surgery: treatment for obstructive sleep apnea (OSA)

1. KHAIRALLAH AOUCAR M.D PGYIII ENT
Holy Spirit University -kaslik
Grand round ENT Sat /12/14

2.  • mild for AHI or RDI ≥ 5 and < 15
 • moderate for AHI or RDI ≥ 15 and ≤ 30
 • severe for AHI or RDI > 30/hr

3. July 2011

4. CPAP vs control
 Only 1 study evaluated a clinical outcome(heart failure
symptomatology)=> no significant effect after 3
months.

5. CPAP vs control
 statistically and clinically significant improvement in
sleepiness as measured by ESS
 Inconsistent effects on other sleepiness tests, quality of
life tests, neurocognitive tests, and blood pressure

6. Conclusion:CPAP vs control
 Despite no evidence or weak evidence on clinical
outcomes
 given the large magnitude of effect on the important
intermediate outcomes:AHI, ESS, and other sleep
study measures=>
 the strength of evidence is moderate that CPAP is an
effective treatment for OSA.
 strength of evidence is insufficient to determine which
patients might benefit most from treatment

7. OSA treatments
MAD vs. control
 No study evaluated clinical outcomes.
 In 2 studies about 5% of patients had tooth damage (or
loosening).
 Substantial jaw pain was reported in about 2–4% of
patients
 no study reported on the long-term consequences of
any adverse events
 same conclusion as CPAP

8. Surgery vs.control
 No study evaluated clinical outcomes.
 Of these 7 studies, 4 found statistically significant
improvements in AHI, other sleep study measures,
and/or sleepiness measures.
 The remaining studies found no differences in these
outcomes or quality of life or neurocognitive function.

9. Conclusion :surgery vs control
 the strength of evidence is insufficient to evaluate
the relative efficacy of surgical interventions for the
treatment of OSA.

10. OSA treatments
Surgery vs CPAP
 Of 12 eligible studies comparing surgery with CPAP (1
quality A, 11 qualityC), only 2 were RCTs.
 There were 2 retrospective studies that evaluated
mortality in UPPP vs. CPAP.
 Of these: 1 study found higher mortality over 6 years
among patients using CPAP
 1 study found no difference in 5-year survival.

11.  Both trials found no difference in outcomes either
between RFA and CPAP after 2 months or between
maxillomandibular advancement osteotomy and CPAP
at after 12 months.
 Conclusion: The strength of evidence is
insufficient to determine the relative merits of
surgical treatments versus CPAP.

12. OSA treatments
Surgery vs. MAD
 A single trial (quality B) compared UPPP and MAD
treatment.
 more patients using MAD achieved 50% reductions in
AHI at 1 year and significantly lower AHI at 4 years.
 Conclusion: The strength of evidence is
insufficient to determine the relative merits of
surgical treatments versus MAD

13. Weight loss
 Conclusion: The strength of evidence is low to
show that some intensive weight loss programs are
effective treatment for OSA in obese patients.

14. MEDICAL AND SURGICAL
EVALUATION
 comprehensive medical history
 head and neck examination
 polysomnography
 Fiberoptic nasopharyngolaryngoscopy
 lateral cephalometric analysis

15. Physical exam
 Vital signs
 BMI
 neck size
 Face-retrognathia,micrognathia
 Nose(sd,valve collapse)
 Oral cavity- palate, uvula, tonsils/pillars, tongue,
occlusion

19.  Success of UPPP was defined as a reduction of the
postoperative(RDI) to< 50%
 In addition, the postoperative RDI must have <20.

22.  type II and III predict bad outcomes for UPPP

23. Tests to determine site of
obstruction
 Muller’s Maneuver
 Sleep endoscopy
 Fluoroscopy
 Manometry
 Cephalometrics
 Dynamic CT scanning and MRI scanning

24. Muller’s maneuver
Katsnatonis etal:prediction efficacy only 33%
Doghramgi et al:no benefit of MM in predictive value for UPPP

25. Sleep endoscopy
 Advantage: Dynamic assessment of sleeping patient
 – Directly visualize location of obstruction and
structures
 Major disadvantages
 – Difficult to fall asleep with fiberoptic scope held in
place manually or otherwise secured externally
 – Difficult to move scope without awakening (to
visualize multiple potential regions of obstruction)

26. Drug-Induced Sleep Endoscopy
 Developed in UK in 1991
 Used in several centers around the world but less
commonly in U.S.
 Fiberoptic endoscopy of sedated, sleeping patient

27.  Not easy: requires sedation, somewhat time consuming
 – Sedatives decrease muscle tone and decrease respiratory
drive
 May artificially worsen OSA and alter pattern of collapse
 Key is avoidance of oversedation (Eastwood 2005:
decreases muscle tone)
 Propofol has less decrease in respiratory drive

28. CEPHALOMETRIC ANALYSIS
 Patient is awake upright
and static
 2 D=>may underestimate
the degree of obstruction

29.  significant correlation between an increase of the
apnea index (AI)
 PAS-epipharynx <7 mm
 MP-H distance >27.4 mm
 Useful for genioglossus advacement and MMA
Naganuma H, Okamoto M, Woodson BT, Hirose H. Cephalometric and fiberoptic
evaluation as a case-selection technique for obstructive sleep apnea syndrome
(OSAS). Acta Otolaryngol Suppl. 2002;57-63.

31. CT and MRI
 Advantage: Assessment during sleep possible
 Disadvantages
 – CT and MRI can be static (although cine-CT)
 – Time-consuming and not inexpensive
 – Specific equipment and technical assistance
 – Radiation exposure (CT and fluoroscopy)

33. Surgery
 The presence and severity of obstructive sleep
apnea must be determined before initiating
surgical therapy (Standard).
 The patient should be advised about potential
surgical success rates and complications, the
availability of alternative treatment options such
as nasal positive airway pressure and oral
appliances, and the levels of effectiveness and
success rates of these alternative treatments
(Standard).
Aurora RN; Casey KR; Kristo D; Auerbach S; Bista SR; Chowdhuri S; Karippot A; Lamm C;
Ramar K; Zak R; Morgenthaler TI. Practice parameters for the surgical modifications of the
upper airway for obstructive sleep apnea in adults. SLEEP 2010;33(10):1408-1413.

34. SURGICAL PREPARATION—RISK
MANAGEMENT
 appropriate laboratory
 cardiopulmonary, and radiographic tests in patients
with existing comorbid medical conditions (diabetes,
hypothyroidism, cardiovascular disease, and
pulmonary disease)
 consultation with the appropriate medical specialist
should be sought

35. SURGICAL TREATMENT
PHILOSOPHY
 Since multilevel obstruction may exist, it may be
necessary to treat more than one site.
 Failure to recognize or treat all anatomical levels will
lead to persistent obstruction.

36.  Powell NB, Riley RW, Guilleminault C. Surgical management of sleep-disordered breathing. In:
 Kryger MH, Roth T, Dement WC, eds. Principles and Practices of Sleep Medicine. 4th ed.
 Philadelphia: Elsevier Saunders, 2005:1081–1097.

37.  Powell NB, Riley RW, Guilleminault C. Surgical management of sleep-disordered breathing. In:
 Kryger MH, Roth T, Dement WC, eds. Principles and Practices of Sleep Medicine. 4th ed.
 Philadelphia: Elsevier Saunders, 2005:1081–1097.

40.  Conservative surgery (phase I) is therefore
recommended initially with the plan to perform
postoperative PSG to assess response to surgery.
 Those patients who are incompletely treated would
then be considered for phase II surgery.

41.  phase II surgery may be the appropriate first step=>in
non obese patients with marked mandibular
deficiency and normal palates
Powell NB, Riley RW. A surgical protocol for sleep disordered breathing. Oral Maxillofac
Surg Clin
North Am 1995; 7(2):345–356.

42. SURGICAL PROTOCOL OUTCOMES
 Clinical response to phase I surgery ranges from 42%
to 75%
Riley R, Powell N, Guilleminault C. Obstructive sleep apnea syndrome: a review of 306
consecutively treated surgical patients. Otolaryngol Head Neck Surg 1993; 108(2):117–125.
Lee N, Givens C, Wilson J, et al. Staged surgical treatment of obstructive sleep apnea
syndrome: areview of 35 patients. J Oral Maxillofac Surg 1999; 57(4):382–385. with sleep
apnea. Arch Otolaryngol Head Neck Surg 1996; 122(9):953–957.

43. Factors for less succ outcome
 RDI>60
 oxygen desaturation <70%
 mandibular deficiency :sella nasion pointB<75’
 BMI> 33 kg/m2

44.  Preoperative CPAP can alleviate the issues associated
with sleep deprivation and may reduce the risk of
postobstructive pulmonary edema.
 Consequently, all patients who are tolerant of CPAP
are encouraged to use this modality for at least two
weeks prior to surgery

45. Nasal Reconstruction
 Nasal reconstruction can improve quality of life and
may improve OSA in select patients
 improve a patient’s tolerance of nasal CPAP
 Rarely, however, will alleviating nasal obstruction cure
OSA.
Olsen K. The role of nasal surgery in the treatment of obstructive sleep apnea. Otolaryngol
HeadNeck Surg 1991; 2(5):63–68.
Hoijer U, Ejnell H, Hedner J, et al. The effects of nasal dilatation on snoring and
obstructive sleepapnea. Arch Otolaryngol Head Neck Surg 1992; 118(3):281–284.

46. Uvulopalatopharyngoplasty/Uvulo
palatal Flap
 UPPP is an excellent
technique to alleviate
isolated retropalatal
obstruction (Fujita
type I)
 UPPP was found to
have a success rate of
39% for curing OSA
Sher AE, Schechtman KB, Piccirillo JF. The efficacy of surgical modifications of the
upper airway in
adults with obstructive sleep apnea syndrome. Sleep 1996; 19(2):156–177.

47.  Uvulopalatopharyngoplasty (UPPP) as a single
surgical procedure: UPPP as a sole procedure,
with or without tonsillectomy, does not reliably
normalize the AHI when treating moderate to
severe obstructive sleep apnea syndrome.
Therefore, patients with severe OSA should
initially be offered positive airway pressure
therapy, while those with moderate OSA should
initially be offered either PAP therapy or oral
appliances. (Option).

48. Mandibular Osteotomy with
Genioglossus Advancement
 The rationale of this surgery is to enlarge the PAS by
preventing prolapse of the tongue during sleep
 no study to determine the compliance of the
genioglossus muscle preoperatively
 limitation :no additional room is created for the
tongue in contrast to maxillomandibular
advancement.

49.  Meticulous hemostasis
+aggressive antihypertensive
management are critical to
prevent hematoma
formation.
 Mild postoperative floor of
mouth edema or ecchymosis
is common and is usually
self-limiting

50. Hyoid Myotomy and Suspension
adjunctive procedure to
treat tongue base
obstruction for those who
previously underwent
genioglossus advancement
and have evidence of a
posteriorly displaced
epiglottis.

51. MMA
 In 1990, Riley et al.
demonstrated no
statistical difference
between nasal CPAP
and surgery in
improving sleep
architecture and
SRBD

52.  Maxillo-Mandibular Advancement (MMA): MMA
is indicated for surgical treatment of severe OSA
in patients who cannot tolerate or who are
unwilling to adhere to positive airway pressure
therapy, or in whom oral appliances, which are
more often appropriate in mild and moderate OSA
patients, have been considered and found
ineffective or undesirable (Option).

53.  Multi-Level or Stepwise Surgery (MLS): Use of
MLS, as a combined procedure or as stepwise
multiple operations, is acceptable in patients with
narrowing of multiple sites in the upper airway,
particularly if they have failed UPPP as a sole
treatment (Option).

54. Radiofrequency ablation (RFA
 mild to moderate
obstructive sleep apnea
who cannot tolerate or
who are unwilling to
adhere to positive
airway pressure
therapy, or in whom oral
appliances have been
considered and found
ineffective or
undesirable (Option).

55. PALATAL IMPLANT SYSTEM
 mild OSA who cannot
tolerate or who are
unwilling to adhere to
positive airway
pressure therapy, or in
whom oral appliances
have been considered
and found ineffective
or undesirable
(Option).

56. Injection Snoreplasty
 3% sodium tetradecyl sulfate (sotradecol) and 50%
Ethanol
 Complete cessation or a significant reduction in
snoring was reported by 92% of patients or bed
partners.
 snoring relapse was 18% at long-term follow-up
 not shown to significantly reduce the RDI

57. The genial bone advancement
trephine system (GBAT)
 long-term objective studies have not documented the
success rate of the GBAT technique when used as
primary treatment for SRBD.

58. Repose Genioglossus
Advancement Hyoid Myotomy
 Subjective improvements in snoring and daytime
fatigue.
 Reduction of the RDI and apnea index with
improvement of oxygen saturation was observed.
 Unfortunately, the overall cure rate was approximately
20% in several studies

59. Tracheostomy
 Effective single intervention to treat obstructive
sleep apnea. This operation should be considered
only when other options do not exist, have failed,
are refused, or when this operation is deemed
necessary by clinical urgency (Option).

60. Conclusion
 Identifying the site(s) of airway obstruction in
OSA is critical
 No single ideal method of identifying site of
obstruction, although there are some options
 Improving our assessment of the airway may
enable targeted, more-effective treatment of OSA
with surgery and oral appliances