Surgical Management of Obstructive Sleep Apnea

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

2. Evaluation of Sleep • Polysomnography • EMG • Airflow • EEG, EOG • Oxygen Saturation • Cardiac Rhythm • Leg Movements • AI, HI, AHI, RDI

3. Evaluation of Sleep • Polysomnography Woodson, Tucker “Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment” SIPAC 1996

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

5. Pathophysiology of OSA • Sites of Obstruction: • Obstruction tends to propagate

6. Pathophysiology of OSA • Sites of Obstruction:

7. Pathophysiology of OSA • Symptoms of OSA • Snoring (most commonly noted complaint) • Daytime Sleepiness • Hypertension and Cardiovascular Disease are Associated • Pulmonary Disease

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

9. Pathophysiology of OSA • Tests to determine site of obstruction: • Muller’s Maneuver • Sleep endoscopy • Fluoroscopy • Manometry • Cephalometrics • Dynamic CT scanning and MRI scanning

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

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

12. Medical Management • BiPAP • Useful when > 6 cm H2O difference in inspiratory and expiratory pressures • No objective evidence demonstrates improved compliance over CPAP

13. Nonsurgical Management • Oral appliance • Mandibular advancement device • Tongue retaining device

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 obstructivesleep apnea: a randomized study. Chest. 121(3):739-46, 2002 Mar.

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

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

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)

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.

19. Surgical Management • Uvulopalatopharyngoplasty

20. Surgical Management • UP3 Complications • Minor • Transient VPI • Hemorrhage<1% • Major • NP stenosis • VPI

21. Surgical Management • Cahali, 2003 proposed the Lateral Pharyngoplasty for patients with significant lateral narrowing: Cahali MB. Lateral pharyngoplasty: a new treatment for obstructivesleep apnea hypopnea syndrome. Laryngoscope. 113(11):1961-8, 2003 Nov.

22. Surgical Management • Lateral Pharyngoplasty

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

24. Surgical Management • Laser Assisted Uvulopalatoplasty • High initial success rate for snoring • Rates decrease, as for UP3, at twelve months • Performed awake

25. Surgical Management Radiofrequency device is inserted into various parts of palate, tonsils and tongue base at various thermal energies • Radiofrequency Ablation – Fischer et al 2003

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

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

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

29. Placement of Implants 2 m.m. apart Minimum Palate Length 25 mm

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

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 FlexibleNaso Scope. If the implant is exposed, it must be removed. Anangled tonsilforceps is recommended. Hard palate Muscle Implant Glandular tissue

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

33. Surgical Management • Tongue Base Procedures • Lingual Tonsillectomy • may be useful in patients with hypertrophy, but usually in conjunction with other procedures

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

35. Surgical Management • Mandibular Procedures • Genioglossus Advancement • Rarely performed alone • Increases rate of efficacy of other procedures • Transient incisor paresthesia

36. Surgical Management • Lingual Suspension

37. Surgical Management • Lingual Suspension

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

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

41. Surgical Management • Maxillary-Mandibular Advancement • Performed in conjunction with oral surgeons • Temporary or permanent paresthesia • Change in facial structure

42. Surgical Management • Algorithms • Studies efficacy of various algorithms • Therapy should be directed toward presumed site of obstruction • This does not always guarantee results

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

44. Surgical Management • Algorithms • Friedman et al developed a staging system for type of operation:

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

47. Ultimate Surgical Management • Tracheotomy • Morbid obesity • Significant anesthetic/surgical risks • Obvious disadvantages • Trach care • Supplies, equipment • aesthetics

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 obstructivesleep apnea. [Journal Article] Laryngoscope. 113(2):201-4, 2003 Feb.

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