OSA- this ppt is just a review of all viable options and their indications

1. Decision Making in OSA
Dr.Malarvizhi .R MBBS,DLO
Prof.Dr.R.Muthukumar Unit
ENT I
UIORL,MMC
June,2015
Dr.R.Malarvizhi

2. History
• Dr.Ikematsu (‘60s) – pharyngopalatoplasty
• Dr.Christian Gilleminault (1979) – OSAS
– (1990)UARS
• Dr.Fujita (1989) –Uvulopharyngoplasty
– 1993 Classification of obstructive area
• Dr.Colin Sullivan – positive airway pressure
• Dr.Murray Johns(1990)– Epworth sleepiness scale
• Dr.Ives Kamami – LASER assisted
Uvulopalatoplasty
Dr.R.Malarvizhi

3. • Snoring X
• Apnoea, Hypopnea, desaturation and arousals
Dr.R.Malarvizhi

4. • Airway pattern and severity of obstruction
vary greatly between patients, which affects
the success rate of given surgical procedure
• As severity increases, so does the invasiveness
• Governing factor- diagnosis based on sleep-
study results and systemised approach with
special care in upper airway anatomy
Dr.R.Malarvizhi

5. Battery of Investigations
• Epworth Sleepiness
scale
• Overnight oximetry
• Home multichannel
testing
• Overnight
polysomnography
• Videoendoscopy
• Sleep nasoendoscopy
±video
• Oesophageal
manometry
• Cephalometry with
Mueller manoeuvre
• 3D CT
• Ultrafast MRI (Dynamic)
Dr.R.Malarvizhi

6. Available Options
• Non-surgical • Surgical
Dr.R.Malarvizhi

7. Sleep endoscopy grading
Grade Obstruction
1 Simple palatal
flutter
2 Single level palatal
obstruction
3 Palatal level with
intermittent
oropharyngeal
involvement
4 Sustained
multisegmental
obstruction
5 BOT obstruction
6 Isolated epiglottic
involvement
Sites of snoring
• Palatal flutter only
• Palatal flutter + Other site
• Supraglottic
• Tonsil
• BOT
• BOT only
• Epiglottic
Dr.R.Malarvizhi

8. Tailored treatment
• Goal- expand the limited space in upper
airway
• Sleep study, polysomnography, CT, Epworth
sleepiness scale measurements (Friedman),
BMI, neck circumference and co-morbidities
• Endocrinological weight gain
Dr.R.Malarvizhi

9. Behavioral treatment
• Sleep hygiene
• Avoidance of fatty meals and alcohol before
bedtime
• Insomniacs – avoid physical exercise, coffee/tea
near bedtime
• Avoid activities like reading and Tele watching in
bed
• WEIGHT LOSS
• Sewing a racket ball/tennis ball into back of shirt
to avoid sleeping in supine position
Dr.R.Malarvizhi

10. Oral appliances
• AHI <20
• No co-morbidities
• Compliance better than CPAP
• Simple snoring and mild/ moderate sleep
apnea
Dr.R.Malarvizhi

11. CPAP
• Mild OSA with EDS and/or co-morbidities
• Moderate-severe OSA with or without EDS
and co-morbidities
• 𝑐𝑚𝐻2𝑂 = 0.16𝐵𝑀𝐼 + 0.13𝑁𝐶 + 0.04𝐴𝐻𝐼 − 5.12
Dr.R.Malarvizhi

12. Surgical
• Successful when AHI drops at least 50% and
desaturation is below 20 per hour
• Surgical
– To improve compliance with CPAP
– To modify upper airway
– That directly alters upper airway
Dr.R.Malarvizhi

13. • Rhinological procedures- Helps tolerate CPAP
better
• Palatal stiffening procedures
– Mallampati I or II, with Grade I or II tonsils and
<43 cm neck circumference, BMI <30
– Techniques
• To increase rigidity and less collapsibility
• Injection snoreplasty, CAPSO, Palatal Radiofrequency,
Palatal Implants
Dr.R.Malarvizhi

14. Uvulopalatopharyngoplasty
• Stand-alone ? combined (BOT/rhino)?
• BMI 28-30 kg/m² (stand alone)
• Grade IV tonsils
• Neck circumference <40cm (f) <43 cm(m)
• AHI < 30
• Desaturation
• Negative outcomes
– Micrognathia and retrognathia
– Previous tonsillectomy
Dr.R.Malarvizhi

15. Z pharyngoplasty
• ZZP ideal in post tonsillectomy
• Failed UPPP
• Need Palate addressing
• Friedman Staging Grade II or III
• Often combined with tongue base / hyoid
Dr.R.Malarvizhi

16. Transpalatal Advancement Technique
• Friedman III
• Enlarge retromaxillary and retropalatal airway
Dr.R.Malarvizhi

17. Tongue Base Suspension
• UPPP
• AHI >20
• Moderate BOT obstruction
• Ideal
– AHI >15
– O₂ desaturation <90%
– High Epworth Sleepiness scale >11
– UARS with poor compliance to CPAP
Dr.R.Malarvizhi

18. SMILE procedure
• Macroglossia
– Pediatric
• Down’s syndrome
• BeckwithWiedemann syndrome
Dr.R.Malarvizhi

19. Palatal Z-pharyngoplasty, injection snoreplasty, Modified UPPP
with extended Uvulopalatal flap, palatal implants
Lateral
pharyngeal wall
Lateral pharyngoplasty, RFTVR
Tongue Base Laser midline glossectomy and lingualplasty, tongue
suspension, lingual tonsillectomy, RFVTR, Hypoglossal
nerve stimulation
Epiglottis Endoscopic epiglottectomy
Trachea Temporary tracheostomy
Maxillomandibul
ar procedures
Hyoid myotomy
and suspension
Maxillomandibul
ar osteotomy and
advancement
Dr.R.Malarvizhi

20. Dr.R.Malarvizhi
Patient Evaluation and Education
Behavioral therapy
PAP
(C,Bi,
A) Oral Appliances
Surgery
(single or
multi stage)
Adjunct
Therapy
(Bariatric,
Medical)
Yes
No
Realistic expectation,
Endocrinology, anatomy,
?follow upFollow up
Yes
No
Follow up
Yes
No
Follow up
Yes
No
Follow up
Follow up
Re-
evalua
PAP not accepted
and BMI >40
Follow up

21. Dr.R.Malarvizhi