SURGICAL OPTIONS FOR OBSTRUCTIVE SLEEP APNEA (OSA)

DR. GIRISH. S

American Academy of Sleep Medicine (AASM)

DEFINITION OF OSA

• Sleep disorder that involves cessation or significant decrease in airflow

through the upper airway in the presence of breathing effort.

• Most common type of sleep-disordered breathing (SDB)

•  Associated with recurrent oxyhemoglobin desaturations and arousals

from sleep.

OSAS

• OSA associated with excessive daytime sleepiness (EDS) is commonly

called obstructive sleep apnea syndrome (OSAS)

• also referred to as obstructive sleep apnea-hypopnea syndrome (OSAHS)

• with severe OSA – more than hundreds of apnea can occur.

OSAS

• OSA is defined by five or more respiratory events—apneas, hypopneas, or

respiratory effort– related arousals—in association with excessive daytime

somnolence; waking with gasping, choking, or breath holding; or

witnessed reports of apneas, loud snoring, or both.

PATHOPHYSIOLOGY OF OSA

PATHOPHYSIOLOGY

• Upper airway is a compliant tube and, therefore, is subject to collapse.

• OSA is caused by soft tissue collapse in the pharynx.

ROLE OF THREE FACTORS

A. a reduction in the dilating forces of the pharyngeal dilators,

B. the negative inspiratory pressure generated by the diaphragm &

C. abnormal upper airway anatomy, the element most effectively

addressed by surgery.

• TRANSMURAL PRESSURE - difference between intraluminal pressure and the surrounding tissue pressure.

• If transmural pressure decreases the cross-sectional area of the pharynx decreases.

• If this pressure passes a critical point (Pcrit), pharyngeal closing pressure is reached .The airway is obstructed.

• OSA duration is equal to the time that Pcrit is exceeded.

PATHOPHYSIOLOGY

• The three major areas of obstruction are the nose,

palate, and hypopharynx.

• NASAL / RETROPALATAL / RETROLINGUAL

NASAL OBSTRUCTION

• Nasal obstruction contributes to increased airway resistance and may

worsen OSA.

• Leads to open-mouth breathing during sleep, which increases upper

airway collapsibility and may decrease the efficacy of dilator muscles.

• Snoring can be caused by nasal obstruction.

PATHOPHYSIOLOGY OF OSA• Findings in Obstruction:

• Nasal Obstruction• Long, thick soft palate• Retrodisplaced Mandible• Narrowed oropharynx• Redundant pharyngeal tissues• Large lingual tonsil• Large tongue• Large or floppy Epiglottis• Retro-displaced hyoid complex

PATENT V/S COLLAPSED AIRWAY

DIAGNOSIS

DIAGNOSIS

• History

• Physical examination

• FIBEROPTIC NASOPHARYNGOSCOPY• Multiple positions• In awake & asleep patients• With Mullers maneuver – awake pt – generates negative pressure by inhaling

against a closed glottis with mouth & nose close – triggers airway collapse.

Fiberoptic view of the hypopharyngeal airway before

the Müller maneuver

Fiberoptic view of hypopharyngeal collapse during the Müller

maneuver.

DISE

• Drug-induced sleep endoscopy (DISE) - guide more effective surgical intervention.

• DISE involves the use of fiberoptic nasopharyngoscopy to evaluate the site of airway collapse during pharmacologically induced sleep.

• Useful tool for assessing the location, severity, and pattern of airway obstruction during sleep.

CEPHALOMETRIC RADIOGRAPH

• 2D representation of the airway, a standardized evaluation system with broad availability and relatively low cost.

• These films provide information on both the bony skeleton and the overlying soft tissues.

• Inferior displacement of the hyoid, a smaller posterior airway space, and longer soft palates.

• AWAKE COMPUTED TOMOGRAPHY

• MRI

• FLUOROSCOPY / SOMNOFLOUROSCOPY

• NOCTURNAL PSG – gold std for the diagnosis of OSA.

PSGSimultaneous recordings of multiple physiological signals during sleep.

Electroencephalogram (EEG)Electrooculogram (EOG)Electromyogram (EMG)Electrocardiogram (ECG)Oronasal airflowChest wall effortSnore microphoneOxyhemoglobin saturation

TREATMENT

MEDICAL TREATMENT

• Weight loss – Bariatric Surgery

• Continuous positive airway pressure (CPAP)

• Gold std for moderate to severe OSA

• Pneumatic splint – prevents collapse

• Provides constant +ve intraluminal pressure during respiration.

POSITIVE AIRWAY PRESSURE

MEDICAL TREATMENT• Bilevel positive airway pressure (BiPAP)

• delivers a separately adjustable, lower expiratory positive airway pressure and higher inspiratory positive airway pressure.

• Autoadjusting positive airway pressure (APAP) • Autotitrate the pressure depending on the variations of airflow to select an

effective level of CPAP.

MEDICAL TREATMENT

• ORAL APPLIANCES – TRD, MPD

• PHARMACOLOGIC THERAY

• MODAFINIL

SURGICAL TREATMENT

OSAS

• Includes a wide variety of procedures that vary in their invasiveness and success rates.

• Generally, success is defined as a drop in the RDI by either 50% or 20 total points.

INDICATION• Factors for surgical treatment of OSA include the

patient’s wishes, CPAP tolerance, severity of symptoms, severity of disease, patient comorbidities,site and severity of upper airway collapse.

CLINICAL STAGING OF OSAS

• In earlier days the sole treatment option for OSAS was UPPP.

• Surgeons were planning treatment based on the severity of disease, avoided severe dse.

• Now we know that OSAS is a multilevel obstruction dse & UPPP is only useful for oropharyngeal obstruction.

CLINICAL STAGING OF OSAS

• An anatomically-based staging system is made to identify areas of obstruction, and helps in tailoring the appropriate surgical treatment for each individual.

• The severity of disease is a secondary factor, which plays a role in determining the need for treatment.

FRIEDMAN STAGING SYSTEM

• Parameters• TONGUE POSITION • TONSIL SIZE• BODY MASS INDEX

FRIEDMAN TONGUE POSITION • FTP I - the entire uvula, tonsils, and tonsillar pillars. • FTP II allows visualization of the uvula, but not the tonsils. • FTP III allows visualization of the soft palate, but not the uvula• FTP IV allows visualization of the hard palate only

TONSIL SIZE• TS 0 - post-tonsillectomy patients. • TS 1 implies tonsils hidden within the pillars. • TS 2 represents tonsils that extend to the pillars. • TS 3 refers to tonsils that extend beyond the pillars, but not all the way to

the midline,• TS 4 tonsils (‘‘kissing tonsils’’) reach the midline.

STAGING OUTCOMES

• Successful treatment of OSAHS with UPPP was most likely achieved in stage I patients because of the predominant palatal and tonsillar component.

• Stage II and III patients were least likely to achieve a cure after UPPP, with an overall objective cure rate of 37.9 and 8.1%, respectively.

• Stage III patients have a predominant base of the tongue obstructive component, thus making single level surgery useless.

PRECAUTIONS

• OSA patients are frequently overweight, hypertensive, and have other cardiac risk factors.

• These patients must be cautiously screened with a comprehensive medical examination before considering surgery.

• The surgical planning should include a discussion between the anesthesia team and the surgeon.

PRECAUTIONS

• Stepwise algorithm frequently used - using an oropharyngeal airway to

prevent airway obstruction by the tongue, refraining from using

paralyzing agents until the patient can be easily ventilated with a mask &

preparing alternative methods of ventilation in case intubation is

unsuccessful.

• Possibility of tracheotomy.

SURGICAL MANAGEMENT

• Staged, stepwise surgical protocol.

• site of obstruction - to determine the type and extent of surgical intervention.

• Before therapy is initiated, patients should be counselled regarding the possible need for multiple surgical procedures.

• Patients with laryngeal obstruction should be considered for tracheostomy if improvement is not achieved surgically or with CPAP.

NASAL SURGERY • Nasal obstruction poor sleep quality, snoring, and OSA.

• Septoplasty, turbinate reduction, nasal valve surgery, and sinus surgery .

• However, nasal procedures are unlikely to significantly improve OSA when used alone.

• Improving nasal patency help to restore physiologic breathing and may allow for the use of nasal CPAP in patients previously unable to tolerate it.

• Initial step in OSA management so as to facilitate better CPAP adherence.

PALATAL SURGERIES

PALATAL SURGERY

• 1981 – Fujita &colleagues – 1st palatal surgery – UPPP

• Ikematsu: 1985 UPPP

• Stiffens the soft palate & increases the space behind the soft palate.

• Complications : temporary nasal reflex ( 12-15%) , post operative bleeding, infection & rare altered speech.

UVULOPALATOPHARYNGOPLASTY (UPPP)

UPPP STEPS• Rose’s position

• Partial uvulectomy – excessive mucosa of uvula tip cutoff without touchin musculae uvulae. Tip sutured

• Incision into the mucosa of the anterior pillar is performed in the oral fold of the palatoglossus muscle.

• Fibers of the M. palatoglossus are dissected from the tonsil. Tonsillectomy follows.

• Posterior tonsilar pillar is partially incised.

• Lengthened posterior pillar edge sewed together with the anterior pillar.

Semi-elliptical soft palate with a functioning uvula.

COMPLICATIONS • Change in voice (rhinolalia aperta)• Pain with swallowing and pain with speech, usually for 1-2 weeks

postoperatively• Hemorrhage (2-4%)• Swallowing difficulties, particularly regurgitation of food• Velopharyngeal Insufficiency• Disturbance in taste• Numbness of tongue• Nasopharyngeal stenosis• Creation of silent apnea

MODIFICATIONS OF UPPP

• Stanford - Uvulopalatal flap [UPF]

• Woodson et al – Transpalatal Advancement Pharyngoplasty

• Friedman – Z Palatoplasty

• Extended Uvulopalatal flap [ EUPF]

UVULOPALATAL FLAP

• Tonsillectomy.

• Incisions into the soft palate bilaterally on both sides.

• Tip of uvula grasped & excessive mucous membrane resected.

• Now extend of UPF is assessed by rotating the uvula upwards.

• Removal of the antr palatine arch, fat n salivary glands with preservation of muscles

• Uvula is loosely folded into the defect & sutured

TRANSPALATAL ADVANCEMENT PHARYNGOPLASTY (TAP)

• Aims to decrease retropalatal obstruction by altering the bony hard palate

and the soft tissue attachments of the posterior maxilla.

• A 1-cm portion of the hard palate is removed, and the soft palate is then

advanced and secured medially and laterally in the tensor aponeurosis,

which enlarges the retropalatal region.

Transpalatal Advancement Pharyngoplasty (TAP)For moderate to severe OSA

A, Drill holes are placed from the oral cavity to the nose and are anterior to bone removal (orange). A strong rim of bone supports the sutures. The anterior extent of the middle flap is placed in the thinner palatal mucosa.Mucosa is thicker posteriorly (asterisk).

B, After osteotomy, sutures are placed through the drill holes, and the bone fragment with attached tendonand ligaments is advanced.

Z–PALATOPLASTY (ZPP)• Outline two adjacent flaps on the palate – together they look butterfly-

shaped – only the mucosa of their anterior aspect is removed.

• Then, the two flaps are separated from each other by splitting the palatal segment down the midline.

Z–PALATOPLASTY (ZPP)

• A two-layered closure brings the midline all the way to the anterolateral margin of the palate.

• The final result creates 3–4 cm of distance between the posterior pharynx and the palate.

• The uvula muscles are preserved within the new palate.

LASER ASSISTED UVULOPALATOPLASTY

• LAUPP

• Kamami : 1993

• Stiffens the soft palate & there by minimizes the

palatal flutter& snoring.

• CO2 / Nd:YAG / KTP

LAUP

• Laser produces pyrolysis and tissue vaporization by heating the target

tissue to a temperature up to 750–900C with consequent considerable

collateral thermal tissue damage.

• In the oral cavity/oropharynx, the potassium titanyl-phosphate crystal

laser (KTP laser) is the laser of choice.

LAUP• The uvula is partly or totally removed.

• Then, two paramedian full-thickness, through-and-

through trenches are made over the soft palate, on

either side of the uvula, to a height of 1–2 cm.

• LAUP is performed under local anesthesia in an

outpatient setting.

CAUP

COBLATION ASSISTED UVULOPALATOPLASTY (CAUP)

• Electro-dissociation.

• A medium rich in sodium is dissociated into free ions, which are responsible for the destruction of intercellular bonds, resulting in tissue dissociation.

• This reaction is achieved at temperatures between 60 - 70C with minimal collateral thermal tissue damage.

• Advntg – faster tissue healing & decreased postop pain.

OTHER PALATAL SURGERIES

• SNORING PALATAL FLUTTER – LENGTH - STIFFNESS

• PALATAL IMPLANTS

• MUCOSAL STRIP TECHNIQUE (MST)

• CAPSO

• INJECTION SNOREPLASTY

PALATAL IMPLANT

PALATAL IMPLANT

• minimally invasive, single-step procedure

• useful for mild OSA.

• Polyethylenterephthalat (PET)

• Three rod-shaped implants are inserted in the soft palate.

• The implants themselves and the surrounding scarring induce a stiffening of the soft palate, reduce snoring sounds.

Applicator : The implants are 18 mm long and have a diameter of 1.5 mm. Delivered in a 14G hollow needle which has three markings at the curved end of the needle

PALATAL IMPLANT

• Developed to reduce pain, cost & morbidity of UPPP , in mild OSA

• Complication – partial implant extrusion

• Advantage – single office visit, minimal morbidity, reduce snoring.

MUCOSAL STRIP TECHNIQUE

• Using LASER

• Central longitudinal strip of mucosa is removed

from the surface of soft palate.

• Heals by fibrosis, produces reqd stiffening.

CAUTERY ASSISTED PALATAL STIFFNESS OPERATION

• Diamond style incision• Using electrocautery• Mucosal removal • Uvula trimming

INJECTION SNOREPLASTY

• Injection of sclerosing agents into the soft palate

• 3% sodium tetradecyl sulphate (STS)

• 2ml 1%STS – single needle penetration – midline soft palate

• After 2min – purple h’gic color

• For repeated rx – 3%STS

OROPHARYNGEAL SURGERY

• Tonsillar hypertrophy - tonsillectomy

• Newer methods• Radiofrequency tonsil reduction by intracapsular tonsillotomy.

• Minimally invasive and has limited morbidity.

• Used in the treatment of OSA in children.

TONSILLOTOMY• Less surgical alternative to ATE.

• Partial tonsillectomy, intracapsular tonsillectomy, subtotal tonsillectomy

• Saving the psudocapsule – resection within the tonsil

• More or less tonsil tissue remains in the patient.

• Bipolar scissors / radiofrequency ablation / lasers / microdebrider.

• Less pain and less morbidity

• C/I chronic tonsillitis

LATERAL PHARYNGOPLASTY• Lateral pharyngoplasty – Cahali in 2003 as an alternative to UPPP. • The technique involves

• Bilateral Tonsillectomy,• Longitudinal Incision Of The Superior Pharyngeal Constrictor,• Diagonal Incision Through The Superior Palatopharyngeus,• Z-plasty Closure Of The Superior Aspect Of The Tonsillar Fossa, &• Suturing Of The Anterior And Posterior Pillars Together At The Inferior Aspect

Of The Tonsillar Fossa.

EXPANSION SPHINCTER PHARYNGOPLASTY

• variation of the lateral pharyngoplasty

• Pang and Woodson in 2006

• This involves bilateral tonsillectomy, transection of the inferior aspect of

the palatopharyngeus, and superolateral rotation and figure-eight

suturing of the mobilized muscle to the arch of the anterior soft palate

A. Preoperative view of the oropharynx. B. Exposure of the palatopharyngeus (vertical fibers). C. Elevation of the palatopharyngeus. D. Rotation and tunnelling of the palatopharyngeus toward the hamulus. E. Suture suspension and approximation.

EXPANSION SPHINCTER PHARYNGOPLASTY TECHNIQUE.

HYPOGLOSSAL NERVE STIMULATION

• Because OSA is primarily associated with relaxation of the pharyngeal

musculature during sleep, electrical stimulation of the hypoglossal nerve

improve the neuromuscular tone of the pharynx during sleep, particularly

the genioglossus.

• Implantable hypoglossal nerve-stimulating device

• Reliably detect the onset of the inspiratory phase of respiration through

chest wall pressure sensors, allowing the electrical stimulation of the

hypoglossal nerve to be timed with inspiration.

HYPOGLOSSAL NERVE STIMULATION

TONGUE BASE PROCEDURES

TONGUE BASE PROCEDURES

• PARTIAL MIDLINE GLOSSECTOMY (PMG)• Removal of a midline rectangular strip of the posterior half of tongue.

• LINGUALPLASTY• Additional tongue tissue removed posteriorly n laterally

• RADIOFREQUENCY TONGUE BASE ABLATION (RFA / RFT)• Lingual Tonsillectomy - Laser Lingual Tonsillectomy (LLT)

TONGUE BASE PROCEDURES

• TONGUE BASE SUSPENSION

• SUBMUCOSAL PARTIAL GLOSSECTOMY TECHNIQUES

• PERCUTANEOUS SUBMUCOSAL TONGUE BASE EXCISION

• SMILE

• SMELL Submucosal midline endoscopic lingual base lysis 

RADIOFREQUENCY TONGUE BASE ABLATION (RFA)

• decreases upper airway collapse by producing a volumetric reduction in tongue-base tissue

• An insulated probe that delivers RF energy at 465 KHz is introduced into several areas of the tongue base and produces coagulation necrosis and healing by scar.

• OP setting under LA

• Require multiple treatments to achieve the desired results.

TONGUE BASE SUSPENSION (REPOSE SYSTEM)

• AHI>20 , moderate base of tongue obstruction

• Fixes the tongue forward, thereby preventing collapse into the airway.

• Intraoral incision made in the frenulum

• Periosteum is elevated over genial tubercle

REPOSE TONGUE SUSPENSION

• A titanium screw is placed at the lingual cortex of the geniotubercle of the mandible

• Permanent suture is passed through the paramedian tongue musculature along the length of the tongue, through the tongue base, and then back through the length of the tongue musculature.

• It is then anchored to the screw to pull the tongue base anteriorly.

SUBMUCOSAL MINIMALLY INVASIVE LINGUAL EXCISION

• Maturo & Mair 2006 – macroglossia in pediatric pts.

• Small incision in the anterior portion of dorsal tongue, advance in posterior direction, moving superior and inferior fashion.

• Plasma wand / coblator

• Avoid injury to muscles

• Always stay medial to the lingual arteries – newly created cavity.

• Incision is not closed to let the drain.

HYPOPHARYNGEAL PROCEDURES

HYPOPHARYNGEAL PROCEDURES

• Procedures designed to prevent tongue collapse into the airway during sleep.

• GENIOGLOSSAL ADVANCEMENT (GA)

• HYOID MYOTOMY (HM)

GENIOGLOSSAL ADVANCEMENT (GA)

• Genial tubercle of the mandible (anterior

attachment of the genioglossus muscle) is

mobilized by means of limited osteotomy.

• The segment is then advanced, rotated and fixed

into place at the inferior aspect of the osteotomy.

GENIOGLOSSAL ADVANCEMENT PROCEDURE:The rectangular geniotubercle osteotomy modification offers excellent tension on the

genioglossus muscle with a minimal fracture risk. The geniotubercle fragment is rotated enough to allow bony overlap. A single inferiorly placed miniscrew is used to fix the

fragment.

HYOID SUSPENSION

• Retrolingual obstruction

• Moderate – severe OSA

• Hyoidthyroidpexia (HTP)

• Stabilization of hyoid bone inferiorly and anteriorly by attachment to superior border of thyroid cartilage

• Tongue base move anteriorly and caudally.

HYOID MYOTOMY (HM)• Result in an enlarged retrolingual airway by fixing the major dilators of

the pharyngeal airway forward.

• Usually done along with GA

• Problems: external incision on neck, infection, temporary dysphagia &

seroma

COMPLICATIONS OF GA & HM

• Permanent numbness

• Infection

• Seroma

• Risk of mandibular fracture , aspiration & death

MAXILLOMANDIBULAR ADVANCEMENT

• Maxillomandibular deficiency results in diminished airway dimension,

which leads to nocturnal obstruction.

• MMA expands the skeletal framework that encircles the airway, thus

enlarging the entire airway, including the nasal, pharyngeal, and

hypopharyngeal airway.

MMA

• Mobilizing the maxilla and mandible to achieve anterior displacement,

after intraoral osteotomy.

• The maxilla and mandible are stabilized with titanium plates in the

advanced position.

MAXILLOMANDIBULAR ADVANCEMENT (MMA)

• Increases the retropalatal and retrolingual airway.

• Usually performed when other surgical intervention fails.

• Complications include malocclusion, relapse, nerve paresthesia, nonunion or malunion, TMJ problems, infection, bleeding, and the need for subsequent dental work.

• Success rate of this procedure approaches 90%.

MMA is the most effective sleep apnea surgical

procedure currently available.

DISTRACTION OSTEOGENESIS (DOG)

• Accepted procedure in the treatment of severe maxillomandibular

deficiency in syndromic and nonsyndromic patients.

• As grossly retropositioned mandible or midface causes a narrow

pharyngeal airway, OSA is often found in these cases.

DISTRACTION OSTEOGENESIS• An osteotomy of the mandible or midface without advancement is

followed by a short latency period of 4 days.

• Then the two or more bony segments are slowly moved apart (mostly at 1 mm/day) using some kind of distraction device.

• Thus the unmineralized tissue filling the osteotomy gap is slowly stretched until – after cessation of distraction – it will turn into bone during the 4–10 weeks lasting consolidation period.

Midfacial distraction in a Crouzon`s disease case

OSA

• MULTILEVEL SURGERY(moderate-severe OSA)• nasal surgery • uvulopalatopharyngoplasty (UPPP),• transoral tongue surgery, • genioglossus advancement (GA), • maxillomandibular advancement

osteotomy (MMA).

• MINIMALLY INVASIVE MULTILEVEL SURGERY• palatal implants and interstitial

radiofrequency treatments (RFT) of the SP, base of tongue, and tonsils.

LARYNGEAL OSA

LARYNGEAL OSA• Rare condition.

• occurs in adults and children.

• Laryngeal OSA has to be diagnosed endoscopically during sleep or sedation.

• ›› In children, laryngeal OSA is caused by malformations, tumors, and laryngomalcia; the latter especially in preterm infants.

• ›› In adults, laryngeal OSA mainly occurs in elder men due to a floppy epiglottis. More rare conditions are laryngeal and hypopharyngeal tumors.

TRACHEOSTOMY• traditional gold standard of surgical management of OSA.

• relieves OSA by completely bypassing the portion of the airway that most commonly collapses during sleep.

• should be considered in patients who have failed all other OSA treatments, in those who have life-threatening OSA and are unable to tolerate CPAP, or in patients who are neurodevelopmentally impaired.

• best option for the morbidly obese or as an interim measure for patients undergoing base of tongue surgery.

ROBOTIC SURGERY

TORS• da Vinci robotic surgical system

• involve the precise excision of oral, pharyngeal and laryngeal tissue with

a surgical robot.

• The robot facilitates these procedures with its articulated instruments and

3-D, high definition camera.

TORS

• TONGUE BASE REDUCTION (TBR)

- removal of a part of the base of the tongue from the foramen cecum to the

vallecula, include removal of lingual tonsillar tissue, tongue base musculature,

or both.

• SUPRAGLOTTOPLASTY (SGP)

- surgical management of collapsible epiglottic, arytenoid and/or aryepiglottic

tissue.

SUPRAGLOTTOPLASTY (SGP)

• ameliorate the inward inspiratory collapse of floppy and/or redundant

epiglottic, aryepiglottic, and arytenoid mucosa.

• two most common techniques performed are the Vertical Midline

Suprahyoid Epiglottic Split and the Horizontal Epiglottic Transection.

POSTOP MANAGEMENT

• In multisite surgical treatment of OSA increased chance of

postoperative airway obstruction because of resultant edema in multiple

sites in the upper airway.

• In addition, postanesthesia sedation along with altered respiration

secondary to narcotic pain medications can be additive in patients with

an already compromised airway.

• It is recommended that patients with severe OSA use CPAP for the first 2

weeks after surgery.

• In addition, it is recommended that postoperative PSG be carried out in 3

to 4 months to evaluate the response to surgery.

POSTOP MANAGEMENT

BARIATRIC SURGERY

• Bariatric surgery encompasses a variety of surgeries.

• The most important ones are adjustable gastric banding, vertical banded gastroplasty, sleeve gastrectomy, intragastric balloons, jejunal bypass, biliopancreatic diversion, and Roux-en-Y gastric bypass.

• Bariatric surgery is recommended for patients with a BMI > 35 kg/m2 and an obesity related concomitant disease or for patients with a BMI > 40 kg/m2.

OTHERWISE SNORE AND THIS WILL

HAPPEN TO YOU….

Or sleep alone….