The Management of Snoring and The Management of Snoring and Obstructive Sleep ApneaObstructive Sleep Apnea
Rex Moulton-Barrett, MDRex Moulton-Barrett, MD
Plastic and Reconstructive SurgeryPlastic and Reconstructive Surgery
Otolaryngology & Head and Head Otolaryngology & Head and Head SurgerySurgery
Alameda Hospital Alameda Hospital
June 2005June 2005
Spectrum of Sleep Disordered Spectrum of Sleep Disordered BreathingBreathing
DefinitionsDefinitions
UUpper pper AAirway irway RResistance esistance SSyndrome yndrome ( UARS )( UARS )
• • Daytime somnolenceDaytime somnolence
• • No significant apnea or O2 desaturationNo significant apnea or O2 desaturation
• • Habitual loud snoring (crescendo)Habitual loud snoring (crescendo)
• • they wake from their own noise of snoringthey wake from their own noise of snoring
Guillaminault C, Stoohs R, Duncan S. Chest 99:40-48;1991Guillaminault C, Stoohs R, Duncan S. Chest 99:40-48;1991
Guilleminault C, Stoohs R, Clerk A et al. Chest 104:781-787;1993Guilleminault C, Stoohs R, Clerk A et al. Chest 104:781-787;1993
DefinitionsDefinitions DefinitionsDefinitions
Hypopnoea: ‘ Chicago Criteria’
1. Fall in average tidal volume by > 50%
but < 10 second apnoea
or < 50% tidal volume reduction and
2. at least 4% in oxyhemoglobin desaturation
3. EEG evidence of arousal
Definitions Definitions Definitions Definitions
ApneaApnea– Cessation of airflow for at least 10 secondsCessation of airflow for at least 10 seconds– Obstructive / Central / MixedObstructive / Central / Mixed
– based on presence or absence of respiratory based on presence or absence of respiratory movementmovement
Prevalence of Sleep ApneaPrevalence of Sleep Apnea
AHIAHI = RDI= RDI= apnoea+hyponoea / hour= apnoea+hyponoea / hour>5 : 24% Males & 9% Females>5 : 24% Males & 9% Females4 - 6 times more common in 4 - 6 times more common in
menmen20 million Americans20 million Americans
Young T, Palta M, Dempsey J. N Engl J Med Young T, Palta M, Dempsey J. N Engl J Med 328:1230-1235;1993 328:1230-1235;1993
Pathophysiology ScalePathophysiology Scale
RDI / AHIRDI / AHI
UARSUARS <5 <5
MildMild 5-20 5-20
Moderate 21-40Moderate 21-40
Severe >40Severe >40
A RDI of 15-20 events per hour is close to what A RDI of 15-20 events per hour is close to what adults seem to be able to tolerate with no clinical adults seem to be able to tolerate with no clinical consequence. consequence.
Hosselet JJ, Ayappa I, Norman RG et al. Classificatin of sleep-disordered Hosselet JJ, Ayappa I, Norman RG et al. Classificatin of sleep-disordered breathing. Am J Respir Crit Care Med 163:398-405;2001breathing. Am J Respir Crit Care Med 163:398-405;2001
What is Significant RDI?
10x > risk, VAMV UCLA 2000
Somnolence Induced MVAsSomnolence Induced MVAs3 fold increase in motor vehicle accidents if RDI> 5
Morbidity and MortalityMorbidity and Mortality Morbidity and MortalityMorbidity and Mortality
Risk factor for cardiovascular diseaseRisk factor for cardiovascular disease– HypertensionHypertension– MI –polycythemia, platelet aggregationMI –polycythemia, platelet aggregation– StrokeStroke
MortalityMortality– AI>20 = 37% mortality over 8 yrs AI>20 = 37% mortality over 8 yrs
compared with 4% for AI<20 compared with 4% for AI<20 (Chest 94:9-14, (Chest 94:9-14, 1988)1988)
HistoryHistory HistoryHistory
Heroic snoringHeroic snoring– Cardinal symptom of OSASCardinal symptom of OSAS
Observed apneas or chokingObserved apneas or choking
Excessive sleepinessExcessive sleepiness
Witnessed apnoeas Witnessed apnoeas
Change in personality – depression, anxietyChange in personality – depression, anxiety
Cognitive dysfunction – memory, concentrationCognitive dysfunction – memory, concentration
Morning headachesMorning headaches
Decreased libido or impotenceDecreased libido or impotence
Car or work accidentsCar or work accidents
History alone is only 60% specific and 60% sensitiveHistory alone is only 60% specific and 60% sensitive– Need objective testingNeed objective testing
Sleep Apnea Risk FactorsSleep Apnea Risk Factors
••ObesityObesity••Increasing ageIncreasing age••Male genderMale gender••Anatomical abnormalities of upper Anatomical abnormalities of upper
airwayairway••Family historyFamily history••Alcohol or sedative useAlcohol or sedative use••SmokingSmoking
Diagnosis: Physical ExamDiagnosis: Physical Exam
Upper body obesity / thick neckUpper body obesity / thick neck– >17” males>17” males– >16” females>16” females
Airway abnormalityAirway abnormality– NasalNasal– OropharyngealOropharyngeal– HypopharyngealHypopharyngeal
Differential Diagnosis of Differential Diagnosis of OSASOSAS Differential Diagnosis of Differential Diagnosis of OSASOSAS
• • NarcolepsyNarcolepsy– REM sleep within 10 minutesREM sleep within 10 minutes
• • Excessive daytime sleepiness associated Excessive daytime sleepiness associated with psychosocial and psychiatric with psychosocial and psychiatric disordersdisorders
• • Drug related syndromesDrug related syndromes
• • Restless Legs / Periodic limb movement Restless Legs / Periodic limb movement disorderdisorder
• • Idiopathic hypersomnolenceIdiopathic hypersomnolence
Evaluation of Upper AirwayEvaluation of Upper AirwayEvaluation of Upper AirwayEvaluation of Upper Airway
No consistent characteristic in OSANo consistent characteristic in OSA– Quantitative measures depend on Quantitative measures depend on
statestate
Methods of EvaluationMethods of Evaluation– Cephalometric radiographsCephalometric radiographs
Anatomic Factors in Airway Anatomic Factors in Airway ObstructionObstruction
••Increased nasal resistance.Increased nasal resistance.••Excessive palatal length.Excessive palatal length.••Increased tongue size.Increased tongue size.••Increased vertical airway Increased vertical airway length length ••Enlarged tonsils.Enlarged tonsils.••Mandibular retrusion.Mandibular retrusion.
Impact of nose on snoring and Impact of nose on snoring and OSASOSAS Impact of nose on snoring and Impact of nose on snoring and OSASOSAS
• • Obstruction increases airway resistanceObstruction increases airway resistance
• • Anterior rhinomanometric volume has an inverse Anterior rhinomanometric volume has an inverse
relationship with RDI p<0.05relationship with RDI p<0.05
• • Nasal obstruction is an important cause of OSANasal obstruction is an important cause of OSA
Virkkula, P et al. Acta Otolaryngol, 2003Virkkula, P et al. Acta Otolaryngol, 2003
(Finland)(Finland)
Malampatti I-IV: Airway Classification
Visualize
• I:Soft palate, tonsils, uvula
• II:No tonsils seen
• III:Soft palate only seen
• IV:Hard palate only seen IV
Muller Maneuver
Maximal inspiratory movement
Velopharyngeal Closure Velopharyngeal Closure PatternsPatterns
A. CoronalA. Coronal 71%71%
B. CircularB. Circular 19%19%
C. Circular +Passavant’s RidgeC. Circular +Passavant’s Ridge 7% 7%
D. SagittalD. Sagittal 2% 2%
Finkelstein , Talmi , Nachman .Plastic Rec Finkelstein , Talmi , Nachman .Plastic Rec Surg 1992;89:631-639Surg 1992;89:631-639
Snoring: Snoring: “a marker for airway resistance during “a marker for airway resistance during sleep”sleep”
Hofffstein V, Mateika S, Nash S. Comparing Perceptions and Measurements of Snoring. Sleep 19:783-789;1996
Balance of forces affecting airway
Kuna ST, Sant’Ambrogio G. JAMA 266:1384-88;1991
Pathophysiology of OSASPathophysiology of OSAS Pathophysiology of OSASPathophysiology of OSAS
• • Collapse of pharyngeal airwayCollapse of pharyngeal airway• • Increased upper airway resistanceIncreased upper airway resistance• • Diaphragm movement increases negative Diaphragm movement increases negative
airway pressureairway pressure• • Increased airway collapseIncreased airway collapse• • Hypopnea and apnea – increase vagal toneHypopnea and apnea – increase vagal tone• • Hypoxia, Hypercarbia – catacholamine riseHypoxia, Hypercarbia – catacholamine rise• • Increased ventilatory effortIncreased ventilatory effort• • Sleep fragmentation and arousalSleep fragmentation and arousal
Who to order a Sleep Study On ?
Epworth v. RDIEpworth v. RDI
RDIRDI EPWORTHEPWORTH
00 8.0+/-3.5 8.0+/-3.5
MildMild 12.112.1 11.0+/-4.2 11.0+/-4.2
ModMod 34.834.8 13.0+/-4.7 13.0+/-4.7
SevereSevere 56.656.6 16.2+/-3.3 16.2+/-3.3
T. Woodson - Monograph
Why Get a Sleep Study ?Why Get a Sleep Study ?
DocumentationDocumentation
QuantificationQuantification
Determine TherapyDetermine Therapy
PolysomnographyPolysomnography PolysomnographyPolysomnography• • Establish diagnosis of sleep apneaEstablish diagnosis of sleep apnea• • Assess disease severityAssess disease severity• • Rule out other disorders of sleepRule out other disorders of sleep• • CPAP titrationCPAP titration• • Components:Components:
– EEGEEG– EOGEOG– EMGEMG– EKGEKG– Chest wall and abdominal Chest wall and abdominal
wall impedance wall impedance– Intercostal EMGIntercostal EMG– Body positionBody position– Pulse OximetryPulse Oximetry
In-Laboratory PolysomnographyIn-Laboratory Polysomnography
ProsPros– ““Full” set of variables recordedFull” set of variables recorded– Technician for patient & equipment problemsTechnician for patient & equipment problems– Able to determine success of C-PapAble to determine success of C-Pap
ConsCons– CostCost– AccessibilityAccessibility– Patient sleeps away from homePatient sleeps away from home – Fails to localize site of obstructionFails to localize site of obstruction
““The Polysomnographic Age …. has The Polysomnographic Age …. has ended”ended”
Unattended ambulatory Unattended ambulatory monitoring is “biologically monitoring is “biologically plausible and technologically plausible and technologically feasible”feasible”
Strohl KP. When, Where and How to Test for Strohl KP. When, Where and How to Test for Sleep apnea. Sleep 2000;23:S99-S101Sleep apnea. Sleep 2000;23:S99-S101
SNAP TestingSNAP Testing
• • PSG: polysomnograpghy “considered gold standard”PSG: polysomnograpghy “considered gold standard” inherant variability, inherant variability, problems of reproducibilityproblems of reproducibility
• • SNAP testing: out-patient, localizes site of obstruction, inexpensiveSNAP testing: out-patient, localizes site of obstruction, inexpensive
• • Direct and solid correlation between both for measurement of RDIDirect and solid correlation between both for measurement of RDI
• • For RDI >= 5 : For RDI >= 5 : 95% positive predictive value, 95% positive predictive value, 96% specificity96% specificity 75% sensitivity75% sensitivity
Allan, P, Chaney, J, Mair, E. Otolaryngol HNSurg, 2004Allan, P, Chaney, J, Mair, E. Otolaryngol HNSurg, 2004
SNAPSNAP TestingTesting Acoustic Analysis ofAcoustic Analysis ofOro-Nasal RespirationOro-Nasal Respiration
• • Sound & Airflow Detection Sound & Airflow Detection
• • Pulse Oximetry & Pulse ratePulse Oximetry & Pulse rate
• • Apnea & Hypopnea IndicesApnea & Hypopnea Indices
• • Snoring AnalysisSnoring Analysis
• • 6 hours+ continuous recording6 hours+ continuous recording
SNAP Data Collection Cannula
Effort & Movement Transducer
Why SNAP ?Why SNAP ?
Patient Selection Patient Selection
OSA detectionOSA detection
Snoring Localization & QuantificationSnoring Localization & Quantification
Outcome MonitoringOutcome Monitoring
SNAP - Apnea
SNAP - Oximetry
SNAP - Snoring
OSA in ChildrenOSA in Children
HistoryHistory– ShynessShyness– Developmental DelayDevelopmental Delay– Aggressive BehaviorAggressive Behavior– Symptoms of ADDSymptoms of ADD– Witnessed apneas: positive predictive value of Witnessed apneas: positive predictive value of
86%86%– T&A are usual source of obstructionT&A are usual source of obstruction
Several studies show improvement in Several studies show improvement in behavior and school performance after T+Abehavior and school performance after T+A
Treatment for OSATreatment for OSA Treatment for OSATreatment for OSA
MedicalMedical– Reduction of Risk factorsReduction of Risk factors– CPAP - Most common treatment CPAP - Most common treatment – DrugsDrugs– Airway appliancesAirway appliances
SurgicalSurgical
Reduction of Risk FactorsReduction of Risk Factors Reduction of Risk FactorsReduction of Risk Factors
ObesityObesity
Sleep hygieneSleep hygiene
Nasal obstructionNasal obstruction
Body positionBody position
Sedative and alcohol useSedative and alcohol use
DrugsDrugs DrugsDrugs
Oxygen - most widely usedOxygen - most widely usedProtriptylineProtriptylineTheophylineTheophylineProgesteroneProgesteroneNicotineNicotineSerotonin antagonistsSerotonin antagonistsModafinil (Provigil) Modafinil (Provigil)
Modafinil in obstructive sleep apnea-hypopnea syndrome: a pilot study in 6 patients
by Arnulf I, Homeyer P, Garma L, Whitelaw WA, Derenne JP.
Service de Pneumologie et Laboratoire du Sommeil,Hopital Pitie-Salpetriere,
Paris, France. Respiration 1997; 64(2):159-61
ABSTRACTWe studied the effects of modafinil, a vigilance-enhancing drug, on excessive daytime sleepiness, memory, night sleep and respiration in 6 patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) using a double-blind random cross-over design with 24-hour polysomnography, verbal memory test and a 5-week sleep-wake diary kept by the patients. There were two 2-week treatment periods in which either modafinil or placebo was used; they were separated by a 1-week wash-out period. Our results show that modafinil reduces daytime sleep duration, lengthens the duration of subjective daytime vigilance and improves long-term memory in patients with OSAHS without modifying night sleep and respiration events.
Pharmacologic TreatmentPharmacologic Treatment
CPAP Splints the Upper AirwayCPAP Splints the Upper AirwayCPAP Splints the Upper AirwayCPAP Splints the Upper Airway
Collapsing forcesTissue pressure and massConstrictor muscle toneNegative inspiratory pressure
Dilating forcesDilating muscle toneTissue pressures that stabilize the airway
CPAP augments dilating forces
CPAP Has Poor ComplianceCPAP Has Poor Compliance CPAP Has Poor ComplianceCPAP Has Poor Compliance
CPAP is effectiveCPAP is effective
Not a cureNot a cure
Pattern of use Pattern of use established earlyestablished early
Drop out rate > 25%Drop out rate > 25%
50% effective use50% effective use
Bi-level Applied PressureBi-level Applied Pressure Bi-level Applied PressureBi-level Applied Pressure
• • CPAP forces patients to produce high CPAP forces patients to produce high expiratory pressures – uncomfortableexpiratory pressures – uncomfortable
• • Collapsing pressures are increased during Collapsing pressures are increased during inspirationinspiration
• • Bi-level pressure applies lower pressures Bi-level pressure applies lower pressures during expiration and higher levels during during expiration and higher levels during inspirationinspiration– Increased initial patient acceptanceIncreased initial patient acceptance– Increased compliance?Increased compliance?
Side Effects of CPAPSide Effects of CPAP Side Effects of CPAPSide Effects of CPAP
Dry nose and mouth (65%)Dry nose and mouth (65%)Mask discomfort (50%)Mask discomfort (50%)Sneezing and rhinitis (25-35%)Sneezing and rhinitis (25-35%)ClaustrophobiaClaustrophobiaSocial impedimentSocial impedimentAlleviating side effects increases complianceAlleviating side effects increases compliance
– Warmed humidityWarmed humidity– Eliminating air leaks Eliminating air leaks – More comfortable masksMore comfortable masks
Airway AppliancesAirway Appliances Airway AppliancesAirway Appliances
Nasal AppliancesNasal Appliances– Breath Rite StripsBreath Rite Strips
Oral appliancesOral appliances– Mandible repositioningMandible repositioning
• Some devices reduce RDISome devices reduce RDI
• Patient compliancePatient compliance
• TMJ and teeth problemsTMJ and teeth problems
– Tongue repositioningTongue repositioning– Patient selectionPatient selection– Follow up PSG to test efficacyFollow up PSG to test efficacy
Surgical Treatment of Snoring & OSASSurgical Treatment of Snoring & OSASSurgical Treatment of Snoring & OSASSurgical Treatment of Snoring & OSAS
Types of proceduresTypes of procedures– Prevent obstructionPrevent obstruction– Bypass obstructionBypass obstruction
Key to success is to localize site of Key to success is to localize site of obstructionobstruction
Nasal SurgeryNasal SurgeryNasal SurgeryNasal SurgeryNasal airway resistanceNasal airway resistance
– Increased nasal airway Increased nasal airway resistance leads to resistance leads to increased negative increased negative inspiratory pressuresinspiratory pressures
Addition of nasal surgery Addition of nasal surgery may improve surgical may improve surgical success and increase success and increase CPAP useCPAP use– Rarely definitive Rarely definitive
treatment for OSAS treatment for OSAS alonealone
Pillar ProcedurePillar Procedure
• • 3 plate palate implants 3 plate palate implants placed in the officeplaced in the office
• • 1% extrusion rate1% extrusion rate
• • 78% response rate 78% response rate with 51% reduction of with 51% reduction of snoringsnoring
Maurer, J, et al. Otolaryngol HNSurg 2005
Mannheim, Germany
TonsillectomyTonsillectomy TonsillectomyTonsillectomy
Should be removed if Should be removed if
enlarged in OSASenlarged in OSAS
Reduces RDIReduces RDI
Rarely curative alone Rarely curative alone
(Except in Children)(Except in Children)
Snare UvulectomySnare UvulectomySnare UvulectomySnare Uvulectomy
• In office procedure• Topical anesthesia• Local anesthesia with epinephrine• Wire snare 1-1.5cm above tip uvula• If redundant palatal folds:• 1-1.5cmVertical wedges in soft palate
Weingarten, C. Laryngoscope, 1995
Injection Somnoplasty
• SNAP Test• sitting position• 20% benzocaine jel on Q tip: 20 minutes• 3 cc syringe with 27g 3/4 inch needle: • 1cc 99% ETOH & 1cc with 1cc Lidocaine 2%• or Thromboject ( sodium tetradecyl sulfate )men: 2cc 3%, women 2cc 1% • inject :mid pharynx point (not base of uvula)just below mucosa• 2 minutes later will turn purple• expected complications: gag on bubble, swelling, mucosal ulcer• f/u 6 weeks later, • if still snoring: repeat just lateral to site: 1cc each side
5 days post procedure
Vital statistics:
• Indicated if RDI< 5
• 1.2 inject/ per patient ( 86% benefit )
• 3/29 palatal fistula: more likely if-larger inject in small pt. inject into muscle
• Not effective in sleep apnoea
Brietzke, S & Mair, E. Otolaryngol HNSurg, 2001.
Injection Somnoplasty
Laser Assisted Laser Assisted UvUvulouloppalatoalatopplastylastyLaser Assisted Laser Assisted UvUvulouloppalatoalatopplastylasty
Radiofrequency Partial Radiofrequency Partial UvulopalatoplastyUvulopalatoplasty
• • 460 kHz 10mmlength, 10mm insulated 22 g needle460 kHz 10mmlength, 10mm insulated 22 g needle• • Target temperature between 80-85 CTarget temperature between 80-85 C• • 20% benzocaine topical20% benzocaine topical• • 4 sites submucosal delivery for 60-170 seconds:4 sites submucosal delivery for 60-170 seconds:1.1. < 750 J superior midline < 750 J superior midline 2.2. <350 J paramedian<350 J paramedian3.3. May amputate long uvula and place within muscleMay amputate long uvula and place within muscle• • 70% snoring improvement at 1 yr70% snoring improvement at 1 yr• • mean number of treatments was 3.6mean number of treatments was 3.6
Troell,R. Otolaryngol Clin N Am 2003Troell,R. Otolaryngol Clin N Am 2003
UvulopalatoplastyUvulopalatoplastyUvulopalatoplastyUvulopalatoplastyTreatment of snoring Treatment of snoring
– 80% effective80% effective
Treatment of OSATreatment of OSA- previously reported - previously reported 50% effective50% effective
- when combined with nasal and or base of - when combined with nasal and or base of tongue surgery higher successtongue surgery higher success
Multiple methods availableMultiple methods available– LaserLaser– CauteryCautery– RadiofrequencyRadiofrequency
Uvulopalatopharyngoplasty Uvulopalatopharyngoplasty (UPPP)(UPPP) Uvulopalatopharyngoplasty Uvulopalatopharyngoplasty (UPPP)(UPPP)
Reduction of snoring (90%)Reduction of snoring (90%)Decreased sleepiness (84%)Decreased sleepiness (84%)Objective reduction in OSAS (50%)Objective reduction in OSAS (50%)
– 50% decrease in RDI - (50%) 50% decrease in RDI - (50%) – RDI < 20 events/hr or AI < 10 events/hr (42%)RDI < 20 events/hr or AI < 10 events/hr (42%)
Determinants of successDeterminants of success– Location of airway obstructionLocation of airway obstruction– Severity of OSASSeverity of OSAS
Risks of UPPPRisks of UPPP
HistoryHistory HistoryHistory
• • William Osler (1906): Pickwickian William Osler (1906): Pickwickian • • Simmons and Hill (1974): Hypersomnia caused by Simmons and Hill (1974): Hypersomnia caused by
upper airway obstructionupper airway obstruction• • Ikematsu (1952): First UPPPIkematsu (1952): First UPPP• • Fujita (1979): Fujita (1979): • • Sullivan (1981): CPAPSullivan (1981): CPAP
1895
1985
UVPP ContraindicationsUVPP Contraindications UVPP ContraindicationsUVPP Contraindications
Velopharyngeal inadequacyVelopharyngeal inadequacy
Submucous cleft palateSubmucous cleft palate
Non-palatal level of obstructionNon-palatal level of obstruction
Uvulopalatopharyngoplasty (UPPP)Uvulopalatopharyngoplasty (UPPP)Uvulopalatopharyngoplasty (UPPP)Uvulopalatopharyngoplasty (UPPP)
Comparison of Treatment Methods
Pillar CPAP LAUP UPPP RF Sclerotherapy
Multiple visits No Yes Yes No Yes Yes
Pain Low Low Very high Very high Low Medium
SE’s Partial extrusion (1%) Nocturnal awakenings (46%),
Nasal congestion and dryness (44%) Transient VPI (27%)3
Transient VPI(20–100%) Ulceration (22%)
Mucosal loss(22%)
Sedation Local None Local General Local Local
Recovery time < 24 HRS None 7 days 10 days < 24 HRS <24 HRS
Reimbursement In process Yes (apnea) No Yes (apnea) No No
Pillar CPAP LAUP UPPP RF Sclerotherapy
OSA Yes Yes Yes Yes No No Snoring Yes Yes Yes Yes Yes Yes Reversible procedure Yes Yes No No No No
EFFICACY
Pillar CPAP LAUP UPPP RF Anlation Sclerotherapy
Type of physician ENT Pulmon ENT ENT ENT ENT
Patient visits One Multiple Multiple One Multiple Multiple
Physician time Low Low High High Medium Medium
Hospital No No Yes Yes Yes No
FDA clearance Snoring and OSA OSA only Not req Not req Snoring only No
PHYSICIAN EXPERIENCE
Surgery of Lower PharynxSurgery of Lower Pharynx Surgery of Lower PharynxSurgery of Lower Pharynx
• • Radiofrequency Base of Tongue Radiofrequency Base of Tongue volumetric reductionvolumetric reduction
• • Hyoid SuspensionHyoid Suspension• • EpiglottectomyEpiglottectomy• • Lingual tonsillectomyLingual tonsillectomy• • Midline glossectomyMidline glossectomy• • LingualplastyLingualplasty
Base of Tongue RFVTRBase of Tongue RFVTR
Prominent Lingual TonsilsProminent Lingual Tonsils
Maxillofacial SurgeryMaxillofacial Surgery Maxillofacial SurgeryMaxillofacial Surgery
Limited mandibular osteotomies & genioglossus Limited mandibular osteotomies & genioglossus advancementadvancement
Hyoid myotomyHyoid myotomy– Airway stabilized when hyoid pulled anterior and Airway stabilized when hyoid pulled anterior and
inferiorinferior
Mandibular advancementMandibular advancement– May require pre-op orthodonticsMay require pre-op orthodontics– Malocclusion may be surgically acquiredMalocclusion may be surgically acquired– Most successful in non-obese retrognathic patientsMost successful in non-obese retrognathic patients
Bimaxillary advancementBimaxillary advancement
Maxillofacial SurgeryMaxillofacial SurgeryMaxillofacial SurgeryMaxillofacial Surgery
Hyoid SuspensionHyoid Suspension
Probably less effective than genioglossus advancement
Electrical StimulationElectrical Stimulation Electrical StimulationElectrical Stimulation
Eisle, D, et al, 2003
Experimental: relies on trans-sternal transducer to induce genioglossus activity
TracheostomyTracheostomy TracheostomyTracheostomy
Bypasses upper airway obstructionBypasses upper airway obstruction– Effective in decreasing M&M associated with OSASEffective in decreasing M&M associated with OSAS
IndicationsIndications– Severe OSAS or obesity hypoventilationSevere OSAS or obesity hypoventilation– Perioperative airway managementPerioperative airway management
MorbidityMorbidity– tracheal stenosistracheal stenosis– InfectionInfection– Effects on appearance and voiceEffects on appearance and voice
Tube Free Tracheostomy Tube Free Tracheostomy (Isaac Eliachar, (Isaac Eliachar, MD)MD)
Top Related