Obstructive sleep apnea is a common disorder characterized by recurrent collapse of the upper airway during sleep, causing disrupted breathing and fragmented sleep. It is diagnosed through a sleep study showing apneic episodes and oxygen desaturation. Risk factors include obesity, enlarged tonsils, and craniofacial abnormalities. Treatment involves lifestyle changes, oral appliances, CPAP, surgery, or a combination. Surgeries aim to enlarge the airway through procedures of the nose, palate, tongue, or jaw.

1. Obstructive Sleep Apnea
Dr. Adhishesh Kaul
Moderator: Dr Nagarathna H.K
Associate Professor
Department of ENT

2. Simple Snoring
‘noisy breathing without obstructive apnea, frequent arousals from sleep or gas
exchange abnormalities’
Definition: Habitual audible snoring with Apnea-Hypoapnea Index (AHI) < 5
events/ hour and without Excessive Daytime Sleepiness (EDS)
Pathophysiology:
Noise due to vibrations of soft tissue in oropharynx as individual
attempts to inhale air into lungs against obstruction.
Incidence:
More common in men due to higher fat deposition around neck.

3. Upper Airway Resistance Syndrome
• Normal Individuals have increase in UAR during sleep due to reduction in
muscle tone, along with collapse of upper airway.
• Prevalence: Not known as symptoms are not usually reported to doctors.
• Symptom: Snoring and Excessive daytime sleepiness
• Cause:
1. Enlarged tonsils
2. Large nasal polyps
3. DNS
4. Craniofacial abnormalities : low soft palate, long uvula

4. • Characteristics: Respiratory effort-related arousals (RERA).
• Investigations:
1. Esophageal manometry
2. Pneumotachographic airflow measurements
3. Polysomnography (PSG)
• Investigation Results:
1. Increase in negative inspiratory esophageal pressure
2. Decrease in oronasal airflow
3. PSG shows frequent arousals a/w snoring, increased diaphragmatic
electromyogram activity
• Impact:
1. Desaturation of <4%
2. Brief EEG arousals
3. Excessive daytime sleepiness

5. • Management:
1. Surgical correction, if obstruction can be dealt
like tonsillectomy, septoplasty etc
craniofacial abnormalities are harder to be corrected
surgically
2. Avoid alcohol and sedatives
3. Avoid sleeping supine
4. Intraoral devices – Mandibular advancement device (MAD)
5. CPAP: if no surgically correctable cause is identified and MAD
is not useful

7. Obstructive Sleep Apnea
‘Disorder of breathing during sleep characterized by prolonged partial
upper airway obstruction and/or intermittent complete obstruction that
disrupts ventilation during sleep and normal sleep patterns.’

8. Epidemiology
• Primary snoring: 6.1% in Germany on the basis of study on PSG
• OSA : 0.7%-1.8% in UK and Italy
• Nocturnal apneas: 1-2% throughout first 6 years of life
• Prevalence of snoring increased form 3-4% at 1 year of age to 7-8%
between 3-4 years of age.
• Prevalence of habitual Snoring: upto 12% of children in UK,
prevalence increased from 10% at 1 year of age to 15% at 6 years of
age.

9. • Common condition characterized by recurrent episodes of upper
airway collapse during sleep resulting in hypoxia and sleep
fragmentation.
• Diagnosis:
Symptoms: Snoring + EDS
Sleep Study: Apneic episodes and desaturation >4% from baseline.

11. Pathophysiology of OSA/OSAHS
Obstruction is due to collapse of pharyngeal airway during sleep, due
to easily collapsible upper airway and relaxation of pharyngeal dilator
muscles.
Structural compromise due to anatomical abnormalities along with
complex reflex pathways from CNS to pharynx, fail to maintain
pharyngeal patency.
Site of obstruction: (3 major)
Nose
Palate
Hypopharynx

12. Type Location of obstruction Prevalence
Type 1 Collapse in retropalatal region only 100%
Type 2 Collapse in retropalatal and retrolingual region
Type 3 Collapse in retrolingual region only 77%
Fujita classification of pattern of obstruction by anatomical location

13. Episodic partial/ complete obstruction of upper airway during sleep
Apnea/cessation of breathing (>10sec in adult)
affect pulmonary ventilation
drop in peripheral oxygen with CO2 retention
hypoxemia and hypercarbia effect on respiratory center: cause
AROUSALS

14. • Nasal Obstruction: increases airway resistance but rarely the sole cause
of OSA.
Nasal obstruction results in open mouth breathing resulting in
1. Increase in upper airway collapsibility
2. Decreased efficacy of pharyngeal dilator muscles
• Obesity: major risk factor for OSA, due to increased fat deposition
around neck and parapharyngeal spaces.

15. Untreated OSA
• Increased mortality (AI: >20)
• Neurocognitive difficulties
• Increased risk of RTA (by ~2.5 times)
• Increased cardiovascular diseases (by ~3 times)
(HTN/ CAD/ CHF/ Arrhythmia/ Pulmonary HTN/ CVA/ Sudden Death)
• Insulin resistance along with MS and DM
• GERD
• Attention/ Working memory/ executive functions

16. Risk factors for OSA
• Adenotonsillar hypertrophy
• Familial predisposition
• Obesity
• Craniofacial disproportion
• Craniofacial syndromes
• Systemic illnesses like CP, sickle cell anemia, achondroplasia

17. Diagnosis

18. • Detailed sleep history and examination
BMI/ BP/ Neck Circumference
GPE: Body habitus/ Maxilla and Mandible position and size/
Facial characteristics
Nose: nasal valve/ deformities/ septal position/ turbinates/
polyps/ mucosa
Oral Cavity: tongue size/ elongation of palate and uvula/ tonsil
size/ MP grade/ dentition/ Oropharyngeal crowding
Neck: Size/ Hyoid position/ jaw position with retrognathia

20. • Epworth Sleepiness Scale
• Fiberoptic nasopharyngoscopy and laryngoscopy: using Muller
maneuver
• Drug induced sleep endoscopy (DISE) – useful for site/ severity and
pattern of obstruction : VOTE classification
• Cephalometric radiograph : inferiorly displaced hyoid/ small posterior
airway/ long soft palate
• CT and MRI : better use for post operative anatomical changes
• Fluoroscopy
• Nocturnal PSG – Gold Standard

38. Volumetric MRI

40. Management

41. Lifestyle changes
• Weight loss by dietary modifications and if needed bariatric surgery
• Avoid alcohol before sleeping, which has effect on neck muscle tone
• Avoid smoking
• Positional therapy: Avoid supine sleeping
• Regular exercise: to increase muscle tone

42. Medical Management
• Mandibular advancement splints
• CPAP
• BiPAP
• Adaptive servo-ventilator (ASV)
• Nasal EPAP

43. Mandibular Advancement Splints

44. • MOA: Forward displacement of mandible and bringing tongue base
anteriorly, thus increasing dimensions of upper airway
• Procedure: Assess for maximum protrusion of mandible and maintain
mandible between 50%-75% of maximal protrusion.
• Side Effects:
Excess salivation
Xerostomia
TMJ Pain
Bite change
• Compliance: 50% - 75%

45. CPAP

46. Recommended therapy as per NICE for moderate – severe OSA
• Mechanism of action: pneumatic splint – air pressure generated by
tube and mask prevents collapse of pharyngeal and palatal walls
• Positive pressure: fixed pressure
autotitrating pressure – depending upon apnea and
hypoapneas.
• Pressure = (0.16 * BMI) + (0.13 * NC) + (0.04 * AHI) – 5.12
• CPAP titration can be done with help of ‘split night’ regime, with
initial pressure of 4cm H2O.
• autoCPAP machine for self-titration
• Side effects: nasal congestion, rhinosinusitis, nasal bridge and facial
irritation, nose bleeds.

48. Adaptive servo-ventilator (ASV)
• Similar to BiPAP but varies with the fact that IPAP and EPAP are
adjusted as per patient’s ventilatory needs.
• Indications:
Central sleep apnea unresponsive to CPAP and BiPAP
Complex sleep apnea

51. Pharmacological Therapy
• Modafinil
Dose: 200mg OD
MOA: sympathomimetic action, similar to amphetamine with no
residual effect or withdrawl
Use: to alleviate symptoms of EDS in OSA patients on CPAP
It should not be used as a primary treatment of OSA

52. • Fluticasone
Dosage form: Intranasal steroid
Indication: OSA with coexistent rhinitis
adenotonsillar hypertrophy (use for 6 weeks)
Warning: not recommended as single line therapy for adults
• Montelukast
MOA: Leukotriene receptor antagonist
Use: reduce adenoid size and respiratory sleep disturbances in
children with mild OSA
• Topical Decongestants with nasal dilator strips
Use: OSA with severe nasal obstruction
Dose: 0.05% 0.4ml oxymetazoline with nasal dilator strips

53. Surgical Management

54. Surgeries
1. Nasal surgery
2. Palatal surgeries
3. Hypopharyngeal surgery

56. Nasal Surgeries
• Septoplasty
• Inferior turbinate reduction
• Adenoidectomy
• Nasal tumor/ polyp resection
• Nasal valve reconstruction

57. • Nasal surgeries improve the airway but impact on snoring is minimal.
• Studies have shown objective improvement in nasal airway by
rhinomanometry without any improvement in snoring time/ intensity,
sleep architecture.
• Studies also show NO CHANGE in PSG.
• Rationale: Improve nasal airway and provide better response and
compliance to CPAP.

58. Palatal Surgeries
• Uvulopalatopharyngoplasty
• Transpalatal advancement pharyngoplasty
• Pillar implants
• Injection snoreplasty
• Palatal radiofrequency ablation
• Tonsillectomy

59. Uvulopalatopharyngoplasty/ Z-palatoplasty

60. Friedman Tongue Position Structures visualised
FTP 1 Uvula
Tonsils
FTP 2a Most of Uvula
Tonsils/Pillar not seen
FTP 2b Entire Soft Palate
Uvular base
FTP 3 Some soft palate only
FTP 4 Hard Palate only

61. Friedman Staging for OSA

62. Transpalatal Advancement Pharyngoplasty
• Aim:
To address more proximal AP narrowing of retropalatal segment
• Selection of patients:
1. long vertical segment of soft palate with genu >2cm from
margin
2. significant anatomical collapse on endoscopic examination of
retropalatal space extending above margin of UPPP
3. Ineffective medical treatment
• Result: Enlargement of retropalatal space by removing posterior
portion of hard palate and advancing it

64. Expansion Sphincter Pharyngoplasty
• Aim:
To address lateral wall collapse proximal to free margin of palate
• Principle:
relocation of palatopharyngeus muscle to open distal lateral wall
of velopharyngeus muscle
• Approach:
Lateral palatal space approach

66. Pillar procedure

68. Barbed Reposition Pharyngoplasty
• Technique: Lateral pharyngoplasty technique using barbed sutures for
relocation of pharyngeal palate muscle with enlargement and
stabilization lateral and posterior velo-pharyngeal space
• Indication: Retropalatal obstruction for OSA

70. Hypopharyngeal Surgeries
• Partial midline glossectomy
• Tongue base radiofrequency ablation
• Mandibular osteotomy and genioglossal advancement
• Hyoid myotomy and suspension
• Tongue suspension suture
• Maxillomandibular osteotomy and advancement
• Lingual tonsillectomy

71. Partial Midline Glossectomy

72. Tongue Base Thermal Ablation

73. Mandibular osteotomy and genioglossal
advancement

75. Maxillomandibular Osteotomy and Advancement

76. Tongue Suspension Suture

77. Powell and Riley’s multilevel surgery
Phase 1
Nasal Surgery, turbinate, valvular
and septal
Tonsillectomy, UP3,
Pharyngoplasty, Submucosal
minimally invasive lingual excision
(SMILE), midline glossectomy
Phase 2
Maxillofacial surgery
MMA and
SMILE and
BOT radiofrequency ablation,
midline glossectomy

79. Powell-Riley Definition of Surgery Responders
• AHI < 20
• Oxygen desaturation nadir ≥ 90%
• EDS alleviated / improved
• Response equivalent to CPAP on full-night titration
• Reduction AHI by ≥ 50% is considered cure if preoperative AHI is < 20