Obstructive Sleep Apnoea: Diagnosis, Criteria, Management

1. Obstructive SleepObstructive Sleep
ApnoeaApnoea
PRASANNA DATTAPRASANNA DATTA
JUNIOR RESIDENTJUNIOR RESIDENT
DEPARTMENT OF ENT-HNSDEPARTMENT OF ENT-HNS
MEDICAL COLLEGE,KOLKATAMEDICAL COLLEGE,KOLKATA

2. APNOEAAPNOEA
Comes from the Greek wordComes from the Greek word
meaning “Without Breathing”meaning “Without Breathing”
 There are three types of Apnoea:There are three types of Apnoea:
 - Obstructive,- Obstructive,
 - Central,- Central,
 - Mixed- Mixed

3. APNOEAAPNOEA
 Obstructive apnoea – cessation ofObstructive apnoea – cessation of
airflow for at least 10 seconds withairflow for at least 10 seconds with
respiratory effortrespiratory effort
 Central apnoea – cessation ofCentral apnoea – cessation of
airflow for at least 10 secondsairflow for at least 10 seconds
without respiratory effortwithout respiratory effort
 Mixed apnoea – characteristics ofMixed apnoea – characteristics of
both for at least 10 secondsboth for at least 10 seconds
 Hypopnoea – reduction in airflow ofHypopnoea – reduction in airflow of
less than 50% accompanied by 3%less than 50% accompanied by 3%
desaturation.desaturation.

4. WHAT IS OSAWHAT IS OSA
 Disorder Of breathing during sleepDisorder Of breathing during sleep
characterized by prolonged partialcharacterized by prolonged partial
upper airway obstruction and /orupper airway obstruction and /or
intermittent complete obstructionintermittent complete obstruction
(obstructive apnoea) that disrupts(obstructive apnoea) that disrupts
normal ventilation during sleep andnormal ventilation during sleep and
normal sleep patternsnormal sleep patterns

5. OSAOSA
 85% of adult patients are male.85% of adult patients are male.
 Men 4%, Female 2%.Men 4%, Female 2%.
 2/32/3rdrd
obese.obese.
 Contributes to HTN andContributes to HTN and
cardiovascular disease.cardiovascular disease.
 Increased motor vehicle accidentsIncreased motor vehicle accidents

6. RISK FACTORSRISK FACTORS
 ObesityObesity
 SexSex
 Cardiovascular diseaseCardiovascular disease
 Cerebrovascular diseaseCerebrovascular disease
 Metabolic syndromeMetabolic syndrome
33% of adults are at risk for OSA

7. Criteria of OSACriteria of OSA
 AHI>5AHI>5
 AHI > 5 & < 15 increases risk ofAHI > 5 & < 15 increases risk of
mortalitymortality
 AHI 15-30=moderate, >30=severeAHI 15-30=moderate, >30=severe

8. SYMPTOMSSYMPTOMS
 Snoring*Snoring*
 Excessive daytime sleepiness*Excessive daytime sleepiness*
 Restless sleep , fragmented sleep.Restless sleep , fragmented sleep.
 Witnessed breath holdsWitnessed breath holds
 Personality changesPersonality changes
 HeadachesHeadaches
 Sexual dysfunctionSexual dysfunction
 Job performanceJob performance
Mood changesMood changes
 Nocturia.Nocturia.

9. PATHOPHSIOLOGYPATHOPHSIOLOGY
 Pharyngeal collapsePharyngeal collapse
 Decreased airway patencyDecreased airway patency
 Increase in negative pressureIncrease in negative pressure
 Becomes a vicious cycleBecomes a vicious cycle

10. Pathophysiology of OSAPathophysiology of OSA
 Sites of Obstruction:Sites of Obstruction:
Nose & nasopharynxNose & nasopharynx
Oral cavity &Oral cavity &
OropharynxOropharynx
Larynx & hypopharyxLarynx & hypopharyx

11. Pathophysiology of OSAPathophysiology of OSA
 Sites of Obstruction:Sites of Obstruction:

12. PATHOPHYSIOLOGYPATHOPHYSIOLOGY
 Occlusion of the oropharyngeal airwayOcclusion of the oropharyngeal airway
results in progressive asphyxia until thereresults in progressive asphyxia until there
is a brief arousal from sleep, whereuponis a brief arousal from sleep, whereupon
airway patency is restored and airflowairway patency is restored and airflow
resumes.resumes.
 The patient then returns to sleep and theThe patient then returns to sleep and the
process is repeated, up to 300-400 x perprocess is repeated, up to 300-400 x per
night – sleep becomes fragmentednight – sleep becomes fragmented

13. PATHOPHYSIOLOGYPATHOPHYSIOLOGY
 The immediated factor leading to collapseThe immediated factor leading to collapse
of the upper airway is generation ofof the upper airway is generation of
subatmospheric pressure duringsubatmospheric pressure during
inspiration and which exceeds ability ofinspiration and which exceeds ability of
airway dilator and abductor muscles toairway dilator and abductor muscles to
maintain airway stability.maintain airway stability.
 During wakefulness upper airway muscleDuring wakefulness upper airway muscle
activity is greater than normal toactivity is greater than normal to
compensate for airway narrowing and highcompensate for airway narrowing and high
airway resistanceairway resistance

14. CONSEQUENCESCONSEQUENCES

15. CLINICAL EVALUATIONCLINICAL EVALUATION
 Detailed history: snoring duringDetailed history: snoring during
sleep,restless disturbed sleep,gasping,sleep,restless disturbed sleep,gasping,
choking, apnoeic events.choking, apnoeic events.
 Physical examination: includes BMI, collarPhysical examination: includes BMI, collar
size, complete head and necksize, complete head and neck
examination, muellers manoevre .examination, muellers manoevre .
 Systemic examination: hypertension,Systemic examination: hypertension,
congestive heart faliure, pedal oedma,congestive heart faliure, pedal oedma,
truncal obesity & hypothyroidism.truncal obesity & hypothyroidism.

16. CLINICAL EVALUATIONCLINICAL EVALUATION
 CEPHALOMETRIC RADIOGRAPHS: toCEPHALOMETRIC RADIOGRAPHS: to
look for cranio facial anomalies & tonguelook for cranio facial anomalies & tongue
base obstruction.Includes CT scan & MRI.base obstruction.Includes CT scan & MRI.
 POLYSOMNOGRAPHY: gold standard forPOLYSOMNOGRAPHY: gold standard for
diagnosis of sleep apnoea.diagnosis of sleep apnoea.
 SPLIT NIGHT POLYSOMNOGRAPHY:SPLIT NIGHT POLYSOMNOGRAPHY:
first part of night in usualfirst part of night in usual
polysomnography while the second part ispolysomnography while the second part is
used in titration of pressures for cpap.used in titration of pressures for cpap.

17. PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
 HeightHeight
 WeightWeight
 Collar sizeCollar size
 Blood pressureBlood pressure
 Calculate BMICalculate BMI
 Wt (kg) / Ht (meters) squaredWt (kg) / Ht (meters) squared
 Men >27.8, Women >27.3Men >27.8, Women >27.3

18. EXAMINATIONEXAMINATION
 PalatePalate
 TongueTongue
 UvulaUvula
 TonsilsTonsils
 Nasal cavityNasal cavity
 HyoidHyoid
 MandibleMandible
 MaxillaMaxilla

19. EXAMINATIONEXAMINATION
 Findings in Obstruction:Findings in Obstruction:
 Nasal ObstructionNasal Obstruction
 Long, thick soft palateLong, thick soft palate
 Retrodisplaced MandibleRetrodisplaced Mandible
 Narrowed oropharynxNarrowed oropharynx
 Redundant pharyngeal tissuesRedundant pharyngeal tissues
 Large lingual tonsilLarge lingual tonsil
 Large tongueLarge tongue
 Large or floppy EpiglottisLarge or floppy Epiglottis
 Retro-displaced hyoid complexRetro-displaced hyoid complex

20. TESTTEST
 Tests to determine site ofTests to determine site of
obstruction:obstruction:
 Mueller’s ManeuverMueller’s Maneuver
 Sleep endoscopySleep endoscopy
 FluoroscopyFluoroscopy
 ManometryManometry
 CephalometricsCephalometrics
 Dynamic CT scanning and MRI scanningDynamic CT scanning and MRI scanning

21. EPWORTH SLEEPINESSEPWORTH SLEEPINESS
SCALESCALE

22. MUELLERS MANUEVREMUELLERS MANUEVRE
 Nasopharyngoscopy is done in awakeNasopharyngoscopy is done in awake
position either sitting or supine positionposition either sitting or supine position
 Patients inhales with mouth closed.Patients inhales with mouth closed.
 Can show the anterior posteriorCan show the anterior posterior
compression of the pharyngeal wall.compression of the pharyngeal wall.

23. SLEEP ENDOSCOPYSLEEP ENDOSCOPY
 Drug induced sleep endoscopy.Drug induced sleep endoscopy.
 First introduced in 1991First introduced in 1991
 Pharmacological sedation & fibreopticPharmacological sedation & fibreoptic
telescopic evaluation of upper airwaytelescopic evaluation of upper airway

24. ANALYSISANALYSIS
 Analysis 1:global analysis of obstructionAnalysis 1:global analysis of obstruction
at the level of soft palate & hypopharynx.at the level of soft palate & hypopharynx.
 Analysis 2: degree of obstruction at theAnalysis 2: degree of obstruction at the
level of palate & hypopharynx.level of palate & hypopharynx.
 Analysis 3 : assessment of individual areaAnalysis 3 : assessment of individual area
of pharynx & specific stuctures.of pharynx & specific stuctures.

25. ANALYSISANALYSIS
PALATE: Palatal tonsilsPALATE: Palatal tonsils
lateral pharyngeal at thelateral pharyngeal at the
level of velopharynx.level of velopharynx.
HYPOPHARYNX: Tongue.HYPOPHARYNX: Tongue.
Epiglottis.Epiglottis.
lateral pharyngeal wall atlateral pharyngeal wall at
the level of the hypopharynx.the level of the hypopharynx.

26. OESOPHAGEALOESOPHAGEAL
MANOMETRYMANOMETRY
 In conjuction with the sleep studies toIn conjuction with the sleep studies to
diagnose apnoeas & hypoapnoeasdiagnose apnoeas & hypoapnoeas
 To evaluate the relationship betweenTo evaluate the relationship between
reflux and OSA.reflux and OSA.
 Adaption of the device allows moreAdaption of the device allows more
precise location of upper airwayprecise location of upper airway
obstruction.obstruction.

27. MRIMRI
 Ultrafast MRI can be used in awake &Ultrafast MRI can be used in awake &
asleep patients.asleep patients.
 To assess the the site of upper airwayTo assess the the site of upper airway
obstruction .obstruction .
 Midline saggital section and cross sectionMidline saggital section and cross section
at various level can be used to evaluateat various level can be used to evaluate

28. DIAGONOSTIC TESTSDIAGONOSTIC TESTS
 Overnight oxymetryOvernight oxymetry
 Home multichannel testingHome multichannel testing
 Overnight polysomnographyOvernight polysomnography

29. OVERNIGHT OXYMETRYOVERNIGHT OXYMETRY
 Screen tool for diagnosis of osa.Screen tool for diagnosis of osa.
 Good specificity & positive predictiveGood specificity & positive predictive
value.value.
 Poor sensivity & negitivite predictive value.Poor sensivity & negitivite predictive value.
 The device measures o2 saturation &The device measures o2 saturation &
provides pulse rate data.provides pulse rate data.

30. 0VERNIGHT OXIMETRY0VERNIGHT OXIMETRY
 Device measures the oxygen dips.Device measures the oxygen dips.
 Oxygen desaturation index can beOxygen desaturation index can be
measured.measured.
 ODI>15 indicates osa.ODI>15 indicates osa.
 Others ESS>10 , BMI> 28 KG / M2.Others ESS>10 , BMI> 28 KG / M2.

31. HOME MULTICHANNELHOME MULTICHANNEL
TESTINGTESTING
 Better patient comfort, cost saving,Better patient comfort, cost saving,
prevention of hospital admission ,speed ofprevention of hospital admission ,speed of
analysis of data.it utilizes nasal airflow,analysis of data.it utilizes nasal airflow,
chest & abd movements & pulse oxymetrychest & abd movements & pulse oxymetry
 It can differentiate betwwen theIt can differentiate betwwen the
obstructive & central sleep apnoea.obstructive & central sleep apnoea.
 Some home portable kits also includesSome home portable kits also includes
EEG probes to determine sleepEEG probes to determine sleep
architecture.architecture.

32.  PolysomnographyPolysomnography
 EMGEMG
 AirflowAirflow
 EEG, EOGEEG, EOG
 Oxygen SaturationOxygen Saturation
 Cardiac RhythmCardiac Rhythm
 Leg MovementsLeg Movements
 AI, HI, AHI, RDIAI, HI, AHI, RDI
OVERNIGHTOVERNIGHT
POLYSOMNOGRAPHYPOLYSOMNOGRAPHY

33. OVERNIGHTOVERNIGHT
POLYSOMNOGRAPHYPOLYSOMNOGRAPHY
 Gold standard for diagnosis of osa.Gold standard for diagnosis of osa.
 Varieties component of sleep disorder canVarieties component of sleep disorder can
be measured.be measured.
 The patient stays overnight at sleepThe patient stays overnight at sleep
centre, most of which have videocentre, most of which have video
monitoring.monitoring.
 This allows for any trouble shooting , suchThis allows for any trouble shooting , such
as disconnected leads,but allowsas disconnected leads,but allows
assessment of titration with CPAP .assessment of titration with CPAP .

34. POLYSMNOGRAPHYPOLYSMNOGRAPHY

35. Medical ManagementMedical Management
 Weight Loss/ExerciseWeight Loss/Exercise
 Nasal Obstruction/AllergyNasal Obstruction/Allergy
TreatmentTreatment
 Sedative AvoidanceSedative Avoidance
 Smoking cessationSmoking cessation
 Sleep hygieneSleep hygiene
 Consistent sleep/wake timesConsistent sleep/wake times
 Avoid alcohol, heavy meals beforeAvoid alcohol, heavy meals before
bedtimebedtime
 Position on sidePosition on side
 Avoid caffeine, TV, reading in bedAvoid caffeine, TV, reading in bed

36. CPAPCPAP
Regarded as theRegarded as the
mainstay of OSAmainstay of OSA
treatment.treatment.
Acts as pneumaticActs as pneumatic
splint & preventssplint & prevents
collapse of airways.collapse of airways.
Assumes a closedAssumes a closed
system between thesystem between the
machine & patient.machine & patient.
Pressure must bePressure must be
titrated.titrated.

37. DIAGRAMDIAGRAM

38. CPAPCPAP

39. SIDE AFFECTSSIDE AFFECTS
 ClaustrophobiaClaustrophobia
 Nasal stiffnessNasal stiffness
 Skin abrasion & leaksSkin abrasion & leaks
 Air swallowingAir swallowing
 Pulmonary barotrauma.Pulmonary barotrauma.

40. AUTO CPAPAUTO CPAP
 Auto cpapAuto cpap
 Useful when > 6 cm H2O difference inUseful when > 6 cm H2O difference in
inspiratory and expiratory pressuresinspiratory and expiratory pressures
 No objective evidence demonstratesNo objective evidence demonstrates
improved compliance over CPAPimproved compliance over CPAP

41. Nonsurgical ManagementNonsurgical Management
 Oral applianceOral appliance
 MandibularMandibular
advancementadvancement
devicedevice
 Tongue retainingTongue retaining
devicedevice

42. Nonsurgical ManagementNonsurgical Management
 Oral AppliancesOral Appliances
 May be as effective as surgicalMay be as effective as surgical
options, especially with sx worse onoptions, especially with sx worse on
patient’s backpatient’s back
 However low compliance rate of aboutHowever low compliance rate of about
60% in study by Walker et al in 200260% in study by Walker et al in 2002
rendered it a worse treatment modalityrendered it a worse treatment modality
than surgical proceduresthan surgical procedures

43. Surgical ManagementSurgical Management
 Measures of success –Measures of success –
 No further need for medical or surgicalNo further need for medical or surgical
therapytherapy
 Response = 50% reduction in RDIResponse = 50% reduction in RDI
 Reduction of RDI to < 20Reduction of RDI to < 20
 Reduction in arousals and daytimeReduction in arousals and daytime
sleepinesssleepiness

44. Surgical ManagementSurgical Management
 Perioperative IssuesPerioperative Issues
 High risk in patients with severeHigh risk in patients with severe
symptomssymptoms
 Associated conditions of HTN, CVDAssociated conditions of HTN, CVD
 Nasal CPAP often required afterNasal CPAP often required after
surgerysurgery
 Nasal CPAP before surgery improvesNasal CPAP before surgery improves
postoperative coursepostoperative course
 Risk of pulmonary edema after relief ofRisk of pulmonary edema after relief of
obstructionobstruction

45. Surgical ManagementSurgical Management
 Nasal SurgeryNasal Surgery
 Limited efficacy when used aloneLimited efficacy when used alone
 Verse et al 2002 showed 15.8%Verse et al 2002 showed 15.8%
success rate when used alone insuccess rate when used alone in
patients with OSA and day-time nasalpatients with OSA and day-time nasal
congestion with snoring (RDI<20 andcongestion with snoring (RDI<20 and
50% reduction)50% reduction)
 Adenoidectomy (children)Adenoidectomy (children)

46. Surgical ManagementSurgical Management
 UvulopalatopharyngoplastyUvulopalatopharyngoplasty
 The most commonly performedThe most commonly performed
surgery for OSAsurgery for OSA
 Severity of disease is poorSeverity of disease is poor
outcome predictoroutcome predictor
 Levin and Becker (1994) up toLevin and Becker (1994) up to
80% initial success decreased to80% initial success decreased to
46% success rate at 12 months46% success rate at 12 months
 Friedman et al showed a successFriedman et al showed a success
rate of 80% at 6 months inrate of 80% at 6 months in
carefully selected patientscarefully selected patients

47. Surgical ManagementSurgical Management
 UvulopalatopharyngoplastyUvulopalatopharyngoplasty

48. Surgical ManagementSurgical Management
 UPAPUPAP
ComplicationsComplications
 MinorMinor
 Transient VPITransient VPI
 Hemorrhage<1%Hemorrhage<1%
 MajorMajor
 NP stenosisNP stenosis
 VPIVPI

49. LATERALLATERAL
PHARYNGOPLASTYPHARYNGOPLASTY
 Cahali, 2003Cahali, 2003
proposed theproposed the
LateralLateral
Pharyngoplasty forPharyngoplasty for
patients withpatients with
significant lateralsignificant lateral
narrowing:narrowing:

50. Surgical ManagementSurgical Management
 Lateral PharyngoplastyLateral Pharyngoplasty

51. LAUPLAUP
 Laser AssistedLaser Assisted
UvulopalatoplastyUvulopalatoplasty
 High initialHigh initial
success rate forsuccess rate for
snoringsnoring
 Rates decrease, asRates decrease, as
for UP3, at twelvefor UP3, at twelve
monthsmonths
 Performed awakePerformed awake

52. RFTVRRFTVR
 RadiofrequencyRadiofrequency
Ablation – FischerAblation – Fischer
et al 2003et al 2003
Radiofrequency device is
inserted into various parts
of palate, tonsils and tongue
base at various thermal
energies

53. RFTVRRFTVR
 Fischer et al 2003Fischer et al 2003
 At 6 months Showed significant reductionAt 6 months Showed significant reduction
of:of:
 RDI (but not to below 20)RDI (but not to below 20)
 ArousalsArousals
 Daytime sleepiness by the Epworth SleepinessDaytime sleepiness by the Epworth Sleepiness
ScaleScale

54. PillarPillar™ Palatal Implant™ Palatal Implant
SystemSystem
 Three Implants Per PatientThree Implants Per Patient
 Implants are made of Dacron®Implants are made of Dacron®
 Implants are 18 mm in length and 1.8Implants are 18 mm in length and 1.8
mmmm
in diameterin diameter
 Implants are meant to be PermanentImplants are meant to be Permanent
 Implants “can be removed”Implants “can be removed”
 FDA Approved for SNORINGFDA Approved for SNORING
 FDA Approved for mild to moderateFDA Approved for mild to moderate
SLEEP APNEA - AHI UNDER 30SLEEP APNEA - AHI UNDER 30

55. AnesthesiaAnesthesia
 AntibioticAntibiotic 1 hour pre-op or as directed1 hour pre-op or as directed
 Mouth RinseMouth Rinse (chlorhexidine gluconate or(chlorhexidine gluconate or
equivalent)equivalent)
 Topical JellyTopical Jelly Anesthetic, optional.Anesthetic, optional.
 Local Anesthetic Infiltration:Local Anesthetic Infiltration: 2 to 3 cc2 to 3 cc..
Beginning at the junction of the Hard and Soft PalateBeginning at the junction of the Hard and Soft Palate
inject entire “Target Zone”. (lidocaine with epinephrineinject entire “Target Zone”. (lidocaine with epinephrine
or equivalent)or equivalent)
 Have availableHave available : Flexible Scope, Angled Tonsil: Flexible Scope, Angled Tonsil
ForcepsForceps

56. Placement of ImplantsPlacement of Implants
2 m.m.
apart
Minimum
Palate
Length
25 mm

57. Placement of ImplantsPlacement of Implants
Insert the needle through the
mucosa layer into the
muscle. The insertion site
should be as close to the
junction of the hard and soft
palate as possible. Continue
needle advancement in an
arcing motion until the “Full
insertion depth marker” is
no longer visible.
Insertion point

58. Placement of ImplantsPlacement of Implants
INSPECTIONINSPECTION
Inspect the needleInspect the needle
insertion site. If a portioninsertion site. If a portion
of the implant is exposed,of the implant is exposed,
it must be removed with ait must be removed with a
hemostat.hemostat.
 Inspect the nasal side ofInspect the nasal side of
the soft palate using athe soft palate using a
FlexibleFlexible Naso ScopeNaso Scope..
If the implant is exposed,If the implant is exposed,
it must be removed.it must be removed. AnAn
angled tonsilangled tonsil forcepsforceps
is recommendedis recommended..
Hard palate
Implant
Muscle
Glandular tissue

59. Patient SelectionPatient Selection
““The Preferred PatientThe Preferred Patient ””
 BMI less than 32BMI less than 32
 AHI Less than 30AHI Less than 30
 No Obvious Nasal ObstructionNo Obvious Nasal Obstruction
 Small to Medium Sized TonsilsSmall to Medium Sized Tonsils
 Mallampati ClassMallampati Class ІІ or Classor Class ΙΙΙΙ
 Friedman Tongue Position I and IIFriedman Tongue Position I and II
 Minimum 25mm Palate to treatMinimum 25mm Palate to treat

60. LINGUALLINGUAL
TONSILLECTOMYTONSILLECTOMY
 Tongue Base ProceduresTongue Base Procedures
 Lingual TonsillectomyLingual Tonsillectomy
 may be useful in patients with hypertrophy,may be useful in patients with hypertrophy,
but usually in conjunction with otherbut usually in conjunction with other
proceduresprocedures

61. LINGUALPLASTYLINGUALPLASTY
 Tongue BaseTongue Base
ProceduresProcedures
 LingualplastyLingualplasty
 Chabolle, et alChabolle, et al
success rate ofsuccess rate of
77% (RDI<20,77% (RDI<20,
50% reduction) in50% reduction) in
22 patients in22 patients in
conjunction withconjunction with
UPPPUPPP
 Complication rateComplication rate
of 25% - bleeding,of 25% - bleeding,
altered taste,altered taste,
odynophagia,odynophagia,
edemaedema
 Can be combinedCan be combined
withwith
epiglottectomyepiglottectomy

62. GENIOGLOSSUSGENIOGLOSSUS
ADVANCEMENTADVANCEMENT
 MandibularMandibular
ProceduresProcedures
 GenioglossusGenioglossus
AdvancementAdvancement
 Rarely performedRarely performed
alonealone
 Increases rate ofIncreases rate of
efficacy of otherefficacy of other
proceduresprocedures
 Transient incisorTransient incisor
paresthesiaparesthesia

63. HYOID SUSPENSIONHYOID SUSPENSION
 Hyoid MyotomyHyoid Myotomy
and Suspensionand Suspension
 Advances hyoidAdvances hyoid
bone anteriorlybone anteriorly
and inferiorlyand inferiorly
 AdvancesAdvances
epiglottis andepiglottis and
base of tonguebase of tongue
 Performed inPerformed in
conjunction withconjunction with
other proceduresother procedures
 Dysphagia mayDysphagia may
resultresult

64. Surgical ManagementSurgical Management
 Maxillary-Mandibular AdvancementMaxillary-Mandibular Advancement
 Severe diseaseSevere disease
 Failure with more conservativeFailure with more conservative
measuresmeasures
 Midface, palate, and mandibleMidface, palate, and mandible
advanced anteriorlyadvanced anteriorly
 Limited by ability to stabilize theLimited by ability to stabilize the
segments and aesthetic facial changessegments and aesthetic facial changes

65. MMAMMA
 Maxillary-Maxillary-
MandibularMandibular
AdvancementAdvancement
 Performed inPerformed in
conjunction withconjunction with
oral surgeonsoral surgeons
 Temporary orTemporary or
permanentpermanent
paresthesiaparesthesia
 Change in facialChange in facial
structurestructure

66. TRACHEOSTOMYTRACHEOSTOMY
 Morbid obesityMorbid obesity
 Significant anesthetic/surgical risksSignificant anesthetic/surgical risks
 Obvious disadvantagesObvious disadvantages
 Tracheostoma careTracheostoma care

67. Surgical ManagementSurgical Management
 TracheostomyTracheostomy
 Primary treatment modalityPrimary treatment modality
 Temporary treatment while other surgery is doneTemporary treatment while other surgery is done
 Thatcher GW. et al: tracheostomy leads to quickThatcher GW. et al: tracheostomy leads to quick
reduction in sequelae of OSA, few complications (seereduction in sequelae of OSA, few complications (see
table II)table II)
 Once placed, uncommon to decannulateOnce placed, uncommon to decannulate

68. CONCLUSIONSCONCLUSIONS
 Surgical management provides effectiveSurgical management provides effective
management for OSAmanagement for OSA
 Can be safely performed in most patientsCan be safely performed in most patients
with proper preoperative preparationwith proper preoperative preparation
 Significant perioperative risks in someSignificant perioperative risks in some
patientspatients
 Surgery should be considered forSurgery should be considered for
patients unable to utilize nonsurgicalpatients unable to utilize nonsurgical
managementmanagement

69. THANK YOUTHANK YOU