The Management of Snoring and The Management of Snoring and Obstructive Sleep ApneaObstructive Sleep Apnea

Rex Moulton-Barrett, MDRex Moulton-Barrett, MD

Plastic and Reconstructive SurgeryPlastic and Reconstructive SurgeryOtolaryngology & Head and Head Otolaryngology & Head and Head

SurgerySurgeryAlameda Hospital Alameda Hospital

June 2005June 2005

Spectrum of Sleep Disordered Spectrum of Sleep Disordered BreathingBreathing

DefinitionsDefinitions

UUpper pper AAirway irway RResistance esistance SSyndrome yndrome ( UARS )( UARS )

• • Daytime somnolenceDaytime somnolence• • No significant apnea or O2 desaturationNo significant apnea or O2 desaturation• • Habitual loud snoring (crescendo)Habitual loud snoring (crescendo)• • they wake from their own noise of snoringthey wake from their own noise of snoring

Guillaminault C, Stoohs R, Duncan S. Chest 99:40-48;1991Guillaminault C, Stoohs R, Duncan S. Chest 99:40-48;1991Guilleminault C, Stoohs R, Clerk A et al. Chest 104:781-787;1993Guilleminault C, Stoohs R, Clerk A et al. Chest 104:781-787;1993

DefinitionsDefinitions

Hypopnoea: ‘ Chicago Criteria’1. Fall in average tidal volume by > 50%

but < 10 second apnoea

or < 50% tidal volume reduction and

2. at least 4% in oxyhemoglobin desaturation

3. EEG evidence of arousal

Definitions Definitions ApneaApnea

– Cessation of airflow for at least 10 secondsCessation of airflow for at least 10 seconds– Obstructive / Central / MixedObstructive / Central / Mixed

– based on presence or absence of respiratory based on presence or absence of respiratory movementmovement

Prevalence of Sleep ApneaPrevalence of Sleep ApneaAHIAHI = RDI= RDI

= apnoea+hyponoea / hour= apnoea+hyponoea / hour>5 : 24% Males & 9% Females>5 : 24% Males & 9% Females4 - 6 times more common in men4 - 6 times more common in men20 million Americans20 million Americans

Young T, Palta M, Dempsey J. N Engl J Med Young T, Palta M, Dempsey J. N Engl J Med 328:1230-1235;1993 328:1230-1235;1993

Pathophysiology ScalePathophysiology Scale

RDI / AHIRDI / AHIUARSUARS <5 <5MildMild 5-20 5-20Moderate 21-40Moderate 21-40Severe >40Severe >40

A RDI of 15-20 events per hour is close to what A RDI of 15-20 events per hour is close to what adults seem to be able to tolerate with no clinical adults seem to be able to tolerate with no clinical consequence. consequence.

Hosselet JJ, Ayappa I, Norman RG et al. Classificatin of sleep-disordered Hosselet JJ, Ayappa I, Norman RG et al. Classificatin of sleep-disordered breathing. Am J Respir Crit Care Med 163:398-405;2001breathing. Am J Respir Crit Care Med 163:398-405;2001

What is Significant RDI?

10x > risk, VAMV UCLA 2000

Somnolence Induced MVAsSomnolence Induced MVAs3 fold increase in motor vehicle accidents if RDI> 5

Morbidity and MortalityMorbidity and MortalityRisk factor for cardiovascular diseaseRisk factor for cardiovascular disease

– HypertensionHypertension– MI –polycythemia, platelet aggregationMI –polycythemia, platelet aggregation– StrokeStroke

MortalityMortality– AI>20 = 37% mortality over 8 yrs AI>20 = 37% mortality over 8 yrs

compared with 4% for AI<20 compared with 4% for AI<20 (Chest 94:9-14, (Chest 94:9-14, 1988)1988)

HistoryHistoryHeroic snoringHeroic snoring

– Cardinal symptom of OSASCardinal symptom of OSASObserved apneas or chokingObserved apneas or chokingExcessive sleepinessExcessive sleepinessWitnessed apnoeas Witnessed apnoeas Change in personality – depression, anxietyChange in personality – depression, anxietyCognitive dysfunction – memory, concentrationCognitive dysfunction – memory, concentrationMorning headachesMorning headachesDecreased libido or impotenceDecreased libido or impotenceCar or work accidentsCar or work accidentsHistory alone is only 60% specific and 60% sensitiveHistory alone is only 60% specific and 60% sensitive

– Need objective testingNeed objective testing

Sleep Apnea Risk FactorsSleep Apnea Risk Factors

••ObesityObesity••Increasing ageIncreasing age••Male genderMale gender••Anatomical abnormalities of upper Anatomical abnormalities of upper

airwayairway••Family historyFamily history••Alcohol or sedative useAlcohol or sedative use••SmokingSmoking

Diagnosis: Physical ExamDiagnosis: Physical Exam

Upper body obesity / thick neckUpper body obesity / thick neck– >17” males>17” males– >16” females>16” females

Airway abnormalityAirway abnormality– NasalNasal– OropharyngealOropharyngeal– HypopharyngealHypopharyngeal

Differential Diagnosis of Differential Diagnosis of OSASOSAS

• • NarcolepsyNarcolepsy– REM sleep within 10 minutesREM sleep within 10 minutes

• • Excessive daytime sleepiness associated Excessive daytime sleepiness associated with psychosocial and psychiatric disorderswith psychosocial and psychiatric disorders

• • Drug related syndromesDrug related syndromes• • Restless Legs / Periodic limb movement Restless Legs / Periodic limb movement

disorderdisorder• • Idiopathic hypersomnolenceIdiopathic hypersomnolence

Evaluation of Upper AirwayEvaluation of Upper Airway

No consistent characteristic in OSANo consistent characteristic in OSA– Quantitative measures depend on Quantitative measures depend on

statestateMethods of EvaluationMethods of Evaluation

– Cephalometric radiographsCephalometric radiographs

Anatomic Factors in Airway Anatomic Factors in Airway ObstructionObstruction

••Increased nasal resistance.Increased nasal resistance.••Excessive palatal length.Excessive palatal length.••Increased tongue size.Increased tongue size.••Increased vertical airway length Increased vertical airway length ••Enlarged tonsils.Enlarged tonsils.••Mandibular retrusion.Mandibular retrusion.

Impact of nose on snoring and Impact of nose on snoring and OSASOSAS

• • Obstruction increases airway resistanceObstruction increases airway resistance• • Anterior rhinomanometric volume has an inverse Anterior rhinomanometric volume has an inverse

relationship with RDI p<0.05relationship with RDI p<0.05• • Nasal obstruction is an important cause of OSANasal obstruction is an important cause of OSA Virkkula, P et al. Acta Otolaryngol, 2003Virkkula, P et al. Acta Otolaryngol, 2003 (Finland)(Finland)

Malampatti I-IV: Airway Classification

Visualize

• I:Soft palate, tonsils, uvula

• II:No tonsils seen

• III:Soft palate only seen

• IV:Hard palate only seen IV

Muller Maneuver

Maximal inspiratory movement

Velopharyngeal Closure Velopharyngeal Closure PatternsPatterns

A. CoronalA. Coronal71%71%B. CircularB. Circular 19%19%C. Circular +Passavant’s RidgeC. Circular +Passavant’s Ridge 7% 7%D. SagittalD. Sagittal 2% 2%

Finkelstein , Talmi , Nachman .Plastic Rec Finkelstein , Talmi , Nachman .Plastic Rec Surg 1992;89:631-639Surg 1992;89:631-639

Snoring: Snoring: “a marker for airway resistance during “a marker for airway resistance during sleep”sleep”

Hofffstein V, Mateika S, Nash S. Comparing Perceptions and Measurements of Snoring. Sleep 19:783-789;1996

Balance of forces affecting airway

Kuna ST, Sant’Ambrogio G. JAMA 266:1384-88;1991

Pathophysiology of OSASPathophysiology of OSAS

• • Collapse of pharyngeal airwayCollapse of pharyngeal airway• • Increased upper airway resistanceIncreased upper airway resistance• • Diaphragm movement increases negative Diaphragm movement increases negative

airway pressureairway pressure• • Increased airway collapseIncreased airway collapse• • Hypopnea and apnea – increase vagal toneHypopnea and apnea – increase vagal tone• • Hypoxia, Hypercarbia – catacholamine riseHypoxia, Hypercarbia – catacholamine rise• • Increased ventilatory effortIncreased ventilatory effort• • Sleep fragmentation and arousalSleep fragmentation and arousal

Who to order a Sleep Study On ?

Epworth v. RDIEpworth v. RDI

RDIRDI EPWORTHEPWORTH 00 8.0+/-3.5 8.0+/-3.5

MildMild 12.112.1 11.0+/-4.2 11.0+/-4.2ModMod 34.834.8 13.0+/-4.7 13.0+/-4.7SevereSevere 56.656.6 16.2+/-3.3 16.2+/-3.3

T. Woodson - Monograph

Why Get a Sleep Study ?Why Get a Sleep Study ?

DocumentationDocumentationQuantificationQuantificationDetermine TherapyDetermine Therapy

PolysomnographyPolysomnography• • Establish diagnosis of sleep apneaEstablish diagnosis of sleep apnea• • Assess disease severityAssess disease severity• • Rule out other disorders of sleepRule out other disorders of sleep• • CPAP titrationCPAP titration• • Components:Components:

– EEGEEG– EOGEOG– EMGEMG– EKGEKG– Chest wall and abdominal Chest wall and abdominal

wall impedance wall impedance– Intercostal EMGIntercostal EMG– Body positionBody position– Pulse OximetryPulse Oximetry

In-Laboratory PolysomnographyIn-Laboratory Polysomnography

ProsPros– ““Full” set of variables recordedFull” set of variables recorded– Technician for patient & equipment problemsTechnician for patient & equipment problems– Able to determine success of C-PapAble to determine success of C-Pap

ConsCons– CostCost– AccessibilityAccessibility– Patient sleeps away from homePatient sleeps away from home – Fails to localize site of obstructionFails to localize site of obstruction

““The Polysomnographic Age …. has The Polysomnographic Age …. has ended”ended”

Unattended ambulatory monitoring Unattended ambulatory monitoring is “biologically plausible and is “biologically plausible and technologically feasible”technologically feasible”

Strohl KP. When, Where and How to Test for Strohl KP. When, Where and How to Test for Sleep apnea. Sleep 2000;23:S99-S101Sleep apnea. Sleep 2000;23:S99-S101

SNAP TestingSNAP Testing• • PSG: polysomnograpghy “considered gold standard”PSG: polysomnograpghy “considered gold standard”

inherant variability, inherant variability, problems of reproducibilityproblems of reproducibility

• • SNAP testing: out-patient, localizes site of obstruction, inexpensiveSNAP testing: out-patient, localizes site of obstruction, inexpensive

• • Direct and solid correlation between both for measurement of RDIDirect and solid correlation between both for measurement of RDI

• • For RDI >= 5 : For RDI >= 5 : 95% positive predictive value, 95% positive predictive value, 96% specificity96% specificity 75% sensitivity75% sensitivity

Allan, P, Chaney, J, Mair, E. Otolaryngol HNSurg, 2004Allan, P, Chaney, J, Mair, E. Otolaryngol HNSurg, 2004

SNAPSNAP TestingTesting Acoustic Analysis ofAcoustic Analysis ofOro-Nasal RespirationOro-Nasal Respiration

• • Sound & Airflow Detection Sound & Airflow Detection • • Pulse Oximetry & Pulse ratePulse Oximetry & Pulse rate• • Apnea & Hypopnea IndicesApnea & Hypopnea Indices• • Snoring AnalysisSnoring Analysis• • 6 hours+ continuous recording6 hours+ continuous recording

SNAP Data Collection Cannula

Effort & Movement Transducer

Why SNAP ?Why SNAP ?

Patient Selection Patient Selection OSA detectionOSA detectionSnoring Localization & QuantificationSnoring Localization & QuantificationOutcome MonitoringOutcome Monitoring

SNAP - Apnea

SNAP - Oximetry

SNAP - Snoring

OSA in ChildrenOSA in ChildrenHistoryHistory

– ShynessShyness– Developmental DelayDevelopmental Delay– Aggressive BehaviorAggressive Behavior– Symptoms of ADDSymptoms of ADD– Witnessed apneas: positive predictive value of 86%Witnessed apneas: positive predictive value of 86%– T&A are usual source of obstructionT&A are usual source of obstruction

Several studies show improvement in behavior Several studies show improvement in behavior and school performance after T+Aand school performance after T+A

Treatment for OSATreatment for OSA

MedicalMedical– Reduction of Risk factorsReduction of Risk factors– CPAP - Most common treatment CPAP - Most common treatment – DrugsDrugs– Airway appliancesAirway appliances

SurgicalSurgical

Reduction of Risk FactorsReduction of Risk Factors

ObesityObesitySleep hygieneSleep hygieneNasal obstructionNasal obstructionBody positionBody positionSedative and alcohol useSedative and alcohol use

DrugsDrugs

Oxygen - most widely usedOxygen - most widely usedProtriptylineProtriptylineTheophylineTheophylineProgesteroneProgesteroneNicotineNicotineSerotonin antagonistsSerotonin antagonistsModafinil (Provigil) Modafinil (Provigil)

Modafinil in obstructive sleep apnea-hypopnea syndrome: a pilot study in 6 patients

by Arnulf I, Homeyer P, Garma L, Whitelaw WA, Derenne JP.

Service de Pneumologie et Laboratoire du Sommeil,Hopital Pitie-Salpetriere,

Paris, France. Respiration 1997; 64(2):159-61

ABSTRACTWe studied the effects of modafinil, a vigilance-enhancing drug, on excessive daytime sleepiness, memory, night sleep and respiration in 6 patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) using a double-blind random cross-over design with 24-hour polysomnography, verbal memory test and a 5-week sleep-wake diary kept by the patients. There were two 2-week treatment periods in which either modafinil or placebo was used; they were separated by a 1-week wash-out period. Our results show that modafinil reduces daytime sleep duration, lengthens the duration of subjective daytime vigilance and improves long-term memory in patients with OSAHS without modifying night sleep and respiration events.

Pharmacologic TreatmentPharmacologic Treatment

CPAP Splints the Upper AirwayCPAP Splints the Upper AirwayCollapsing forces

Tissue pressure and massConstrictor muscle toneNegative inspiratory pressure

Dilating forcesDilating muscle toneTissue pressures that stabilize the airway

CPAP augments dilating forces

CPAP Has Poor ComplianceCPAP Has Poor Compliance

CPAP is effectiveCPAP is effectiveNot a cureNot a curePattern of use Pattern of use

established earlyestablished earlyDrop out rate > 25%Drop out rate > 25%50% effective use50% effective use

Bi-level Applied PressureBi-level Applied Pressure

• • CPAP forces patients to produce high CPAP forces patients to produce high expiratory pressures – uncomfortableexpiratory pressures – uncomfortable

• • Collapsing pressures are increased during Collapsing pressures are increased during inspirationinspiration

• • Bi-level pressure applies lower pressures Bi-level pressure applies lower pressures during expiration and higher levels during during expiration and higher levels during inspirationinspiration– Increased initial patient acceptanceIncreased initial patient acceptance– Increased compliance?Increased compliance?

Side Effects of CPAPSide Effects of CPAP

Dry nose and mouth (65%)Dry nose and mouth (65%)Mask discomfort (50%)Mask discomfort (50%)Sneezing and rhinitis (25-35%)Sneezing and rhinitis (25-35%)ClaustrophobiaClaustrophobiaSocial impedimentSocial impedimentAlleviating side effects increases complianceAlleviating side effects increases compliance

– Warmed humidityWarmed humidity– Eliminating air leaks Eliminating air leaks – More comfortable masksMore comfortable masks

Airway AppliancesAirway Appliances

Nasal AppliancesNasal Appliances– Breath Rite StripsBreath Rite Strips

Oral appliancesOral appliances– Mandible repositioningMandible repositioning

• Some devices reduce RDISome devices reduce RDI• Patient compliancePatient compliance• TMJ and teeth problemsTMJ and teeth problems

– Tongue repositioningTongue repositioning– Patient selectionPatient selection– Follow up PSG to test efficacyFollow up PSG to test efficacy

Surgical Treatment of Snoring & OSASSurgical Treatment of Snoring & OSAS

Types of proceduresTypes of procedures– Prevent obstructionPrevent obstruction– Bypass obstructionBypass obstruction

Key to success is to localize site of Key to success is to localize site of obstructionobstruction

Nasal SurgeryNasal SurgeryNasal airway resistanceNasal airway resistance

– Increased nasal airway Increased nasal airway resistance leads to resistance leads to increased negative increased negative inspiratory pressuresinspiratory pressures

Addition of nasal surgery Addition of nasal surgery may improve surgical may improve surgical success and increase success and increase CPAP useCPAP use– Rarely definitive Rarely definitive

treatment for OSAS treatment for OSAS alonealone

Pillar ProcedurePillar Procedure

• • 3 plate palate implants 3 plate palate implants placed in the officeplaced in the office

• • 1% extrusion rate1% extrusion rate• • 78% response rate 78% response rate

with 51% reduction of with 51% reduction of snoringsnoring

Maurer, J, et al. Otolaryngol HNSurg 2005

Mannheim, Germany

TonsillectomyTonsillectomy

Should be removed if Should be removed if enlarged in OSASenlarged in OSAS

Reduces RDIReduces RDI

Rarely curative alone Rarely curative alone (Except in Children)(Except in Children)

Snare UvulectomySnare Uvulectomy

• In office procedure• Topical anesthesia• Local anesthesia with epinephrine• Wire snare 1-1.5cm above tip uvula• If redundant palatal folds:• 1-1.5cmVertical wedges in soft palate

Weingarten, C. Laryngoscope, 1995

Injection Somnoplasty

• SNAP Test• sitting position• 20% benzocaine jel on Q tip: 20 minutes• 3 cc syringe with 27g 3/4 inch needle: • 1cc 99% ETOH & 1cc with 1cc Lidocaine 2%• or Thromboject ( sodium tetradecyl sulfate )men: 2cc 3%, women 2cc 1% • inject :mid pharynx point (not base of uvula)just below mucosa• 2 minutes later will turn purple• expected complications: gag on bubble, swelling, mucosal ulcer• f/u 6 weeks later, • if still snoring: repeat just lateral to site: 1cc each side

5 days post procedure

Vital statistics:

• Indicated if RDI< 5

• 1.2 inject/ per patient ( 86% benefit )

• 3/29 palatal fistula: more likely if-larger inject in small pt. inject into muscle

• Not effective in sleep apnoea

Brietzke, S & Mair, E. Otolaryngol HNSurg, 2001.

Injection Somnoplasty

Laser Assisted Laser Assisted UvUvulouloppalatoalatopplastylasty

Radiofrequency Partial Radiofrequency Partial UvulopalatoplastyUvulopalatoplasty

• • 460 kHz 10mmlength, 10mm insulated 22 g needle460 kHz 10mmlength, 10mm insulated 22 g needle• • Target temperature between 80-85 CTarget temperature between 80-85 C• • 20% benzocaine topical20% benzocaine topical• • 4 sites submucosal delivery for 60-170 seconds:4 sites submucosal delivery for 60-170 seconds:1.1. < 750 J superior midline < 750 J superior midline 2.2. <350 J paramedian<350 J paramedian3.3. May amputate long uvula and place within muscleMay amputate long uvula and place within muscle• • 70% snoring improvement at 1 yr70% snoring improvement at 1 yr• • mean number of treatments was 3.6mean number of treatments was 3.6

Troell,R. Otolaryngol Clin N Am 2003Troell,R. Otolaryngol Clin N Am 2003

UvulopalatoplastyUvulopalatoplastyTreatment of snoring Treatment of snoring

– 80% effective80% effective

Treatment of OSATreatment of OSA- previously reported - previously reported 50% effective50% effective

- when combined with nasal and or base of - when combined with nasal and or base of tongue tongue surgery higher successsurgery higher success

Multiple methods availableMultiple methods available– LaserLaser– CauteryCautery– RadiofrequencyRadiofrequency

Uvulopalatopharyngoplasty Uvulopalatopharyngoplasty (UPPP)(UPPP)

Reduction of snoring (90%)Reduction of snoring (90%)Decreased sleepiness (84%)Decreased sleepiness (84%)Objective reduction in OSAS (50%)Objective reduction in OSAS (50%)

– 50% decrease in RDI - (50%) 50% decrease in RDI - (50%) – RDI < 20 events/hr or AI < 10 events/hr (42%)RDI < 20 events/hr or AI < 10 events/hr (42%)

Determinants of successDeterminants of success– Location of airway obstructionLocation of airway obstruction– Severity of OSASSeverity of OSAS

Risks of UPPPRisks of UPPP

HistoryHistory

• • William Osler (1906): Pickwickian William Osler (1906): Pickwickian • • Simmons and Hill (1974): Hypersomnia caused by Simmons and Hill (1974): Hypersomnia caused by

upper airway obstructionupper airway obstruction• • Ikematsu (1952): First UPPPIkematsu (1952): First UPPP• • Fujita (1979): Fujita (1979): • • Sullivan (1981): CPAPSullivan (1981): CPAP

1895

1985

UVPP ContraindicationsUVPP Contraindications

Velopharyngeal inadequacyVelopharyngeal inadequacySubmucous cleft palateSubmucous cleft palateNon-palatal level of obstructionNon-palatal level of obstruction

Uvulopalatopharyngoplasty (UPPP)Uvulopalatopharyngoplasty (UPPP)

Comparison of Treatment Methods

Pillar CPAP LAUP UPPP RF Sclerotherapy

Multiple visits  No Yes   Yes   No Yes Yes  Pain   Low Low   Very high   Very high Low Medium SE’s  Partial extrusion (1%) Nocturnal awakenings (46%),

Nasal congestion and dryness (44%)  Transient VPI (27%)3  

Transient VPI(20–100%)   Ulceration (22%)

 Mucosal loss(22%)

  Sedation  Local None Local General Local Local  Recovery time  < 24 HRS None 7 days 10 days   < 24 HRS <24 HRS  

  Reimbursement In process Yes (apnea) No Yes (apnea) No No

                            

 

Pillar CPAP LAUP UPPP RF Sclerotherapy

 OSA   Yes Yes  Yes  Yes No No Snoring   Yes Yes  Yes  Yes Yes Yes Reversible procedure Yes Yes  No  No No No                   

          

EFFICACY

Pillar CPAP LAUP UPPP RF Anlation Sclerotherapy Type of physician ENT  Pulmon  ENT  ENT  ENT   ENT Patient visits One  Multiple  Multiple  One  Multiple   Multiple Physician time Low  Low  High  High  Medium   Medium Hospital   No  No  Yes  Yes  Yes   No FDA clearance Snoring and OSA OSA only Not req  Not req  Snoring only No

PHYSICIAN EXPERIENCE

Surgery of Lower PharynxSurgery of Lower Pharynx

• • Radiofrequency Base of Tongue Radiofrequency Base of Tongue volumetric reductionvolumetric reduction

• • Hyoid SuspensionHyoid Suspension• • EpiglottectomyEpiglottectomy• • Lingual tonsillectomyLingual tonsillectomy• • Midline glossectomyMidline glossectomy• • LingualplastyLingualplasty

Base of Tongue RFVTRBase of Tongue RFVTR

Prominent Lingual TonsilsProminent Lingual Tonsils

Maxillofacial SurgeryMaxillofacial Surgery

Limited mandibular osteotomies & genioglossus Limited mandibular osteotomies & genioglossus advancementadvancement

Hyoid myotomyHyoid myotomy– Airway stabilized when hyoid pulled anterior and Airway stabilized when hyoid pulled anterior and

inferiorinferiorMandibular advancementMandibular advancement

– May require pre-op orthodonticsMay require pre-op orthodontics– Malocclusion may be surgically acquiredMalocclusion may be surgically acquired– Most successful in non-obese retrognathic patientsMost successful in non-obese retrognathic patients

Bimaxillary advancementBimaxillary advancement

Maxillofacial SurgeryMaxillofacial Surgery

Hyoid SuspensionHyoid Suspension

Probably less effective than genioglossus advancement

Electrical StimulationElectrical StimulationEisle, D, et al, 2003

Experimental: relies on trans-sternal transducer to induce genioglossus activity

TracheostomyTracheostomy

Bypasses upper airway obstructionBypasses upper airway obstruction– Effective in decreasing M&M associated with OSASEffective in decreasing M&M associated with OSAS

IndicationsIndications– Severe OSAS or obesity hypoventilationSevere OSAS or obesity hypoventilation– Perioperative airway managementPerioperative airway management

MorbidityMorbidity– tracheal stenosistracheal stenosis– InfectionInfection– Effects on appearance and voiceEffects on appearance and voice

Tube Free Tracheostomy Tube Free Tracheostomy (Isaac Eliachar, (Isaac Eliachar, MD)MD)