MANAGMENT OF OSA

DR MANOHAR, RESIDENT ENTINHS ASVINI

Management under following headings:

• Behavioural measures

• Medical management

- Pharmacologic therapy

- Oral appliances

- Positive airway pressure

• Surgical treatment by site

- Nose

- Oral, oro pharyngeal and Nasopharyngeal procedures

- Hypo pharynx

- Tracheostomy (Bypass procedure)

Approach Considerations

• General and behavioural measures weight loss,

avoidance of alcohol for 4-6 hours prior to bedtime

• Positional therapy: sleeping on one side, head elevated

• 10% reduction in weight leads to a 26% reduction in the

respiratory disturbance index (RDI)

• Benefits of weight reduction in patients with SDB

include the following:

• Decreased RDI

• Lowered blood pressure

• Improved pulmonary function and arterial blood gas

values

• Improved sleep structure and snoring

• Possible reduction of optimum CPAP pressure

required

Benefits of weight reduction contd...

Pharmacologic therapy

• Modafinil 200-400 mg/d

• Binds dopamine transporters and inhibits dopamine

reuptake

• Improve wakefulness in patients with excessive

sleepiness

• Residual daytime sleepiness despite optimal use of CPAP

• Armodafinil

• Mechanical measures:

- Oral appliance (OA) therapy

- Continuous positive airway pressure (CPAP)

- Bilevel positive airway pressure (BiPAP) device

• Indications for OAs:

- Patients with mild-to-moderate OSA who

prefer oral appliances to CPAP devices

- Patients with mild-to-moderate OSA who do

not respond to CPAP therapy

• Patients with mild-to-moderate OSA in whom

treatment attempts with CPAP devices fail

Indications for Oas contd...

• Contraindications for OA:

• Less than 6-10 teeth in each arch

• Patient unable to protrude the mandible forward and

open the jaw widely

• Pre-existing temporo-mandibular joint problems

• Severe bruxism

• Patient with full denture

• Therapeutic nightly stimulation of the hypoglossal

nerve

• Electrical stimulation of genioglossus using

intramuscular or transcutaneous electrodes

CPAP

• CPAP machine

• Three main parts:

- A mask that fits over nose or nose and mouth with

straps

- A tube that connects the mask to the machine's

motor

- A motor that blows air into the tube

Working of CPAP

• Splint the airway open and prevent the collapse of

the upper airway

• Other benefits of CPAP:

• Increased end-expiratory lung volume

• Increase in oxygen stores

• Increased tracheal traction to improve upper airway

patency

• Lower cardiac after- load and consequent increase in

cardiac output

• Increased pressure in the airways allows for better

distribution of gases, which leads to an increase in

alveolar pressure and re-expansion of collapsed

alveoli

• BPAP

- Bilevel positive airway pressure (BPAP) devices

have two alternating levels of pressure

• AutoCPAP machines

- Collect data on compliance, leaks and pressure

profile

• Side effects of CPAP:

• Claustrophobia

• Nasal stuffiness-> poor compliance

• Skin abrasions and leaks

• Ulceration of the bridge of the nose-> ill fitting of

mask

• Air swallowing and pulmonary barotraumas: very rare

Surgical management

INDICATIONS FOR SURGERY

• Patients with severe, antisocial snoring:

- without OSA

- localized obstruction at one level in the upper

airway, usually at palatal level

- multisegmental obstruction with predominant

obstruction at palatal level

• Patients with mild-to-moderate sleep apnoea:

- with severe antisocial snoring;

- failed or inadequate response to CPAP

- localized obstruction at one level in the upper

airway, usually at palatal level

• Patients with moderate-to-severe sleep apnoea:

- with severe antisocial snoring;

- failed or inadequate response to CPAP;

- multisegmental obstruction

Nostrils and Columella

Luminal (Nasal) Valve

• Transverse nasal collapse is seen when the upper and

lower lateral cartilages are deficient in substance

• Lateral nasal walls collapse with inspiration

• Batten grafts can be used to bolster up the width of

the nose and give it more substance and firmness

Hypertrophied Turbinates

Macroglossia (Large Tongue)

Tori of the Maxilla or Mandible

Tonsils and Adenoid Tissue

Uvulopalatopharyngoplasty:

• Ikematsu in the 1950s

• Popularized by Fugita in 1985

• Principle

• Modifications

- Preservation of the uvula

- Eliminating the pharyngoplasty part

• Success: It is effective in 40% of patients

- Recurrence if continue to gain weight

• Complications :

• Severe postoperative pain

• Haemorrhage

• Respiratory events: airway obstruction due to

laryngospasm, postoperative pulmonary

oedema and hypoxia

• Nasal regurgitation due to excessive palatal resection

• Velopharyngeal stenosis

• Dry throat

• Swallowing problems

• Taste disturbances

Radiofrequency tissue volume reduction/

thermal ablation:

• Procedure:

• Thermal injury to specific submucosal sites

in the soft palate resulting in fibrosis of the muscular

layer and volumetric tissue reduction.

• Three types of radiofrequency devices

• Somnus unit

• Celon device: bipolar electrode tip, auto stop

application and reduced procedure time

• Coblator unit: larger electrode tip

Coblation continued..

• Advantages

- OPD procedure

- Local anaesthesia

- Less postoperative pain and other complications

- Single and multilesion groups showed significant

improvement in snoring

• Complications:

• Ulcers of the tongue base or soft palate

• Dysphagia

• Temporary hypoglossal nerve palsy

• Abscess at the base of tongue

• Maxillomandibular procedures:

- Insertion of the genioglossus or geniohyoid muscle

advanced without moving the entire mandible or

teeth- Designed to enlarge and stabilize the retrolingual

airway

• Hyoid myotomy and suspension

- Horizontal anterior cervical neck incision over hyoid

- Released from inferior attachment and advanced

anteriorly and inferiorly over thyroid cartilage

• Maxillomandibular osteotomy and advancement

- Aims to move the maxilla and mandible as far

forward as possible

- Dentofacial deformities

- Consists of Le Fort I osteotomy of the maxilla and

a bilateral sagittal split osteotomy of the mandible

Laser-assisted uvulopalatoplasty:

• Introduced by Kamami in France, in 1993, as OPD

procedure under LA

• Bilateral vertical incisions are made in the soft palate

followed by partial vaporization of the uvula with a

CO2 laser

Laser-assisted uvuloalatoplasty:

• Advantages:

- Brief surgical session

- Reduces far less palatal tissue and does not alter the

tonsils or the pharyngeal pillars

- Uses a laser rather than a scalpel

- Requires no wound closure

• Under local anesthesia

• Requires no postoperative hospital stay

Advantages contd...

• Increased tendency of:

- Worsening in nasal breathing in previously simple

snorers

Pillar procedure

• The pillar procedure involves surgically placing small

polyester rods in the soft palate.

• Each implant measures 18 millimeters (mm) in length

— slightly less than an inch — and 1.5 mm in

diameter.

Pillar procedure

Radiofrequency cold ablation

Turbinate reduction

Radiofrequency turbinate ablation

• Tracheostomy:

- Tongue base procedures such as genioglossus

advancement or laser midline glossectomy

Bariatric surgery

References

• Scott-Brown’s 7th edition

• Cummings 5th edition

• OCNA

THANK YOU