Obstructive sleep apnoea syndrome

1. Obstructive Sleep ApnoeaObstructive Sleep Apnoea
SyndromeSyndrome
Review-Surgical treatmentReview-Surgical treatment
considerationsconsiderations
Christos Michaelides DDS,MDChristos Michaelides DDS,MD
Oral-Maxillofacial SurgeonOral-Maxillofacial Surgeon
O.M.F.S dept YGIA PolyclinicO.M.F.S dept YGIA Polyclinic
Limassol Medical Association, 20/04/2016Limassol Medical Association, 20/04/2016

2. O.S.A.S-IntroductionO.S.A.S-Introduction
O.S.A.S is characterized byO.S.A.S is characterized by
• intermittent upper airway obstructionintermittent upper airway obstruction
• average duration of episodes 20-40sec.average duration of episodes 20-40sec.
• However, sometimes last > 100secHowever, sometimes last > 100sec
(Thawley 1985)(Thawley 1985)

3. O.S.A.S-Introduction/EpidemiologyO.S.A.S-Introduction/Epidemiology
• Obstructive sleep apnoea syndrome is aObstructive sleep apnoea syndrome is a
potentially severe disorder that affectspotentially severe disorder that affects
approximately 2%-9% of the adult population.approximately 2%-9% of the adult population.
• 10% of men and 5% of women are habitual10% of men and 5% of women are habitual
snorers in the 3rd decade with an increase tosnorers in the 3rd decade with an increase to
20% and 15% respectively, during the 520% and 15% respectively, during the 5thth
decade.decade.
• However, apnea during sleep has beenHowever, apnea during sleep has been
described in neonates, infants and teenagersdescribed in neonates, infants and teenagers
due to congenital or acquired pathology egdue to congenital or acquired pathology eg
Pierre-Robin syndr, Apert syndr etcPierre-Robin syndr, Apert syndr etc

4. O.S.A.S- Aetiology-DiagnosisO.S.A.S- Aetiology-Diagnosis
• The precise cause and pathogenesis of the upper airwayThe precise cause and pathogenesis of the upper airway
obstruction during sleep in O.S.A.S is not clarified inobstruction during sleep in O.S.A.S is not clarified in
most of the casesmost of the cases
• In some cases anatomic factors are implicated in theIn some cases anatomic factors are implicated in the
pathology of the disorderpathology of the disorder
• The diagnosis of the disorder demands a sequence ofThe diagnosis of the disorder demands a sequence of
laboratory investigations such as nocturnal polygraphiclaboratory investigations such as nocturnal polygraphic
sleep recording, blood oxygen saturation, breathingsleep recording, blood oxygen saturation, breathing
pattern and body positioning monitoringpattern and body positioning monitoring
(polysomnography)(polysomnography)
• The average of apneas and hypopneas during sleep isThe average of apneas and hypopneas during sleep is
represented by the respiratory distress index (R.D.I),represented by the respiratory distress index (R.D.I),
which is considered pathologic when >5/hwhich is considered pathologic when >5/h

5. O.S.A.S-Clinical manifestationsO.S.A.S-Clinical manifestations
• SnoringSnoring
• Restless sleepRestless sleep
• Excessive daytime somnolence (especially if RDI>20/h)Excessive daytime somnolence (especially if RDI>20/h)
• Morning headachesMorning headaches
• Depression, memory impairmentDepression, memory impairment
• Decreased libidoDecreased libido
• Increased risk for accidentsIncreased risk for accidents
• Sleep related arrhythmiasSleep related arrhythmias
• Systemic and pulmonary hypertensionSystemic and pulmonary hypertension
• Congestive heart failureCongestive heart failure

6. Pathophysiology of O.S.APathophysiology of O.S.A
The main factors that contribute to theThe main factors that contribute to the
development of O.S.A are:development of O.S.A are:
Reduced force of the pharyngeal dilatorsReduced force of the pharyngeal dilators
The negative inspiratory pressureThe negative inspiratory pressure
generated by the diaphragmgenerated by the diaphragm
Abnormalities of the upper airway (mostAbnormalities of the upper airway (most
effectively addressed by surgery)effectively addressed by surgery)
(Thawley 1985)(Thawley 1985)

7. Pathophysiology of O.S.APathophysiology of O.S.A
• Airway collapse often occurs when patientsAirway collapse often occurs when patients
sleep on their back and the base of the tonguesleep on their back and the base of the tongue
abuts the posterior pharyngeal wall and softabuts the posterior pharyngeal wall and soft
palate.palate.
• Any pathology of the tongue, soft palate, tonsils,Any pathology of the tongue, soft palate, tonsils,
pharyngeal mucosa that cause narrowing of thepharyngeal mucosa that cause narrowing of the
airway could cause snoring and O.S.A.airway could cause snoring and O.S.A.
• Further, an increased inspiratory pressure isFurther, an increased inspiratory pressure is
needed to maintain adequate ventilation.needed to maintain adequate ventilation.
• The negative pressure on inspiration causesThe negative pressure on inspiration causes
more collapse of the upper airway which inmore collapse of the upper airway which in
patients who snore or have O.S.A has poor tonepatients who snore or have O.S.A has poor tone
due to the repeated vibratory trauma.due to the repeated vibratory trauma.

9. Soft
Palate
PAS
Tongue
Epigloittis
Genioglossous
Muscle Palate

10. O.S.A.S - PathophysiologyO.S.A.S - Pathophysiology
• Genioglossus m.Genioglossus m.
• Geniohyoid m.Geniohyoid m.
• Tensor palati m.Tensor palati m.
• Stylopharyngeus m.Stylopharyngeus m.
The role of the above muscles on respiration isThe role of the above muscles on respiration is
crucial not only due to their anatomical locationcrucial not only due to their anatomical location
but also because their function is regulated bybut also because their function is regulated by
respiratory stimuli (hypercapnia,hypoxemia)respiratory stimuli (hypercapnia,hypoxemia)
(Shepard 1991,Powell 1995)(Shepard 1991,Powell 1995)

11. Diagnosis and treatment of O.S.ADiagnosis and treatment of O.S.A
• The success of any airway operation is basedThe success of any airway operation is based
on the accurate diagnosis of the site of theon the accurate diagnosis of the site of the
obstructionobstruction
• There is increasing evidence that multilevelThere is increasing evidence that multilevel
treatment is more likely to achieve better resultstreatment is more likely to achieve better results
than focusing on single site proceduresthan focusing on single site procedures
• An algorithmic approach to select the sites asAn algorithmic approach to select the sites as
well as the modalities of surgical interventionwell as the modalities of surgical intervention
would improve the outcome and would assist thewould improve the outcome and would assist the
patient to avoid procedures that is unlikely topatient to avoid procedures that is unlikely to
achieve the desirable resultachieve the desirable result (Ephros H, Madani M,(Ephros H, Madani M,
GellerBH, Atlas O.M.F.S Clin North Am 2007;15:89-100)GellerBH, Atlas O.M.F.S Clin North Am 2007;15:89-100)

12. The role of nasal obstruction inThe role of nasal obstruction in
snoring and O.S.Asnoring and O.S.A
Increased resistanceIncreased resistance
• producesproduces turbulent flowturbulent flow in the nasal cavity,in the nasal cavity,
induces oral breathing that alter upper airwayinduces oral breathing that alter upper airway
dynamics and promotes oscillation of pharyngealdynamics and promotes oscillation of pharyngeal
airway which can lead to snoringairway which can lead to snoring
• Increases negative inspiratory pressureIncreases negative inspiratory pressure andand
functional narrowing of the pharyngeal airwayfunctional narrowing of the pharyngeal airway
resulting to hypoxia and sleep apnearesulting to hypoxia and sleep apnea
Although it is unlikely the nasal pathology to beAlthough it is unlikely the nasal pathology to be
the sole cause of snoring or O.S.A should not bethe sole cause of snoring or O.S.A should not be
overlookedoverlooked

13. Obstruction at the level ofObstruction at the level of
oropharynxoropharynx
• Pathology and obstruction at the level of soft palate, pharynx andPathology and obstruction at the level of soft palate, pharynx and
tonsillar pillars is a more common finding in patients that developtonsillar pillars is a more common finding in patients that develop
snoring and O.S.Asnoring and O.S.A
Surgical procedures mostly used:Surgical procedures mostly used:
• Uvulopalatopharyngoplasty (UPPP) Fujita et al.)Uvulopalatopharyngoplasty (UPPP) Fujita et al.)
• Laser assisted uvulopalatoplasty (LAUPP) Kamani 1980Laser assisted uvulopalatoplasty (LAUPP) Kamani 1980
• Laser assisted-UPPP Madani et alLaser assisted-UPPP Madani et al
• Nd-YAG laser Ellis,1993Nd-YAG laser Ellis,1993
• RF (radiofrequency) tissue ablation initiated by Powell et alRF (radiofrequency) tissue ablation initiated by Powell et al
• Placement of palatal implants (minimal invasive procedure) (PET)Placement of palatal implants (minimal invasive procedure) (PET)
• Tonsillectomy in enlarged tonsils either with standard techniques orTonsillectomy in enlarged tonsils either with standard techniques or
with carbon-dioxide laser or RF ablation of tonsilswith carbon-dioxide laser or RF ablation of tonsils
The success of the above techniques relies on cautious patientsThe success of the above techniques relies on cautious patients
selection and the low BMI (Body mass index<25)selection and the low BMI (Body mass index<25)

14. Retrolingual - HypopharyngealRetrolingual - Hypopharyngeal
ObstructionObstruction
• Obstruction of the retrolingual space is commonly encountered in snoring
and O.S.A patients
• The anterior and lateral borders of the floor of the mouth are defined by the
mandibular framework
• The superior strap muscles are located inferior to the framework and the
pharyngeal wall completes this framework posteriorly and laterally
• The tongue and the hyoid bone are both related to the above frameworkThe tongue and the hyoid bone are both related to the above framework
through the genioglossus and superior strap muscles respectively as well asthrough the genioglossus and superior strap muscles respectively as well as
to each otherto each other
• Obstruction at this level could be the result of inadequacy of this frameworkObstruction at this level could be the result of inadequacy of this framework
either due to the size (micrognathia) or to the position (retrognathia) of theeither due to the size (micrognathia) or to the position (retrognathia) of the
mandible, to maintain the support to the related soft tissuesmandible, to maintain the support to the related soft tissues

15. Minimize predisposing factorsMinimize predisposing factors
•Weight loss (10% loss of weight leads to 26% reduction of AHIWeight loss (10% loss of weight leads to 26% reduction of AHI))
•Stop alcohol consumptionStop alcohol consumption
•Stop smokingStop smoking
•Avoid sedativesAvoid sedatives
•Head up during sleepHead up during sleep
Non-surgical treatmentNon-surgical treatment

16. C-PAP:C-PAP:
Improves day sleepiness, blood-pressure and quality of life in generalImproves day sleepiness, blood-pressure and quality of life in general
However, many studies revealed controversial results with reference toHowever, many studies revealed controversial results with reference to
cardiovascular disease controlcardiovascular disease control,, insulin resistanceinsulin resistance control as well ascontrol as well as
improvement of neurophysiology especially in non-severe OSA casesimprovement of neurophysiology especially in non-severe OSA cases
According to significant number of studies that considered as “adequate”According to significant number of studies that considered as “adequate”
the use of the respirator for > 4 hours per night and in >70% of the totalthe use of the respirator for > 4 hours per night and in >70% of the total
time of use : 30%-80% of the patients used the C-PAP non regularly andtime of use : 30%-80% of the patients used the C-PAP non regularly and
inadequatelyinadequately
(Kushida CA,(Kushida CA, HirshkowitzHirshkowitz,, 2006;29(3):375-80)2006;29(3):375-80)
Treatment withTreatment with
C-PositiveC-Positive
Airway PressureAirway Pressure

18. Oral Appliances
•Applicable in mild-moderate cases only
•Keep the tongue and lower jaw in an
anterior position during sleep
•Contraindicated in TMJ Syndrome
cases
•Follow-up on regular basis by the
Dentist and Evaluation by Sleep
Laboratory is necessary

19. Which patient is a candidate for O.S.A surgicalWhich patient is a candidate for O.S.A surgical
treatment:treatment:

20. • Pre-op medical history, clinical manifestationsPre-op medical history, clinical manifestations
(information given by the partner, obesity, structure(information given by the partner, obesity, structure))
• Clinical and para-clinical evaluation of concomitantClinical and para-clinical evaluation of concomitant
complications and other diseasescomplications and other diseases
• Confirmation study by accredited Sleep LaboratoryConfirmation study by accredited Sleep Laboratory
• Evaluation of the efficacy of previous treatmentEvaluation of the efficacy of previous treatment
methods eg C-PAPmethods eg C-PAP
Pre-opPre-op
investigationinvestigation

21. • Lateral cephalometric analysisLateral cephalometric analysis ((craniofacial anomalycraniofacial anomaly
compatible to O.S.Acompatible to O.S.A)) combined with:combined with:
• Naso-phyryngoscopy(Naso-phyryngoscopy( fiberoptic endoscopefiberoptic endoscope ++ Mueller’sMueller’s
maneuvermaneuver//
((location of dynamic obstruction or airway collapselocation of dynamic obstruction or airway collapse))
• 33D imagingD imaging // face and airwayface and airway
Pre-opPre-op
investigationinvestigation

23. Cephalometric analysisCephalometric analysis
(Parameters for pre-op and post-op(Parameters for pre-op and post-op
comparison)comparison)
1.1.PASPAS: (norms 11+/- 1 mm) If less than normal range suggests posterior location of tongue: (norms 11+/- 1 mm) If less than normal range suggests posterior location of tongue
and obstruction during sleepand obstruction during sleep
2.2.SNASNA:: Indicates the location of maxilla with reference to the base of skullIndicates the location of maxilla with reference to the base of skull
3.3.SNBSNB:: Indicates >> >> mandible >> >> >>>>Indicates >> >> mandible >> >> >>>>
4.4.BaSN: indicates the position of posterior pharyngeal wallBaSN: indicates the position of posterior pharyngeal wall (norms 129)(norms 129)
5.5.PNS-P:PNS-P: If > (norms 37+/- 3mm) indicates posterior position of the palate and obstruction ofIf > (norms 37+/- 3mm) indicates posterior position of the palate and obstruction of
nasopharynx during sleepnasopharynx during sleep
6.6.MP-H:MP-H: (norms(norms15.4 +/- 3mm)15.4 +/- 3mm) If > than norms suggests lowerIf > than norms suggests lower
location of the hyoid bone and obstruction at retrolingual levellocation of the hyoid bone and obstruction at retrolingual level

24. • The success of the surgical approachThe success of the surgical approach
depends on the identification of the site ofdepends on the identification of the site of
obstruction and the application of the moreobstruction and the application of the more
suitable operation according to each patientsuitable operation according to each patient
needsneeds
• There is general and constantly growingThere is general and constantly growing
indication that the intervention in multipleindication that the intervention in multiple
levels suggests better results than operationslevels suggests better results than operations
focusing on a single level of obstructionfocusing on a single level of obstruction
SurgicalSurgical
TreatmentTreatment

25. Advancement proceduresAdvancement procedures
 Genioglossus advancementGenioglossus advancement for mild or moderatefor mild or moderate
O.S.A. for the anterior repositioning of the tongue (smallO.S.A. for the anterior repositioning of the tongue (small
rectangular bone cut that captures the attachment ofrectangular bone cut that captures the attachment of
genioglossus is moved forward and fixed with a 2mmgenioglossus is moved forward and fixed with a 2mm
titanium screw)titanium screw)
 The above combined withThe above combined with hyoidhyoid
myotomy/suspension (GAHM)myotomy/suspension (GAHM) may be indicatedmay be indicated
when hypopharynx is the site of obstruction (detach thewhen hypopharynx is the site of obstruction (detach the
infrahyoid muscles from the hyoid and the bone is fixatedinfrahyoid muscles from the hyoid and the bone is fixated
to the thyroid cartilage with non resorbable sutures)to the thyroid cartilage with non resorbable sutures)
 The above combined with UPPP or MMA in patients withThe above combined with UPPP or MMA in patients with
multilevel obstructionmultilevel obstruction

26. Advancement proceduresAdvancement procedures
 Advancement genioplastyAdvancement genioplasty Apart from theApart from the
advancement of genioglossus the attachments of theadvancement of genioglossus the attachments of the
anterior bellies of digastrics and geniohyoid muscles areanterior bellies of digastrics and geniohyoid muscles are
also advanced. Therefore, simultaneous anterioralso advanced. Therefore, simultaneous anterior
movement of the tongue and more favourable hyoidmovement of the tongue and more favourable hyoid
bone position is achievedbone position is achieved
 Maxillo-mandibular advancement (MMA)Maxillo-mandibular advancement (MMA) RatherRather
major operation that should be considered when themajor operation that should be considered when the
conservative therapy fails or is not tolerated and patientsconservative therapy fails or is not tolerated and patients
anatomy suggests that other methods are not likely toanatomy suggests that other methods are not likely to
produce significant improvementproduce significant improvement

28. Distraction Osteogenesis as aDistraction Osteogenesis as a
treatment option for O.S.Atreatment option for O.S.A
• Viable alternative to MMA or in conjunction withViable alternative to MMA or in conjunction with
MMAMMA
• Reliable surgical method to alleviate the narrowReliable surgical method to alleviate the narrow
upper airway especially in patients with severeupper airway especially in patients with severe
cranio-facial deformities (Lu et al)cranio-facial deformities (Lu et al)
Consists of slow and controlled advancement ofConsists of slow and controlled advancement of
the tooth-bearing segments of the jaws withthe tooth-bearing segments of the jaws with
simultaneous growth of the surrounding softsimultaneous growth of the surrounding soft
tissue envelope. Needs minor surgery andtissue envelope. Needs minor surgery and
insertion-fixation of the distractorinsertion-fixation of the distractor

29. O.S.A.S-Distraction OsteogenesisO.S.A.S-Distraction Osteogenesis
• Distraction osteogenesis is divided in fourDistraction osteogenesis is divided in four
phases:phases:
 Surgery (osteotomies)Surgery (osteotomies)
Distraction 1-2mm/day (In adults starts in 5-7Distraction 1-2mm/day (In adults starts in 5-7
days after osteotomies and distractor fixation)days after osteotomies and distractor fixation)
Consolidation (6-10/52)Consolidation (6-10/52)
Hardware removalHardware removal

31. Case ReportCase Report
• A 48y male presented at Pulmonary Medicine dept of our hospitalA 48y male presented at Pulmonary Medicine dept of our hospital
c/o dyspnea, sleep disturbance and daytime sleepiness.c/o dyspnea, sleep disturbance and daytime sleepiness.
• Lab investigation: Ht=58%, PO2=58.5mmHg, PCO2=56.9mmHg.Lab investigation: Ht=58%, PO2=58.5mmHg, PCO2=56.9mmHg.
• Severe O.S.A.S with associated respiratory failure was diagnosedSevere O.S.A.S with associated respiratory failure was diagnosed
and the patient was treated with C-PAP ventilator during sleep for aand the patient was treated with C-PAP ventilator during sleep for a
couple of weeks.couple of weeks.
• Referred to the O.M.F.S dpt for consultation and probable surgicalReferred to the O.M.F.S dpt for consultation and probable surgical
intervention due to micrognathiaintervention due to micrognathia
• On admission the patient had significant micrognathia andOn admission the patient had significant micrognathia and
asymmetry of the lower jaw plus significant class II-divisionasymmetry of the lower jaw plus significant class II-division
malocclusion and limited mouth opening (18mm) and macroglossia.malocclusion and limited mouth opening (18mm) and macroglossia.
• The radiological examination revealed L TMJ ankylosis, increased LThe radiological examination revealed L TMJ ankylosis, increased L
antegonial notch and hypopoplastic L ramus of the mandibleantegonial notch and hypopoplastic L ramus of the mandible

32. Case ReportCase Report
• Underwent surgery under G.A. by endoscopicallyUnderwent surgery under G.A. by endoscopically
induced intubationinduced intubation
• Vertical osteotomy was performed bilaterally in theVertical osteotomy was performed bilaterally in the
posterior premolar region followed by the subperiostealposterior premolar region followed by the subperiosteal
placement of the Vaquez-Diner distractors.placement of the Vaquez-Diner distractors.
• A traction tongue-base suture was then applied and theA traction tongue-base suture was then applied and the
two ends of the triangular suture were tied togethertwo ends of the triangular suture were tied together
having passed through a preformed hole in thehaving passed through a preformed hole in the
symphysis.symphysis.
• The patient was transferred to I.C.U for the first 24 hoursThe patient was transferred to I.C.U for the first 24 hours

33. Case ReportCase Report
• Bilateral distraction was started with a rate of 0.4mm b.d after a latencyBilateral distraction was started with a rate of 0.4mm b.d after a latency
period of 7 daysperiod of 7 days
• The 20th post-op day the patient had developed ClassIII incisorsThe 20th post-op day the patient had developed ClassIII incisors
relationship and anterior open bite (A.O.B) Therefore, intermaxillary elasticrelationship and anterior open bite (A.O.B) Therefore, intermaxillary elastic
traction was applied to manipulate the callus formation in order to eliminatetraction was applied to manipulate the callus formation in order to eliminate
the A.O.Bthe A.O.B
• The distraction lasted 25 consequtive days on the R side and the achievedThe distraction lasted 25 consequtive days on the R side and the achieved
length was 20mmlength was 20mm
• On the left side was extended for one more week to correct asymmetry.On the left side was extended for one more week to correct asymmetry.
• After a consolidation period of 10 weeks the distractors and tongue-baseAfter a consolidation period of 10 weeks the distractors and tongue-base
suture were removed along with L condylectomy/arthroplastysuture were removed along with L condylectomy/arthroplasty
• Though the patient had no need of ventilator the post-op period wasThough the patient had no need of ventilator the post-op period was
referred back to the P.M.D for respiratory evaluation and monitoring at thereferred back to the P.M.D for respiratory evaluation and monitoring at the
sleep apnea laboratory.sleep apnea laboratory.
• Significant improvement of the parameters was confirmedSignificant improvement of the parameters was confirmed

34. Pre-op O.P.TPre-op O.P.T

36. Pre-op and Post-op profile photosPre-op and Post-op profile photos

37. Pre-op and post-op lateral CephPre-op and post-op lateral Ceph

38. Lab values: Pre-op /C-PAP /Post-Lab values: Pre-op /C-PAP /Post-
opop