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S LEEP A PNEA

S LEEP A PNEA. Stephen A. Schendel , M.D., D.D.S . Richard L. Jacobson, D.M.D., M.S. Joseph A. Broujerdi , M.D., D.M.D. Prepared by Jenny R. Armstrong, B.A. Stephen A. Schendel , M.D., D.D.S.

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S LEEP A PNEA

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  1. SLEEP APNEA Stephen A. Schendel, M.D., D.D.S. Richard L. Jacobson, D.M.D., M.S. Joseph A. Broujerdi, M.D., D.M.D. Prepared by Jenny R. Armstrong, B.A.

  2. Stephen A. Schendel, M.D., D.D.S. • Surgical interests are craniofacial and maxillofacial surgery, including sleep apnea and orthognathicsurgery • Professor of Surgery Emeritus at Stanford University Medical Center and Lucile Packard Children’s Hospital EDUCATION AND TRAINING: • Graduate of University of Minnesota Dental School in 1973 • Residency at Parkland Memorial Hospital in Dallas • Studied as a Fulbright Fellow at the University of Nantes in France • Emphasis of cleft lip & palate surgery and dentofacial orthopedics under the tutelage of Dr. Jean Delaire • Graduate of University of Hawaii Medical School in 1983 • Assistant to Dr. Paul Tessier 1987 to 1988 in Paris, France • General Surgery internship at Baylor University Medical Center, Dallas • General Surgery and Plastic Surgery training at Stanford University Medical Center ACHIEVEMENTS: • Recipient of a Chateaubriand French Research Fellowship • Full-time faculty of the Division of Plastic and Reconstructive Surgery at Stanford University Medical School from 1989 until 2007 • Leader in the field of distraction osteogenesis for the correction of facial deformities. • Board-certified in Oral and Maxillofacial Surgery and Plastic Surgery • Fellow of the American College of Surgeons • Fellow in the American Academy of Pediatrics • Former President of the American Society of Maxillofacial Surgeons • Former board member of the American Society of Plastic Surgeons from 1992 to 2002 • Former Chief of Plastic Surgery at Stanford University Medical Center and Chief of Pediatric Surgery • Chairman of the Department of Functional Restoration from 1994 to 2001 • Director of The Craniofacial Anomalies Center at Lucile Packard Children’s Hospital from 1994-2007 • Full-time faculty of the Division of Plastic and Reconstructive Surgery at Stanford University Medical School from 1989 until 2007 PUBLICATIONS • He has published over 100 articles and chapters including a textbook on maxillofacial surgery.

  3. Richard L. Jacobson, D.M.D., M.S. • Board certified orthodontist practicing in Pacific Palisades for 30 years • Additional areas of interest and expertise include orthognathic surgery and temporomandibular joint disorders • Part-time instructor at UCLA School of Dentistry Department of Orthodontics EDUCATION AND TRAINING: • UCLA School of Dentistry Department of Orthodontics 1981 • M.S. in Oral Biology UCLA 1979-1983 TMJ Department • American Institute of Bioprogressive Education • Mentored by Robert M. Ricketts, D.D.S., M.S., and Tom Graber, D.D.S., M.S, PhD. SERVICE • Director of the Foundation for Orthodontic Research and Education 1990-2000, elected President in 2000 • Director of the Western Orthogmorphic Diagnostic team • Service on the UCLA/St. John's Cleft Palate and Craniofacial Team • President of the UCLA Orthodontics Alumni Association 1985, 2001 • Reviewer for the American Journal of Orthodontics and World Journal of Orthodontics (2011) • International Review Board approval for an airway study on 1300 patients (May 2011) PUBLICATIONS • Textbook: Radiographic Cephalometry: From Basics to 3-D (Quintessence) • American Journal of Orthodontics, Journal of Clinical Orthodontics, Journal of Oral and Maxillofacial Surgery

  4. Joseph A. Broujerdi, M.D., D.M.D. • Dual training in Plastic & Reconstructive surgery and Oral & Maxillofacial Surgery • Sub-specialty and surgical interests: Cranio-Maxillofacial Surgery and Surgical Treatment of Sleep Disorders EDUCATION AND TRAINING: • Graduate of the University of Pennsylvania School of Dental Medicine • Craniofacial/Pediatric Plastic Surgery fellowship at Stanford University Medical Center, Lucile Packard Children’s Hospital • Plastic & Reconstructive Surgery at Wayne State University/Detroit University Medical Center • General Surgery and Oral & Maxillofacial Surgery at SUNY Downstate/Kings County Hospital Center ACHIEVEMENTS: • Recipient of Henry M. Goldman award from the University of Pennsylvania PUBLICATIONS: • Dr. Broujerdi has written many papers covering new developments in the field of Plastic & Reconstructive Surgery, contributed to peer-reviewed journals, and co-authored a book chapter on Maxillofacial Surgery. He has given presentations and spoken at national and international conferences.

  5. Relevant Terminology

  6. EPIDEMIOLOGY

  7. Epidemiology of Snoring • Affects 90 million adults in the USA • 37% of adults self-report snoring a few nights a week in previous year • 27% of adults self-report snoring every night • Studies indicate that a more reasonable estimate is 50% of adults snore • Men slightly more likely to snore than women National Sleep Foundation, 2002. Sleep in America. www.sleepfoundation.org, 4 May 2011 Powell N., Riley R., Schendel S. California Sleep Institute, 2009. www.calsleep.com, Snoring. 4 May 2011

  8. Epidemiology of UARS • No gender bias • Non-obese (BMI <25) • Younger patient • Mean age 37.5 years Guilleminault C., Takaoka S. 2009, Signs and Symptoms of Obstructive Sleep Apnea And Upper Airway Resistance Syndrome. Friedman M., ed. Sleep Apnea and Snoring: Surgical and Non-Surgical Therapy, Saunders Elsevier, Chicago, p 3-8.

  9. Epidemiology of Sleep Apnea • 2-5% of the population • 18 million people in the USA • More males than females until menopause • 25% of adult men • 9% of adult women • Typically presents between ages of 40-60 • 1/3 of those with OSA have cases severe enough to warrant immediate treatment Stevens, Damien R. Sleep Medicine Secrets. Hanley & Belfus, Inc.: Philadelphia, 3004. p 3 Powell N., Riley R., Schendel S. California Sleep Institute, 2009. www.calsleep.com, Snoring. 4 May 2011

  10. Epidemiology of Sleep Apnea Friedman et al, 2009. pp 3, 51.

  11. Epidemiology of Sleep Apnea: Women National Sleep Foundation, Women and Sleep. http://www.sleepfoundation.org/article/sleep-topics/women-and-sleep 4 May 2011

  12. Symptoms Friedman et al, pp 1

  13. Non-Specific Symptoms: Women Friedman et al, pp 8

  14. Epidemiology of Sleep Apnea

  15. Epidemiology of Sleep Apnea: Medical Complications

  16. ANATOMY

  17. AirwayAnatomy

  18. Airway Anatomy Friedman et.al, 2009. pp 96

  19. Anatomy: Nasopharynx

  20. Anatomy: Nasopharynx • Airflow of Inspiration • Parabolic curve • directed superiorly through the nostril • Up through the nasal cavity passing the turbinates • Posteriorly passes through the nasopharynx

  21. Anatomy: Internal Nasal Valve • 4 structures • SUPERIOR: Upper lateral cartilage • MEDIAL: Nasal septum • INFERIOR: Pyriform aperture • POSTERIOR: Head of inferior turbinate • Narrowest part of the nasal passage • Source of nasal resistance • Narrowest portion of IV is region between septum and near the posterior border of the upper lateral cartilage • 10-15 degrees in Caucasians • Wider in African Americans and Asians • IV angles < 10 degrees more prone to nasal valve collapse Friedman et.al, 2009. pp 120

  22. Anatomy: Turbinates • Filter and heat air from 0 to 36 and humidify it • Special air flow receptor cells on surface of inferior turbinates • Secretes mucous that keeps nose moist and limits drying Friedman et.al, 2009. pp 120

  23. Anatomy: External Nasal Valve • Nares • Alar margin • Soft tissue triangle • Columella • Nasal sill • Nasal vestibule • Inside the external naris • Septum and Columella are located medially • Alar sidewalls are lateral to the vestibule • Vibrissae • Located within vestibule • Filter air • Direct air posteriorly into nasal cavity • Limit rate of inspired air Friedman et.al, 2009. pp 120

  24. Anatomy: Nasal Musculature • Elevator muscles • Procerus • Levatorlabiisuperiorisalaequenasi • Anomalusnasi • Depressor muscles • Alar nasalis • Depressor septinasi • Compressor muscles • Transverse nasalis • Compressor nariummino • Dilator muscles • Alar muscles • Dilate the IV to keep the lumen open

  25. Airflow: Nasal Structures • IV and EV function together to deliver smooth air current • Inspiration: • Nostrils flare • EV is increased • Bernoulli Principle • Intraluminal pressure in the IV decreases when airflow is increased • cartilage in nose counterbalances tendency towards IV collapse • IV area should remain unchanged during normal nasal function

  26. Normal nose contributes to 50% of upper airway resistance Causes for Nasal Obstruction 3 Causes

  27. Structures of the Nose Often indicating nasal Obstruction

  28. Anatomy: Oropharynx & Hypopharynx

  29. Anatomy: Retropalatal Space • Hard Palate • Bony structure • Separates nasal and oral cavities • Occupies 2/3 of total oral palate • Soft Palate • Occupies 1/3 of total oral palate • Uvula • Prevents air escape into nasal cavity during speech • secretes mucus for swallowing and digestion • prevents choking and regurgitation of liquids • controls gag reflex • prevents passage of food/liquids into nasal passages • Tongue

  30. Anatomy: Palate • Soft Palate • Fibromuscular tissue • Separates oral and nasal cavities • Ends posteriorly with the uvula • Musculature: • Levatorvelipalatini • Tensor velipalatini • Palatopharyngeus • Musculus uvulae • Palatoglossus • Nerve • Pharyngeal Plexus • CN V2 • Function: • Mucous secretion • Prevents regurgitation of food into nasal cavity

  31. Anatomy: Retroglossal Space • Epiglottis • Base of Tongue • Hyoid • Genioglossus, geniohyoid, and middle pharyngeal constrictor muscles insert on hyoid bone • Tonsils • Mandible • Genioglossus

  32. Causes of Potential Airway Obstruction • MOST COMMON CAUSE IS ANATOMIC ABNORMALITY LEADING TO OBSTRUCTION

  33. Major Sites of Potential Airway Obstruction • Nose • Septum • Nasal valve • Turbinate • Polyp • Palate • Oropharynx • Tonsils • Lateral pharynx • Tongue • Mandible • Hyoid • Epiglottis

  34. Sleep Architecture • Sleep Stages: • REM – Rapid Eye Movement • 20-25% of total sleep time • Memorable dreaming occurs as well as atonia • NREM – Non-Rapid Eye Movement • 3 Stages: • N1 • Somnolence • Sudden twitches/jerks can occur with onset of sleep • Loss of muscle tone • N2 • Muscular activity decreases • Awareness of external environment disappears • 45-55% of total sleep in adults • N3 – Delta Sleep or Slow-Wave Sleep • Parasomnias occur • NREM-REM Cycle • N1  N2  N3  N2  REM • Each cycle lasts from 90 to 110 minutes on average • Deep sleep is stage N3 and occurs earlier in cycle • REM is later in sleep cycle before awakening

  35. DIAGNOSTICS

  36. Diagnosing Sleep Apnea in our Practice

  37. Clinical Examination

  38. Clinical Examination: BMI

  39. Clinical Examination: Nasopharynx

  40. Clinical Examination: Nasopharynx

  41. Clinical Examination: Oropharynx and Hypopharynx

  42. Clinical Examination: Tongue Size • Mallampati Position of Tongue • Based upon patient sticking tongue out • 3 grades • Friedman Tongue Postions (FTP) • Method to approximate obstruction at hypopharyngeal level • Evaluate tongue in neutral, natural position inside mouth • Repeat procedure 5 times • 5 Positions • I – Tonsils, Uvula, Pillars • IIa– Uvula • IIb – Most of soft palate, base of uvula • III – Some of soft palate • IV – Only hard palate Friedman et al., 2009, pp 106

  43. Clinical Examination: Tonsil Size • 0 – surgically absent • 1 – less than 25% • hidden within pillars • 2 – 25-50% • extending to pillars • 3 – 50-75% • Extending beyond pillars • 4 – 75-100% • Extending to midline

  44. Clinical Examination: OSAHS Score Friedman et al., 2009, pp 109 • INTERPRETING RESULTS • >8 Positive OSAHS • 74% effective in predicting severe OSAHS (AHI >45) • <4 Negative OSAHS • 67% effective in predicting AHI <20

  45. Clinical Examination: Craniofacial Characteristics

  46. Clinical Examination: Epworth Sleepiness Scale (ESS)

  47. Clinical Examination: Epworth Sleepiness Scale (ESS)

  48. Clinical Examination: Mueller Maneuver • THERE IS SOME EVIDENCE THAT • MUELLER MANEUVER DOES NOT REFLECT ACTUAL SITES OF OBSTRUCTION DURING SLEEP Friedman et al., 2009, pp 104, 224

  49. Upper Airway Analysis

  50. Historically: 2-D Cephamalometric Analysis • Standardized lateral x-ray of H&N for skeletal and soft tissue assessment • Multiple bony and soft tissue measurements • Skeletal Class I, II, III • Good estimate of A-P dimension • No estimate of transverse dimension • Performed upright when patient is awake • muscles are active • Head position is different than when resting • may underestimate degree tissue falls

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