Obstructive sleep apnea

1. Obstructive Sleep Apnea Hypopnea
(OSAH)
Dr Vivek Makadiya

2. INTRODUCTION
• Good sleep hygiene is critical for one’s overall physical and
mental health.
• Normally it should take about 10 - 15 minutes to fall asleep after
going to bed.
• If you are asleep in less than 5 minutes, that could be a sign of
excessive sleepiness.
• Sleep is a temporary state of unconciousness that can be
interrupted by external stimuli
• Divided into 2 phases i.e. “Quiet” or non rapid eye movement
sleep (NREM) & “Active” or rapid eye movement sleep (REM)

3.  NREM
 EEG waves progressively slow down & increase in amplitude
 Stage I & II- Low voltage & mixed frequency
• Stage I & II at the sleep initiation
• Stage II – Half of adult’s sleep
 Stage III & IV- High voltage & low frequency
• Aka “Slow Wave Sleep” or “Delta Sleep”
• Gradual progression to deeper “Slow Wave Sleep”
• % decreases with age
• About 40 - 50% in children to total absence by age 40 - 50

5.  REM Sleep
 Low voltage & high frequency waves
 Periods of rapid eye movements & twitching of face as well as
limbs
 Occurrence of dreams
 Increased autonomic activity with marked fluctuations in heart
rate, respiratory rate & blood pressure
 90 minutes after onset of sleep
 Recurrence between 4 to 6 times during a night’s sleep
 Longer periods with sleep progression
 25 % of total sleeptime

6. Central
Chemoreceptors
Peripheral
Chemoreceptors
Mechanoreceptors Cerebral Cortex
Respiratory Centre
(Medulla)
Phrenic N Nucleus Other Motor Nuclei
Spinal Cord
Peripheral Nerves
Respiratory Muscles
CONNECTIONS OF RESPIRATORY CENTRE

8.  Apnoea
 Cessation of airflow at the nostrils and mouth for atleast
10 seconds
 Hypopnoea (reduction in tidal volume)
 50% reduction in airflow, lasting for 10 seconds in the
presence of continued respiratory effort
 Respiratory Disturbance Index (RDI) or Apnoea
Hypopnoea index (AHI)
 Number of apnoeas and hypopnoeas per hour of
sleep

9. • Primary snoring
• Upper Airway Resistance Syndrome (UARS)
• Obstructive sleep apnoea syndrome (OSAS)
SLEEP DISORDERED BREATHING

10. RDI O2 desaturation Day time
sleepiness
Primary
snoring
UARS
OSAS
< 5 / hr
< 5 / hr
> 5 / hr
SaO2 > 90%
SaO2 > or = 90%
SaO2 < 90%
No
Yes
Yes
SLEEP-RELATED UPPER
AIRWAY OBSTRUCTION

11. SLEEP APNOEA - TYPES
• Obstructive sleep apnoea - cessation of airflow in the
presence of continued respiratory effort
• Central sleep apnoea - no airflow at the nose or mouth
associated with a cessation of all respiratory effort
• Mixed apnoea - begins initially as central apnoea, then
becomes obstructive

12. • Intrinsic dyssomnia characterized by recurrent episodes
of upper airway collapse and obstruction during sleep
• Associated with recurrent oxyhemoglobin desaturation
and arousal from sleep
• Both anatomic and neuromuscular factors are important
OBSTRUCTIVE SLEEPAPNOEA

13.  Pcrit for airway collapse
• Balance between force of dilator muscles & negative pressure
of inspiratory muscles
• Normal Negative, OSAH Positive
PATHOGENESIS

14. Narrow upper airways
• Fat deposition around airway & in related soft tissues
• Increasing age
• Individual variations in mandibular, tongue & soft palate size
(Genetically determined)
• Adenotonsillar hypertrophy during childhood

15.  Upper Airway Dilator muscles
• Include those influencing hyoid position (Geniohyoid), tongue
position (Genioglosssus) & palate position(Tensor palatini)
Stiffen upper airway & oppose negative airway pressure
• Hypertrophic in OSAH to compensate for narrow airway
• Delay between upper airway muscle activity & diaphragmatic
activity in OSAH
• Activity reduced during sleep due to decreased Seretonin in
OSAH
• Activity further impaired by recurrent hypoxia
• Upper airway muscle damage consistent with overuse
myopathy
• Impairment of dilator muscle activity due chronic sleep
deprivation

16.  Nonmuscular Factors
• Sleep Position (Posterior displacement of tongue & mandible in
supine position, more in REM)
• Low end expiratory volumes because of abdominal weight
leading to small upper airway
• More oval airway due to fat deposition in lateral wall leading to
impaired dilator muscle function
• Upper airway edema due to chronic vascular over perfusion &
mechanical trauma associated with snoring and recurrent upper
airway obstruction

17. • Hypoxemia, hypercapnia, increased respiratory effort & negative
airway pressure cause arousal by direct stimulation of
respiratory centre & RAS
• Apnoea termination associated with brief cortical or subcortical
arousal
• Increased upper airway muscle activity at the time of arousal
associated with loud snort and a short period of compensatory
hyperventilation.

19. •
•
•
Common
Snoring
Excessive daytime
sleepiness
Obstructive episodes
•
•
•
•
•
•
•
•
Less common
Morning headaches
Personality change
Intellectual deterioration
Depression
Abnormal body movements
Frequent waking
Nocturnal choking
Impotence
OBSTRUCTIVE SLEEPAPNOEA
Clinical features

20. • Loud snoring
• Noisy breathing during sleep
• Mouth breathing
• Growth retardation
• Repetitive upper airway
infection
• Abnormal shyness
• Nocturnal enuresis
• Poor growth problems
• Rebellious and aggressive
behavior
• Attention deficit disorder
PEDIATRIC OSAS

22. HISTORY
• Snoring: Heard in same room, anywhere in the house
or by neighbours as well
• Drug History: Sedatives, antipsychotic drugs
• H/O of cardiac abnormalities
• H/O thyroid problems
• H/O alcohol intake, quantity per day
• H/O smoking, number per day
• Current weight & whether it is increasing
• Sleep latency: Increased in patients with OSAH

23. GENERAL EXAMINATION
• Obesity BMI > 27.8 Kg/m2 (Males)
> 27.3 Kg/m2 (Females)
• Short & bulky neck
Collar Size > 17” (Males)
> 15” (Females)
• Pedal edema in RHF
• Pulse rate (May have Bradycardia)
• Blood Pressure (Hypertension)

24. Face
 Maxillary Retrusion
• Subnasale posterior to vertical line drawn from soft tissue
nasion (point of deepest depression at root of nose) to
subnasale (junction of columella & upper lip)
 Mandible Retrusion:
• Anterior prominence of chin is > 2mm behind the vertical
line drawn from vermilion border of lower lip
• Buccal groove of mandibular first molar is posterior to
buccal cusp of maxillary first molar
ENT & HEAD AND NECK EXAMINATION

25. Oral Cavity & Pharynx
Tongue
• Macroglossia/Microglossia
• Freidman Tongue Position
 I - Tonsils, tonsillar pillars & uvula seen
 II - Uvula seen but not tonsils
 III - Soft palate seen
 IV - Only hard palate seen

26. • Hard Palate :- High arched
• Soft Palate: Low lying, Thick, Webbed
(Redundant posterior pillars)

27.  Uvula
• Long/Wide/Thick/Embedded in
soft tissue
 Tonsil
• Grade I - < 25% obliteration of airway
• GradeII - 25-50% obliteration of airway
• GradeIII - 50-75% obliteration of airway
• GradeIV - >75% obliteration of airway
 Pharynx
• Nasopharyngeal tumor/ enlarged adenoids/
palatal & lingual tonsils/ retropharyngeal mass

28. • Deformities of ext. nose
• Soft tissue asymmetry
• Nasal valve collapse
• Polyps
• Stenosis
• DNS
• Turbinate hypertrophy
• Nasal masses
 Larynx
 Tumors/ Oedema/ Laryngotracheomalacia
 Nose
 Increased nasal resistance leads to negative pressure in
the pharynx

29.  OVERNIGHT POLYSOMNOGRAPHY
• EEG- Division of NREM into Stages 1 to 4
• Submental EMG- Differentiates between REM & arousal
• EOG- Detection of REM stage
• O2 Saturation- pO2 < 92% & pCO2 > 53% is diagnostic
• ECG/Holter for Apnoea induced arrythmia
• Nasal/Oral Airflow
• Chest/Abdominal Movememt- Elastic belt around chest &
abdomen differentiates between Central & Obstructive Sleep
Apnoea
• ET CO2 - >50 % for more than 9 % of sleep / > 53 % peak level
• Oesophageal Baloon Manometer- Measurement of respiratory
effort instead of respiratory movement
• Anterior Tibial EMG – Periodic movement during sleep
• Arterial Blood Gas – Adequacy of alveolar ventilation, Severity
of hypoxia & Acid-base balance status
• Rhinomanometry to measure amount of nasal resistance

30.  MULLER’s MANEOUVRE
 Flexible nasopharyngoscopy in awake patients
 Swallowing with closed mouth & nostrils
 Lateral narrowing > AP Narrowing
 Doesn’t satisfactorily predict the level of airway obstuction
during sleep
 Evaluates only airway lumen
 Grade I- Minimal collpase
 Grade II- 50% collpase
 Grade III- 75% collpase
 GradeIV- Obliteration of airway

31.  CEPHALOMETRY
 Lateral X-ray Head & Neck
 Length of Soft Palate: Males-41mm, Females-37.3mm
 Posterior Airway Space: Males-14.5mm, Females-13.7mm
 Position of hyoid relative to mandibular plane (MPH)
Males-19.5mm, Females-15.8mm
 MPH>24mm & PAS <5mm Increased chances of OSAH
 FLUOROSCOPY
 Detection of upper closure during sleep in patients with OSAH
 Not sensitive & significant
 Radiation exposure
IMAGING STUDIES

32.  COMPUTED TOMOGRAPHY
• Narrowing in the retropalatal region during wakefulness & sleep
• Large tongue volume & small airway in obese patients with sleep
apnoea
• Dynamic Imaging with Electon Beam CT can analyse changes in
upper airway during inspiraton and expiration in wakefullness
• Gives an accurate assesssment of upper airway cross sectional
area
• Poor resolution of upper airway adipose tissue
 Phase I- Increased upper airway area (Onset of Inspiration)
 Phase II- Constant upper airway area (During Inspiration)
 Phase III- Largest airway calibre (Onset of expiration)
 Phase IV- Least upper airway area (End of expiration)

33.  MAGNETIC RESONANCE IMAGING
 Excellent upper airway soft tissue resolution including adipose
tissue
 Accurate determination of cross sectional area & volume
 Contraindicated in patients with ferromagnetic clips or
pacemakers

34. Grade
I
II
III
IV
V
VI
Obstruction
Simple palatal flutter
Single level palatal obstruction
Palatal level obstruction with intermittent
oropharyngeal involvement
Sustained multisegmental obstruction
Tongue base level obstruction
Isolated epiglottic involvement
 SLEEP NASENDOSCOPY
 Sedation with Propofol to a level of sleep sufficient to induce
snoring
 Examination of upper aerodigestive tract in supine position
with a nasendoscope, to determine the levels of obstruction

35. TREATMENT
•
•
•
•
Medical
Appliances - nasal splint, mandibular positioning device,
tongue retaining device
Surgical
If anatomic obstruction is present, corrective surgery should
be done
NONSURGICAL TREATMENT
•
•
•
•
Weight loss
Treatment of systemic disorders
Alcohol advice
Drugs review

36. MEDICAL TREATMENT
Drug treatment
•
•
•
• Protryptiline (increases the neuromuscular activity of upper
airway & decreases REM sleep)
• Theophylline
• Progesterone
• Modafinil (improves wakefulness by decreasing GABA
mediated neurotransmission)

37. APPLIANCES
• Mandibular positioning device – in non obese patients with
micrognathia / retrognathia, advances the mandible and
increases posterior airway space, has success rate of 50 % &
compliance rate of 25%
• Tongue retaining device
• Positional devices
• Nasal splints
• Nasal CPAP & Nasal BiPAP

38. MANDIBULAR POSITIONING
DEVICE
NOZOVENT NASAL SPLINT
TONGUE RETAINING DEVICE

39. Continuous positive airway pressure
treatment
• The CPAP is a machine composed of a flow generator, a
hose, and an interface
• The flow generator provides airflow, the interface is a
mask placed on the person’s face, and the hose connects
the two
• The user is provided with a constant stream of
compressed air
• The pressure from the air keeps the airway open &
preventing the number of sleep apnea episodes
• It is the pressure, not the actual airflow that forces the
airway to stay open
• The air pressure is measured in cm per water, and most
patients use a range from 6 to 14 cm per water

41. Disadvantages of CPAP
• Many are reluctant to try this method at first due to the
inconvenience of the mask, hose, and machine
• The air pressure also causes some patients to experience
nasal congestion or a runny nose, and it may take a few
weeks to adjust to the machine
• The disadvantages are mainly because of comfort reasons,
and there are really no serious side effects

42. SURGICAL TREATMENT
 Indications
 Oxygen saturation < 85%
 Apnoeic Index > 40
 Significant day time sleep
 Heroic sleep
 Significant cardiac arrythmia during sleep
 Failed medical treatment

43. NASAL PROCEDURES
• The main goal is to relive the obstruction as an
adjunctive measure to improve the outcomes of
continuous positive airway pressure (CPAP) by
reducing CPAP pressure requirements, an oral
appliance, or other surgery.
• Although nasal surgery in isolation does not have a
consistent effect on the apnea-hypopnea index in
OSA patients.
 Adv:- improving snoring
 Improve subjective sleep quality
 Reduce daytime sleepiness

44. Turbinate reductions reduce the obstruction
caused by inferior turbinate.
• Submucosal resection combined with lateral
displacement is the most effective at decreasing nasal
obstruction caused by inferior turbinate hypertrophy.
• In patients with turbinate hypertrophy from allergic and
nonallergic rhinitis, medical therapy is the primary
treatment.
• Include intranasal corticosteroid sprays, antihistamines,
decongestants, cromolyn, sympathomimetics,
immunotherapy, and even direct injection of the
turbinates with corticosteroids

45. • Patients with mucosal redundancy or bony
turbinate hypertrophy will not respond to
medical therapy and are surgical candidates.
• Partial inferior turbinectomy; turbinoplasty;
laser-assisted turbinoplasty; cryosurgery;
treatment with infrared light; chemical or
electrical coagulation; and radiofrequency
volume turbinate reduction.

46. • Preserving mucociliary clearance is one of the most
important factors for maintaining functionality of
the turbinates.
• The surgeon must also keep in mind that techniques
that involve a laser, radiofrequency device, or other
devices add additional cost and time to the surgery

47. 1) Turbinectomy :-
 A total turbinectomy should not be
performed because it predisposes to the
empty nose syndrome and causes
excessive drying and crusting of the nose.
 It is done with the help of nasal endoscope
and microdebrider ,is used to shave away
the extra tissue and suction it out.
 Done under GA or LA .

48. MODIFIFIED MABRY TECHNIQUE
• To resect the redundant mucosa and conchal
bone while preserving adequate turbinate to
maintain function and prevent empty nose
syndrome.
• Disruption in the remaining turbinate is
minimal so as to preserve mucociliary
clearance.

49. Modifified Mabry technique
An incision is made on the undersurface of the inferior turbinate (blue arrow) and the
mucosal flap is elevated medially (black arrow). The Knight scissors are then used to
conservatively resect the lateral mucosal flap in continuity with excess bone (white
arrow). Then, the mucosa is reapproximated laterally .

50. 2) Turbinoplasty :-
 Also called outfracture technique.
 It is done in order to change the position of the
turbinate.
 Depending on the severity of nasal obstruction,
some turbinate tisssue may be shaved off.
 Microdebrider assisted or ultrasound turbinate
reduction.
 Done under GA or LA.

51. 3) Radiofrequency ablation :-
Radiofrequency energy is used to shrink
down the turbinates.
Most minimally invasive technique.
Can be done under LA.
If the turbinate grows back, this procedure
can be repeated later.

52. Needle like instrumnt inserted into the turbinate
Energy is transmitted to the tissue to cause a
controlled damage
So by the time healing process occurs
Turbinate will be reduced
Allowing improved airflow through the nose

53. COMPLICATION OF TURBINATE
REDUCTION
• Bleeding
• Infection

54.  Septoplasty straightening a deformity of
the nasal septum.
Rhinoplasty corrects any anatomical
deformities that compromise the nasal
airway.

55.  Nasal valve surgery improves the airflow
in patient with nasal valve obstruction.
• The harvested septal cartilage can easily be
fashioned into spreader grafts for stenting of
the internal nasal valves or batten grafts for
bolstering the valve area.
• Ear carilage can also be used.

56. Spreader graft Batten graft

57. Internal nasal valve
correction :-
• Starting from the
hemitransfixion incision,
extramucosal
skeletonization of the
endonasal section of the
middle vault allowed for
the exposure of supero-
medial, superior and
lateral aspect of the valve
area.

58. • Deformities of the caudal margin of the upper
lateral cartilages (ULCs) were corrected, as
well as thickening or deflections of the
superior segment of the septum.
• The septum-upper lateral cartilage complex
was contoured to restore a normal anatomic
relationship and a physiologic valve angle.

59. External nasal valve correction :-
• Morphologic columellar anomalies are corrected by
columelloplasty.
• The acute naso-labial angle is adjusted by placing an
intracolumellar strut.
• Intrcolumellar strut graft is usually constructed from autologous
septal cartilage.

60. UPPER PHARYNGEAL PROCEDURES
Tonsillectomy:--
• The extent to which tonsillar hypertrophy contributes to
OSA in adults remains unclear.
• Tonsillectomy with adenoidectomy is the first line
treatment in pediatric patients with severe OSA and
adenotonsillar hypertrophy.
• It also showed substantial improvement in AHI severity,
oxyhemoglobin saturation and sleep quality in obese
patient with OSA .
• Patients who undergo tonsillectomy often experience
significant reduction in the CPAP pressure required.

61. COMPLICATION OF
ADENOTONSILLECTOMY
• Hemorrhage
• Injury to surrounding structure
• Aspiration
• Pulmonary oedema
• Pain
• Infection
Velopharyngeal insufficiency
• Grisel syndrome
• Recurrence

62. Uvulopalatopharyngoplasty
• First surgical procedure specifically
• Most commonly performed surgical procedure to
treat OSA.
• There are multiple approaches have been introducing to
address the narrowing or collapse of the retropalatal
region.
• It traditionally involved removal of the uvula, a portion of
the soft palate, tonsils and closure of the tonsillar pillars.
• All the new techniques increase the dimension of the
pharyngeal airway to reduce obstruction.

63. LATERAL PHARYNGOPLASTY
• Done under GA.
• This procedure combined with tonsillectomy
and involve combination of tissue removal
and tissue repositioning of the soft palate as
well as the lateral pharyngeal wall.

64. • Goal :- Increase the size of the airway
without affecting breathing, speaking, and
swallowing.
Drawback :-
• Require more dissection
• More difficult to perform
• Longer recovery time

65. Microdissection of the superior pharyngeal constrictor muscle within the tonsillar
fossa, sectioning of this muscle

66. Suturing of the created laterally based flap of that muscle to the
same side palatoglossus muscle

67. Zetapalatopharyngoplasty
(Z-palatoplasty)
• Done under GA.
• Criteria :- Friedman Stage 2 and 3
:- Appearance of obstruction at the level
of soft palate contributing to OSAH
• Widen the space between the palate and
posterior pharyngeal wall, between the palate
and tongue base, and either to maintain or even
widen the lateral dimensions of the pharynx.

68. Tonsillectomy Incision of the palatal flap

69. Mucosa over the palatal flap is
removed, exposing the palatal
musculature
Uvula and palate are split in the midline
with cold knife

70. Uvular flap along with the soft palate
are reflected back laterally over the
soft palate
Two layered closure of the palatal
flaps

71. Lateral view of the soft palate and
the uvula after the mucosa is
excised. Note the uvula and palate
are hanging close to the posterior
pharyngeal wall, narrowing the
retropharyngeal space.
Lateral view showing the
widening of the nasopharynx
after midline palatoplasty.

72. • After the ZPPP, the anterolateral direction of pull
on the soft palate widens the retropalatal space.

73. Traditional uvulopalatopharyngoplasty. The direction of pull
is anteromedial, eventually narrowing the retropharyngeal
airway in the midline.

74. Expansion sphincter pharyngoplasty
• Also known as functional expansion
pharyngoplasty.
• Done under GA.
• Better result than UPPP.
• Used to treat OSA and is combined with
tonsillectomy in patient who have tonsils that
have not previously been removed.

75. • Goal :- Increase the size of the airway without
affecting breathing, speaking, and swallowing.
• Indication :- Moderate or severe OSA with
lateral pharyngeal wall collapse.
• Creates more powerful tension in the lateral
pharyngeal wall and reduces the bulk of lateral
pharyngeal soft tissue by isolating and rotating
the palatopharyngeus muscle
superoanterolaterally.

77. After completion of tonsillectomy, the right
palatopharyngeus muscle (asterisk) is identified

78. A horizontal incision is made to divide the inferior
end of the palatopharyngeus muscle (asterisk),
with care taken to leave its fascia attachments to
the deeper horizontal constrictor muscle.

79. Absorbable suture is used to fix the
palatopharyngeus muscle to the pterygo
mandibular raphe (white arrowhead) through a
mucosal tunnel (yellow arrowhead) at the anterior
pillar.

80. Mucosal closure is performed, and ESP
creates tension in the lateral
pharyngeal wall.

83. Palatal advancement
• Also known as Transpalatal advancement
phayngoplasty or Palatal advancement
pharyngoplasty.
• Done under GA.
• It is performed less often than other type
of palatal surgery.

84. • Goal :- Increase the size of the airway without
affecting breathing, speaking, and swallowing.
• Soft palate is elevated by advancing it towards
the hard palate.
• Advantage :- Less pain than other palatal
surgery

88. ADVERSE EFFECT OF PALATAL
SURGERY
• Bleeding
• Oronasal fistula :- Generally heal without any
treatment , certain patient require mouthpiece to
covering the healing area
• Infection
• Difficult swallowing
• Change in speech
• Throat dryness
• Tooth injury
• Continued snoring:-This surgery eliminate OSA
but some patient have loud snoring.

89. PALATAL RADIOFREQUENCY
• GA or sedation not required.
• Criteria :- Typically reserved for snoring or
Upper airway resistant syndrome patient
• Required 2 to 3 treatment session.

90. •Energy is delivered at 3-5 locations with a
specially designed probe to heat the soft tissue in
a controlled fashion and create a certain amount
of damage.

92. Adverse effect of palatal radiofrequency
• Palatal ulcer
• Palatal hole

93. •To determine the likelihood for successful resolution of
OSA after UPPP, a staging system was developed based
on tonsil size, tongue-palate position, and BMI.
Stage Friedman palate
position
Tonsil size BMI
I 1-2 3-4 <40
II 1-2
3-4
0-1-2
3-4
<40
III 3-4 0-1-2 <40
IV any any >40

94. Success rate of UPPP :-
• Stage I - 80%
• Stage II - 37.9%
• Stage III - 8.7%

95. UPPP
• Procedure addresses the obstruction at the soft
palate area only, without improving the airway at
the base of the tongue (hypopharyngeal area) or
nasal cavity.
• In addition, scar contracture at the posterior
border of the soft palate can create a “curtain”
effect, pulling the soft palate downward against
the tongue and causing significant transverse
narrowing between the posterior faucial pillars,
further contributing to OSA.

96. ADVERSE EFFECTS OF UPPP
• Severe transient throat pain and chronic subjective
dysphagia.(MOST COMMON)
• Pharyngonasal reflux (nasal regurgitation)
• Trouble with smell and taste
• Pharyngeal dryness
• Voice change(Hyoernasal speech)
• Palatal stenosis
• The new technique used in UPPP like radiofrequency
tissue volume reduction (RFTVR) is safer and less
painful than resection technique.

97. LOWER PHARYNGEAL AND
LARYNGEAL PROCEDURES
1) Tongue reduction procedures
2) Tongue advancement
3) Maxillomandibular advancement
4) Hypoglossal nerve stimulation
5) Tracheostomy

98. TONGUE REDUCTION PROCEDURES
1) Radiofrequency tissue ablation :-
• Also known as tongue coblation,
Somnoplasty.
• It is a minimal invasive procedure.
• Procedure can be done in outpatient clinic
without requiring sedation or GA.
• Usually 2-3 treatment sessions required.

101. 2) Lingual tonsillectomy:-
• Improves airway by removing obstructing
lingual tonsil tissue.
• Done under GA.

103. 3) Partial Midline Glossectomy:-
• Resection of the midline tongue base tissue.
• Done unde GA.
• Adverse effect :- More painful so abandoned.
• It is performed by working through the open mouth
without any external incisions except a small one on
the neck for a plastic drain placed at the time of
surgery

106. ADVERSE EFFECT OF TONGUE
REDUCTION
• Bleeding
• Infection
• Change of voice :-
Due to hypoglossal nerve damage which change the
movement of tongue

107.  Tongue numbness or tingling :-
 Radiofrequency treatment involves heating part of the tongue,
and this can produce lingual nerve damage.
 This nerve is located along the sides of the tongue deep
down in the tongue, and therefore the treatments are
primarily given to the central part of the tongue and the
superficial areas on the sides of the tongue.
 If nerve damage or these symptoms do occur, usually the
damage is temporary with recovery over the course of days or
weeks, but the damage can take months to recover or be
permanent.
 Tongue weakness or trouble swallowing:-
 Due to Hypoglossal nerve involvement

108. TONGUE ADVANCEMENT
1. Tongue-base suspension :-
• Done under GA.
• Stabilize the tongue and prevent
retrolingual collapse by placing a suture
to the anterior mandible to create a
tongue base sling.

109. • The mouth was opened by a
jaw retractor and the
operation was performed
using the repose bone screw
system , which consists of a
bone screw, which is a
sharp-tipped small-diameter
titanium screw with two
prolene monofilament
number 1 sutures crimped
into its base.

110. • The floor of the mouth at
the frenulum was
anesthetized locally using a
vasoconstrictor.
• An incision of about 1.5cm
was made in the midline of
the frenulum, between the
two Wharton ducts, taking
care not to injure the ductal
orifices.

111. • The inner periosteum was
then lifted by a curved
hemostat that was passed
through the incision into
the floor of the mouth.
• Inserter is activated to
drive the screw to the
inner table of mandible.

112. • One of the 2 prolene
sutures is passed to the
tongue base about 1.5 cm
lateral to the midline on the
right side by the suture
passer.

113. • Second prolene suture is
passed to the opposite
side of the tongue base
about 1.5 cm lateral to the
midline on the left side by
the suture passer.

114. • The Mayo needle is passed
submucosally to the
opposite side.

115. • Prolene suture is now
threaded onto the empty
suture loop.

116. • A triangular-shaped suture
pass with its base in the
posterior tongue.

117. 2. Genioglossus advancement :-
• Genioglossus is the largest muscle of the
tongue.
• Advancing the genial tubercle of the
anterior mandible forward and create an
osteotomy around it.
• Done under GA.

118. • An incision is made inside
the lower lip.
• The chin muscle and other
soft tissues are cleared away
to expose the central part of
the lower jaw.
• Small rectangular cuts
(roughly 1 x 2 cm) are made
in the lower jaw below the
lower front teeth to capture
the area of attachment of
the genioglossus muscle.
• This rectangle of bone is
moved forward and turned
slightly.

119. • A small titanium screw is
used to hold the bone
fragment in place by securing
it to the remainder of the
lower jawbone.
• The chin muscle and soft
tissues are replaced, and
stitches are used to close the
incision.
• The teeth and lower jawbone
are not moved.

120. 3. Hyoid suspension :-
• Suspend the hyoid bone to the thyroid cartilage
by using permanent suture.
• Done under GA.
• A small (usually 7-8 cm or 3 inches) skin
incision is made, ideally in a natural neck skin
crease to camouflage the scar.

121. • Four stitches are placed
around the hyoid bone
and the upper portion of
the thyroid cartilage to
stabilize the hyoid bone.

122. • The skin incision is
closed with stitches,
and usually a small
drain is placed for 1-2
days to allow any fluid
to escape without being
trapped underneath the
skin.

123. Maxillomandibular advancement
• The maxilla and the mandible are advanced
together with both upper and lower teeth to
widen the retrolingual and the retropalatal
segments of the upper airway.
• It is beneficial mainly for patients with
craniofacial issues.

124. • The maxilla is moved by a Le fort I osteotomy
and the mandible by a sagittal split
osteotomy.
• It showed a significant increase in the
pharyngeal airway dimensions and decrease
AHI score below the threshold of 20.

126. HYPOGLOSSAL NERVE STIMULATION
• New treatment for OSA by Implantable
neurostimulator device was approved by US
Food and Drug Administration in 2014.
• It keeps the lower pharyngeal airway open
during sleep by activates the protrusion
muscles of the tongue via the hypoglossal
nerve.

127. • Selective hypoglossal nerve
stimulation with respiratory
sensing uses an intercostal
sensor for the detection of the
patient’s breathing cycle.
• This information is processed
in the subclavian impulse
generator, which then delivers
an impulse to the stimulation
electrode at the lateral neck.
• The submentally positioned
cuff of the electrode activates
protrusor branches of the
distal hypoglossal nerve and
herewith, opens the upper
airway.

128. • For optimal positioning of
the stimulation electrode,
neuromonitoring guidance is
recommended to identify the
protrusor branches of the
hypoglossal nerve.
• The system is activated four
weeks after implantation
with another four weeks to
allow acclimatization.
• About eight weeks after
implantation, a
polysomnographic therapy
adjustment is performed in a
sleep laboratory to optimize
OSA therapy.

129. • Later, a regular annual
follow-up appointment is
recommended.
• When the sensing lead
detects inspiration is
occurring, the impulse
generator sends a signal
via the stimulation lead to
the hypoglossal nerve,
which results in slight
forward displacement of
the stiffened tongue.

130. OPERATIVE TECHNIQUE
• Plan neck incision:- 4-6 cm in
length, 1 cm from midline, 2 cm
below mandible
• Divide skin and platysma, small
inferior subplatysma flap identify
and retract digastric tendon and
submandibular gland, identify
mylohyoid and divide ranine vein
as necessary
• Hypoglossal nerve identification:
place vessel loop to isolate nerve

132. • Plan implantable pulse generator
(IPG) pocket: 5 cm inferior to
clavicle, 5.5 cm in length.
• Divide skin and subcutaneous
tissue. Bluntly dissect directly
down to pectoralis fascia,Size
pocket to 3 finger breadths.

133. • Sensor lead placement:-
• Incision at inferior margin of
right pectoralis major, inferior to
nipple.
• Choose intercostal space that is
superior to the xiphoid.
• Divide skin and serratus muscle.
• Identify external intercostals
(traversing inferior-medial).
• Place 1 cm bent malleable
retractor under external
intercostal to identify internal
intercostal muscle.

134. • Retractor should meet no
resistance at it enters
correct the correct plane
between internal and
external intercostal
muscles.
• Carefully place sensor lead
between intercostals and
secure with anchor
sutures.

135. Eligibility criteria include:
• Age > = 21 years old
• Moderate or severe OSA (AHI > 20 but less
than 65 events per hour)
• Predominantly obstructive events (central and
mixed apneas <= 25 percent of AHI).
• Unable to tolerate CPAP
• DISE shows no concentric velopharyngeal
collapse or any other anatomical findings.
• BMI < 32 kg/m2

136. • Hypoglossal Nerve Stimulation showed 68% decrease in
AHI score, oxygen desaturation index score decreased
by 70%, and improved quality of life.
• Adverse efffect :-
• Bleeding
• Infection
• Tongue weakness
• Tongue numbness
• Facial weakness
• Change in voice
• Limitation on MRI examination
• Pneumothorax (Collapsed lung)

137. TRACHEOSTOMY
• It is recommended primarily for patient with
sever and life threating OSA who failed all the
other treatment options and in morbid obese
patients.
• The most immediate, effective and definitive
treatment for OSA is placing a permanent
cannula in the neck to bypassing the upper
pharyngeal airway.

138. BARIATRIC SURGERY
• OSA is seen in about 45% of bariatric patients .
• Surgically induced weight loss showed
significantly improves obesity-related sleep
apnea.

139. MULTILEVEL SURGERY
• Patient with OSA could have multiple locations of
collapse in upper and lower pharyngeal tracts.
• Those patients would benefit from multilevel
surgery.
• DISE is now a standard procedure during the
presurgical evaluation which gives the surgeon
personalized anatomical information.
• A combination of multilevel procedures improved
the outcome compare to single-site procedure.