 Removal of a midline rectangular strip of the posterior half
of tongue.
LINGUALPLASTY
 Additional tongue tissue removed posteriorly n laterally
RADIOFREQUENCY TONGUE BASE ABLATION (RFA / RFT)
 Lingual Tonsillectomy - Laser Lingual Tonsillectomy (LLT)

51. Orthognathic
surgical procedures
 Mandibular advancement
 genial advancement
 Maxillimandibular advancement
 They work by changing the position of the mandible and
hyoid bone with subsequent effects on the genioglossus
and hyoglossus muscles.

52. Genial Advancement
 rectangular osteotomy genioplasty
 Sliding gnioplasty

55. Genial Advancement with Hyoid
Myotomy and Suspension
 In 1984 Riley and colleagues described an alternative technique in
which an inferior mandibular osteotomy and an associated hyoid
myotomy and suspension were used in the treatment of obstructive
sleep apnea.
Inferior sagittal osteotomy

56. Complications
 severe aspiration
 wound infections,
 transient sensory disturbances of the mental nerve, an
 mandibular fracture.
 An advantage to hyoid suspension is that it circumvents
the need for maxillomandibular fixation and does not affect
the occlusion

57. Mandibular Advancement
 Total mandibular advancement was the first orthognathic
surgical procedure used in the treatment of obstructive
sleep apnea.
 A bilateral sagittal ramus osteotomy is usually the
procedure of choice for total mandibular advancement.
The amount of advancement is determined preoperatively
from the orthognathic surgery database.

58. Mandibular Advancement
 MA the pulling of the tongue forward off the pharyngeal
wall. This effect is created by anteriorly moving the
insertion of the genioglossus and geniohyoid muscles.

59. Maxillomandibular
Advancement
 Combined advancement of the maxilla and mandible with
or without hyoid suspension is the most recent and
efficacious surgical procedure for the treatment of
obstructive sleep apnea.
 The surgical technique includes a standard Le Fort I
osteotomy in combination with a mandibular sagittal split
osteotomy for advancement of the maxilla and mandible.

60.  MMA was initially advocated as phase II surgery for those who
failed to improve after phase I surgery, which included UPPP
and genioglossal advancement with hyoid myotomy.
 However, a recent comparative study evaluated the
effectiveness of MMA and UPPP. The study found that MMA
alone is more effective than UPPP alone and that UPPP
followed by MMA (phase I surgery followed by phase II
surgery) is no more effective than MMA alone.
 Offering MMA as a primary procedure confers additional
benefits over staged surgery, including decreased total
treatment time, fewer surgical and anesthetic risks to the
patient, and an improved cost:benefit ratio.

62. Distraction osteogenesis
 Accepted procedure in the treatment of severe
maxillomandibular deficiency in syndromic and non
syndromic patients.
 As grossly retropositioned mandible or midface causes a
narrow pharyngeal airway, OSA is often found in these
cases.

63. Distraction osteogenesis
 An osteotomy of the mandible or midface without
advancement is followed by a short latency period of 4
days.
 Then the two or more bony segments are slowly moved
apart (mostly at 1 mm/day) using some kind of distraction
device.
 Thus the unmineralized tissue filling the osteotomy gap
is slowly stretched until – after cessation of distraction – it
will turn into bone during the 4–10 weeks lasting
consolidation period.

64. Tracheostomy
 traditional gold standard of surgical management of OSA.
 Relieves OSA by completely bypassing the portion of the
airway that most commonly collapses during sleep.
 should be considered in patients who have failed all other
OSA treatments, in those who have life-threatening OSA
and are unable to tolerate CPAP, or in patients who are
neurodevelopmentally impaired.

65. Postoperative management
 In multisite surgical treatment of OSA - increased chance of
postoperative airway obstruction because of resultant
edema in multiple sites in the upper airway.
 It is recommended that patients with severe OSA use CPAP
for the first 2 weeks after surgery.
 In addition, it is recommended that postoperative PSG be
carried out in 3 to 4 months to evaluate the response to
surgery.

66. Conclusion
 Surgery should be considered for patients unable to utilize
nonsurgical management
 Surgical procedures provides effective management for
OSA
 Can be safely performed in most patients with proper
preoperative preparation

67. References
 Principles of Oral and Maxillofacial Surgery by Peterson
 Oral and maxillofacial surgery 3rd ed. vol 3 by Fonseca
 Oral and maxillofacial surgery 1st ed. vol 2 by Fonseca

68. Thank You……