Dr.

Supreet Singh Nayyar, AFMC 2012

SLEEP DISORDERED BREATHING (PART 3) Treatment

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Non-Surgical therapy for OSAHS

Address co-existent, predisposing conditions Obesity Documented reduction in symptom after weight reduction Degree of improvement has no linear correlation with weight Few may not benefit if co-existent craniofacial abnormalities Life style modification Avoid tobacco /smoking Dietary modification Sleep deprivation Avoiding agents affecting sleep Treat hypothyroidism Mechanical devices (positive airway pressure) Body posture modification Sleeping with head and trunk elevated to 30-60 degree angle to horizontal reduces OSA Lateral decubitus is also effective in reducing episodes (sleep ball) Pharmacological therapy Protriptyline Non-sedating tricyclic antidepressant Increasing tone of airway muscle Statistically significant improvement Side effects : dry mouth, urinary hesitancy, constipation, confusion, ataxia Dose: 30 mg/day Agents with uncertain limited role Serotonin agonists Affects dilators
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Dr. Supreet Singh Nayyar, AFMC 2012

Busiprone Data insufficient Stimulants Amphetamines CVS complication Insufficient data

Continuous Positive Airway Pressure (CPAP)

Indications Mild OSA with EDS Moderate to severe OSA Co-morbidities Many consider it to be mainstay of OSA treatment Mechanism: Acts as pneumatic splint Equipment: Machine provides fixed pressure or vary pressure depending on the presence of apnoeas (Auto CPAP) Mask is nasal or full face, kept in place by Velcro straps Port of exhalation Newer machine small and light so portable Humidifier also available as an optional mode Compliance By 3 years 25-40% stop using CPAP Treatment failure Cost factor o Regular service and maintenance o Change of mask Side effects Claustrophobia Nasal stuffiness Skin abrasions, nasal bridge abrasions Leaks are uncomfortable for eyes Air swallowing if pressure more than esophageal sphincter pressure Pulmonary baro trauma ( very rare) Treatment Failure
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Dr. Supreet Singh Nayyar, AFMC 2012

Surgical management
SURGICAL TREATMENT OPTIONS
Nasal Surgery

1. 2. 3. 4. 5.

Nasal septoplasty Inferior turbinectomy Adenoidectomy Nasal tumor or polyp excision Nasal valve reconstruction

Palatal Surgery

1. 2. 3. 4. 5. 6.

Uvulopalatopharyngoplasty Uvulopalatal flap Tonsillectomy Transpalatal advancement pharyngoplasty Laser-assisted uvulopalatoplasty Palatal radiofrequency

Hypopharyngeal Surgery

1. 2. 3. 4. 5. 6. 7.

Maxillomandibular osteotomy and advancement Mandibular osteotomy with genioglossus advancement Hyoid myotomy and suspension Tongue base radiofrequency Partial glossectomy Lingual tonsillectomy Repose tongue suspension

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Dr. Supreet Singh Nayyar, AFMC 2012

Indications for surgery

Uvulopalatopharyngoplasty(UPPP) First described by Ikematsu(1950), Fugita popularized in 1985 Principle: Stiffen the soft palate by scarring Increase space behind soft palate Consists of Tonsillectomy Reorientation of the anterior and posterior tonsillar pillars Excision of the uvula and posterior rim of the soft palate. Complications: Nasal regurgitation Swallowing & voice problems Severe post op pain Hemorrhage Laryngospasm

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Dr. Supreet Singh Nayyar, AFMC 2012

Pulmonary edema, hypoxia Not satisfied post surgery 75-95% short term success Long term 45% Modification: Preserve uvula

Laser-assisted Uvulopalatoplasty(LAUP) Described by Kamami in France in 1993 Principle Stiffen the soft palate Prevent palatal flutter Surgery Local anesthesia on soft palate B/l vertical incision in soft palate followed by partial vaporization of
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Dr. Supreet Singh Nayyar, AFMC 2012

uvula with CO2 Laser Various modification done Complications Low Globus like symptom common Post operative pain

Uvulopalatoplasty

Reversible uvulopalatal flap A, Preoperative palate anatomy B, Uvula is grasped with a forceps and reflected back toward the softhard palate junction; note the muscular crease. C, The mucosa of the oral aspect of the uvula and soft palate in a diamond shape is removed with cold knife dissection; the uvular tip is amputated and the uvular muscle thinned, if necessary D, Trimmed and sutured flap, with the shaded area indicating the location of the tissue before it is repositioned. E, Postoperative appearance, with closure up on the soft palate

Radiofrequency tissue volume reduction/Thermal ablation(RFTVR)

Principle Similar to diathermy Lower temperature, lower current and voltage
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Dr. Supreet Singh Nayyar, AFMC 2012

Insulated probe delivering radiofrequency energy at a frequency of 465 KHz Thermal injury to specific submucosal sites in soft palate causing fibrosis and contraction Introduced into the base-of-tongue tissue under local anesthesia Advantage Day care, LA Less post operative pain Significant improvement reported Good for multi level obstruction Low relapse rate

Mandibular osteotomy and genioglossal advancement

Intraoral approach To enlarge the retrolingual area. The genial tubercle, which is the anterior attachment of the genioglossus muscle, is mobilized by osteotomy The segment is advanced and rotated to allow bony overlap to lock the inner (lingual) surface of the mandible and the geniotubercle at the outer (labial) surface The fragment is fixed at the inferior aspect of the osteotomy with a titanium screw

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Dr. Supreet Singh Nayyar, AFMC 2012

Other Procedures
Palatal: Z-pharyngoplasty, palatal implants Tongue base RFTVR Laser midline glossectomy to enlarge the retrolingual airway excision of approximately 2.5 5 cm of midline tongue tissue intraoral approach may also require lingual tonsillectomy reduction of the aryepiglottic folds partial epiglottectomy usually combined with a tracheotomy for airway protection Tongue suspension suture Hypoglossal nerve stimulation Lingualplasty. Same procedure as the LMG (laser midline glossectomy) Except that additional tongue tissue is extirpated posteriorly and laterally to the portion removed by LMG Epiglottis epiglottectomy Temporary tracheostomy

Repose tongue suspension.

Intraoral incision is made in the frenulum Titanium screw is placed at the lingual cortex of the geniotubercle of the mandible Permanent suture is passed through the paramedian tongue musculature along the length of the tongue, through the tongue base, and then back through the length of the tongue musculature Then anchored to the screw, pulling the tongue base anteriorly

Hyoid myotomy and suspension

Addresses retrolingual area Can alleviate obstruction caused by redundant lateral pharyngeal tissue or a retrodisplaced epiglottis Horizontal cervical incision over the hyoid bone is preferred Dissection is carried down to the suprahyoid musculature www.nayyarENT.com
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Dr. Supreet Singh Nayyar, AFMC 2012

Midline hyoid bone is isolated and then advanced over the thyroid ala Secured with two medial and two lateral permanent sutures

Maxillomandibular osteotomy and advancement

Improves retropalatal collapse by stabilizing the superior pharyngeal muscles and widening the nasopharyngeal inlet Also improves retrolingual obstruction by placing the genioglossus muscle under tension, thereby providing more room in the oral cavity for soft tissues and also stabilizing the lateral pharyngeal wall Outer-table cranial bone graft may be necessary, along with arch bar placement (or orthodontic banding) before the osteotomies Usually performed if previous upper airway procedures have not completely relieved the sleep-related obstruction.

Clinical Outcomes
Overall success rate for UPPP 40% With multilevel surgical strategy have achieved 60% when applying strict response criteria 80% have been reported when applying commonly accepted measures of improvement However, the results may be reduced in morbidly obese patients www.nayyarENT.com
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Dr. Supreet Singh Nayyar, AFMC 2012

Johnson and Chinn achieved a mean reduction of 44.1 points on the RDI (from a preoperative value of 58.7 to a mean postoperative value of 10.5) in patients undergoing UPPP and genioglossal advancement without HM When defining success as a RDI of less than 10, seven out of nine patients (78%) were successfully treated Troell and colleagues[57] reported that seven of 11 patients (63.6%) who underwent a palatopharyngoplasty combined with genioglossus advancement and HM were cured,

with cure defined as a postoperative RDI of less than 10, with resolution of EDS

Oral Appliances
Two basic types of appliances
Mandibular advancement devices Popular Positioning the lower jaw and tongue downward and forward The airway passage is increased Comfortable More effective Tongue repositioners Pulling only the tongue forward and not the entire lower jaw. Teeth, jaw muscles and joints are less affected Less studied A period of consistent nightly wear is required Patient motivation and cooperation essential

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