Obstructive Sleep Apnea

Shashidhar Reddy, MD, MPH

Faculty Advisor: Matthew W. Ryan, MD
The University of Texas Medical Branch
Department of Otolaryngology
December 2004

Overview

Physiology of Sleep
Evaluation of Sleep
Definition of Obstructive Sleep
Apnea (OSA)
Prevalence of OSA
Pathophysiology of OSA
Medical Treatment of OSA
Surgical Treatment of OSA

Physiology of Sleep

Woodson, Tucker Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment SIPAC 1996

REM
Sleep Latency, REM Latency
Arousal

Evaluation of Sleep

Polysomnography

EMG
Airflow
EEG, EOG
Oxygen Saturation
Cardiac Rhythm
Leg Movements
AI, HI, AHI, RDI

Evaluation of Sleep

Polysomnography

Woodson, Tucker Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment SIPAC 1996

Evaluation of Sleep

Split-Night Polysomnography
Epworth Sleepiness Scale
Multiple Sleep Latency Test

Definition of OSA

RDI>5
RDI > 20 increases risk of mortality
RDI 20-40=moderate, >40=severe
Upper Airway Resistance Syndrome

Shares pathophysiology with OSA

No desaturation, continuous ventilatory
effort

Snoring

Prevalence of OSA

Study
Location

Age
Prevalence of
Range AHI>5 (95%CI)

Prevalence of
AHI15 (95%CI)

Men

Women

Men

Women

Wisconsin

626

30-60

24
(19-28)

9
(6-12)

9
(6-11)

4
(2-7)

Penn

1741 20-99

17
(15-20)

Not given

7
(6-9)

2
(2-3)

Spain

400

26
(20-32)

28
(20-35)

14
(10-18)

7
(3-11)

30-70

Pathophysiology of OSA

Airway size:

Pathophysiology of OSA

Sites of
Obstruction:
Obstruction
tends to
propagate

Pathophysiology of OSA

Sites of Obstruction:

Pathophysiology of OSA

Symptoms of OSA

Snoring (most commonly noted

complaint)
Daytime Sleepiness
Hypertension and Cardiovascular
Disease are Associated
Pulmonary Disease

Pathophysiology of OSA

Findings in Obstruction:

Nasal Obstruction
Long, thick soft palate
Retrodisplaced Mandible
Narrowed oropharynx
Redundant pharyngeal tissues
Large lingual tonsil
Large tongue
Large or floppy Epiglottis
Retro-displaced hyoid complex

Pathophysiology of OSA

Tests to determine site of

obstruction:

Mullers Maneuver
Sleep endoscopy
Fluoroscopy
Manometry
Cephalometrics
Dynamic CT scanning and MRI
scanning

Medical Management

Weight Loss
Nasal Obstruction
Sedative Avoidance
Smoking cessation

Medical Management

CPAP

Pressure must be
individually titrated
Compliance is as
low as 50%
Air leakage,
eustachian tube
dysfunction,
noise, mask
discomfort,
claustrophobia

Medical Management

BiPAP

Useful when > 6 cm H2O difference in

inspiratory and expiratory pressures
No objective evidence demonstrates improved
compliance over CPAP

Nonsurgical Management

Oral appliance

Mandibular
advancement
device
Tongue retaining
device

Nonsurgical Management

Oral Appliances

May be as effective as surgical options,

especially with sx worse on patients
back
However low compliance rate of about
60% in study by Walker et al in 2002
rendered it a worse treatment modality
than surgical procedures

Walker-Engstrom ML. Tegelberg A. Wilhelmsson B. Ringqvist I. 4-year follow-up of

treatment with dental appliance or uvulopalatopharyngoplasty in patients with
obstructive sleep apnea: a randomized study. Chest. 121(3):739-46, 2002 Mar.

Surgical Management

Measures of success

No further need for medical or surgical

therapy
Response = 50% reduction in RDI
Reduction of RDI to < 20
Reduction in arousals and daytime
sleepiness

Surgical Management

Perioperative Issues

High risk in patients with severe

symptoms
Associated conditions of HTN, CVD
Nasal CPAP often required after surgery
Nasal CPAP before surgery improves
postoperative course
Risk of pulmonary edema after relief of
obstruction

Surgical Management

Tracheostomy

Primary treatment modality

Temporary treatment while other surgery is done
Thatcher GW. et al: tracheostomy leads to quick
reduction in sequelae of OSA, few complications (see
table II)
Once placed, uncommon to decannulate

Thatcher GW. Maisel RH. The long-term evaluation of tracheostomy in the

management of severe obstructive sleep apnea. [Journal Article]
Laryngoscope. 113(2):201-4, 2003 Feb.

Surgical Management

Nasal Surgery

Limited efficacy when used alone

Verse et al 2002 showed 15.8%
success rate when used alone in
patients with OSA and day-time nasal
congestion with snoring (RDI<20 and
50% reduction)

Adenoidectomy

Surgical Management

Uvulopalatopharyngoplasty

Surgical Management

Uvulopalatopharyngoplasty

The most commonly performed surgery

for OSA
Severity of disease is poor outcome
predictor
Levin and Becker (1994) up to 80%
initial success decreased to 46%
success rate at 12 months
Friedman et al showed a success rate
of 80% at 6 months in carefully
selected patients
Friedman M, Ibrahim H, Bass L. Clinical staging
for sleep-disordered breathing. Otolaryngol Head
Neck Surg 2002; 127: 1321.

Surgical Management

UP3
Complications

Minor
Transient
VPI
Hemorrhage
<1%
Major
NP stenosis
VPI

Surgical Management

Cahali, 2003
proposed the
Lateral
Pharyngoplasty for
patients with
significant lateral
narrowing:
Cahali MB. Lateral pharyngoplasty: a
new treatment for obstructive sleep
apnea hypopnea syndrome.
Laryngoscope. 113(11):1961-8, 2003
Nov.

Surgical Management

Lateral Pharyngoplasty

Surgical Managment

Lateral Pharyngoplasty

Median apnea-hypopnea index

decreased from 41.2 to 9.5 (P = .009)
No control group
No evaluation at 12 months

Surgical Management

Laser Assisted
Uvulopalatoplasty

High initial success

rate for snoring
Rates decrease, as
for UP3 at twelve
months
Performed awake

Surgical Management

Radiofrequency
Ablation Fischer
et al 2003

Radiofrequency device is
inserted into various parts of
palate, tonsils and tongue base
at various thermal energies

Surgical Management

Fischer et al 2003

At 6 months Showed significant reduction

of:
RDI (but not to below 20)
Arousals
Daytime sleepiness by the Epworth
Sleepiness Scale

Surgical Management

Tongue Base Procedures

Lingual Tonsillectomy

may be useful in patients with

hypertrophy, but usually in conjunction
with other procedures

Surgical Management

Tongue Base
Procedures

Lingualplasty

Chabolle, et al
success rate of
77% (RDI<20,
50% reduction) in
22 patients in
conjunction with
UPPP
Complication rate
of 25% - bleeding,
altered taste,
odynophagia,
edema
Can be combined
with
epiglottectomy

Surgical Management

Mandibular
Procedures

Genioglossus
Advancement
Rarely performed
alone
Increases rate of
efficacy of other
procedures
Transient incisor
paresthesia

Surgical Management

Lingual
Suspension:

Surgical Management

Lingual
Suspension:

Surgical Management

Hyoid Myotomy and

Suspension

Advances hyoid
bone anteriorly and
inferiorly
Advances epiglottis
and base of tongue
Performed in
conjunction with
other procedures
Dysphagia may
result

Surgical Management

Maxillary-Mandibular Advancement

Severe disease
Failure with more conservative
measures
Midface, palate, and mandible
advanced anteriorly
Limited by ability to stabilize the
segments and aesthetic facial changes

Surgical Management

MaxillaryMandibular
Advancement

Performed in
conjunction with
oral surgeons

Surgical Management

Algorithms

Studies efficacy of various algorithms

Therapy should be directed toward
presumed site of obstruction

This does not always guarantee results

Surgical Management

Algorithms

Riley et al 1992

Studied 2 phase approach for multilevel

site of obstruction (Stanford Protocol):

Phase 1: Genioglossal advancement, hyoid

myotomy and advancement, UP3
Phase 2: Maxillary-Mandibular advancement
in 6 months if phase 1 failed
Reported >90% success rate in patients who
completed both phases
Other studies have lowered this number
Testing is done at 6 months

Surgical Management

Algorithms

Friedman et al
developed a
staging system for
type of operation:

Surgical Management

Algorithms:

Friedman
et al:

Surgical Management

Algorithms:

Friedman et al:
Success =
RDI<20 and
RDI reduced
50%

Friedman, Michael MD; Ibrahim,

Hani MD; Joseph, Ninos J. BS
Staging of Obstructive Sleep
Apnea/Hypopnea Syndrome: A
Guide to Appropriate Treatment.
Laryngoscope. 114(3):454-459,
March 2004.

Conclusions

Physiology of Sleep
Evaluation of Sleep
Definition of Obstructive Sleep Apnea
(OSA)
Prevalence of OSA
Pathophysiology of OSA
Medical Treatment of OSA
Surgical Treatment of OSA

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