- 1. Preoperative Assessment & Perioperative Management
Ho-Sheng Lin, MD Associate Professor Department of Otolaryngology/
Head and Neck Surgery SCS Educational Day 11/27/07
2. Introduction
- OSA is a multi-level upper airway disease
- Positive Airway Pressure effective in relieving obstruction at
all levels
- Surgical Treatments (UPPP and BOT procedures)
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- Address only specific segment of the upper airway
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- Effective only if precise localization of the site of airway
obstruction can be identified
3. Introduction
- Failure to recognize the multi-level nature of airway
obstruction may account for the poor surgical outcome following
UPPP alone
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- Meta-analysis (n = 337 pts) - UPPP alone
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- No selection for level of airway obstruction (Types I -
III)
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- Discredited by many in the field of sleep medicine
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- May not be a bad procedure
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- Poor result due to misuse by Surgeons
- Attempt to identify site(s) of obstruction and tailor surgical
approach to address this obstruction resulted in improved outcome
following surgery
4.
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- Genioglossus advancement and hyoid myotomy (GAHM) - BOT
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- Stanford Powell Riley Protocol (Response rate =76. 5 % ,
n=306)
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- Phase I:Select surgical procedures based on site of airway
obstruction
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- Phase II:Bimaxillary Advancement
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- Basis of modern surgical management of OSA
Powell Riley 2-Phase Surgical Protocol 66% GAHM BOT only Type
III 60% UPPP and GAHM Palatal and BOT Type II 80% UPPP Palatal only
Type I Response Rate Type of Surgical Procedure(s) Site of
Obstruction Fujita Classification 5. Powell Riley 2-Phase Surgical
Protocol 6. Powell Riley 2-Phase Surgical Protocol
- Overall success =76.5% (234/306)
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- Phase I surgery =61%cure rate (145/239)
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- Phase II surgery =97%cure rate (89/91)
- Cure rate =95%for pts who completed protocol
N=306 Phase ISurgeryN=239 Failed priorUPPPN=60 ResponderN=145
Nonresponder N=94 SkeletaldeformityN=7 Refusedfurther surg N=70
Proceed tophase II N=24 Phase II Surgery N=91 Responder N=89
Nonresponder N=2 7. Powell-Riley Phase I Soft Tissue
- Riley and Powell reported Cure rate of 61%
- Other investigators reported Cure rate ranging from 24 -
84%
Sleep 2007; 30:461-7 8. Powell-Riley Phase I Soft Tissue
- Good Phase I surgical result depend on precise localization of
site of obstruction
- Problem:Current Modalities to Identify Exact Sites of Airway
Obstruction is Imprecise and Subjective
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- Wide variation in surgical success rate( 24 - 84%)
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- Less than perfect results following phase I surgery(56%)
9. Diagnostic Modalities
- Current diagnostic modalities are inadequate
- Limited by lack of accuracy, high cost, invasiveness
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- Assess size of tongue, tonsil, soft palate, OP airway
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- Modified Mullers Maneuver
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- Lateral Cephalometric Analysis
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- Pharyngeal Pressure Measure
10.
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- Retrognathia facial profile
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- Tonsil size, BOT position, BMI
General Head & Neck Examination 11. General Head & Neck
Examination
12. General Head & Neck Examination
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- Performed with tongue inside mouth
13. Friedman Clinical Staging
< 40 < 40 3, 4 3, 4 I II BMI Tonsil Size Friedman Tongue
Position 14. Friedman Clinical Staging
< 40 < 40 0, 1, 2 0, 1, 2 III IV BMI Tonsil Size Friedman
Tongue Position 15. Friedman Clinical Staging
< 40 < 40 0, 1, 2 3, 4 I, II III, IV BMI Tonsil Size
Friedman Tongue Position 16. Friedman Clinical Staging
All patients with significant craniofacial or other anatomic
deformities 40 0, 1, 2, 3, or 4 1, 2, 3, or 4 BMI Tonsil Size
Friedman Tongue Position 17. Successful Treatment of OSAHS with UP3
% Successful Treatment Friedman et al. Otolaryngol Head Neck Surg
2003;129:611-21. 18. Distribution of Patients with OSAHS by Stage
Percentage of Patients Friedman et al. Otolaryngol Head Neck Surg
2003;129:611-21. 19. Successful Treatment of OSAHS with UP3 vs. UP3
+ TBRF % Successful Treatment * * * Different from UP3 only ( P<
.001) Friedman et al. Otolaryngol Head Neck Surg 2003;129:611-21.
20. Modified Muller Maneuver
- Attempt to duplicate negative pressure during sleep
- Inspiration against closed nose and mouth
- Sitting and supine positions
- Identify amount of pharyngeal collapse at soft palate and BOT
level
21. Lateral Cephalometric Analysis SNB SNB < 72oSevere
mandibular deficiencyBOT obstruction PNS-P > 40velopharyngeal
obstruction PAS < 7 mmBOT obstruction MP-H> 20 BOT
obstruction
- Taken using standardized technique
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- Sitting natural head position
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- Upright rather than supine
22. Fluoroscopy and Somnofluoroscopy
- Can be performed with PSG
- Ingestion of barium contrast to coat lumen
- Dynamic assessment of airway collapse
- Visualization of propagation of obstruction
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- Only a limited number of apnea events can be captured due to
worry about excessive radiation exposure
23. Pharyngeal Pressure Measurement
- Performed at time of sleep study
- 2.3 mm Catheter w/ microtip pressure sensors
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- Nasopharynx (above uvula)
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- Oropharynx (between uvula and BOT)
- Level of airway collapse determined by changes in pressure
patterns
- If a portion of airway collapse, sensor proximal to the
obstruction becomes silent
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- May alter sleep architecture
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- Able to detect only the lowest site of airway obstruction
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- Stenting of airway by catheter
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- Precise localization of obstruction depends upon number of
pressure sensors
24. Cine CT Scan
- Capable of scanning entire airway from nasopharynx to larynx (8
cm) in 0.24 seconds
- Allow analysis of entire airway during inspiration, expiration,
and apneic episodes
- Accurately localize the level of obstruction during apneic
episodes
25. MRI
- Excellent soft tissue anatomy
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- Noisy and may require sedation
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- Can not be combined w/ PSG
26. Sleep Endoscopy
- Can be performed for surgical planning before or at the same
time as the definitive procedure
- Determine the site of airway obstruction / collapse during
simulated natural sleep state (induced w/ low dose propofol)
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- Use of sedation may not completely simulate natural sleep
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- Expensive and time consuming (if performed as part of surgical
planning separately from surgical Tx)
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- Stenting of airway by endoscope
27. Palatal Level:Posterior Collapse of Soft Palate 28. Palatal
Level: Circumferential Narrowing 29. Oropharyngeal Level :Posterior
Collapse of BOT 30. Oropharyngeal Level :Collapse of Lateral OP
Wall 31. Oropharyngeal Level:Circumferential Narrowing 32.
Supraglottic Level: Collapse of Epiglottis 33. Summary
- Precise localization of the site(s) of airway obstruction is
crucial for surgical success
- Current diagnostic modalities are inadequate
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- May account for the less than perfect results following phase I
surgery(54%)
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- Validate our current existing diagnostic modalities
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- Identify new and better diagnostic modalities for localization
of upper airway obstruction
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- Standardization of diagnostic modalities in order to evaluate
and assess effectiveness of surgical procedures
34. Preoperative Considerations: Selection of Surgical
Candidates
- Reason for surgical consideration
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- Desire surgical Tx despite good result using PAP
- Weigh carefully the benefit to risk ratio
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- Chance of surgical cure depends on:
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- Severity of OSA (Inferior result if RDI > 60)
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- Body mass index (Inferior result if BMI > 35)
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- Site of airway obstruction (Inferior result if large BOT)
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- Comorbidities and surgical risks
35. Preoperative Considerations
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- Ancef 1 g and Flagyl 500 mg x 1
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- If PCN allergic, Clinda 600 mg iv
- Do not sedate patients preop
- Decadron 10-16 mg iv prior to surgery
- Discuss w/ anesthesia about difficult intubation
36. Intraoperative Considerations
- Plan for difficult intubation
- Toradol 30 mg IV (if < 65 yo) or 15 mg IV (if > 65 yo or
weight < 110 lbs.)
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- Cautious use in pts w/ h/o CAD, COPD, Asthma, peptic ulcers,
bleeding tendency
- Decadron 10-16 mg iv at end of surgery
- Extubate only when patient is completely awake
37. Postoperative Considerations
- Obstruction may get worse after surgery due to
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- Use of postop pain medication
- Low threshold to admit to ICU
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- Patient must use CPAP/BiPAP when sleeping
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- Call HO if patient refuse to wear CPAP
- Keep SBP < 140 and diastolic BP < 90
38.
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- Toradol 30 mg IV Q6 hours or 15 mg IV (if >65 yo or wt <
110lbs) given over 30 sec (standing order) x 3 days
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- Tylenol with codeine elixir (120mg/12mg/5cc) 20-40 cc Q 4hrs
prn
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- 2% Viscuous lidocaine 15 cc gargle and spit Q4 hrs prn
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- Morphine sulfate 2-4 mg iv Q 2hrs prn
- Decadron 10-18 mg iv Q6 hour
- Peridex oral rinse 15 cc swish and spit Q6 hrs prn
Postoperative Considerations