SnoringSnoringSnoringCan We Live Without SnoringCan We Live Without It?It?

Hisham KhalilConsultant ENT Surgeon Clinical Senior LecturerClinical Senior Lecturer

Pl hPl hPlymouthPlymouth

Derriford Hospital Peninsula Medical S h lSchool

Snoring &OSASnoring &OSAggDefinitionsDiagnostic Approach Treatment ModalitiesModalitiesTreatment ModalitiesDiscussion

ENT Sleep DisordersENT Sleep DisordersppSleep-Disordered Breathingp g

Obstructive Sleep Apnea Syndrome (OSAS)(OSAS)Obstructive Sleep Hypopnea Syndrome (OSHS)(OSHS)Upper Airway Resistance Syndrome (UARS)(UARS)

Snoring

Prevalence of Snoring in the UKPrevalence of Snoring in the UKf gf g43.75% of the middle aged (30 - 69 years)population snore 41.5% of the adult population snore. p pThe male to female ratio is approximately 2:1, with 29% of males and 12.5% femaleswith 29% of males and 12.5% females snoring. Approximately 14 9 million adults snore withApproximately 14.9 million adults snore with 10.4 million males and 4.5 million females.

DefinitionsDefinitionsffApnea – cessation of airflow >10 sec, pends in arousalHypopnea reduction in airflow withHypopnea – reduction in airflow with desaturation, ends in arousalApnea / Hypopnea Index (Respiratory Disturbance Index))

Pathophysiology of Snoring/OSAPathophysiology of Snoring/OSAp y gy f gp y gy f gAnatomy Physiology

ObesityNasal Obstruction

Failure of dilator muscles

Pharyngeal Obstruction

Excessive intrathoracic pressureJaw

TonguePalate

pressure

Palate

Anatomical SitesAnatomical Sites

Risk FactorsRisk FactorsMale gendergObese (increased BMI)I dIncreased ageNeck size > 17SnoringU f bl tUnfavourable anatomy

Diagnosis Diagnosis ggHistory from partner/familyNasal obstructionIncrease in weightInterrupted sleepSmokingS o gAlcoholSedativesSedativesEpworth Sleepiness Scale

Epworth Sleepiness ScaleEpworth Sleepiness Scalep pp pIntroduced by Murray J h f E thJohns of Epworth hospital, Melbourne, 19911991

Maximum score of 24Maximum score of 24

Scores > 10 areScores > 10 are significant

Epworth Sleepiness ScaleEpworth Sleepiness Scalep pp pESS is consistent with clinical diagnosis and could be used as a primary diagnostic method in patientsprimary diagnostic method in patients with Obstructive Sleep Apnoea, especially in primary care hospitalsespecially in primary-care hospitals.

(Chen et al, 2002)

ExaminationExamination

ExaminationExaminationHigh BMIgLarge Neck Collar SizeD i t d N l S tDeviated Nasal SeptumTurbinate Hypertrophyyp p yRedundant Soft Palate/Long UvulaL T BLarge Tongue Base

ExaminationExamination

Rhinitis and Turbinate HypertrophyRhinitis and Turbinate Hypertrophy

Deviated Nasal SeptumDeviated Nasal Septumpp

Nasal PolyposisNasal Polyposisypyp

RhinosinusitisRhinosinusitis

Redundant Soft PalateRedundant Soft Palateff

Hypertrophied TonsilsHypertrophied Tonsilsyp pyp p

Receding MandibleReceding Mandiblegg

Muller Muller ManeuverManeuver

Collapse of lateral ppharyngeal walls on breathing in againstbreathing in against a closed nose and

thmouth

Clinical Findings SummaryClinical Findings Summaryg yg y

InvestigationsInvestigationsgg

PolysomnographyPolysomnographyy g p yy g p yStandards vary from lab to labto labIncludes:

EEGEl t lElectro-oculogramEMG Nasal/oral airflowRespiratory movementOximetryECGPosition

ApnoeaGraphApnoeaGraph

T1

CMCMP2

T0

Determination of Obstruction SiteDetermination of Obstruction SiteUpper Obstruction:•Septum deviation, Polyposis S ft l tT1 •Soft palate

•Uvula •Tonsils

T1

•TonsilsKMP2

T0Lower Obstruction:•Macroglossia

l•Epiglottis•Narrow airways (Retrognathia Micrognathia)(Retrognathia, Micrognathia)

•Goiter

OSASOSASRDI SaO2 (%)( )

Mild 5 20 >85Mild 5–20 >85Moderate 21–40 65–84Severe >40 <65

Sleep NasendoscopySleep Nasendoscopyp pyp py

TreatmentTreatment

Treatment StrategiesTreatment StrategiesggReduce ObstructionReduce Turbulence during InspirationR d Vib ti f S ft Ti fReduce Vibration of Soft Tissue of Throat

ConservativeConservativeLoose weightSleep hygieneImprove nasal airway- Steroid sprays- Nasal devicesasa de cesMandibular devicesCPAPCPAP

Sleep HygieneSleep Hygienep ygp ygLimit caffeine, alcoholAvoid bedtime TV, readingM t i b ll i t T hi t t idMay sew tennis ball into T-shirt to avoid supine position

Surgical TreatmentSurgical TreatmentggNasal PalatalT BTongue BaseMaxillomandibularTracheotomy

Snoring / OSA ManagementSnoring / OSA Managementg gg g

Ear, Nose, Throat DevicesEar, Nose, Throat DevicesDental DevicesDental Devices

Ear, Nose, Throat DevicesEar, Nose, Throat Devices

•• Nasal DilatorsNasal Dilators••Cervical PillowsCervical Pillows

••Oral AppliancesOral Appliances••Jaw Positioning DevicesJaw Positioning Devices

•• Mandibular Support DevicesMandibular Support Devices

Respiratory Respiratory

••CPAPCPAPSurgerySurgery

••LasersLasersR di fR di f••RadiofrequencyRadiofrequency

Snoring DevicesSnoring Devicesgg

Nasal DilatorsNasal DilatorsI t lI t l

Breathe With EezBreathe With EezTMTM

InternalInternalExternalExternalBreathe EZBreathe EZTMTMea e eea e e Breathe EZBreathe EZ

Breathe Right Nasal Strip®Breathe Right Nasal Strip®

NozoventNozovent®®

Nasal Dilators: The EvidenceNasal Dilators: The EvidenceNozovent®

Clinical data provided to support use

P t B A h Ot l l H d N k SPetruson B. Arch Otolaryngol Head Neck Surg 1990;116:462-4.

Petruson B. Rhinology 1988;26:289-92.

Nasal Dilators for Snoring Nasal Dilators for Snoring

Precautions/Warnings

Seek medical attention for abnormal breathing patterns during sleep daytime sleepiness difficultypatterns during sleep, daytime sleepiness, difficulty breathing, etc.

Cease use if skin/mucosal irritation

Do not exceed recommended duration of use

Not for use under 5 yr

Cervical PillowsCervical Pillows

Oral AppliancesOral AppliancesppppTwo basic typesyp

Advance tongueAdvance mandibleAdvance mandible

Best for mild/moderate OSAPreferred by many over CPAP

Mandibular Advancement DevicesMandibular Advancement Devices

Significant Improvement in Snoring (Level II)Significant Improvement in Snoring (Level II)Eur Respir J 1998; 11: 447–450.

Mandibular Advancement DevicesMandibular Advancement DevicesPrimary snoring y gUpper airway resistance syndrome Mild t d t b t ti lMild to moderate obstructive sleep apnea with a sufficient number of retaining teeth and a body mass index (BMI) of up to 30 kg/m2( ) p g

Positive Airway PressurePositive Airway PressureyyCPAP or BiPAPMay be delivered nasally or by full-face maskmaskMay still be necessary after surgeryCompliance an issueIndicated for snoring with severe OSAIndicated for snoring with severe OSA

CPAPCPAP

Surgical TreatmentSurgical TreatmentggFailed conservative measuresRisk factors addressed

Nasal Surgery in SnoringNasal Surgery in Snoringg y gg y gOnly a 1/3 to a ½ of patients notice an improvement in ptheir snoring with nasal surgerynasal surgerySurgery includes septoplastyseptoplasty, Turbinate

d ti dreduction and Nasal Polypectomy

UvulopalatopharyngoplastyUvulopalatopharyngoplasty(UVPP)(UVPP)

Ikematsu 1950s snoringIkematsu – 1950s – snoringFujita – 1980 – OSA

UPPPUPPP

Classic UVPPClassic UVPP

Classic UVPPClassic UVPPEarly results are goody gHigh incidence of recurrenceP i f lPainfulHigher incidence of complicationsg p

Classic UVPPClassic UVPPUPPP in patients complaining of snoring is quite successful but the results decline significantly with time and patients should be warned of the possibility of snoring remaining or y g greturning (Hassid et al, Acta Otorhinolaryngol Belg(Hassid et al, Acta Otorhinolaryngol Belg 2002;56(2):157-62. )

LAUPLAUPLaser-assisted uvulopalatoplastyp p yCan be done in officeT i ll lti l iTypically multiple sessionsMore common for non-apneic snoringp gNewer data shows poor long-term resultsresults

Laser AssistedLaser AssistedLaser Assisted UvulopalatoplastyLaser Assisted Uvulopalatoplastyp p y(LAUP)

p p y(LAUP)

Soft Palate ImplantsSoft Palate Implantsf pf p

Coblation® Soft Tissue DissectionCoblation® Soft Tissue DissectionCoblation® - Soft Tissue Dissection and Ablation with Minimal Damage Coblation® - Soft Tissue Dissection and Ablation with Minimal Damage to Collateral Tissueto Collateral Tissue

Coblation or “Controlled Ablation” is a unique patented process for softprocess for soft tissue removal.

Coblation – How it worksCoblation – How it works

1 R di f t l f i i d li d t th1. Radiofrequency energy at low frequencies is delivered to the tip of bipolar Wand (active and return electrodes located in close proximity).

2. A conductive medium, such as saline solution, is delivered to the gap between the active and return electrodesto the gap between the active and return electrodes.

3. The combination of the RF energy and the conductive medium creates a highly focused “plasma” field containing highly ionized particles.

Coblator (bipolar) Molecular Disintegration (before & after)

Coblation ProcessCoblation Process

Before molecular disintegration: t i l l itypical large organic molecule (protein)

After molecular disintegration: elementary molecules and low weight molecular gasesmolecular gases

Coblation vs Conventional ElectrocauteryCoblation vs Conventional ElectrocauteryConventional ElectrocauteryConventional Electrocautery

Conventional monopolar l t telectrosurgery current

causes arc to form between the electrode and tissueThis arc rapidly heats i d i itissue and tissue is

vaporized into steam, releasing cellularreleasing cellular fragments

Coblation-Assisted UvulopalatoplastyCoblation-Assisted Uvulopalatoplasty

Postoperative CarePostoperative CareppParacetamol, antibiotics ?Paracetamol, antibiotics ?Ice water aIce water aN h t d i k 24 h tN h t d i k 24 h tNo hot drinks 24 hour postNo hot drinks 24 hour post--opopSleep at 45 degree angle first nightSleep at 45 degree angle first nightp g g gp g g gSwelling may occur, not dangerousSwelling may occur, not dangerous

Coblation-Assisted UPPCoblation-Assisted UPPContinuing Evaluation Multilevel RF Continuing Evaluation Multilevel RF ggBaseline vs. Baseline vs. LongtermLongterm Outcomes Outcomes Stewart, Weaver Woodson, Stewart, Weaver Woodson, OtoOto HNS(2004)HNS(2004)

Other ProceduresOther ProceduresLingual tonsillectomyLaser midline glossectomy / Lingualplasty

trachTongue suspensionRF volumetric tissue reductionMandibular osteotomy/genioglossus advancementHyoid myotomy & suspension

ConclusionsConclusionsConservative measures are the first line of treatmentSurgery is useful for those who haveSurgery is useful for those who have addressed risk factors with persistent

isnoringLong term results are unpredictableg p

DiscussionDiscussion

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