Obstructive sleep apnea syndrome (OSAS)

A class on OSAS

1. Obstructive Sleep Apnea
Syndrome (OSAS)
Dr. Krishna Koirala
MBBS, MS (E.N.T. )
2019-12-23

2. •Sleep
–Reversiblebehavioralstateofperceptual
disengagementandunresponsivenessto
surrounding
•2Stages
•REM(20%)-AlertMind,Relaxedbody
•NREM(80%)-RelaxedMind,Active
body

3. •Apnea : Cessation of breathing from nose and mouth
for >10 sec
–Obstructive: Chest wall moves
–Central : Chest wall doesn’t move
–Mixed : Chest wall partly moves
•Hypopnea : Decreased airflow (<50% from baseline)
with > 4% Hb O
2desaturation and arousal

5. •TheApnea–HypopneaIndex(AHI)
–Usedtoindicatetheseverityofsleepapnea
–Representedbythenumberofapneaand
hypopneaeventsperhourofsleep
•OSASisdefinedasAHI>5
•Grades:
–Mild :5-14
–Moderate:15-29
–Severe :>30

6. Pathophysiology
•Incompletely Understood !
•Hypothesis
–During REM sleep : Collapse occurs in upper airway
‘pharynx’ (due to defect in pharyngeal dilator
muscles activity and anatomical abnormalities) 
Hypoxia arousal Upper airway collapse
improves and patient sleeps again
–During sleep, airway again collapses leading to
hypoxia and arousal

7. •Multiple arousals result in poor quality of sleep
and day -time sleepiness
•Chronic repeated hypoxia causes hemodynamic
complications like
–Pulmonary HTN ,Systemic HTN
–CAD, CVA, CHF

8. Pharyngeal Dilators
•Medial Pterygoid
•Tensor Veli Palatini
•Genioglossus
•Geniohyoid
•Stylohyoid

9. Upper Airway Obstruction

10. Symptoms
•Day-time
–Sleepiness
–Morning Fatigue
–Morning headache
–Cognitive Impairment
–Heartburn
–Depression
–Impotence, Xerostomia
•Night-time
–Snoring
–Observed Gasping/
Apnea/ Choking
–Repeated waking
–Nocturnal sweating
–Nocturnal enuresis

11. Typical Syndromic Patient
•Old Age
•Male
•Obese -BMI > 30
•Thick / Short Neck >17″
•Hypertension/Thyromegaly
•Large Bulky tongue/Tonsils
•Nasal Obstruction
•Pitting Edema
•Disproportionate Anatomy

12. Approach to management
•Detailed History /Involve
Bed-partner
•Sleep history
–Bed time
–Alcohol / Sedative use
–Body position/Snoring
–Arousals/Apneas
•Assess Day time
sleepiness
–Epworth Sleepiness
Scale
–Stanford Sleepiness
Scale

13. Examination
•B.M.I/B.P
•E.N.T.Examination
–AnteriorRhinoscopy:DNS,Turbinatehypertrophy,
Polyp,Mass
–Oro-pharynx:Tongue,Tonsils,Uvula,Pharyngeal
walls
–Neck:Circumference(>17”),Thyroid
–CVSExamination

14. •FlexibleNasopharyngoscopy:Mueller’sManeuver,assess
airwaycollapse
Normal Airway Bulky Base of Tongue
Before Mueller’s ManeuverAfter Mueller’s Maneuver
Afteraforcedexpiration,an
attemptatinspirationis
madewithclosedmouthand
nose(reverseValsalva)

15. Investigations
•Polysomnography
–Gold Standard Investigation
–Done in a “SLEEP LAB”
–Measures:
•EEG/EOG/ EMG
•ECG / B.P
•Position of Patient / Movements of Chest and abdomen
•Airflow /O
2 Saturation
•Esophageal Pressure

16. •Cephalometry
–Enlarged tongue and soft palate
–Inferiorly displaced hyoid bone
–Inferior displacement of the
mandibular body
–Reduced oropharyngeal and
hypopharyngeal airway

17. •Anatomical Risk assessment
–X-Ray /CT Scan /MRI /Fluoroscopy /Acoustic Reflex
•Multiple Sleep Latency Test
–Document daytime sleepiness
–Subject asked to sleep 4-5 times in day every 2
hours
•TFT/ECHO

18. Differentials
•Primary Snoring
•Mild upper airway obstruction
•RDI < 5
•No Daytime sleepiness
•Upper Airway Resistance Syndrome
•Moderate upper airway obstruction
•RDI < 5
•Arousal Index > 15
•Excessive Negative Intra-thoracic pressure
•Daytime sleepiness occurs

19. General Treratment
•Weight Reduction
•Sleep Hygiene
–Elevate head end of bed
–Avoid alcohol, sedatives
–Avoid lying supine (T-shirt with tennis ball at back )
•Positive Airway Pressure (PAP) Device
–CPAP (Continuous) / Bi–PAP(Biphasic) /APAP(Automated)
•Positioning Devices
–Mandibular Advancement Device
–Tongue Retaining Device

20. •Nasal CPAP is first line treatment with ~100%
Efficacy (Gold standard medical R
x )
•Pressure must be individually titrated
•A/E :Noise, Mask discomfort, Claustrophobia
•Compliance low ~ 50%

22. Surgical Treatment
1.Nasal Surgery
2.Palatal Surgery
3.Tongue Base Surgery
4.Maxillo -facial Surgery
5.Tracheostomy

23. Nasal Surgeries
•Rarely suffice alone
•Relieve snoring > apnea
1.Office Radio-frequency Turbinate Ablation
2.Septo-turbinoplasty
3.Polypectomy
4.Nasal Valve Reconstruction
5.Adenoidectomy
6.Nasal mass Excision

24. Palatal Surgeries
•UPPP (Uvulo Palato Pharyngo Plasty)
–Most commonly performed procedure
•Others
–LAUP (Laser assisted Uvulo Palatoplasty)
–RFUP (Radio frequency Uvulo Palatoplasty)
–Uvulopalatal Flap
–Lateral Pharyngoplasty
–Transpalatal Advancement Pharyngoplasty

25. UPPP
Complications : Hemorrhage, Stenosis, Velopharyngeal
Incompetence

26. LAUP

27. RF Palatal Ablation

28. Lateral Pharyngoplasty

29. UvulaFlap

30. Tongue Procedures
1.Radiofrequency Tongue Ablation
2.Lingual Tonsillectomy
3.Linguloplasty
4.Tongue Base Suspension
5.Hyoid Myotomy & Advancement

31. Linguloplasty

32. Tongue Suspension

33. Maxillofacial Procedures
Genio-glossal advancement and hyoid myotomy

34. Maxillofacial Procedures
Maxillo-mandibular osteotomy & Advancement

35. Tracheostomy
Last Resort in Treatment Failure cases

36. Complications
•Systemic Hypertension
•CAD
•CHF
•Arrhythmias
•Pulmonary Hypertension
•CVA
•Risk Accidents
•Marital Discord
•Professional Setbacks
•Depression
•Impotence
•Sudden Death