Surgical Management of Obstructive Sleep Apnea Marilene B. Wang, MD Chief of Otolaryngology, VAGLAHS...

Surgical Management Surgical Management of Obstructive Sleep of Obstructive Sleep

ApneaApnea

Marilene B. Wang, MDMarilene B. Wang, MDChief of Otolaryngology, Chief of Otolaryngology,

VAGLAHSVAGLAHSProfessorProfessor

UCLA Division of Head and UCLA Division of Head and Neck SurgeryNeck Surgery

Evaluation of SleepEvaluation of Sleep

PolysomnographyPolysomnography EMGEMG AirflowAirflow EEG, EOGEEG, EOG Oxygen SaturationOxygen Saturation Cardiac RhythmCardiac Rhythm Leg MovementsLeg Movements AI, HI, AHI, RDIAI, HI, AHI, RDI

Evaluation of SleepEvaluation of Sleep PolysomnographPolysomnograph

yy

Woodson, Tucker “Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment” SIPAC 1996

Definition of OSADefinition of OSA

RDI>5RDI>5 RDI > 20 increases risk of mortalityRDI > 20 increases risk of mortality RDI 20-40=moderate, >40=severeRDI 20-40=moderate, >40=severe Upper Airway Resistance Upper Airway Resistance

SyndromeSyndrome Shares pathophysiology with OSAShares pathophysiology with OSA No desaturation, continuous No desaturation, continuous

ventilatory effortventilatory effort SnoringSnoring

Pathophysiology of OSAPathophysiology of OSA

Sites of Sites of Obstruction:Obstruction:

Obstruction Obstruction tends to tends to propagatepropagate


Sites of Obstruction:Sites of Obstruction:


Symptoms of OSASymptoms of OSA Snoring (most commonly noted Snoring (most commonly noted

complaint)complaint) Daytime SleepinessDaytime Sleepiness Hypertension and Cardiovascular Hypertension and Cardiovascular

Disease are AssociatedDisease are Associated Pulmonary DiseasePulmonary Disease

Pathophysiology of OSAPathophysiology of OSA Findings in Obstruction:Findings in Obstruction:

Nasal ObstructionNasal Obstruction Long, thick soft palateLong, thick soft palate Retrodisplaced MandibleRetrodisplaced Mandible Narrowed oropharynxNarrowed oropharynx Redundant pharyngeal tissuesRedundant pharyngeal tissues Large lingual tonsilLarge lingual tonsil Large tongueLarge tongue Large or floppy EpiglottisLarge or floppy Epiglottis Retro-displaced hyoid complexRetro-displaced hyoid complex


Tests to determine site of Tests to determine site of obstruction:obstruction: Muller’s ManeuverMuller’s Maneuver Sleep endoscopySleep endoscopy FluoroscopyFluoroscopy ManometryManometry CephalometricsCephalometrics Dynamic CT scanning and MRI Dynamic CT scanning and MRI

scanningscanning

Medical ManagementMedical Management Weight Loss/ExerciseWeight Loss/Exercise Nasal Obstruction/Allergy Nasal Obstruction/Allergy

TreatmentTreatment Sedative AvoidanceSedative Avoidance Smoking cessationSmoking cessation Sleep hygieneSleep hygiene

Consistent sleep/wake timesConsistent sleep/wake times Avoid alcohol, heavy meals before Avoid alcohol, heavy meals before

bedtimebedtime Position on sidePosition on side Avoid caffeine, TV, reading in bedAvoid caffeine, TV, reading in bed

Medical ManagementMedical Management

CPAPCPAP Pressure must be Pressure must be

individually individually titratedtitrated

Compliance is as Compliance is as low as 50%low as 50%

Air leakage, Air leakage, eustachian tube eustachian tube dysfunction, noise, dysfunction, noise, mask discomfort, mask discomfort, claustrophobiaclaustrophobia

Medical ManagementMedical Management

BiPAPBiPAP Useful when > 6 cm H2O difference Useful when > 6 cm H2O difference

in inspiratory and expiratory in inspiratory and expiratory pressurespressures

No objective evidence demonstrates No objective evidence demonstrates improved compliance over CPAPimproved compliance over CPAP

http://www.cpap.com/productpage/bipap-auto-biflex.html

Nonsurgical Nonsurgical ManagementManagement

Oral applianceOral appliance Mandibular Mandibular

advancement advancement devicedevice

Tongue retaining Tongue retaining devicedevice

Nonsurgical Nonsurgical ManagementManagement

Oral AppliancesOral Appliances May be as effective as surgical May be as effective as surgical

options, especially with sx worse on options, especially with sx worse on patient’s backpatient’s back

However low compliance rate of However low compliance rate of about 60% in study by Walker et al about 60% in study by Walker et al in 2002 rendered it a worse in 2002 rendered it a worse treatment modality than surgical treatment modality than surgical proceduresproceduresWalker-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.

Surgical ManagementSurgical Management

Measures of success –Measures of success – No further need for medical or No further need for medical or

surgical therapysurgical therapy Response = 50% reduction in RDIResponse = 50% reduction in RDI Reduction of RDI to < 20Reduction of RDI to < 20 Reduction in arousals and daytime Reduction in arousals and daytime

sleepinesssleepiness


Perioperative IssuesPerioperative Issues High risk in patients with severe High risk in patients with severe

symptomssymptoms Associated conditions of HTN, CVDAssociated conditions of HTN, CVD Nasal CPAP often required after Nasal CPAP often required after

surgerysurgery Nasal CPAP before surgery improves Nasal CPAP before surgery improves

postoperative coursepostoperative course Risk of pulmonary edema after relief Risk of pulmonary edema after relief

of obstructionof obstruction


Nasal SurgeryNasal Surgery Limited efficacy when used aloneLimited efficacy when used alone Verse et al 2002 showed 15.8% Verse et al 2002 showed 15.8%

success rate when used alone in success rate when used alone in patients with OSA and day-time patients with OSA and day-time nasal congestion with snoring nasal congestion with snoring (RDI<20 and 50% reduction)(RDI<20 and 50% reduction)

Adenoidectomy (children)Adenoidectomy (children)

Surgical ManagementSurgical Management UvulopalatopharyngoplastyUvulopalatopharyngoplasty

The most commonly performed The most commonly performed surgery for OSAsurgery for OSA

Severity of disease is poor Severity of disease is poor outcome predictoroutcome predictor

Levin and Becker (1994) up to Levin and Becker (1994) up to 80% initial success decreased to 80% initial success decreased to 46% success rate at 12 months46% success rate at 12 months

Friedman et al showed a success Friedman et al showed a success rate of 80% at 6 months in rate of 80% at 6 months in carefully selected patientscarefully selected patients

Friedman M, Ibrahim H, Bass L. Clinical staging for sleep-disordered breathing. Otolaryngol Head Neck Surg 2002; 127: 13–21.


UvulopalatopharyngoplastyUvulopalatopharyngoplasty


UP3 UP3 ComplicationsComplications MinorMinor

Transient VPITransient VPI Hemorrhage<1%Hemorrhage<1%

MajorMajor NP stenosisNP stenosis VPIVPI


Cahali, 2003 Cahali, 2003 proposed the proposed the Lateral Lateral Pharyngoplasty Pharyngoplasty for patients with for patients with significant significant lateral lateral narrowing:narrowing:

Cahali MB. Lateral pharyngoplasty: a new treatment for obstructive sleep apnea hypopnea syndrome. Laryngoscope. 113(11):1961-8, 2003 Nov.


Lateral PharyngoplastyLateral Pharyngoplasty

Surgical ManagmentSurgical Managment

Lateral PharyngoplastyLateral Pharyngoplasty Median apnea-hypopnea index Median apnea-hypopnea index

decreased from 41.2 to 9.5 (P decreased from 41.2 to 9.5 (P = .009) = .009)

No control groupNo control group No evaluation at 12 monthsNo evaluation at 12 months


Laser Assisted Laser Assisted UvulopalatoplastUvulopalatoplastyy High initial High initial

success rate for success rate for snoringsnoring

Rates decrease, Rates decrease, as for UP3, at as for UP3, at twelve monthstwelve months

Performed awakePerformed awake


Radiofrequency Radiofrequency Ablation – Ablation – Fischer et al Fischer et al 20032003

Radiofrequency device is inserted into various parts of palate, tonsils and tongue base at various thermal energies


Fischer et al 2003Fischer et al 2003 At 6 months Showed significant At 6 months Showed significant

reduction of:reduction of: RDI (but not to below 20)RDI (but not to below 20) ArousalsArousals Daytime sleepiness by the Epworth Daytime sleepiness by the Epworth

Sleepiness ScaleSleepiness Scale

PillarPillar™ Palatal Implant ™ Palatal Implant SystemSystem

Three Implants Per PatientThree Implants Per Patient Implants are made of Dacron®Implants are made of Dacron® Implants are 18 mm in length and 1.8 mm Implants are 18 mm in length and 1.8 mm in diameterin diameter Implants are meant to be PermanentImplants are meant to be Permanent Implants “can be removed”Implants “can be removed” FDA Approved for SNORINGFDA Approved for SNORING FDA Approved for mild to moderate FDA Approved for mild to moderate SLEEP APNEA - AHI UNDER 30SLEEP APNEA - AHI UNDER 30

AnesthesiaAnesthesia

AntibioticAntibiotic 1 hour pre-op or as directed 1 hour pre-op or as directed Mouth RinseMouth Rinse (chlorhexidine gluconate or (chlorhexidine gluconate or

equivalent) equivalent) HurricaneHurricane or Equivalent Topical Spray or Equivalent Topical Spray Ponticane Ponticane or Equivalent or Equivalent Topical JellyTopical Jelly Anesthetic, optional. Anesthetic, optional. Local Anesthetic Infiltration: Local Anesthetic Infiltration: 2 to 3 cc2 to 3 cc. .

Beginning at the junction of the Hard and Soft Beginning at the junction of the Hard and Soft Palate inject entire “Target Zone”. (lidocaine with Palate inject entire “Target Zone”. (lidocaine with epinephrine or equivalent)epinephrine or equivalent)

Have availableHave available: Flexible Scope, Angled Tonsil : Flexible Scope, Angled Tonsil ForcepsForceps

Placement of ImplantsPlacement of Implants

2 m.m. apart

Minimum Palate Length25 mm

Placement of ImplantsPlacement of ImplantsPlacement of ImplantsPlacement 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

Placement of ImplantsPlacement of ImplantsPlacement of ImplantsPlacement of ImplantsINSPECTIONINSPECTION

Inspect the needle insertion Inspect the needle insertion site. If a portion of the site. If a portion of the implant is exposed, it must implant is exposed, it must be removed with a be removed with a hemostat.hemostat.

Inspect the nasal side of the Inspect the nasal side of the soft palate using a soft palate using a FlexibleFlexible Naso ScopeNaso Scope. If the implant . If the implant is exposed, it must be is exposed, it must be removed. removed. AnAn angled tonsilangled tonsil forceps is recommendedforceps is recommended..

Hard palate

ImplantMuscle

Glandular tissue

Patient SelectionPatient Selection

““The Preferred PatientThe Preferred Patient”” BMI less than 32BMI less than 32 AHI Less than 30AHI Less than 30 No Obvious Nasal ObstructionNo Obvious Nasal Obstruction Small to Medium Sized TonsilsSmall to Medium Sized Tonsils Mallampati Class Mallampati Class ІІ or Class or Class ΙΙΙΙ Friedman Tongue Position I and IIFriedman Tongue Position I and II Minimum 25mm Palate to treatMinimum 25mm Palate to treat


Tongue Base ProceduresTongue Base Procedures Lingual TonsillectomyLingual Tonsillectomy

may be useful in patients with may be useful in patients with hypertrophy, but usually in conjunction hypertrophy, but usually in conjunction with other procedureswith other procedures

Surgical ManagementSurgical Management Tongue Base Tongue Base

ProceduresProcedures LingualplastyLingualplasty

Chabolle, et al Chabolle, et al success rate of success rate of 77% (RDI<20, 77% (RDI<20, 50% reduction) 50% reduction) in 22 patients in in 22 patients in conjunction with conjunction with UPPPUPPP

Complication Complication rate of 25% - rate of 25% - bleeding, altered bleeding, altered taste, taste, odynophagia, odynophagia, edemaedema

Can be combined Can be combined with with epiglottectomyepiglottectomy


Mandibular Mandibular ProceduresProcedures Genioglossus Genioglossus

AdvancementAdvancement Rarely performed Rarely performed

alonealone Increases rate of Increases rate of

efficacy of other efficacy of other proceduresprocedures

Transient incisor Transient incisor paresthesiaparesthesia

Surgical ManagementSurgical Management Lingual Lingual

SuspensionSuspension

Surgical ManagementSurgical Management Hyoid Myotomy Hyoid Myotomy

and Suspensionand Suspension Advances hyoid Advances hyoid

bone anteriorly bone anteriorly and inferiorlyand inferiorly

Advances Advances epiglottis and epiglottis and base of tonguebase of tongue

Performed in Performed in conjunction with conjunction with other proceduresother procedures

Dysphagia may Dysphagia may resultresult


Maxillary-Mandibular AdvancementMaxillary-Mandibular Advancement Severe diseaseSevere disease Failure with more conservative Failure with more conservative

measuresmeasures Midface, palate, and mandible Midface, palate, and mandible

advanced anteriorlyadvanced anteriorly Limited by ability to stabilize the Limited by ability to stabilize the

segments and aesthetic facial changessegments and aesthetic facial changes


Maxillary-Maxillary-Mandibular Mandibular AdvancementAdvancement Performed in Performed in

conjunction with conjunction with oral surgeonsoral surgeons

Temporary or Temporary or permanent permanent paresthesiaparesthesia

Change in facial Change in facial structurestructure


AlgorithmsAlgorithms Studies efficacy of various Studies efficacy of various

algorithmsalgorithms Therapy should be directed toward Therapy should be directed toward

presumed site of obstructionpresumed site of obstruction This does not always guarantee resultsThis does not always guarantee results


AlgorithmsAlgorithms Riley et al 1992Riley et al 1992

Studied 2 phase approach for multilevel Studied 2 phase approach for multilevel site of obstruction (Stanford Protocol):site of obstruction (Stanford Protocol):

Phase 1: Genioglossal advancement, hyoid Phase 1: Genioglossal advancement, hyoid myotomy and advancement, UP3myotomy and advancement, UP3

Phase 2: Maxillary-Mandibular advancement Phase 2: Maxillary-Mandibular advancement in 6 months if phase 1 failedin 6 months if phase 1 failed

Reported >90% success rate in patients who Reported >90% success rate in patients who completed both phasescompleted both phases

Other studies have lowered this numberOther studies have lowered this number Testing is done at 6 monthsTesting is done at 6 months


AlgorithmsAlgorithms Friedman et al Friedman et al

developed a developed a staging system staging system for type of for type of operation:operation:


Chance of success with surgical Chance of success with surgical management decreases with management decreases with increasing Friedman stageincreasing Friedman stage

Stage I and II patients have good Stage I and II patients have good success with UPPP and tongue base success with UPPP and tongue base proceduresprocedures

Stage III and IV patients have much Stage III and IV patients have much lower rates of success following lower rates of success following UPPP/tongue baseUPPP/tongue base

Ultimate Surgical Ultimate Surgical ManagementManagement

TracheotomyTracheotomy Morbid obesityMorbid obesity Significant anesthetic/surgical Significant anesthetic/surgical

risksrisks Obvious disadvantagesObvious disadvantages Trach care Trach care

Supplies, equipmentSupplies, equipment aestheticsaesthetics


TracheostomyTracheostomy Primary treatment modalityPrimary treatment modality Temporary treatment while other surgery is doneTemporary treatment while other surgery is done Thatcher GW. et al: tracheostomy leads to quick Thatcher GW. et al: tracheostomy leads to quick

reduction in sequelae of OSA, few complications (see reduction in sequelae of OSA, few complications (see table II)table II)

Once placed, uncommon to decannulateOnce 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.

CONCLUSIONSCONCLUSIONS

Surgical management provides effective Surgical management provides effective management for OSAmanagement for OSA

Can be safely performed in most patients Can be safely performed in most patients with proper preoperative preparationwith proper preoperative preparation

Significant perioperative risks in some Significant perioperative risks in some patientspatients

Surgery should be considered for Surgery should be considered for patients unable to utilize nonsurgical patients unable to utilize nonsurgical managementmanagement

Surgical Management of Obstructive Sleep Apnea Marilene B. Wang, MD Chief of Otolaryngology, VAGLAHS...

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