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Surgical treatment of snoring & obstructive sleep apnoea


Hillel D. Ephros, Mansoor Madani
*
& Sumitra C. Yalamanchili
*
Oral & Maxillofacial Surgery & Department of Dentistry, St Josephs Regional Medical Center Paterson, NJ,
Department of Dentistry & Oral & Maxillofacial Surgery, Seton Hall University School of Health & Medical
Sciences, South Orange, NJ,
*
Department of Oral & Maxillofacial Surgery, Capital Health System Trenton, NJ,
Associate Professor, Temple University, Philadelphia, PA, Center for Corrective Jaw Surgery, North Presidential
Blvd. Suite, Bala Cynwyd, PA &
**
Oral & Maxillofacial Surgery, St. Josephs Regional Medical Center, Paterson,
NJ & Seton Hall University School of Health & Medical Sciences, South Orange, NJ, USA
Received November 3, 2008
Obstructive sleep apnoea (OSA) syndrome is a potentially serious disorder affecting millions of people
around the world. Many of these individuals are undiagnosed while those who are diagnosed, often
exhibit poor compliance with nightly use of continuous positive airway pressure (CPAP), a very effective
nonsurgical treatment. Various surgical procedures have been proposed to manage and, in some cases,
treat OSA. In this article we review methods used to assess the sites of obstruction and a number of
surgical procedures designed to address OSA.
Effective surgical management of OSA depends upon developing a complete database and determining
different levels of obstruction, which may include nasal, nasopharyngeal, oropharyngeal, and
hypopharyngeal/retrolingual, or a combination of these sites. A systematic approach to clinical evaluation,
treatment planning and surgical management is recommended and is likely to result in more predictable
outcomes. Surgical treatment may involve various procedures that are performed in different stages
depending on the patients sites of obstruction. The most commonly performed procedures include
nasal reconstruction, uvulopalatopharyngoplasty (UPPP), advancement genioplasty, mandibular
osteotomy with genioglossus advancement, and hyoid myotomy and suspension. In more severe cases,
maxillomandibular advancement (MMA) with advancement genioplasty may be indicated. Even after
appropriate surgical treatment, some patients may demonstrate continued obstruction with associated
symptoms. Published indications for surgical treatment include an elevated respiratory disturbance
index (RDI) with excessive daytime somnolence (EDS), oxygen desaturations below 90 per cent, medical
co-morbidities including hypertension and arrhythmias, anatomic abnormalities of the upper airway
and failure of medical treatment. The success of surgery in OSA is generally measured by achieving a
(RDI) of less than 5, improvement of oxygen nadir to 90 per cent or more with no desaturations below
90 per cent and quality of life improvements with elimination or signifcant reduction of OSA symptoms.
From a practical point of view, achieving these goals may be extremely diffcult without patients co-
operation, most notably in the realm of weight loss and maintenance of a healthy lifestyle.
Key words Hypopharyngeal obstruction - mandibular osteotomy - maxillomandibular advancement - nasal obstruction - obstructive sleep
apnoea - uvulopalatopharyngoplasty
Indian J Med Res 131, February 2010, pp 267-276
Review Article
Pathophysiology of obstructive sleep apnoea
Three factors that play a signifcant role in the
development of OSA are: (i) a reduction in the dilating
forces of the pharyngeal dilators, (ii) the negative
inspiratory pressure generated by the diaphragm, and
(iii) abnormal upper airway anatomy, the element most
effectively addressed by surgery. The multifactorial
nature of this condition may explain why surgical
procedures in the upper airway often address the sound
of snoring but do not necessarily result in the complete
elimination of OSA.
The most common sites of obstruction are located
in the pharynx
1-8
. The muscles of the upper airway,
including the sternohyoid, genioglossus, and tensor
veli palatini, work synergistically to dilate or stiffen
the extrathoracic airway and to maintain its caliber
(Fig. 1). Airway collapse often occurs when patients
sleep on their back and the base of the tongue abuts the
posterior pharyngeal wall and soft palate. Elongated
or excessive tissue of the soft palate, a bulky tongue,
enlarged uvula, large tonsils, and redundant pharyngeal
mucosa are the most common causes of snoring and
obstructive sleep apnoea (Fig. 2). Along with the
narrowing of the airway, an increased inspiratory
pressure is needed to maintain adequate ventilation.
Fig. 1. Anatomy of the upper airway demonstrates the complexity
of the muscular structure of the pharynx. When treatment planning
any surgical procedure one should bear in mind that the concept of
the upper airway surgery may include multiple surgical approaches.
Hence promise of a cure for sleep apnoea may not be easily achievable
or feasible. Source: Ref. 4. (Reproduced with permission).
Fig. 2. Elongated or excessive tissue of the soft palate, bulky tongue,
enlarged uvula, large tonsils, and redundant pharyngeal mucosa are
the most common causes of snoring and obstructive sleep apnoea.
Source: Ref. 4 . (Reproduced with permission).
A virtual vacuum on inspiration promotes further
collapse of the upper airway, which often has poor tone
in patients who snore or have obstructive sleep apnoea
due to repeated vibratory trauma (Table I).
The success of airway surgery depends on an
accurate diagnosis of the sites of obstruction and the
appropriate selection of procedures to address these
sites. Rather than applying a standardized approach to
the surgical management of OSA, it seems preferable
to tailor treatment to the specifc needs of each patient.
A growing body of evidence supports the effectiveness
of multiple site surgery to effectively treat snoring
and OSA. Looking at a variety of surgical procedures
proposed and performed in past and the results of
extended follow up studies, it appears that multilevel
treatments are more likely to provide signifcantly
better results than focusing on single site procedures.
The goal of treatment for snoring and OSA is to improve
quality of life, daytime sleepiness and psychomotor
vigilance, and to reduce or eliminate snoring and sleep
apnoea. An algorithmic approach to select the sites as
well as modalities of surgical intervention should not
Table I. Adult upper airway abnormalities in sleep apnoea
Enlarged and elongated uvula
Hyperplastic or thick soft palate
Constricted oropharynx
Macroglossia
Enlarged tongue base
Prominent oropharyngeal folds
Skeletal deformities, Maxillary
& Mandibular Retrognathism or
hypoplasia, Receded chin
Adenoids
Obstructive tonsils
Deviated septum
Enlarged nasal turbinates
Nasal polyps or any other
obstructive masses
268 INDIAN J MED RES, FEBRUARY 2010
EPHROS et al: SURGICAL TREATMENT FOR OSA 269
only produce more favourable outcomes but may allow
patients to avoid procedures that are less likely to be
benefcial. The focus of this article is on describing
various techniques intended to manage multiple sites
of obstruction.
Nasal obstruction
The role of nasal obstruction in snoring and OSA.
Increased resistance produces turbulent fow in the
nasal cavity, induces oral breathing, and promotes
oscillation of pharyngeal airway, which can lead to
snoring have been identifed. Oral breathing alters
the functional dynamics of the upper airway, which
predisposes it to obstruction. In patients with OSA,
high nasal resistance increases negative inspiratory
pressure, which may lead to upper airway collapse
during sleep. Another consequence of nasal obstruction
is increased negative pressure and functional
narrowing of the pharyngeal airway, resulting in
hypoxia and sleep apnoea
9
. Nasal obstruction is most
easily diagnosed by direct physical examination with
a nasal speculum, a zero-degree intraoral camera,
or by nasal endoscopy. Although it is unlikely that
nasal pathology is the sole source of snoring or OSA,
these entities should not be overlooked (Fig. 3). The
most commonly encountered and relevant anatomic
abnormalities are nasal polyps, deviated nasal septum
and hypertrophic inferior turbinates (Table I).
The treatment for nasal polyps is surgical
removal with cauterization, if needed. The goal of
this treatment is to improve turbulent airfow through
the nasal passages and to allow more laminar fow
of air with a corresponding decrease in snoring and
OSA parameters. Hypertrophic turbinates create an
obstructive phenomenon that can substantially reduce
the fow of air through one or both nares. If the fow of
air through one nostril is obstructed, then the airfow
on the contralateral side becomes turbulent and may
cause excessive snoring. If both nares are obstructed,
the patient becomes an obligate mouth breather, which
may further alter the functional dynamics of the upper
airway and predispose the patient to obstruction at
other levels. Treatment at this level may include
turbinectomy or nasal radioablation procedures.
Oropharyngeal obstruction
Obstruction at the level of the soft palate, pharynx,
and tonsillar pillars is a more common fnding in
patients with snoring and OSA. These sites are the
focus of many of the surgical procedures traditionally
labelled phase I therapies. The goals of surgery here
are to expand and open the oropharyngeal airway and
to remove obstructing or redundant tissue leading to a
reduction in the resistance to airfow.
Uvulopalatopharyngoplasty (UPPP), initially
described by Fujita & collegues
10-12
, is used to correct
obstruction at the oropharyngeal level by modifcation of
the uvula, removal of redundant pharyngeal and palatal
tissue, and primary closure of the posterior and anterior
pillars to enlarge the retropalatal airway. Numerous
experts have subsequently attempted to modify the initial
procedure, with proposed changes aimed at enlarging the
pharynx and reducing the redundancy and collapsibility
of hypopharyngeal tissues. These modifcations include
complete removal of the uvula and distal soft palate,
removal of part of the palatopharyngeus muscle and the
use of an uvulopalatal fap
13-20
.
Laser also has been used to reduce the vertical
height of the uvula or remove the elongated or enlarged
tissues in the oropharynx. Kamami, a French surgeon,
frst described laser-assisted uvulopalatoplasty (LAUP)
in the 1980s to reduce the uvula and distal portion of
the soft palate without total excision of the muscle
uvulus
21
. A laser was used to vaporize the uvula and
a specifed portion of the palate in a series of small
procedures. He suggested that scar contracture would
lead to a reduction in the redundancy of the soft
palate and to dilatory effect on the pharynx
21,22
(Fig.
4). Although the procedure may be conducted in a
single sitting, LAUP has been described in the past as a
staged procedure with incremental treatments avoiding
excessive reduction that could result in velopharyngeal
Fig. 3. Enlarged nasal turbinates, deviated septum and presence of
nasal polyps are few contributing factors to snoring and obstructive
sleep apnoea. Source: Ref. 4. (Reproduced with permission).
insuffciency (VPI). VPI is a complication that may
be associated with LAUP or UPPP particularly if the
resection includes the levator veli palatini muscle.
While LAUP may reduce or eliminate snoring in many
patients, the procedure does not seem very effective
as a treatment for OSA. Madani frst described a
modifed version of the procedure using laser to
perform traditional UPPP in an offce setting, - laser-
assisted uvulopalatopharyngoplasty (LA-UPPP) with
a 70 per cent reduction in snoring and up to 50 per
cent improvement in OSA symptoms in appropriately
selected patients
23
.
The concept of radiofrequency (RF) tissue ablation
or volumetric tissue reduction has recently generated
considerable interest. Ellis et al
24
presented preliminary
work on stiffening of palatal tissue using Nd-YAG
laser in 1993. In 1995, Whinney et al
25
described an
approach for stiffening of the soft palate by creating
10-15 penetration sites on the palatal mucosa using
diathermy. Powell and colleagues
26
initiated the use of
radiofrequency for the treatment of snoring and sleep
apnoea in an animal model. This and other animal and
human studies demonstrated that using RF energy
could safely reduce tongue and soft palate volume in
a controlled manner
26
. Madani studied the effect of
radiofrequency for volumetric reduction of enlarged
turbinates and obstructive tonsils as well as soft palate
and tongue from 1997-2006
27
.
Radiofrequency generates frictional heating of
the tissue around an electrode by ionic agitation. The
electrode tip is placed into the soft tissues and the heat
causes localized ablation of the soft tissue leading to
reduction in volume and stiffening of the tissues. These
procedures can be repeated several times until clinical
success is observed with reduction in snoring sounds
or in the degree of obstruction. Re-treated 62 per cent
of patients who had relapse after palatal radioablation
with LA-UPPP
28
showed that radioablation procedures
are only effective if patients are chosen properly and the
length of the uvula is short, the tongue is not enlarged
and not signifcantly retropositioned, and the patient
has a body mass index (BMI) of less than 25. Relapse
after radioablation has been far less of an issue with
nasal surgery than with similar procedures done on the
tongue and other tissues
29
.
Another method proposed for the reduction
of airway collapse at the oropharyngeal level is
the placement of palatal implants. Polyethylene
terephthalate (PET) implants are approved by the
Food and Drug Administration of the United States for
reduction of snoring and for the treatment of mild to
moderate OSA. These palatal implants measuring 18
x 1.8 mm, are cylindrical and braided. The technique
involves transmucosal placement of 3 implants into the
central portion of the soft palate with the most proximal
portion of the implants near the junction of the hard
and soft palate. This serves to stiffen the soft palate
tissues and reduce dynamic futter while the braided
material encourages tissue in-growth and stabilizes the
implant, usually within 4 to 6 wk. The effectiveness
of these minimally invasive procedures also relies on
patient selection and lower BMI
30
.
Tonsillectomy
Although rare in adulthood, obstructive tonsils,
if present, are an important element of upper airway
anatomy and may be a major factor in obstructive sleep
apnoea. Many studies support the notion that enlarged
tonsils play a signifcant role in oropharyngeal airway
obstruction. In severe cases of obstructive tonsillitis,
tonsillectomy at any age might prove benefcial and
is likely to have a positive impact on upper airway
obstruction.
In addition to traditional tonsillectomies, several
techniques have been utilized in recent years. Post-
operative bleeding and pain can complicate the
traditional use of a guillotine with a blade. Bleeding
may be signifcantly decreased with the use of
Fig. 4. Following LA-UPPP the upper airway opens up but patients
may continue to have obstruction at the level of the tongue base.
Source: Ref. 4. (Reproduced with permission).
270 INDIAN J MED RES, FEBRUARY 2010
electrocautery or an ultrasonic blade, however, post-
operative pain is still reported consistently regardless
of the technique used
31-35
.
Krespi and Ling
36
have described serial
tonsillectomy with carbon-dioxide laser in the
outpatient setting. Tonsillar tissue is removed, resulting
in a faster surgical procedure with decreased blood
loss and reportedly, with lower levels of post-operative
pain when compared with traditional tonsillectomy.
Performed over a few visits, serial tonsillectomy is
associated with an increased risk of tonsillar tissue re-
growth and the chance for recurrent infection as well as
some degree of pain.
Radiofrequency ablation of the tonsils is used to
accomplish volume reduction and stiffening and may
be accompanied by similar treatment of the tongue
base. Energy is delivered with a needle device resulting
in soft tissue volume reduction. Usually, a single
procedure is adequate in reducing the size of the tonsils;
however, an additional procedure may be indicated.
Clinical trials suggest decreased pain when reducing,
rather than removing, the tonsil
37,38
. However, some
have expressed concern about the potentially increased
risk for haemorrhage using this technology
39-40
.
Hypopharyngeal obstruction
Hypopharyngeal obstruction of the retrolingual
area is commonly encountered in the snoring and OSA
population. Surgical management is directed toward
either a reduction in the volume of tongue mass or
advancement of the tongues anterior attachments.
Radiofrequency ablation of the tongue follows the
principles described for the soft palate, nose and
tonsils. This procedure, as described by Powell and
colleagues
26
, can be performed on an outpatient
basis with conscious sedation and local anaesthesia.
Numerous modifcations of this procedure have
been reported. Most of them, however, still involve
radiofrequency ablation at various sites located near
the circumvallate papillae with treatment taking place
over several sessions a few weeks apart. Madani has
noted comparable improvements in hypopharyngeal
obstruction resulting from moderate weight loss and he
reported signifcant relapse with tongue radioablation,
particularly in those patients who have gained
weight
7
.
The advancement genioplasty is a skeletal procedure
used to reposition the insertion point of the genioglossus
musculature
41-43
(Fig. 5). The genial tubercles also bear
the attachments of the geniohyoid muscles, whereas the
anterior bellies of the digastrics attach laterally along
the posterior aspect of the mandibular symphysis. The
muscle attachments of the digastrics and geniohyoid
muscles are also advanced when the bony segment is
repositioned. The procedure not only results in a more
anterior post-operative position of the tongue, but it
also improves the post-operative position of the hyoid
bone. Horizontal osteotomies with genial advancement
may offer more beneft than anterior positioning
of the genial tubercles and their connections using
anterior mandibular osteotomies. This more limited
genial advancement procedure does not reposition the
digastric muscle or the hyoid bone, and delayed muscle
detachment associated with these procedures has been
reported.
EPHROS et al: SURGICAL TREATMENT FOR OSA 271
Fig. 5. The advancement genioplasty: is a skeletal procedure used to
reposition the insertion point of the genioglossus musculature. This
procedure not only results in a more anterior postoperative position
of the tongue but it also improves the postoperative position of the
hyoid bone. Source: Ref. 41. (Reproduced with permission).
Genioglossus advancement for mild to moderate
obstructive sleep apnoea with or without hyoid
advancement is a demonstrated technique for relieving
airway obstruction by anteriorly repositioning the
tongue. Genioglossus advancement with hyoid
myotomy/suspension (GAHM) may be indicated when
the hypopharynx is a site of obstruction. The procedure
is performed through a transoral incision. The chin is
exposed and small rectangular cuts (approximately
1 x 2 cm) are made in the bone to capture the area of
attachment of the genioglossus muscle. The rectangle
of bone is moved forward and turned slightly. A 2.0
mm titanium screw is used to secure the bone fragment
to the underlying mandible in an anterior position
dictated by the thickness of the segment. This results
in advancement of the genial musculature without a
change in the skeletal position of the chin and with no
impact on the tooth-bearing portion of the jaw
26
.
This procedure with or without hyoid myotomy
appears to be an effective method for enlarging the
retrolingual space. The hyoid myotomy operation
involves moving the hyoid bone forward, detaching
the muscles (sternohyoid, omohyoid, thyrohyoid and
stylohyoid) and fxating the hyoid bone to the thyroid
cartilage with non-resorbable sutures. The success
rate of hyoid advancement is variable, from 17 to
65 per cent
44
. This procedure may be performed in
conjunction with UPPP or maxillomandibular (MMA)
advancement for patients with multilevel obstruction.
Data regarding success and failure are complicated
by the frequent combination of this procedure with
others.
Maxillomandibular advancement (MMA)
A number of authors have reported on the success
rates of MMA for the treatment of OSA
42
. While
it is viewed as aggressive surgery and traditionally
relegated to phase II, MMA has consistently produced
results that make it the most predictable surgical
method in the management of OSA. Patients who have
severe maxillofacial skeletal disharmony, particularly
mandibular and maxillary retrusion, and patients who
suffer from severe OSA are candidates for MMA.
Because the presence of skeletal abnormalities is a
well-established predictor of OSA, MMA has been
encouraged to improve pharyngeal and hypopharyngeal
airway dimensions (Fig. 6). It expands the skeletal
framework that encompasses the nasal, pharyngeal
and hypopharyngeal airway thus leading to airway
expansion and reduction of lateral pharyngeal wall
collapse. MMA should be considered when medical
therapy fails or is not tolerated and patient anatomy
suggests that other surgical procedures are not likely to
produce signifcant beneft.
The mean age for MMA in the OSA population
is signifcantly higher than for patients undergoing
traditional orthognathic surgery. This can lead
to differences between the two groups involving
parameters such as vascular supply, bone healing,
stability and general health. The American Society
for Anesthesiologists Classifcation (ASA) status of
patients who have OSA is also likely to be higher so
that surgical as well as anaesthesia-related complication
rates may be higher for MMA in OSA patients than for
patients without OSA who undergo similar orthognathic
procedures
45
.
Fig. 6. Maxillomandibular Advancement has consistently produced
results that make it the most predictable surgical method in the
management of OSA. Patients who have severe maxillofacial
skeletal disharmony particularly mandibular and maxillary
retrusion, and patients who suffer from severe OSA are candidates
for MMA. Source: Ref. 41. (Reproduced with permission).
272 INDIAN J MED RES, FEBRUARY 2010
Although concerns with velopharyngeal
incompetence (VPI) resulting from MMA have not
been substantiated in recently published studies, that
possibility should be considered and, if indicated,
appropriate assessment may be conducted prior to
advancement surgery. VPI is most commonly associated
with cleft palate and submucous cleft palate, and can
occur following adenoidectomy. A diagnosis of VPI can
best be determined with multiview videofuorography
and fexible nasal endoscopy. These methods accurately
assess the velopharyngeal sphincter and can help to
plan and direct treatment for VPI
46,47
. Published results
of MMA in the OSA population and data gathered from
potentially higher risk patients with cleft palate suggest
that VPI is not likely to be a signifcant issue unless the
patient exhibited that tendency preoperatively.
A serious concern is the impact of MMA on the
airway in the immediate post-operative period. While
the procedure is done to improve airway anatomy, early
post-operative oedema in this at risk population has
been reported. Mild to moderate lateral pharyngeal
oedema and ecchymosis of the pyriform sinus
and aryepiglottic fold have been noted in a
signifcant number of MMA patients. Fiberoptic
nasopharyngolaryngoscopy is a useful instrument in the
early post-operative period to assess this oedema. Peri-
operative medical management as well as close post-
operative airway monitoring and possible intubation
may be necessary if airway compromise is present
48
.
There are limitations to the surgical outcomes
obtained with MMA. The magnitude of advancement
is generally no greater than 10-12 mm due to soft tissue
limitations. The well-known tendency for relapse due
to the soft tissues can be better appreciated in the adult
MMA patient. In the adult OSA patient, an advancement
of usually at least 1cm is required to achieve treatment
objectives. In patients for whom such a movement is
likely to be diffcult or impossible, there may be a role
for combined treatment with distraction osteogenesis.
Studies have consistently shown that MMA
is the most defnitive, successful and predictable
surgical procedure in the management of OSA other
than tracheostomy. The reported success rate of these
procedures ranges from 75-100 per cent and long-term
improvements in apnoea hypopnoea index (AHI) and
quality of life are seen in about 90 per cent of those
who have had MMA
49
. Even in patients who have
signifcant weight gain, the results of MMA remain
stable. The relegation of MMA to phase II by many
is related to the invasiveness and complexity of the
surgery and acknowledged complications such as
potentially catastrophic bleeding, infection, sensory
changes, malocclusion, and aesthetic changes that may
not be desirable in this population.
Distraction osteogenesis
Distraction osteogenesis may be a viable alternative
to MMA or, more likely, can be used in conjunction
with MMA. With distraction osteogenesis, there is a
slow and controlled advancement of the tooth-bearing
segments of the jaws that allows for regeneration in
the distraction site and for growth of the surrounding
soft tissue envelope along the vector of distraction.
Distraction osteogenesis is classically divided into
four phases: surgery, distraction, consolidation, and
hardware removal. In toddlers and young children, a
lag phase of 24 to 72 h is generally advocated, while in
adults, distraction is generally initiated 5-7 days after the
osteotomy. Various rates and rhythms of distraction have
been proposed, but most authors agree on a rate of 1 to
2 mm per day. Once the desired advancement has been
achieved, the consolidation phase begins and continues
for about twice the length of time needed for the
distraction, often two months or more. The fnal stage of
distraction osteogenesis is the removal of hardware and
occlusal splint placement to aid in retention. Distractions
of up to 25mm have been reported and relapse after
distraction may be less signifcant than after conventional
MMA, particularly with larger advancements
50
. Lu
et al
51
describe distraction osteogenesis as a reliable
surgical method to alleviate the narrow upper airway
growing OSA patients, especially those with severe
craniomaxillomandibular deformities.
Anaesthesia for OSA surgery
Given the nature of the OSA population, the risks
of anaesthesia must be carefully considered for any of
the surgical procedures that may be offered. While
there are a few defnitive studies to quantify and defne
the increased risk, the effects of anaesthesia, sedation
and analgesia on the integrity of the upper airway
and on ventilatory drive are potentially troublesome.
The risk of anaesthesia-related peri-operative
complications is elevated not only by the OSA, but by
its co-morbid conditions. Most notably, hypertension
and other cardiovascular diseases are common in the
OSA populations and these are likely to contribute to
the increased risk. In addition, for patients who have a
maxillofacial skeletal dysmorphology that is associated
with OSA, mandibular retrognathia, retrogenia and
the position of the hyoid bone may also contribute to
EPHROS et al: SURGICAL TREATMENT FOR OSA 273
airway diffculties during attempted intubation as well
as during open airway sedation
52
. OSA patients who
have unrelated surgery such as orthopaedic procedures
have been shown to have double the anaesthesia risk
compared to those without OSA who undergo the same
operations
53
. For OSA patients undergoing general
anaesthesia for upper airway surgery and MMA,
concerns have been expressed about extubation,
particularly when postsurgical oedema or haematoma
complicates an already diffcult situation. Respiratory
depression and periods of apnoea have been reported
in this patient population immediately following
extubation
52
. This problem may be exacerbated by the
use of opioids for post-surgical pain management.
There is little evidence to support a particular
approach to anaesthesia for patients at risk for OSA
or with known OSA. Nonetheless, the following is
derived from common sense along with available data.
Most importantly, screening for OSA should be part of
the routine pre-anaesthetic work up with surgeons and
anaesthesiologists asking appropriate questions during
history taking. These should include inquiries about
snoring, daytime somnolence and sleep disturbed
breathing witnessed by a bed partner. For patients who
have had prior exposures to anaesthesia, a history of
diffculty with intubation is associated with OSA and
certainly alerts the anaesthesia team to the likelihood
that the airway may again be problematic and intubation
might prove challenging. Elements of the physical
examination of particular signifcance include neck
circumference, BMI, chin-throat length, Mallampati
classifcation and the position of the mandible relative
to other facial structures
7
. Findings suggestive of
undiagnosed OSA should prompt additional evaluation
prior to elective surgery while individuals with
diagnosed OSA presenting for elective surgery of
any type should be medically optimized. Patients
perceived to be at risk should be encouraged to select
regional anaesthesia when applicable and reasonable.
Premedication with sedatives or opioids is undesirable
and is best avoided. During induction, sniffng position
has been shown to improve airway dimensions and
reduce its collapsibility
54
. Published algorithms and
recommendations for diffcult airways should be
followed and challenging endotracheal intubation
should be anticipated. Post-anaesthesia, those who use
CPAP at home must have it available for use during
recovery. For patients who are not CPAP users but
may be at risk in the post-anaesthesia care unit, lateral
positioning may be appropriate when possible. If
tolerated, a nasopharyngeal airway may also contribute
to the effective delivery of oxygen beyond the
compromised upper airway
55,56
.
For procedures that can be accomplished on an
outpatient basis using local anaesthesia and sedation, an
unprotected and potentially problematic airway remains
a serious concern. Nonetheless, titrated sedation is
a reasonable choice for appropriately selected, well-
positioned patients who require short procedures. The
usual parameters must be monitored carefully and the
clinician must be prepared to manage complications
that may arise. Rapid desaturations are not uncommon
in obese patients due to a smaller functional residual
capacity. Outcomes may be enhanced by careful patient
selection as well as by the use of agents and techniques
least likely to exacerbate the underlying condition.
Table II. Causes of obstructive sleep apnoea in younger age
Structure Neonates & infants Toddlers - Teens
Nasal Aplasia, Stenosis, Atresia, Masses Enlarged turbinates, Deviated septum, Polyps, Stenosis,
Masses, Rhinitis & post nasal drip
Tonsils Obstructive tonsils, Recurrent infection
Tongue Macroglosia, Vascular malformations of the tongue
and pharynx, Congenital cysts of the vallecula of
tongue.
Macroglosia, Vascular malformations of the tongue and
pharynx
Skeleton (Craniofacial
anomalies)
Facial or skull abnormalities, Birth injuries Skeletal deformities, Maxillary &/or mandibular
retrognathism or hypoplasia, Receded chin
Muscular Neuromuscular Disorders Neuromuscular disorders
Other Factors GERD, Hypoglycaemia, poor sleep posture, Down
syndrome, Apert, and Crouzon syndromes, Pierre-
Robin syndrome leading to a narrow airway, poor
sleep posture
Obesity, Soft palate collapse, elongated uvula, Down
syndrome, Apert, and Crouzon syndromes, Pierre-Robin
syndrome leading to a narrow airway, poor sleep posture
Neonates and infants rarely have signifcant lymphoid hyperplasia, on the other hand with increasing age and development, the likely
causes of disordered breathing changes. In toddlers and teenagers may demonstrate other issues as listed above. GERD, gastroesophageal
refux disease
274 INDIAN J MED RES, FEBRUARY 2010
It is clear that those who relegate surgical
procedures to third line treatment for OSA after CPAP
and oral appliances do so in part because of elevated
anaesthesia risks in patients with OSA. Clinicians who
are involved in the surgical management of snoring
and OSA should understand the anaesthesia-related
risks and weigh those along with potential surgical
complications when assessing the risks and benefts of
surgery for patients with OSA.
Children
In the peadiatric population, airway anatomy is
different than in adults, as are the most likely causes of
sleep-disordered breathing. Surgical procedures such
as those described for adults, are generally deferred in
children, central causes of sleep apnoea must be ruled out
and careful evaluation of the tonsils and adenoids must
take place. In younger children, the distance between the
tonsils, adenoids and the pharyngeal soft tissue may be
short. This can result in stertor, stridor, or both, making
the source of the breathing disorder diffcult to localize.
In children with at least mild adenotonsillar hyperplasia,
adenotonsillectomy is considered to be the frst-line
surgical treatment. For patients with craniofacial
anomalies impacting on airway anatomy such as the
Robin anomalad, surgical procedures including tongue
reduction, labioglossopexy, distraction osteogenesis and
even tracheostomy are utilized for airway management
57
.
Children who suffer from apnoea show continued
sleepiness after awakening in the morning and tiredness
and attention problems at school and throughout the day.
Some children who are diagnosed with attention defcit
hyperactivity disorder (ADHD) may actually have
attention problems in school because of disrupted sleep
patterns caused by obstructive sleep apnoea (Table II).
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Reprint requests: Dr Mansoor Madani, 15 N. Presidential Blvd. Suite 301, Bala Cynwyd, PA 19004, USA
e-mail: drmmadani@gmail.com
276 INDIAN J MED RES, FEBRUARY 2010