Laser vs. Coblator For Snoring and OSA Dr.K.O.Paulose FRCS,DLO Consultant ENT SurgeonJubilee Hospital,Trivandrum,Kerala,India. www.drpaulose.com www.snorefreesleep.com
ENT Surgical Experience in Sleep Surgery Over 35 years Experience in ENT 1978-1986UK-NHS Hospitals 1986-2003Bahrain Military Hospital 2004-2009S.U.T Hospital.Trivandrum 2010-OnwardsJubilee Hospital,Trivandrum
History of UPPP Surgery Fujita et al in 1981 introduced the operation of UPPP for OSA. This involved excision of tonsils, terminal soft palate and uvula under general anesthesia.
Kumbhakarna-Great Snorer Kumbhakarna is an important character in the Hindu epic Ramayana. He is a Rakshas as well as brother of Ravana, king of Lanka. Brahma was pleased with Kumbhakarna and offered him a boon. He used to snore very loud while sleeping.
Mechanism of Snoring Snoring is the sound produced by the vibration of soft palate and Uvula. It causes air turbulence in the upper airway
Causes Of Snoring Nasal Obstruction Enlarged, Uvula, Soft Palate, Tongue Enlarged Ts Ads Lack of Muscle tone upper airway Air Turbulence in the oropharynx Vibration of soft palate and uvula Venturi Effect- Bernoulli principle
About Sleep apneaWhat is Sleep apnea? Stoppage of breathing while asleep More than 10 seconds 100-500 episode of apneas in one night Plus Hypopneas Cause Hypoxia and HypercarbiaTypes of sleep apnea Obstructive Sleep Apnea (OSA)Obstruction of upper airway, Snoring Central Sleep Apnea (CSA)Brain stem lesion, stroke, polio, brain tumors-No snoring Mixed sleep apnea (OSA+CSA) Chronic respiratory failure>central
Snoring in Women Men: women ratio 2:1 Undiagnosed Hormonal changes Post menopausal Pregnancy and snoring Hypothyroid,DM
Signs and symptoms of sleep apnea Choking or gasping during sleep Loud snoring Sudden awakenings to restart breathing Waking up in a sweat during the night Feeling tired in the morning Headaches, memory loss Daytime sleepiness Lack of concentration,fatigue,irritable Low O2- Brain and Heart-BP, Stroke Type 2 Diabetes Low sex drive-libido
Diagnosis of Sleep Apnea Good History from spouse or parents Physical examination-Nose and Throat Voice recording Flexible Endoscopy CT imaging or MRI retro palatal and pharyngeal airway Sleep study-Polysomnogram-Home Sleep Study Cardiac evaluation
Sleep Study Polysomnogram Home Sleep study Sleep Lab Study
Treatment of Snoring and Sleep ApneaConservative Weight Loss Avoid Alcohol Dental devices, dilators Avoid sleeping pills or narcotics before bed Stop Smoking Dont sleep on your backSurgical Treatment Nasal surgery, Septal surgery,LAPT UPPP-LAUP+Coblator surgery Ts Ads RF Somnoplasty Glossectomy Mandibular osteotomy Hyoid advancement Tracheostomy-last option
Types of LaserLaser is an acronym that stands for Light Amplification by Stimulated Emission of Radiation. The first concept of the laser was initiated by Albert Einstein in 1917.CO2 LaserArgon laserThe Nd:YAG (Neodymium:Yttrium-aluminum- garnet)The potassium-titanyl-phosphate (KTP)Diode Laser
Co2 Laser CO2Laser The CO2 laser is the most versatile laser in otolaryngology. The carbon dioxide (CO2) laser emits a colorless, infrared light at a specific wavelength of 10,600 microns, which has an extremely high affinity for the intercellular water of cells. A second, built-in, coaxial helium neon laser is necessary to indicate with its red color the site where the invisible CO2 laser beam will impact the target tissue. This laser, then, acts as an aiming beam for the invisible CO2 laser beam.Advantages of Laser Surgery Fast Painless Bleeding-nil Fast recovery No hospitalization if done under LA GA for difficult casesDisadvantages of Laser Cost of equipment and maintenance Special surgical skills Increased setup time of equipment Need of safety eyewear Increased care for patient safety - explosion or fire hazard. smoke
Other Non surgical treatment Dental splint Nasal dilator, strips Chin Strap Special Pillows Tennis ball strapped on dress Nasal Treatment of allergy CPAP Machine
CPAP Machine Treat OSA=Remove obstruction. When Surgery cannot be done Central apnea After surgery fail Very old, medical problems Costly Cumbersome to wear But useful in cases
CPAP user in rural village Is it a better picture of an Indian villager to the world? Gandhi had the vision of uplifting quality of lives of millions living in rural India, by bringing appropriate technology and developments to the countless villages of this vast nation. The fast and speedy advent of modern technology in our country. What is the benefit?
Results of Laser surgery showed the correction of sleep apnea by an average of 70-80% However, the snoring sound reduction was between 75-95%.Side Effects post op infection -rare nasal fluid reflux –temporary nasal regurgitation for few days, but rarely permanent no voice changes were noted Bleeding-rare Dryness of throat-rareCauses of failure if any mixed apnea-central component Inadequate excision of tissues-Redo Obesity,alcohol,sedative Lack of muscle tone in the neck Base of tongue factor-coblator reduction Jaw factor-need mandibular advancement
About Coblation Technique Coblation is a non- heat driven process in which radiofrequency energy is applied to a conductive medium saline causing a highly focused plasma field to form around the electrodes.
Coblation=Controlled Ablation Electrosurgical ablation probe 1999 By Philip E. Eggers et al Coblation energizes the ions in the saline to form a small plasma field.
Cold Ablation-Coblation Technology RF turbinate- Turbinoplasty Polypectomy Tonsillothomy- pediatric CAUP –Snoring and OSA Tongue base reduction
How Coblation Turbinoplasty done Under LA a coblation wand is inserted into the turbinate. The wand emits RF energy which shrinks the turbinates.
Coblation Turbinoplasty In Snoring and OSA Treat severe or chronic nasal allergies Relieve nasal congestion and drainage Reduce sinus-related snoring Improve breathing
Saline Gel for Coblation In Coblation channeling saline gel should be applied before the wands inserted. Saline is used as solution, sprays, drops and gel form in nasal passage Good healer,moisturising,post op use Is saline gel is available in India ? Any pharma companies making saline gel?
Advantage of Coblator over Laser Significantly less pain and less frequent use of narcotic analgesics Significantly faster return to normal diet (2-4 days) Less incidence of postoperative nausea and throat edema Less depth of thermal adjacent tissue necrosis No Fire Hazard Can reduce the tongue base
Disadvantages of Coblator Cost of Machine Cost of wands Saline gel for Nose Fibrotic Tonsil: bleeding Haemostasis:secon dary bleeding Need experience