1. OBSTRUCTIVE SLEEP APNOEA
SYNDROME
Prof. Mohan Kameswaran
MS, FRCS, FICS, FAMS, DSc, DLO
Madras ENT Research Foundation
Chennai

2. OBSTRUCTIVE SLEEP APNOEA SYNDROME
• OSA is a common disorder resulting from collapse of
the pharyngeal airway during sleep
• Significant advances have been made in the
evaluation and treatment of OSAS over the past
several years

3. SLEEP DISORDERED BREATHING
• Primary snoring
• Upper Airway Resistance Syndrome (UARS)
• Obstructive sleep apnoea syndrome (OSAS)

4. RDI O2 desaturation Day time
sleepiness
Primary < 5 / hr SaO2 > 90% No
snoring
UARS < 5 / hr SaO2 > or = 90% Yes
OSAS > 5 / hr SaO2 < 90% Yes
SLEEP-RELATED UPPER
AIRWAY OBSTRUCTION

5. SLEEP APNOEA SYNDROME -
Semantics
• Apnoea - cessation of airflow at the nostrils and mouth
for atleast 10 seconds
• SAS - 30 or more apnoeic episodes during a
7-hour period of sleep or an apnoea index (number of
apnoeas per hour of sleep) equal to or greater than 5

6. • Hypopnoea (reduction in tidal volume) - 50% reduction
in airflow, lasting for 10 seconds in the presence of
continued respiratory effort
• Respiratory Disturbance Index (RDI) or Apnoea
Hypopnoea index (AHI) - number of apnoeas and
hypopnoeas per hour of sleep
• In OSAS, RDI is greater than 10

7. SLEEP APNOEA - TYPES
• Obstructive sleep apnoea - cessation of airflow in the
presence of continued respiratory effort
• Central sleep apnoea - no airflow at the nose or mouth
associated with a cessation of all respiratory effort
• Mixed apnoea - begins initially as central apnoea, then
becomes obstructive

8. OBSTRUCTIVE SLEEP APNOEA
• Intrinsic dyssomnia characterized by recurrent episodes
of upper airway collapse and obstruction during sleep
• Associated with recurrent oxyhemoglobin desaturation
and arousal from sleep
• Both anatomic and neuromuscular factors are important

9. OSA - PATHOPHYSIOLOGY
Abnormal neuromuscular control of pharyngeal dilators
(genioglossus, geniohyoid, palatoglossus, medial pterygoids)
during sleep
Airway narrowing
(space occupying lesion from
the nasal vestibule to glottis)
Venturi effect
Increased intraluminal negative pressure
UPPER AIRWAY OBSTRUCTION

10. How many people have sleep apnea?
Older guidelines (AHI > 10) - 2 - 4% of the population
Children: 1- 3%
Newer guidelines (AHI > 5 with symptoms) - 9 - 24%

11. OSAS
3 major levels of obstruction (Fujita)
• Retropalatal (Type1)
• Retropalatal and retrolingual (Type 2)
• Exclusively retrolingual (Type 3)

12. SLEEP MRI - Type 1 obstruction

13. SLEEP MRI - Type 2 obstruction

14. OSAS - EFFECTS
• Oxygen desaturation causing increased
sympathetic output & peripheral vasoconstriction
• High negative intrathoracic pressures with arousal
& termination of obstructive episode

15. OBSTRUCTIVE SLEEP APNOEA
CAUSES
• Nose - nasal polyps, DNS, • Larynx – tumors, oedema
rhinitis, nasal packing Shy- Drager syndrome
• Pharynx - nasopharyngeal laryngotracheomalacia
tumor, enlarged adenoids, vascular ring
palatal & lingual tonsils,
retropharyngeal mass, Male sex
enlarged tongue, Obesity
micro/retrognathia Increasing age

16. PEDIATRIC OSAS
Commonest etiology
• Adenotonsillar hypertrophy
• Neuromuscular hypotonia
• Craniofacial and neurologic syndromes
OBSTRUCTIVE TONSILS

17. OBSTRUCTIVE SLEEP APNOEA
Clinical features
Common Less common
• Snoring • Morning headaches
• Excessive daytime
• Personality change
sleepiness
• Obstructive episodes • Intellectual deterioration
• Depression
• Abnormal body movements
• Frequent waking
• Nocturnal choking
• Impotence

18. PEDIATRIC OSAS
• Loud snoring • Nocturnal enuresis
• Noisy breathing during sleep • Poor growth problems
• Mouth breathing • Rebellious and aggressive
• Growth retardation behavior
• Repetitive upper airway • Attention deficit disorder
infection
• Abnormal shyness

19. Sleep MRI - Craniosynostosis

20. OSAS - common associations
• LPR • Left ventricular hypertrophy
• Systemic hypertension • MI
(50 - 70%) • Depression
• Coronary artery disease • Sudden death?
• Pulmonary hypertension • Vehicular and work-related
• Right heart failure accidents
• Cardiac arrhythmias

21. LARYNGOPHARYNGEAL REFLUX

22. OSAS - HISTORY & EXAMINATION
• General appearance, weight, height, blood pressure
• H/O alcohol, drugs e.g. sedatives
• Thyroid evaluation
• ENT & Head and Neck examination - nasal airway, tongue
size, soft palate, uvula, tonsils, naso / hypopharynx, larynx
• Craniofacial morphology
Snoring / OSAS
If OSAS, the site of obstruction
Associated problems

23. ENT & Head and Neck examination
• Short thick neck (Collar size > 17.5)
• Enlarged floppy uvula
• Elongated soft palate
• Tonsillar hypertrophy
• Enlarged tongue
• Micrognathia / retrognathia

24. INVESTIGATIONS
• FBC, ECG, chest X-ray, Lung function tests
• Polysomnography (Holland, Dement, Raynall, 1974)
- Level 1 PSG - gold standard investigation
- Overnight monitoring of pulse oximetry, End tidal CO2,
ECG, EEG, anterior tibialis EMG, EOG, nasal & oral
airflow, chest & abdominal movements & sleeping position
- Differentiates obstructive from central sleep apnoea
- Evaluates the severity

25. Polysomnography

26. Polysomnography

27. Sleep MRI & Fiberoptic endoscopy - assessment of
the site of obstruction - retropalatal / retrolingual /
combined

28. Sleep MRI
Sleep endoscopy

29. OSAS - TREATMENT
• Medical
• Appliances - nasal splint, mandibular positioning device,
tongue retaining device
• Surgical
• If anatomic obstruction is present, corrective surgery should
be done
NONSURGICAL TREATMENT
• Weight loss
• Treatment of systemic disorders
• Alcohol advice
• Drugs review

30. NONSURGICAL TREATMENT
Drug treatment
• Protryptiline (increases the neuromuscular activity of upper
airway & decreases REM sleep)
• Theophylline
• Progesterone
• Modafinil (improves wakefulness by decreasing GABA
mediated neurotransmission)

31. NONSURGICAL TREATMENT
• Mandibular positioning device – in non obese patients with
micrognathia / retrognathia, advances the mandible and
increases posterior airway space, has success rate of 50 % &
compliance rate of 25%
• Tongue retaining device
• Positional devices
• Nasal splints
• Nasal CPAP, Nasal BiPAP & Demand PAP

32. MANDIBULAR POSITIONING NOZOVENT NASAL SPLINT
DEVICE
TONGUE RETAINING DEVICE

33. Nasal Continuous Positive Airway Pressure
(Colin Sullivan, 1981)
• Noninvasive and highly effective primary treatment
modality
• Delivers a continuous flow of air & provides a pneumatic
splint to the upper airway during inspiration preventing
collapse during sleep by increasing airway volume, area and
lateral dimensions in retropalatal and retroglossal regions

34. Continuous Positive Airway Pressure

35. Nasal CPAP
• Problems: dermal irritation, dryness, sneezing,
rhinorrhoea, claustrophobia, panic attacks leading to
noncompliance
• Auto-CPAP is as effective as constant CPAP
• The auto-CPAP is characterized by its ability to
modify the positive-pressure level applied

36. Nasal CPAP
• Restores normal respiration during sleep, normalizes
sleep organization
• Improves day time alertness, neuropsychiatric
function, right heart function, and systemic blood
pressure
• Success rate - 90%
• Compliance - 50%

37. SURGICAL TREATMENT
Indications
• Primary snoring
• AHI > 15
• O2 desaturation < 90%
• AHI > 5 or < 14, with excessive daytime sleepiness
• UARS
• Unsuccessful medical treatment
• Type 1 collapse (mainly retropalatal)
• Failure of compliance for CPAP

38. POOR SURGICAL CASES
• Extreme obesity
• Lack of physical activity
• Alcoholism
• Type 2 collapse
• Cardiac arrhythmias

39. SURGICAL TREATMENT
• Nasal surgery, Adenotonsillectomy
• Uvulopalatopharyngoplasty, LAUP, RAUP, CAUP
• Hyoid advancement
• Midline Laser glossectomy
• Mandibular / Maxillary osteotomy & advancement
• Tracheostomy - gold standard

40. Enlargement of retropalatal airway
• Uvulopalatopharyngoplasty (UPPP)
• Laser - LAUP
• Radiofrequency - RAUP
• Coblation - CAUP

41. UVULOPALATOPHARYNGOPLASTY
Dr. Ikematsu (1964), Dr. Fujita (1981)
• Removal of excessive redundant tissue in the oropharynx
with increased cross-sectional area
• Success rates in curing snoring: 85 - 90%
• Success rates in reducing apnoeic index: 23 - 77%
• Complications: bleeding, velopharyngeal insufficiency, dry
throat, nasopharyngeal stenosis, airway compromise,
hypernasal speech & taste disturbances

42. Uvulopalatopharyngoplasty (UPPP)
For successful UPPP, Mandibular - hyoid angle must be less than
25 - 30

43. LASER ASSISTED
UVULOPALATOPHARYNGOPLASTY
(Dr. Kamami, 1993)
• Effective and has the advantage of a bloodless field
• Success rates: short term - 77 - 89%
long term - 75%
no snoring - 52%

46. Sleep MRI – post UPPP
showing retrolingual obstruction

47. UPPP / LAUP - Anesthetic considerations
• Pre-op evaluation
• Avoid sedatives, narcotics
• Difficult intubation (FO intubation may be required)
• After extubation - nasopharyngeal airway, pulse oximetry and
avoidance of narcotic analgesia, monitoring for post obstructive
pulmonary edema
NASOPHARYNGEAL AIRWAY

48. RADIOFREQUENCY IN OSAS
• Radiofrequency thermal ablation uses low levels of RF
energy to create targeted tissue ablation resulting in
tissue volume reduction
• The procedure is quick, painless and is associated with
minimal edema

49. Radiofrequency in OSAS

50. COBLATION
• Voltages applied to convert conductive fluid between
electrodes and tissue into ionized vapor layer (plasma)
• Ionized layer contains excited particles which, when in
contact with tissue, break tissues molecular bonds with
minimal thermal penetration
• Energy used - up to 8 eV

52. Enlargement of retrolingual space
• Tongue base reduction procedures
• Mandibular osteotomy with genioglossal advancement
• Repose tongue suspension intraoral approach
• Hyoid Myotomy and suspension
• Genioglossal advancement and hyoid suspension (GAHM)
• Maxillofacial techniques
• Uvulopalatopharyngoglossoplasty (UPPGP)
(UPPP with limited resection of the tongue base)

53. Tongue base reduction procedures
Type 3 (Riley)
• Tracheostomy required
• Midline Laser glossectomy - laser is used to extirpate a
rectangular strip (2.5 into 5 cms) of the posterior portion of
tongue, useful in Down’s syndrome, Mucopolysaccharidosis
• Lingualplasty - modification of LMG, involves additional
excision of lateral tongue tissue
• Radiofrequency tissue ablation of tongue base - RF probe with
465 KHZ

54. GENIOGLOSSUS ADVANCEMENT PROCEDURE
Osteotomies in the mandible at the geniotubercle advancing the
insertion of genioglossus or geniohyoid by 10-14 mm & rotating
it by 90%. This increases the tension placed on the tongue

55. CANDIDATE FOR GENIOGLOSSUS ADVANCEMENT

57. Tongue suspension
Tongue base is pulled forward and secured anteriorly
by a titanium screw placed at the lingual cortex of genial
tubercle of mandible

58. MODIFIED HYOID MYOTOMY & SUSPENSION

59. Genioglossal advancement and hyoid
suspension (GAHM)
• Combined procedure of inferior mandibular osteotomy
with genioglossal advancement with hyoid myotomy &
suspension
• Success rates - 70%
• Complications: infection, need for root canal therapy,
permanent anesthesia, seroma, mandibular fracture,
aspiration

60. Hyoid distraction procedure
(Tucker Woodson)
The hyoid bone is split and two separate loops of suture
are used to pull the bone not only anteriorly and
superiorly, but also laterally

61. MAXILLOFACIAL TECHNIQUES
• Used in severe OSAS where the tongue base is the cause
of obstruction
• Advances the skeletal support of soft tissues (tongue and
pharynx) that collapse during sleep

62. Candidate for
maxillomandibular
advancement

63. MAXILLOMANDIBULAR OSTEOTOMY
& ADVANCEMENT (Riley & Powell)
• Phase 2 surgery
• Improves retropalatal and retrolingual space and increases
airway caliber in an anteroposterior direction
• Success rates: 95%
• Complications: malocclusion, inferior alveolar, lingual or
infraorbital paresthesia, nonunion/malunion, relapse of
advancement, TMJ complications, need for restorative dental
work

64. MAXILLOMANDIBULAR ADVANCEMENT PROCEDURE
(Riley & Powell)

65. Presurgical evaluation
Phase I
(site of obstruction)
UPPP UPPP + MOHM MOHM
Type I oropharynx Type 2 oro - hypopharynx Type 3 hypopharynx
Postop polysomnogram (6 months)
Failure
Phase II - MMO
Riley-Powell-Stanford surgical protocol

66. Tracheostomy
Bypasses airway obstruction
Indications - severe OSAS with
• RDI above 50
• Lowest O2 saturation below 60%
• Cardiac arrhythmias

67. OSAS - Adults Vs Children
Adults Children
Symptoms Sleepiness, fatigue, nocturia Behavioral problems,
learning difficulty, nocturnal
enuresis
Gender More common and severe in No difference prior to
males puberty
Physical findings Obese, large neck High-arched palate, enlarged
circumference tonsils, orthodontic
problems, less likely obese,
failure to thrive
Apnea duration 10 seconds Two breaths
Diagnostic criteria AHI > = 5 AHI > =1
Primary treatment Positive airway pressure Adenotonsillectomy

68. Snoring Intermittent with pauses Continuous
Mouth breathing Less common Common
Weight Commonly obese Underweight
Enlarged tonsils / adenoids Uncommon Common
Sex distribution Male:Female (8:1) Male:Female (1:1)
Obstructive pattern Mostly apneas Mostly hypopneas
Clinically obvious arousals Common Uncommon
Sleep architecture disruption Common Uncommon
Sequelae Excessive daytime sleepiness Behavioral changes
Hypertension Neurocognitive
Cardiovascular Cardiovascular
Treatment Most often CPAP Most often T & A
Less often UPPP Less often CPAP

69. CONCLUSION
• OSA is a common disease of adult & pediatric age groups
with a myriad of presentations
• Often the patient is unaware of his condition
• A detailed history, clinical examination & simple
overnight observation will help to clinch the diagnosis

70. • Sleep MRI ( dynamic MRI ) with F.O.nasendoscopy
has obviated the need for cumbersome cephalometric
measures to establish the site of obstruction
• A comprehensive presurgical evaluation to identify the
site of airway obstruction improves surgical success
rates