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Management of obstructive sleep apnea

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									MANAGEMENT OF OBSTRUCTIVE
       SLEEP APNEA


   Mohamed Farouk Helal
      Head of E.N.T. Dept.
       Air Force Hospital
         Cairo - Egypt
Diagnosis
Physical Exam
•Vital signs
•Head & Neck exam
•Flexible endoscopy
Vital signs
•Height
•Weight
•Collar size
•Blood pressure
•Calculate BMI
  Wt (kg) / Ht (meters) squared
  Men >27.8, Women >27.3
Examination
 Tongue       Nasal   cavity
 Palate       Hyoid

 Uvula        Mandible

 Tonsils      Maxilla
Palate
Variations
Mallampati Classification
           Müller Maneuver

   Designed to look for site of airway
    collapse
   While scope is in, patient
    inspires against closed
    nostrils/mouth
Müller Maneuver
Muller
Maneuver
   Predominant
    collapse is lateral
    pharyngeal walls
Radiography
   Cephalometrics
   Computed tomography
   Magnetic resonance imaging
Cephalometrics
   Standardized lateral radiographs
   Examines bony and soft-tissue structure
   Two-dimensional evaluation
   Lack of volumetric data
   Maxillomandibular surgery, oral
    appliances
    COMPUTED TOMOGRAPHY
   Supine
   Volumetric
    reconstruction
   Disadvantages
     – Cost
     – Weight limitations
     – Ionizing radiation
    Magnetic Resonance Imaging

   Excellent soft tissue anatomy
   Multiple planes
   No ionizing radiation
   Disadvantages
    Cost
    Weight limitations
    Noisy
    claustrophobia
Treatment
 Nonsurgical modalities
 Surgical modalities
Treatment
Judging Success
   Many define as 50% decrease in RDI
    and RDI < 20
   Objective assessment of response –
    post-treatment polysomnogram
    – Logistically often difficult to obtain
Nonsurgical Treatment

   Weight loss
   Sleep hygiene
   Pharmacotherapy
   Nasal continuous positive airway
    pressure
   Oral appliances
     Nonsurgical Treatment

   Weight loss
    – Get below “trigger weight”
    – Diet, exercise, bariatric surgery, medications




   Sleep hygiene
    – Avoidance of sedatives
    – Positional changes
Oral Appliances

   Two basic types
    – Advance tongue (Retains the tongue
      anteriorly)
    – Advance mandible
   Best for mild/moderate OSA
   Preferred by many over CPAP
               Oral Appliances


   Most effective in nonobese patients with
    retro or micrognathia
   Better for mild to moderate cases
   51% achieve normal sleep, 61%
    improved RDI < 20
   Consider TMJ dysfunction and occlusal
    changes
Tongue-Retaining Device
Pharmacotherapy

   Protriptyline – decreases REM
    sleep
   Xanthine based drugs
   Steroids
   Antibiotics
   Nasal medications
Positive Airway Pressure

 CPAP or BiPAP
 May be delivered nasally or by full-
  face mask
 May still be necessary after surgery

 Compliance an issue
CPAP
CPAP Axial MR
CPAP Effect on Airway
Surgical Treatment

   Nasal
   Palatal
   Tongue Base
   Maxillomandibular
   Tracheotomy
Surgical Treatment
Anesthesia Considerations

   High rate of comorbidity (COPD, CAD,
    etc)
   Preop CPAP/BiPAP
   Short, obese neck / retrognathia – setup
    for disaster unless prepared
   Post-obstructive pulmonary edema
UPPP
   Ikematsu – 1950s – snoring
   Fujita – 1980 – OSA
       UPPP
UPPP
UPPP Pre/Post
UPPP Pre/Post
UPPP Pre/Post
UPPP Pre/Post
UPPP Pre/Post
UPPP Complications
UPPP Complications
Complication Stenosis
LAUP

   Laser-assisted
    uvulopalatoplasty
   Can be done in office
   Typically multiple sessions
   More common for non-apneic
    snoring
   Newer data shows poor long-
    term results
LAUP
Nasal surgery

   Improved symptoms and CPAP
    – Septoplasty
    – Turbinate reduction
    – Functional nasal reconstruction
Tongue Procedures

   Lingual tonsillectomy
   Laser midline glossectomy /
    Lingualplasty
    – trach
   Tongue suspension
   RF volumetric tissue reduction
   Mandibular osteotomy/genioglossus
    advancement
   Hyoid myotomy & suspension
Genioglossus Advancement
Enlarges the retrolingual airway without
disturbing dentition
Prevents retrolingual collapse
Genioglossus Advancement
Genioglossus Advancement
Maxillomandibular Osteotomy
and 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
Mandibulomaxillary
Advancement
Mandibular Exposure
Hyoid Myotomy and
Suspension
   Enlarges retrolingual airspace
   Advances the tongue base and epiglottis
    anteriorly
Hyoid Advancement

   Myotomy to free
    hyoid bone
   Suspended
    anteriorly to
    thyroid cartilage
Hyoid Suspension
    Permananent
    Trach
   Skin-lined flaps
    for more
    permanent tract
   Serves as
    upper airway
    bypass
Riley-Powell-Stanford Protocol
Riley-Powell-Stanford Protocol
Conclusion
   Sleep medicine exciting, relatively
    new field
   Otolaryngologist is key player
    – Expertise in airway
    – Can offer surgical solutions

								
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