Presented by Dr Paulose at the International Live Surgical Workshop, held in Hyderabad, India at the Taj Deccan. For more information visit: http://DrPaulose.com http://SnoreFreeSleep.com

1. Laser vs. Coblator
For Snoring and OSA
Dr.K.O.Paulose FRCS,DLO
Consultant ENT Surgeon
Jubilee Hospital,Trivandrum,Kerala,India.
www.drpaulose.com
www.snorefreesleep.com

2. ENT Surgical Experience in Sleep Surgery
 Over 35 years
Experience in ENT
 1978-1986
UK-NHS Hospitals
 1986-2003
Bahrain Military Hospital
 2004-2009
S.U.T Hospital.Trivandrum
 2010-Onwards
Jubilee Hospital,Trivandrum

3. History of UPPP Surgery
 Fujita et al in 1981
introduced the
operation of UPPP
for OSA.
 This involved
excision of tonsils,
terminal soft palate
and uvula under
general anesthesia.

4. Kumbhakarna-Great Snorer
 Kumbhakarna is an
important character in the
Hindu epic Ramayana. He
is a Rakshas as well as
brother of Ravana, king of
Lanka.
 Brahma was pleased
with Kumbhakarna
and offered him a
boon.
 He used to snore very loud
while sleeping.

5. How Snoring and OSA

6. Mechanism of Snoring
 Snoring is the
sound produced by
the vibration of
soft palate and
Uvula. It causes air
turbulence in the
upper airway

7. Causes Of Snoring
 Nasal Obstruction
 Enlarged, Uvula, Soft
Palate, Tongue
 Enlarged Ts Ads
 Lack of Muscle tone
upper airway
 Air Turbulence in the
oropharynx
 Vibration of soft palate
and uvula
 Venturi Effect-
Bernoulli principle

8. Stop Snore and Save your Marriage

9. About Sleep apnea
What is Sleep apnea?
 Stoppage of breathing while
asleep
 More than 10 seconds
 100-500 episode of apneas in one
night
 Plus Hypopneas
 Cause Hypoxia and Hypercarbia
Types of sleep apnea
 Obstructive Sleep Apnea (OSA)
Obstruction of upper airway, Snoring
 Central Sleep Apnea (CSA)
Brain stem lesion, stroke, polio, brain
tumors-No snoring
 Mixed sleep apnea (OSA+CSA)
Chronic respiratory failure>central

10. Snoring in Women
 Men: women ratio
2:1
 Undiagnosed
 Hormonal changes
 Post menopausal
 Pregnancy and
snoring
 Hypothyroid,DM

11. Signs and symptoms of sleep apnea
 Choking or gasping during sleep
 Loud snoring
 Sudden awakenings to restart breathing
 Waking up in a sweat during the night
 Feeling tired in the morning
 Headaches, memory loss
 Daytime sleepiness
 Lack of concentration,fatigue,irritable
 Low O2- Brain and Heart-BP, Stroke
 Type 2 Diabetes
 Low sex drive-libido

12. Risks and Complications

13. Diagnosis of Sleep Apnea
 Good History from spouse or parents
 Physical examination-Nose and Throat
 Voice recording
 Flexible Endoscopy
 CT imaging or MRI retro palatal and
pharyngeal airway
 Sleep study-Polysomnogram-Home Sleep
Study
 Cardiac evaluation

14. CT/MRI Imaging

15. ENT Examination And Endoscopy

16. Sleep Study
 Polysomnogram  Home Sleep study
 Sleep Lab Study

17. Treatment of Snoring and Sleep Apnea
Conservative
 Weight Loss
 Avoid Alcohol
 Dental devices, dilators
 Avoid sleeping pills or narcotics before bed
 Stop Smoking
 Don't sleep on your back
Surgical Treatment
 Nasal surgery, Septal surgery,LAPT
 UPPP-LAUP+Coblator surgery
 Ts Ads
 RF Somnoplasty
 Glossectomy
 Mandibular osteotomy
 Hyoid advancement
 Tracheostomy-last option

18. Types of Laser
Laser is an acronym that stands for Light Amplification by Stimulated Emission
of Radiation.
The first concept of the laser was initiated by Albert Einstein in 1917.
CO2 Laser
Argon laser
The Nd:YAG (Neodymium:Yttrium-aluminum-
garnet)
The potassium-titanyl-phosphate (KTP)
Diode Laser

19. Co2 Laser
 CO2Laser
The CO2 laser is the most versatile laser in otolaryngology. The carbon dioxide (CO2) laser
emits a colorless, infrared light at a specific wavelength of 10,600 microns, which has an
extremely high affinity for the intercellular water of cells.
A second, built-in, coaxial helium neon laser is necessary to indicate with its red color the
site where the invisible CO2 laser beam will impact the target tissue. This laser, then,
acts as an aiming beam for the invisible CO2 laser beam.
Advantages of Laser Surgery
 Fast
 Painless
 Bleeding-nil
 Fast recovery
 No hospitalization if done under LA
 GA for difficult cases
Disadvantages of Laser
 Cost of equipment and maintenance
 Special surgical skills
 Increased setup time of equipment
 Need of safety eyewear
 Increased care for patient safety - explosion or fire hazard.
 smoke

20. Other Non surgical treatment
 Dental splint
 Nasal dilator, strips
 Chin Strap
 Special Pillows
 Tennis ball strapped on dress
 Nasal Treatment of allergy
 CPAP Machine

21. Anti Snoring Devices-Contd

22. CPAP Machine
 Treat OSA=Remove
obstruction.
 When Surgery cannot
be done
 Central apnea
 After surgery fail
 Very old, medical
problems
 Costly
 Cumbersome to wear
 But useful in cases

23. CPAP user in rural village
Is it a better picture of an Indian villager to the world?
 Gandhi had the vision
of uplifting quality of
lives of millions living
in rural India, by
bringing appropriate
technology and
developments to the
countless villages of
this vast nation.
 The fast and speedy
advent of modern
technology in our
country.
 What is the benefit?

24. LAPT under LA

25. LAUP-LA as Day Case

26. GA:Difficult Intubation

27. Laser Surgery-Snoring and OSA
 LAUP:Laser Assisted
Uvulopalatopharyngoplasty
 LAPT:Laser Assisted Partial
turbinectomy
 LAS:Laser assisted
Septoplasty
 LAT:Laser assisted
Tonsillectomy
 Laser Removal Pharyngeal
Bands
 Laser Ts Ads in Children

28. Laser Surgery of Nose:GA

29. Diode laser surgery

30. Laser Surgery:GA

31. Results of Laser surgery
 showed the correction of sleep apnea by an average of 70-80%
However, the snoring sound reduction was between 75-95%.
Side Effects
 post op infection -rare
 nasal fluid reflux –temporary nasal regurgitation for few days, but
rarely permanent
 no voice changes were noted
 Bleeding-rare
 Dryness of throat-rare
Causes of failure if any
 mixed apnea-central component
 Inadequate excision of tissues-Redo
 Obesity,alcohol,sedative
 Lack of muscle tone in the neck
 Base of tongue factor-coblator reduction
 Jaw factor-need mandibular advancement

32. Tonsils,soft palate and uvula

33. Oldest LAUP

34. Coblation Surgery: My Experience

35. About Coblation Technique
 Coblation is a non-
heat driven process in
which radiofrequency
energy is applied to a
conductive medium
saline causing a highly
focused plasma field
to form around the
electrodes.

36. Coblation=Controlled Ablation
 Electrosurgical
ablation probe 1999
 By Philip E. Eggers et
al
 Coblation energizes
the ions in the saline
to form a small
plasma field.

37. Cold Ablation-Coblation Technology
 RF turbinate-
Turbinoplasty
 Polypectomy
 Tonsillothomy-
pediatric
 CAUP –Snoring and
OSA
 Tongue base
reduction

38. How Coblation Turbinoplasty done
 Under LA a
coblation wand is
inserted into the
turbinate. The
wand emits RF
energy which
shrinks the
turbinates.

39. Coblation Surgery GA

40. Coblation Surgery for OSA

41. Coblation Turbinoplasty In Snoring
and OSA
 Treat severe or
chronic nasal allergies
 Relieve nasal
congestion and
drainage
 Reduce sinus-related
snoring
 Improve breathing

42. Saline Gel for Coblation
 In Coblation channeling
saline gel should be
applied before the wands
inserted.
 Saline is used as solution,
sprays, drops and gel form
in nasal passage
 Good
healer,moisturising,post op
use
 Is saline gel is available in
India ?
 Any pharma companies
making saline gel?

43. Advantage of Coblator over Laser
 Significantly less pain and
less frequent use of
narcotic analgesics
 Significantly faster return
to normal diet (2-4 days)
 Less incidence of
postoperative nausea and
throat edema
 Less depth of thermal
adjacent tissue necrosis
 No Fire Hazard
 Can reduce the tongue
base

44. Disadvantages of Coblator
 Cost of Machine
 Cost of wands
 Saline gel for Nose
 Fibrotic Tonsil:
bleeding
 Haemostasis:secon
dary bleeding
 Need experience

45. After Surgery:LA

46. Post Op Recovery:GA

47. Happily living after

48. www.SnoreFreeSleep.com

49. www.DrPaulose.com

50. THANK YOU !
Dr.K.O.Paulose FRCS,DLO
Consultant ENT Surgeon
Jubilee Hospital,Trivandrum,Kerala,India.
www.drpaulose.com
www.snorefreesleep.com