Hisham Khalil Consultant ENT Surgeon Clinical with Obstructive Sleep Apnoea, especially in primaryespecially

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  • SnoringSnoringSnoring Can We Live Without Snoring Can We Live Without It?It?

    Hisham Khalil Consultant ENT Surgeon Clinical Senior LecturerClinical Senior Lecturer

  • Pl hPl hPlymouthPlymouth

    Derriford Hospital Peninsula Medical S h lSchool

  • Snoring &OSASnoring &OSAgg Definitions Diagnostic Approach Treatment ModalitiesModalities Treatment Modalities Discussion

  • ENT Sleep DisordersENT Sleep Disorderspp Sleep-Disordered Breathingp g

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


  • Prevalence of Snoring in the UKPrevalence of Snoring in the UKf gf g 43.75% of the middle aged (30 - 69 years) population snore 41.5% of the adult population snore. p p The 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.

  • DefinitionsDefinitionsff Apnea – cessation of airflow >10 sec, p ends in arousal Hypopnea reduction in airflow withHypopnea – reduction in airflow with desaturation, ends in arousal Apnea / Hypopnea Index (Respiratory Disturbance Index))

  • Pathophysiology of Snoring/OSAPathophysiology of Snoring/OSAp y gy f gp y gy f g Anatomy Physiology

    Obesity Nasal Obstruction

    Failure of dilator muscles

    Pharyngeal Obstruction

    Excessive intrathoracic pressureJaw

    Tongue Palate



  • Anatomical SitesAnatomical Sites

  • Risk FactorsRisk Factors Male genderg Obese (increased BMI) I dIncreased age Neck size > 17 Snoring U f bl tUnfavourable anatomy

  • Diagnosis Diagnosis gg History from partner/family Nasal obstruction Increase in weight Interrupted sleep SmokingS o g Alcohol SedativesSedatives Epworth Sleepiness Scale

  • Epworth Sleepiness ScaleEpworth Sleepiness Scalep pp p Introduced 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 p ESS 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

  • ExaminationExamination High BMIg Large Neck Collar Size D i t d N l S tDeviated Nasal Septum Turbinate Hypertrophyyp p y Redundant Soft Palate/Long Uvula L 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 p pharyngeal walls on breathing in againstbreathing in against a closed nose and


  • Clinical Findings SummaryClinical Findings Summaryg yg y

  • InvestigationsInvestigationsgg

  • PolysomnographyPolysomnographyy g p yy g p y Standards vary from lab to labto lab Includes:

    EEG El t lElectro-oculogram EMG Nasal/oral airflow Respiratory movement Oximetry ECG Position

  • ApnoeaGraphApnoeaGraph


    CMCM P2


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

    •Uvula •Tonsils


    •TonsilsKM P2

    T0 Lower Obstruction: •Macroglossia

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


  • OSASOSAS RDI SaO2 (%)( )

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

  • Sleep NasendoscopySleep Nasendoscopyp pyp py

  • TreatmentTreatment

  • Treatment StrategiesTreatment Strategiesgg Reduce Obstruction Reduce Turbulence during Inspiration R d Vib ti f S ft Ti fReduce Vibration of Soft Tissue of Throat

  • ConservativeConservative Loose weight Sleep hygiene Improve nasal airway - Steroid sprays - Nasal devicesasa de ces Mandibular devices CPAPCPAP

  • Sleep HygieneSleep Hygienep ygp yg Limit caffeine, alcohol Avoid bedtime TV, reading M t i b ll i t T hi t t idMay sew tennis ball into T-shirt to avoid supine position

  • Surgical TreatmentSurgical Treatmentgg Nasal Palatal T BTongue Base Maxillomandibular Tracheotomy

  • Snoring / OSA ManagementSnoring / OSA Managementg gg g

    Ear, Nose, Throat DevicesEar, Nose, Throat Devices Dental 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

    ••CPAPCPAP SurgerySurgery

    ••LasersLasers R di fR di f••RadiofrequencyRadiofrequency

  • Snoring DevicesSnoring Devicesgg

  • Nasal DilatorsNasal Dilators I t lI t l

    Breathe With EezBreathe With EezTMTM

    InternalInternalExternalExternal Breathe EZBreathe EZTMTMea e eea e e Breathe EZBreathe EZ

    Breathe Right Nasal Strip®Breathe Right Nasal Strip®


  • Nasal Dilators: The EvidenceNasal Dilators: The Evidence Nozovent®

    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


    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 Appliancespppp Two basic typesyp

    Advance tongue Advance mandibleAdvance mandible

    Best for mild/moderate OSA Preferred 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 Devices Primary snoring y g Upper 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 Pressureyy CPAP or BiPAP May be delivered nasally or by full-face maskmask May still be necessary after surgery Compliance an issue Indicated for snoring with severe OSAIndicated for snoring with severe OSA


  • Surgical TreatmentSurgical Treatmentgg Failed conservative measures Risk factors addressed

  • Nasal Surgery in SnoringNasal Surgery in Snoringg y gg y g Only a 1/3 to a ½ of patients notice an improvement in p their snoring with nasal surgerynasal surgery Surgery includes septoplastyseptoplasty, Turbinate

    d ti dreduction and Nasal Polypectomy

  • UvulopalatopharyngoplastyUvulopalatopharyngoplasty (UVPP)(UVPP)

    Ikematsu 1950s snoringIkematsu – 1950s – snoring Fujita – 1980 – OSA


  • Classic UVPPClassic UVPP

  • Classic UVPPClassic UVPP Early results are goody g High incidence of recurrence P i f lPainful Higher incidence of complicationsg p

  • Classic UVPPClassic UVPP UPPP 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 g returning (Hassid et al, Acta Otorhinolaryngol Belg(Hassid et al, Acta Otorhinolaryngol Belg 2002;56(2):157-62. )

  • LAUPLAUP Laser-assisted uvulopalatoplastyp p y Can be done in office T i ll lti l iTypically multiple sessions More common for non-apneic snoringp g Newer data shows poor long-term resultsresults

  • Laser AssistedLaser AssistedLaser Assisted Uvulopalatoplasty Laser Assisted Uvulopalatoplastyp p y (LAUP)

    p p y (LAUP)

  • Soft Palate ImplantsSoft Palate Implantsf pf p