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Surgical Management of Obstructive Sleep Apnea PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Surgical Management of Obstructive Sleep Apnea" by Marilene B. Wang, MD.

This medical PowerPoint presentation is about the options for the surgical management of obstructive sleep apnea. Obstructive Sleep Apnea (OSA) is a common sleep disorder that affects millions of people worldwide. It is characterized by partial or complete collapse of the upper airway during sleep, leading to repetitive cessation of breathing, or apnea, resulting in decreased oxygenation and frequent arousals during sleep.

While non-surgical treatment options, such as weight loss, positional therapy, continuous positive airway pressure (CPAP) therapy, and oral appliances, are effective for many patients, surgical intervention may be necessary in some cases.

The surgical management of OSA aims to address the anatomic factors that contribute to airway obstruction during sleep. The following are some of the surgical options available:

Uvulopalatopharyngoplasty (UPPP): This surgery involves the removal of excess tissue from the back of the throat, including the uvula, tonsils, and part of the soft palate. UPPP is most effective for patients with mild to moderate OSA who have enlarged tonsils, elongated uvula, and a thickened soft palate.
Maxillomandibular advancement (MMA): This surgery involves repositioning the upper and lower jaws forward to increase the space in the airway. MMA is most effective for patients with severe OSA and a retrognathic (retruded) mandible.
Nasal surgery: This surgery is designed to improve nasal airflow by correcting a deviated septum, removing nasal polyps, or reducing the size of nasal turbinates. Nasal surgery is most effective for patients with nasal obstruction that contributes to OSA.
Lingual tonsillectomy: This surgery involves removing the tonsil tissue located at the base of the tongue, which can contribute to airway obstruction during sleep.
Hypoglossal nerve stimulation: This is a newer surgical technique that involves implanting a device that delivers electrical stimulation to the hypoglossal nerve, which controls the movement of the tongue. This stimulation can help keep the airway open during sleep.

It is important to note that surgery is not the first-line treatment for OSA, and should only be considered in cases where non-surgical treatments have failed or are not appropriate. The choice of surgical procedure should be tailored to the individual patient based on their specific anatomy and the severity of their OSA.

Tags : Obstructive Sleep Apnea, sleep disorder, Uvulopalatopharyngoplasty, Maxillomandibular advancement, Nasal surgery, Lingual tonsillectomy, Hypoglossal nerve stimulation

Published on : Jun 23, 2023 | Views : 900 | Downloads : 1

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Slide 1-

Surgical Management of Obstructive Sleep Apnea Marilene B. Wang, MD Chief of Otolaryngology, VAGLAHS Professor UCLA Division of Head and Neck Surgery
Slide 2-

Evaluation of Sleep Polysomnography EMG Airflow EEG, EOG Oxygen Saturation Cardiac Rhythm Leg Movements AI, HI, AHI, RDI
Slide 3-

Evaluation of Sleep Polysomnography Woodson, Tucker “Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment” SIPAC 1996
Slide 4-

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
Slide 5-

Pathophysiology of OSA Sites of Obstruction: Obstruction tends to propagate
Slide 6-

Pathophysiology of OSA Sites of Obstruction:
Slide 7-

Pathophysiology of OSA Symptoms of OSA Snoring (most commonly noted complaint) Daytime Sleepiness Hypertension and Cardiovascular Disease are Associated Pulmonary Disease
Slide 8-

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
Slide 9-

Pathophysiology of OSA Tests to determine site of obstruction: Muller’s Maneuver Sleep endoscopy Fluoroscopy Manometry Cephalometrics Dynamic CT scanning and MRI scanning
Slide 10-

Medical Management Weight Loss/Exercise Nasal Obstruction/Allergy Treatment Sedative Avoidance Smoking cessation Sleep hygiene Consistent sleep/wake times Avoid alcohol, heavy meals before bedtime Position on side Avoid caffeine, TV, reading in bed
Slide 11-

Medical Management CPAP Pressure must be individually titrated Compliance is as low as 50% Air leakage, eustachian tube dysfunction, noise, mask discomfort, claustrophobia
Slide 12-

Medical Management BiPAP Useful when > 6 cm H2O difference in inspiratory and expiratory pressures No objective evidence demonstrates improved compliance over CPAP
Slide 13-

Nonsurgical Management Oral appliance Mandibular advancement device Tongue retaining device
Slide 14-

Nonsurgical Management Oral Appliances May be as effective as surgical options, especially with sx worse on patient’s 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.
Slide 15-

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
Slide 16-

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
Slide 17-

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 (children)
Slide 18-

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: 13–21.
Slide 19-

Surgical Management Uvulopalatopharyngoplasty
Slide 20-

Surgical Management UP3 Complications Minor Transient VPI Hemorrhage<1% Major NP stenosis VPI
Slide 21-

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.
Slide 22-

Surgical Management Lateral Pharyngoplasty
Slide 23-

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
Slide 24-

Surgical Management Laser Assisted Uvulopalatoplasty High initial success rate for snoring Rates decrease, as for UP3, at twelve months Performed awake
Slide 25-

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
Slide 26-

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
Slide 27-

Pillar™ Palatal Implant System Three Implants Per Patient Implants are made of Dacron® Implants are 18 mm in length and 1.8 mm in diameter Implants are meant to be Permanent Implants “can be removed” FDA Approved for SNORING FDA Approved for mild to moderate SLEEP APNEA - AHI UNDER 30
Slide 28-

Anesthesia Antibiotic 1 hour pre-op or as directed Mouth Rinse (chlorhexidine gluconate or equivalent) Hurricane or Equivalent Topical Spray Ponticane or Equivalent Topical Jelly Anesthetic, optional. Local Anesthetic Infiltration: 2 to 3 cc. Beginning at the junction of the Hard and Soft Palate inject entire “Target Zone”. (lidocaine with epinephrine or equivalent) Have available: Flexible Scope, Angled Tonsil Forceps
Slide 29-

Placement of Implants 2 m.m. apart Minimum Palate Length 25 mm
Slide 30-

Placement of Implants Insert the needle through the mucosa layer into the muscle. The insertion site should be as close to the junction of the hard and soft palate as possible. Continue needle advancement in an arcing motion until the “Full insertion depth marker” is no longer visible. Insertion point
Slide 31-

Placement of Implants INSPECTION Inspect the needle insertion site. If a portion of the implant is exposed, it must be removed with a hemostat. Inspect the nasal side of the soft palate using a Flexible Naso Scope. If the implant is exposed, it must be removed. An angled tonsil forceps is recommended. Hard palate Implant Muscle Glandular tissue
Slide 32-

Patient Selection“The Preferred Patient” BMI less than 32 AHI Less than 30 No Obvious Nasal Obstruction Small to Medium Sized Tonsils Mallampati Class І or Class ΙΙ Friedman Tongue Position I and II Minimum 25mm Palate to treat
Slide 33-

Surgical Management Tongue Base Procedures Lingual Tonsillectomy may be useful in patients with hypertrophy, but usually in conjunction with other procedures
Slide 34-

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
Slide 35-

Surgical Management Mandibular Procedures Genioglossus Advancement Rarely performed alone Increases rate of efficacy of other procedures Transient incisor paresthesia
Slide 36-

Surgical Management Lingual Suspension
Slide 37-

Surgical Management Lingual Suspension
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Slide 39-

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
Slide 40-

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
Slide 41-

Surgical Management Maxillary-Mandibular Advancement Performed in conjunction with oral surgeons Temporary or permanent paresthesia Change in facial structure
Slide 42-

Surgical Management Algorithms Studies efficacy of various algorithms Therapy should be directed toward presumed site of obstruction This does not always guarantee results
Slide 43-

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
Slide 44-

Surgical Management Algorithms Friedman et al developed a staging system for type of operation:
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Slide 46-

Surgical Management Chance of success with surgical management decreases with increasing Friedman stage Stage I and II patients have good success with UPPP and tongue base procedures Stage III and IV patients have much lower rates of success following UPPP/tongue base
Slide 47-

Ultimate Surgical Management Tracheotomy Morbid obesity Significant anesthetic/surgical risks Obvious disadvantages Trach care Supplies, equipment aesthetics
Slide 48-

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.
Slide 49-

CONCLUSIONS Surgical management provides effective management for OSA Can be safely performed in most patients with proper preoperative preparation Significant perioperative risks in some patients Surgery should be considered for patients unable to utilize nonsurgical management