By Dr.K.O.Paulose FRCS DLO
Consultant ENT Surgeon, Jubilee Hospital, Trivandrum, South India.www.drpaulose.com
www.snorefreesleep.com
Presentation in Indian Medical Association meeting on 07102011, Trivandrum Chapter.
1. Snoring and Sleep Apnea
Management
Dr.K.O.Paulose FRCS.DLO
Consultant ENT Surgeon
Jubilee Hospital Trivandrum
web:www.drpaulose.com
2. About me
2010-Consultant ENT Surgeon Jubilee
Hospital, Trivandrum
2004-2010-Consultant ENT Surgeon SUT
Hospital, Trivandrum
1987-2003-Consultant ENT Surgeon Bahrain
Military Hospital
1978-1987-UK NHS Teaching Hospitals
1973-MBBS Trivandrum Medical College
1980-DLO RCS London UK
1982-FRCS RCS Glasgow UK
35 years of ENT Experience
5. Causes of Snoring
Nasal Obstruction
Enlarged, Uvula, Soft Palate, Tongue
Narrow retroplalatal, retrolingual
area
Enlarged Ts Ads in children
Lack of Muscle tone upper airway
Air Turbulence in the oropharynx
Vibration of soft palate and uvula
Venturi Effect-Bernoulli principle
8. About Sleep Apnea
What is Sleep apnea?
Stoppage of breathing while asleep
More than 10 seconds
100-500 episode of apneas in one night
Plus Hypopneas
Cause Hypoxia and Hypercarbia
Types of sleep apnea?
Obstructive Sleep Apnea (OSA)
Most common-loud snoring
Obstruction of upper airway
Central Sleep Apnea (CSA)
Brain stem lesion, stroke, polio, tumors
No snoring
Mixed sleep apnea (OSA+CSA)
Chronic respiratory failure>central
9. Signs and symptoms of sleep apnea
Choking or gasping during sleep
Loud snoring
Sudden awakenings to restart breathing
Waking up in a sweat during the night
Feeling tired in the morning
Headaches
Daytime sleepiness
Lack of concentration,fatigue,irritable
Low O2- Brain and Heart
10. Diagnosis of Sleep Apnea
Good History from spouse or parents
Physical examination-Nose and Throat
Voice recording
Flexible Endoscopy
CT imaging or MRI retropalatal and
pharyngeal airway
Sleep study-Polysomnogram-Home Sleep
Study
Cardiac evaluation
18. Sagital CT-PN ratio
Pharyngeal Narrowing Ratio-Its significance
Soft palate-tongue contact and automatically
calculated pharyngeal narrowing ratio (PNR),
defined as a ratio between the airway cross-
section at the hard palate level and the narrowest
cross-section from the hard palate to the
epiglottis
Soft palate should therefore be the target for
causal treatment of snoring, LAUP, CAUP, RF
somnoplasty all aimed at the soft palate in OSA
surgery.
27. LASER TYPES
Laser is an acronym that stands for Light Amplification by Stimulated Emission
of Radiation.
The first concept of the laser was initiated by Albert Einstein in 1917.
CO2 Laser
Argon laser
The Nd:YAG (Neodymium:Yttrium-aluminum-garnet)
The potassium-titanyl-phosphate (KTP)
Diode Laser
28. Co2 Laser
CO2Laser
The CO2 laser is the most versatile laser in otolaryngology. The carbon dioxide (CO2) laser
emits a colorless, infrared light at a specific wavelength of 10,600 microns, which has an
extremely high affinity for the intercellular water of cells.
A second, built-in, coaxial helium neon laser is necessary to indicate with its red color the
site where the invisible CO2 laser beam will impact the target tissue. This laser, then,
acts as an aiming beam for the invisible CO2 laser beam.
Advantages of Laser Surgery
Fast
Painless
Bleeding-nil
Fast recovery
No hospitalization if done under LA
GA for difficult cases
Disadvantages of Laser
Cost of equipment and maintenance
Special surgical skills
Increased setup time of equipment
Need of safety eyewear
Increased care for patient safety - explosion or fire hazard.
smoke
29. Laser surgery for snoring and OSA
LAUP (Laser Assisted Uvulopalatopharyngoplasty)
involves removal of the uvula, shorten the soft palate and
reduce the volume of the tonsils using CO2 laser done
under-LA / GA
LAPT-Laser assisted Partial
turbinectomy
LAS-Laser assisted Septoplasty
LAT-Laser assisted Tonsillectomy
51. COBLATOR SURGERY
Cold Ablation-Coblation Technology
a controlled, non-heat driven process — uses
radiofrequency energy to excite the electrolytes in a
conductive medium, such as saline
Temperature 40-70*C-less thermal damage
Coblator II, Arthrocare ® USA Machine
Coblator Surgery
RF turbinate-Turbinoplasty
Polypectomy
Tonsillothomy-pediatric
CAUP –Snoring and OSA
Tongue base reduction
62. Number of OSA Surgery
1980s-UPPP
1996-2003 Laser Surgery-1000+cases
(approx)
2004-2010-SUT Hospital- 422 Cases
(LAUP+LAPT+LAS+Ts+Ads+CAUP)
2010- Jubilee Hospital-86 cases
(LAUP+LAPT+TS+Ads etc)
Result-70-80% cure OSA, 80-90% cure
Snoring
Redo-3-4 cases per year
Causes of Failure-Retrognathia, Large
Tongue,Obesity,Hypothyroid, Central apnea,
Hypotonia, Medications etc
63. Results of Laser surgery
showed the correction of sleep apnea by an average of 70-80%
However, the snoring sound reduction was between 80-90%.
Side Effects
post op infection -rare
nasal fluid reflux –temporary nasal regurgitation for few days, but
rarely permanent
no voice changes were noted
Bleeding-rare
Dryness of throat-rare
Causes of fauilure if any
mixed apnea-central component
Inadequate excision of tissues-Redo
Obesity,alcohol,sedative
Lack of muscle tone in the neck
Base of tongue factor-coblator reduction
Jaw factor-need mandibular advancement