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Osas iran

  1. 1. OBSTRUCTIVE SLEEP APNOEA SYNDROME Prof. Mohan Kameswaran MS, FRCS, FICS, FAMS, DSc, DLO Madras ENT Research Foundation Chennai
  2. 2. OBSTRUCTIVE SLEEP APNOEA SYNDROME• OSA is a common disorder resulting from collapse of the pharyngeal airway during sleep• Significant advances have been made in the evaluation and treatment of OSAS over the past several years
  3. 3. SLEEP DISORDERED BREATHING• Primary snoring• Upper Airway Resistance Syndrome (UARS)• Obstructive sleep apnoea syndrome (OSAS)
  4. 4. RDI O2 desaturation Day time sleepinessPrimary < 5 / hr SaO2 > 90% NosnoringUARS < 5 / hr SaO2 > or = 90% YesOSAS > 5 / hr SaO2 < 90% Yes SLEEP-RELATED UPPER AIRWAY OBSTRUCTION
  5. 5. SLEEP APNOEA SYNDROME - Semantics• Apnoea - cessation of airflow at the nostrils and mouth for atleast 10 seconds• SAS - 30 or more apnoeic episodes during a 7-hour period of sleep or an apnoea index (number of apnoeas per hour of sleep) equal to or greater than 5
  6. 6. • 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• In OSAS, RDI is greater than 10
  7. 7. 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
  8. 8. OBSTRUCTIVE SLEEP APNOEA• 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
  9. 9. OSA - PATHOPHYSIOLOGY Abnormal neuromuscular control of pharyngeal dilators(genioglossus, geniohyoid, palatoglossus, medial pterygoids) during sleep Airway narrowing (space occupying lesion from the nasal vestibule to glottis) Venturi effect Increased intraluminal negative pressure UPPER AIRWAY OBSTRUCTION
  10. 10. How many people have sleep apnea?Older guidelines (AHI > 10) - 2 - 4% of the population Children: 1- 3%Newer guidelines (AHI > 5 with symptoms) - 9 - 24%
  11. 11. OSAS3 major levels of obstruction (Fujita)• Retropalatal (Type1)• Retropalatal and retrolingual (Type 2)• Exclusively retrolingual (Type 3)
  12. 12. SLEEP MRI - Type 1 obstruction
  13. 13. SLEEP MRI - Type 2 obstruction
  14. 14. OSAS - EFFECTS• Oxygen desaturation causing increased sympathetic output & peripheral vasoconstriction• High negative intrathoracic pressures with arousal & termination of obstructive episode
  15. 15. OBSTRUCTIVE SLEEP APNOEA CAUSES• Nose - nasal polyps, DNS, • Larynx – tumors, oedema rhinitis, nasal packing Shy- Drager syndrome• Pharynx - nasopharyngeal laryngotracheomalacia tumor, enlarged adenoids, vascular ring palatal & lingual tonsils, retropharyngeal mass, Male sex enlarged tongue, Obesity micro/retrognathia Increasing age
  16. 16. PEDIATRIC OSASCommonest etiology• Adenotonsillar hypertrophy• Neuromuscular hypotonia• Craniofacial and neurologic syndromes OBSTRUCTIVE TONSILS
  17. 17. OBSTRUCTIVE SLEEP APNOEA Clinical features Common Less common• Snoring • Morning headaches• Excessive daytime • Personality change sleepiness• Obstructive episodes • Intellectual deterioration • Depression • Abnormal body movements • Frequent waking • Nocturnal choking • Impotence
  18. 18. PEDIATRIC OSAS• Loud snoring • Nocturnal enuresis• Noisy breathing during sleep • Poor growth problems• Mouth breathing • Rebellious and aggressive• Growth retardation behavior• Repetitive upper airway • Attention deficit disorder infection• Abnormal shyness
  19. 19. Sleep MRI - Craniosynostosis
  20. 20. OSAS - common associations• LPR • Left ventricular hypertrophy• Systemic hypertension • MI (50 - 70%) • Depression• Coronary artery disease • Sudden death?• Pulmonary hypertension • Vehicular and work-related• Right heart failure accidents• Cardiac arrhythmias
  22. 22. OSAS - HISTORY & EXAMINATION• General appearance, weight, height, blood pressure• H/O alcohol, drugs e.g. sedatives• Thyroid evaluation• ENT & Head and Neck examination - nasal airway, tongue size, soft palate, uvula, tonsils, naso / hypopharynx, larynx• Craniofacial morphology Snoring / OSAS If OSAS, the site of obstruction Associated problems
  23. 23. ENT & Head and Neck examination• Short thick neck (Collar size > 17.5)• Enlarged floppy uvula• Elongated soft palate• Tonsillar hypertrophy• Enlarged tongue• Micrognathia / retrognathia
  24. 24. INVESTIGATIONS• FBC, ECG, chest X-ray, Lung function tests• Polysomnography (Holland, Dement, Raynall, 1974) - Level 1 PSG - gold standard investigation - Overnight monitoring of pulse oximetry, End tidal CO2, ECG, EEG, anterior tibialis EMG, EOG, nasal & oral airflow, chest & abdominal movements & sleeping position - Differentiates obstructive from central sleep apnoea - Evaluates the severity
  25. 25. Polysomnography
  26. 26. Polysomnography
  27. 27. Sleep MRI & Fiberoptic endoscopy - assessment ofthe site of obstruction - retropalatal / retrolingual /combined
  28. 28. Sleep MRI Sleep endoscopy
  29. 29. OSAS - TREATMENT• Medical• Appliances - nasal splint, mandibular positioning device, tongue retaining device• Surgical• If anatomic obstruction is present, corrective surgery should be doneNONSURGICAL TREATMENT• Weight loss• Treatment of systemic disorders• Alcohol advice• Drugs review
  30. 30. NONSURGICAL TREATMENTDrug treatment• Protryptiline (increases the neuromuscular activity of upper airway & decreases REM sleep)• Theophylline• Progesterone• Modafinil (improves wakefulness by decreasing GABA mediated neurotransmission)
  31. 31. NONSURGICAL TREATMENT• 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 & Demand PAP
  33. 33. Nasal Continuous Positive Airway Pressure (Colin Sullivan, 1981)• Noninvasive and highly effective primary treatment modality• Delivers a continuous flow of air & provides a pneumatic splint to the upper airway during inspiration preventing collapse during sleep by increasing airway volume, area and lateral dimensions in retropalatal and retroglossal regions
  34. 34. Continuous Positive Airway Pressure
  35. 35. Nasal CPAP• Problems: dermal irritation, dryness, sneezing, rhinorrhoea, claustrophobia, panic attacks leading to noncompliance• Auto-CPAP is as effective as constant CPAP• The auto-CPAP is characterized by its ability to modify the positive-pressure level applied
  36. 36. Nasal CPAP• Restores normal respiration during sleep, normalizes sleep organization• Improves day time alertness, neuropsychiatric function, right heart function, and systemic blood pressure• Success rate - 90%• Compliance - 50%
  37. 37. SURGICAL TREATMENTIndications• Primary snoring• AHI > 15• O2 desaturation < 90%• AHI > 5 or < 14, with excessive daytime sleepiness• UARS• Unsuccessful medical treatment• Type 1 collapse (mainly retropalatal)• Failure of compliance for CPAP
  38. 38. POOR SURGICAL CASES• Extreme obesity• Lack of physical activity• Alcoholism• Type 2 collapse• Cardiac arrhythmias
  39. 39. SURGICAL TREATMENT• Nasal surgery, Adenotonsillectomy• Uvulopalatopharyngoplasty, LAUP, RAUP, CAUP• Hyoid advancement• Midline Laser glossectomy• Mandibular / Maxillary osteotomy & advancement• Tracheostomy - gold standard
  40. 40. Enlargement of retropalatal airway• Uvulopalatopharyngoplasty (UPPP)• Laser - LAUP• Radiofrequency - RAUP• Coblation - CAUP
  41. 41. UVULOPALATOPHARYNGOPLASTY Dr. Ikematsu (1964), Dr. Fujita (1981)• Removal of excessive redundant tissue in the oropharynx with increased cross-sectional area• Success rates in curing snoring: 85 - 90%• Success rates in reducing apnoeic index: 23 - 77%• Complications: bleeding, velopharyngeal insufficiency, dry throat, nasopharyngeal stenosis, airway compromise, hypernasal speech & taste disturbances
  42. 42. Uvulopalatopharyngoplasty (UPPP)For successful UPPP, Mandibular - hyoid angle must be less than25 - 30
  43. 43. LASER ASSISTED UVULOPALATOPHARYNGOPLASTY (Dr. Kamami, 1993)• Effective and has the advantage of a bloodless field• Success rates: short term - 77 - 89% long term - 75% no snoring - 52%
  44. 44. Sleep MRI – post UPPPshowing retrolingual obstruction
  45. 45. UPPP / LAUP - Anesthetic considerations• Pre-op evaluation• Avoid sedatives, narcotics• Difficult intubation (FO intubation may be required)• After extubation - nasopharyngeal airway, pulse oximetry and avoidance of narcotic analgesia, monitoring for post obstructive pulmonary edema NASOPHARYNGEAL AIRWAY
  46. 46. RADIOFREQUENCY IN OSAS• Radiofrequency thermal ablation uses low levels of RF energy to create targeted tissue ablation resulting in tissue volume reduction• The procedure is quick, painless and is associated with minimal edema
  47. 47. Radiofrequency in OSAS
  48. 48. COBLATION• Voltages applied to convert conductive fluid between electrodes and tissue into ionized vapor layer (plasma)• Ionized layer contains excited particles which, when in contact with tissue, break tissues molecular bonds with minimal thermal penetration• Energy used - up to 8 eV
  49. 49. Enlargement of retrolingual space• Tongue base reduction procedures• Mandibular osteotomy with genioglossal advancement• Repose tongue suspension intraoral approach• Hyoid Myotomy and suspension• Genioglossal advancement and hyoid suspension (GAHM)• Maxillofacial techniques• Uvulopalatopharyngoglossoplasty (UPPGP) (UPPP with limited resection of the tongue base)
  50. 50. Tongue base reduction procedures Type 3 (Riley)• Tracheostomy required• Midline Laser glossectomy - laser is used to extirpate a rectangular strip (2.5 into 5 cms) of the posterior portion of tongue, useful in Down’s syndrome, Mucopolysaccharidosis• Lingualplasty - modification of LMG, involves additional excision of lateral tongue tissue• Radiofrequency tissue ablation of tongue base - RF probe with 465 KHZ
  51. 51. GENIOGLOSSUS ADVANCEMENT PROCEDURE Osteotomies in the mandible at the geniotubercle advancing theinsertion of genioglossus or geniohyoid by 10-14 mm & rotatingit by 90%. This increases the tension placed on the tongue
  53. 53. Tongue suspension Tongue base is pulled forward and secured anteriorlyby a titanium screw placed at the lingual cortex of genial tubercle of mandible
  55. 55. Genioglossal advancement and hyoid suspension (GAHM)• Combined procedure of inferior mandibular osteotomy with genioglossal advancement with hyoid myotomy & suspension• Success rates - 70%• Complications: infection, need for root canal therapy, permanent anesthesia, seroma, mandibular fracture, aspiration
  56. 56. Hyoid distraction procedure (Tucker Woodson)The hyoid bone is split and two separate loops of sutureare used to pull the bone not only anteriorly andsuperiorly, but also laterally
  57. 57. MAXILLOFACIAL TECHNIQUES• Used in severe OSAS where the tongue base is the cause of obstruction• Advances the skeletal support of soft tissues (tongue and pharynx) that collapse during sleep
  58. 58. Candidate formaxillomandibular advancement
  59. 59. MAXILLOMANDIBULAR OSTEOTOMY & ADVANCEMENT (Riley & Powell)• Phase 2 surgery• Improves retropalatal and retrolingual space and increases airway caliber in an anteroposterior direction• Success rates: 95%• Complications: malocclusion, inferior alveolar, lingual or infraorbital paresthesia, nonunion/malunion, relapse of advancement, TMJ complications, need for restorative dental work
  61. 61. Presurgical evaluation Phase I (site of obstruction) UPPP UPPP + MOHM MOHMType I oropharynx Type 2 oro - hypopharynx Type 3 hypopharynx Postop polysomnogram (6 months) Failure Phase II - MMO Riley-Powell-Stanford surgical protocol
  62. 62. TracheostomyBypasses airway obstructionIndications - severe OSAS with • RDI above 50 • Lowest O2 saturation below 60% • Cardiac arrhythmias
  63. 63. OSAS - Adults Vs Children Adults ChildrenSymptoms Sleepiness, fatigue, nocturia Behavioral problems, learning difficulty, nocturnal enuresisGender More common and severe in No difference prior to males pubertyPhysical findings Obese, large neck High-arched palate, enlarged circumference tonsils, orthodontic problems, less likely obese, failure to thriveApnea duration 10 seconds Two breathsDiagnostic criteria AHI > = 5 AHI > =1Primary treatment Positive airway pressure Adenotonsillectomy
  64. 64. Snoring Intermittent with pauses ContinuousMouth breathing Less common CommonWeight Commonly obese UnderweightEnlarged tonsils / adenoids Uncommon CommonSex distribution Male:Female (8:1) Male:Female (1:1)Obstructive pattern Mostly apneas Mostly hypopneasClinically obvious arousals Common UncommonSleep architecture disruption Common UncommonSequelae Excessive daytime sleepiness Behavioral changes Hypertension Neurocognitive Cardiovascular CardiovascularTreatment Most often CPAP Most often T & A Less often UPPP Less often CPAP
  65. 65. CONCLUSION• OSA is a common disease of adult & pediatric age groups with a myriad of presentations• Often the patient is unaware of his condition• A detailed history, clinical examination & simple overnight observation will help to clinch the diagnosis
  66. 66. • Sleep MRI ( dynamic MRI ) with F.O.nasendoscopy has obviated the need for cumbersome cephalometric measures to establish the site of obstruction• A comprehensive presurgical evaluation to identify the site of airway obstruction improves surgical success rates