Slides prepared and compiled by highly experienced ENT teacher, Dr. Krishna Koirala from Nepal , for teaching undergraduate and postgraduate ENT students in the field of otorhinolaryngology. A clear and concise explanation of the basic concepts in the subject matter concerned. He is the Head of department with a sound knowledge in the field of ENT to teach both undergraduate and postgraduate ENT students

1. Obstructive Sleep Apnea
Syndrome (OSAS)
Dr. Krishna Koirala
MBBS, MS (E.N.T. )
2019-12-23

2. • Sleep
–Reversible behavioral state of perceptual
disengagement and unresponsiveness to
surrounding
• 2 Stages
•REM ( 20 % ) - Alert Mind, Relaxed body
•NREM ( 80 % ) - Relaxed Mind, Active
body

3. • Apnea : Cessation of breathing from nose and mouth
for >10 sec
– Obstructive : Chest wall moves
– Central : Chest wall doesn’t move
– Mixed : Chest wall partly moves
• Hypopnea : Decreased airflow (<50% from baseline)
with > 4% Hb O2 desaturation and arousal

5. • The Apnea–Hypopnea Index (AHI)
– Used to indicate the severity of sleep apnea
– Represented by the number of apnea and
hypopnea events per hour of sleep
• OSAS is defined as AHI > 5
• Grades:
– Mild : 5-14
– Moderate : 15-29
– Severe : >30

6. Pathophysiology
• Incompletely Understood !
• Hypothesis
– During REM sleep : Collapse occurs in upper airway
‘pharynx’ (due to defect in pharyngeal dilator
muscles activity and anatomical abnormalities) 
Hypoxia  arousal  Upper airway collapse
improves and patient sleeps again
– During sleep, airway again collapses leading to
hypoxia and arousal

7. • Multiple arousals result in poor quality of sleep
and day - time sleepiness
• Chronic repeated hypoxia causes hemodynamic
complications like
–Pulmonary HTN ,Systemic HTN
–CAD, CVA, CHF

8. Pharyngeal Dilators
• Medial Pterygoid
• Tensor Veli Palatini
• Genioglossus
• Geniohyoid
• Stylohyoid

9. Upper Airway Obstruction

10. Symptoms
• Day- time
– Sleepiness
– Morning Fatigue
– Morning headache
– Cognitive Impairment
– Heartburn
– Depression
– Impotence, Xerostomia
• Night- time
– Snoring
– Observed Gasping/
Apnea/ Choking
– Repeated waking
– Nocturnal sweating
– Nocturnal enuresis

11. Typical Syndromic Patient
• Old Age
• Male
• Obese - BMI > 30
• Thick / Short Neck >17″
• Hypertension/Thyromegaly
• Large Bulky tongue/Tonsils
• Nasal Obstruction
• Pitting Edema
• Disproportionate Anatomy

12. Approach to management
• Detailed History /Involve
Bed-partner
• Sleep history
– Bed time
– Alcohol / Sedative use
– Body position/Snoring
– Arousals/Apneas
• Assess Day time
sleepiness
– Epworth Sleepiness
Scale
– Stanford Sleepiness
Scale

13. Examination
• B.M.I /B.P
• E.N.T. Examination
– Anterior Rhinoscopy : DNS, Turbinate hypertrophy,
Polyp , Mass
– Oro-pharynx : Tongue, Tonsils, Uvula, Pharyngeal
walls
– Neck : Circumference (> 17” ),Thyroid
– CVS Examination

14. • Flexible Nasopharyngoscopy : Mueller’s Maneuver, assess
airway collapse
Normal Airway Bulky Base of Tongue
Before Mueller’s Maneuver After Mueller’s Maneuver
After a forced expiration, an
attempt at inspiration is
made with closed mouth and
nose (reverse Valsalva)

15. Investigations
• Polysomnography
– Gold Standard Investigation
– Done in a “SLEEP LAB”
– Measures:
•EEG/EOG/ EMG
•ECG / B.P
•Position of Patient / Movements of Chest and abdomen
•Airflow /O2 Saturation
•Esophageal Pressure

16. • Cephalometry
– Enlarged tongue and soft palate
– Inferiorly displaced hyoid bone
– Inferior displacement of the
mandibular body
– Reduced oropharyngeal and
hypopharyngeal airway

17. • Anatomical Risk assessment
– X-Ray /CT Scan /MRI /Fluoroscopy /Acoustic Reflex
• Multiple Sleep Latency Test
– Document daytime sleepiness
– Subject asked to sleep 4-5 times in day every 2
hours
• TFT/ECHO

18. Differentials
• Primary Snoring
•Mild upper airway obstruction
•RDI < 5
•No Daytime sleepiness
• Upper Airway Resistance Syndrome
•Moderate upper airway obstruction
•RDI < 5
•Arousal Index > 15
•Excessive Negative Intra-thoracic pressure
•Daytime sleepiness occurs

19. General Treratment
• Weight Reduction
• Sleep Hygiene
– Elevate head end of bed
– Avoid alcohol, sedatives
– Avoid lying supine (T- shirt with tennis ball at back )
• Positive Airway Pressure (PAP) Device
– CPAP (Continuous) / Bi–PAP(Biphasic) /APAP(Automated)
• Positioning Devices
– Mandibular Advancement Device
– Tongue Retaining Device

20. •Nasal CPAP is first line treatment with ~100%
Efficacy (Gold standard medical Rx )
•Pressure must be individually titrated
•A/E : Noise, Mask discomfort, Claustrophobia
•Compliance low ~ 50%

22. Surgical Treatment
1. Nasal Surgery
2. Palatal Surgery
3. Tongue Base Surgery
4. Maxillo -facial Surgery
5. Tracheostomy

23. Nasal Surgeries
• Rarely suffice alone
• Relieve snoring > apnea
1. Office Radio-frequency Turbinate Ablation
2. Septo-turbinoplasty
3. Polypectomy
4. Nasal Valve Reconstruction
5. Adenoidectomy
6. Nasal mass Excision

24. Palatal Surgeries
• UPPP (Uvulo Palato Pharyngo Plasty)
– Most commonly performed procedure
• Others
– LAUP (Laser assisted Uvulo Palatoplasty)
– RFUP (Radio frequency Uvulo Palatoplasty)
– Uvulopalatal Flap
– Lateral Pharyngoplasty
– Transpalatal Advancement Pharyngoplasty

25. UPPP
Complications : Hemorrhage, Stenosis, Velopharyngeal
Incompetence

26. LAUP

27. RF Palatal Ablation

28. Lateral Pharyngoplasty

29. Uvula Flap

30. Tongue Procedures
1. Radiofrequency Tongue Ablation
2. Lingual Tonsillectomy
3. Linguloplasty
4. Tongue Base Suspension
5. Hyoid Myotomy & Advancement

31. Linguloplasty

32. Tongue Suspension

33. Maxillofacial Procedures
Genio-glossal advancement and hyoid myotomy

34. Maxillofacial Procedures
Maxillo-mandibular osteotomy & Advancement

35. Tracheostomy
Last Resort in Treatment Failure cases

36. Complications
• Systemic Hypertension
• CAD
• CHF
• Arrhythmias
• Pulmonary Hypertension
• CVA
• Risk Accidents
• Marital Discord
• Professional Setbacks
• Depression
• Impotence
• Sudden Death