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Untitled Prezi

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Marisa Ryan

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Traditional Preop Evaluation
continued respiratory effort with partial or complete cessation of airflow from upper airway obstruction
Surgery
Palatal/velopharyngeal
Surgical Results
Drug Induced Sleep Endoscopy
(DISE)
Can better localization increase the benefit?
Surgery for Obstructive Sleep Apnea
Obstructive Sleep Apnea
weight loss
positioning
positive pressure
oral appliances
nasal appliances
surgery
35,000/yr or 0.2% of 18 million pts with OSA
Sequelae
Treatment
Definition
References
Flint: Cummings Otolaryngology: Head & Neck Surgery, 5th ed. Chapter 18. Mosby-Elsevier. 2010.
Kezirian EJ. Nonresponders to pharyngeal surgery for obstructive sleep apnea: insights from drug-induced sleep endoscopy. Laryngoscope. 2011 Jun;121(6):1320-6.
Operative Otolaryngology – Head and Neck Surgery, 2nd Edition, edited by E.N. Myers. Saunders/Elsiever, Philadelphia, PA, 2008.
Morrison DL, Launois SH, Isono S, et al: Pharyngeal narrowing and closing pressures in patients with obstructive sleep apnea. Am Rev Respir Dis 1993; 148:606-611
Kezirian EJ, Maselli J, Vittinghoff E, Goldberg AN, Auerbach AD. Obstructive sleep apnea surgery practice patterns in the United States: 2000 to 2006. Otolaryngol Head Neck Surg. 2010 Sep;143(3):441-7.
Sundaram S, Bridgman SA, Lim J, Lasserson TJ. Surgery for obstructive sleepapnoea. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD001004.
Ephros HD, Madani M, Yalamanchili SC. Surgical treatment of snoring &obstructive sleep apnoea. Indian J Med Res. 2010 Feb;131:267-76.
Bachar G, Feinmesser R, Shpitzer T, Yaniv E, Nageris B, Eidelman L. Laryngeal and hypopharyngeal obstruction in sleep disordered breathing patients, evaluated by sleep endoscopy. Eur Arch Otorhinolaryngol. 2008 Nov;265(11):1397-402.
Rojewski TE, Schuller DE, Clark RW, Schmidt HS, Potts RE. Synchronous video recording of the pharyngeal airway and polysomnograph in patients withobstructive sleep apnea. Laryngoscope. 1982 Mar;92(3):246-50.
Friedman M, Schalch P. Z-palatoplasty. Oper Techn Otolaryngol. 2007;18:2.
Kezirian EJ, Goldberg AN. Hypopharyngeal surgery in obstructive sleep apnea: an evidence-based medicine review. Arch Otolaryngol Head Neck Surg. 2006 Feb;132(2):206-13.
Woodson BT. Transpalatal advancement pharyngoplasty. Oper Tech Otolaryngol. 2007;18;11.
Lin HC, Friedman M, Chang HW, Gurpinar B. The efficacy of multilevel surgery of the upper airway in adults with obstructive sleep apnea/hypopnea syndrome. Laryngoscope. 2008 May;118(5):902-8.
Troell RJ, Riley RW, Powell NB, Li K. Surgical management of the hypopharyngeal airway in sleep disordered breathing. Otolaryngol Clin North Am. 1998;13:983
Riley R, Powell N, Guilleminault C. Obstructive sleep apnea and the hyoid: a revised surgical procedure. Otolaryngol Head Neck Surg. 1994;111:717
Gillespie MB, Reddy RP, White DR, Discolo CM, Overdyk FJ, Nguyen SA. A trialof drug-induced sleep endoscopy in the surgical management of sleep-disordered breathing. Laryngoscope. 2013 Jan;123(1):277-82.
Hypopharyngeal/
retrolingual/
retroglossal
Palatal radiofrequency






Pillar implants
Injection snoreplasty
Tonsillectomy
Uvulopalatopharyngoplasty






Z-palatoplasty






Transpalatal advancement pharyngoplasty
Combinations

Tracheotomy
DISE
pharmacologic
unconscious state
fiberoptic
examination
spontaneous
breathing
http://nursing.advanceweb.com/Features/Articles/Coming-Into-Focus.aspx
http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79932-1963060-2118148tn.jpg
http://video-hned.com/video/IQDEWxmgXBA/Dynamic-Endoscopy-Snoring-and-Sleep-Apnea-Surgery-Dr-KOPaulose-FRCS-DLO.html
33 nonresponders to pharyngeal surgery (palate, genioglossus advancement, tongue radiofrequency, hyoid suspension)
75% of OSA surgery is limited to palate
persistent obstruction is multifactorial and multilevel
no epiglottic obstruction after hyoid suspension
pharyngeal lateral wall prolapse associated with poor response from primary and secondary surgery
Kezirian EJ. Nonresponders to pharyngeal surgery for obstructive sleep apnea: insights from drug-induced sleep endoscopy. Laryngoscope. 2011 Jun;121(6):1320-6.
http://fauquierent.files.wordpress.com/2011/11/3.jpg
http://www.sleep-doctor.com/blog/wp-content/uploads/2012/08/sleep_diagram_2regions-very-low-resolution-C18.jpg
Obstruction:
Nasal: septal deviation, turbinates, nasal valve collapse, adenoids, polyps
Oropharyngeal: soft palate, palatine tonsil, posterior pharyngeal wall banding, macroglossia, mandibular tori, narrow skeletal arch, tumor








Hypopharyngeal: lateral pharyngeal wall collapse, omega-shaped epiglottis, lingual tonsil, retrognathia, micrognathia, tumor
Laryngeal: vocal cord immobility, tumor
General neck obstruction: increased neck circumference, redundant cervical adipose tissue
Fujita :
Type I-collapse in the retropalatal region only
Type II-collapse in both retropalatal and retrolingual regions
Type III-collapse in the retrolingual region only

Friedman:
Stage 1–tonsils 3+ or 4+, Malampatti I or II, BMI < 40 (70% success rate)
Stage 2–between stages 1 and 3 (30% success rate)
Stage 3–tonsils 1+ or 2+, Malampatti III or IV, or BMI > 40 (10% success rate

Moore (pharyngeal classification based on lateral neck x-rays which could be used to stratify patients for tongue base procedures):
Type A – upper tongue base obstruction with normal lower tongue base and epiglottis
Type B1 – combined upper tongue base and epiglottic obstruction
Type B2 – combined upper and lower tongue base and epiglottic obstruction
Type C – epiglottic obstruction
cephalograms
limited role
Myers Chapter 21
Lingual tonsillectomy
Partial midline glossectomy
Tongue base radiofrequency
Hyoid myotomy and suspension:









Tongue suspension suture
Mandibular osteotomy and genioglossal advancement:






Maxillomandibular osteotomy and advancement:

meta-analysis of12 studies, 706 patients
no significant benefit shown in Epworth Sleepiness Scale or AHI from surgery
"Localisation of the site of airway obstruction may allow more specific selection of surgical procedures"
Myers Chapter
Bachar G, Feinmesser R, Shpitzer T, Yaniv E, Nageris B, Eidelman L. Laryngeal and hypopharyngeal obstruction in sleep disordered breathing patients, evaluated by sleep endoscopy. Eur Arch Otorhinolaryngol. 2008 Nov;265(11):1397-402.
20 min exam in 53/55 preop patients that failed CPAP
technique is safe and simple
21% nasal obstruction
Rojewski TE, Schuller DE, Clark RW, Schmidt HS, Potts RE. Synchronous video recording of the pharyngeal airway and polysomnograph in patients with obstructive sleep apnea. Laryngoscope. 1982 Mar;92(3):246-50.
endoscopy during PSG
time consuming
difficult keeping patient asleep
Croft CB, Pringle M. Sleep nasendoscopy: a technique of assessment in snoring and obstructive sleep apnoea. Clin Otolaryngol Allied Sci. 1991 Oct;16(5):504-9.
preop assesment to determine success of isolated UVPP for OSA
89% palatal
33% tongue base
33% hypopharyngeal
72% multilevel
33% laryngeal
obesity
end of apnea
always with another site
overall response rate of UPPP in OSA was 39.2%, (AI<10 and at least a 50% reduction)
61% success after phase I surgical therapy in 239 patients (genioglossus advancement, hyoid suspension, and UPPP)
75% in mild to moderate OSA (RDI < 60)
42% in severe OSA (RDI > 60).
Sher AE, Schechtman KB, Piccirillo JF. The efficacy of surgical modifications of the upper airway in adults with obstructive sleep apnea syndrome. Sleep. 1996 Feb;19(2):156-77.
Troell RJ, Riley RW, Powell NB, Li K. Surgical management of the hypopharyngeal airway in sleep disordered breathing. Otolaryngol Clin North Am.1998 Dec;31(6):979-1012.
Physical Examination
Maneuvers
Polysomnography
inhale sharply
snore
Müller maneuver: fiberoptic exam at retropalatal and retrolingual level in awake pt generating negative pressure by inhaling against a closed glottis, nose and mouth
Imaging

EEG, electrooculogram, ECG, EMG, airflow monitors, thoracoabdominal movement, sleep position, capnography, BP, O2 Sat, awakenings
AHI: # apneas and hypopneas/hr of total sleep time
mild 5-14
moderate 15-29
severe >30
RDI: # apneas, hypopneas and RERAs/hr of total sleep time
Classifications

daytime sleepiness
mood changes
headaches
snoring
MVA
diabetes
HTN
heart dz
CVA
Sundaram S, Bridgman SA, Lim J, Lasserson TJ. Surgery for obstructive sleepapnoea. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD001004.

AHI 5 -14 and excessive daytime sleepiness
AHI > 15
Oxyhemoglobin desat < 90%
Significant cardiac arrhythmias associated with obstructions
Unsuccessful or refused medical therapy
stable for surgery

Cummings Chapter 18
Indications
Mallampati
Friedman M, Schalch P. Z-palatoplasty.
Oper Techn Otolaryngol. 2007;18:2.
Nasal
snoring
positive pressure tolerance
Laryngeal
supraglottoplasty
vocal cord procedures
Cummings Chapter 18
Cummings chapter 18
Moore and Phillips, A Practical Method for Describing Patterns of Tongue-Base Narrowing (Modification of Fujita) in Awake Adult Patients With Obstructive Sleep Apnea, J Oral Maxillofac Surg 60:252-260, 2002
Fairbanks et al, Snoring and Obstructive Sleep Apnea, 2003 Lippincott Williams & Wilkins.
Kezirian EJ, Goldberg AN. Hypopharyngeal surgery in obstructive sleep apnea: an evidence-based medicine review. Arch Otolaryngol Head Neck Surg. 2006 Feb;132(2):206-13.
review of 36 genioglossus advancement, mortised genioplasty, tongue radiofrequency, midline glossectomy, hyoid suspension and tongue stabilization articles
35%-62% success (AHI<20 and at least a 50% reduction)
mostly level 4 evidence
review of 49 multilevel surgery articles
66.4% success (AHI<20 and at least a 50% reduction)
increased AHI in 9.8%
mean f/u at 7.3 months
14.6% complication rate
mostly level 4 evidence
Lin HC, Friedman M, Chang HW, Gurpinar B. The efficacy of multilevel surgery of the upper airway in adults with obstructive sleep apnea/hypopnea syndrome. Laryngoscope. 2008 May;118(5):902-8.
Kezirian EJ, Maselli J, Vittinghoff E, Goldberg AN, Auerbach AD. Obstructive
sleep apnea surgery practice patterns in the United States: 2000 to 2006.
Otolaryngol Head Neck Surg. 2010 Sep;143(3):441-7.
Woodson BT. Transpalatal advancement pharyngoplasty. Oper Tech Otolaryngol. 2007;18;11.
Troell RJ, Riley RW, Powell NB, Li K. Surgical management of the hypopharyngeal airway in sleep disordered breathing. Otolaryngol Clin North Am. 1998;13:983
Riley R, Powell N, Guilleminault C. Obstructive sleep apnea and the hyoid: a revised surgical procedure. Otolaryngol Head Neck Surg. 1994;111:717
http://www.entsurgery.com.sg/Special/Sutter%20RF%20ver%203.htm
not identical to natural sleep
Myers Chapter 21
Cummings chapter 18
Gillespie MB, Reddy RP, White DR, Discolo CM, Overdyk FJ, Nguyen SA. A trialof drug-induced sleep endoscopy in the surgical management of sleep-disordered breathing. Laryngoscope. 2013 Jan;123(1):277-82.
prospective trial of 38 pts undergoing preop DISE
more severe collapse than awake endoscopy
73% multilevel collapse
surgical plan changed in 62% of cases
good intrarater and interrater correlation
Full transcript