Rhinologic And Sleep Apnea Surgical Techniques Pdf File
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To evaluate the effect of obstructive sleep apnea OSA surgery on long-term 5-year subjective outcomes, including sleep disordered breathing SDB symptoms and other complications, in patients with OSA. We enrolled patients who underwent diagnostic polysomnography for OSA between January and December in ten hospitals. All patients completed a brief telephone survey regarding their SDB signs and symptoms e.
- Otorhinolaryngological aspects of sleep-related breathing disorders
- Nasal Involvement in Obstructive Sleep Apnea Syndrome
- Download Rhinologic And Sleep Apnea Surgical Techniques 1St Edition Online
Evaluation of cranial base repair techniques utilizing a novel cadaveric CPAP model. Evans , Thomas Jefferson University Follow. This is the peer reviewed version of the following article: Chitguppi, C.
Otorhinolaryngological aspects of sleep-related breathing disorders
Sleep-related breathing disorders SRBD encompass a wide range of conditions in which there is recurrent partial or complete cessation of breathing, including simple snoring, upper airway resistance syndrome, central sleep apnoea-hypopnoea syndrome, obesity-related sleep hypoventilation syndrome and obstructive sleep apnoea-hypopnoea syndrome OSAHS 1. This spectrum of disorders is common and not only negatively impacts on patient health but also induces a significant social and economic burden 2 - 4.
SRBD, particularly OSAHS, can increase the risk of cardiac arrhythmias, pulmonary and systemic hypertension, myocardial infarction, type 2 diabetes mellitus, cerebrovascular accidents, impaired cognition and road traffic accidents 8 - Furthermore, there is evidence that moderate-to-severe OSAHS independently correlates with a large increased risk of all-cause mortality The pathophysiology of SRBD is complex and multifactorial, with a single cause rarely identified.
Associations include obesity, increased neck circumference, craniofacial abnormalities and anatomical variations e.
The clinical history is attained from both the patient and the partner, if present. In many cases, patients attend with a recording to outpatient clinic which can be of value.
The principle symptom is often of socially embarrassing snoring; severe snoring can be as loud as 90 dB. The partner may also elucidate concerns of apnoeic episodes.
Patients may also complain of daytime somnolence. Further direct questioning is required to ascertain how refreshed the patient feels in the morning, the presence of morning headaches, night sweats, palpitations during the night, choking sensation, restless sleep, acid reflux, decreased libido alongside impaired concentration and memory. A useful adjunct in this regard is the ubiquitous use of the Epworth Sleepiness Scale questionnaire, whereby higher scores, particularly above 10, are correlated with OSAHS Table 1 It is also important to ascertain any associated rhinological symptoms, mouth breathing and medical history to include alcohol and sedative intake, as these act as muscle relaxants and worsen symptoms.
Nasal problems such as polyposis, alar collapse and a deviated septum can contribute significantly to SRBDs and form an important part of treatment non-compliance with nasal continuous positive airway pressure nCPAP. It is thus important to fully delineate and examine for this subset of conditions A full assessment of patient health status and past medical history is also warranted to assess co-morbidities and rule out acromegaly or hypothyroidism, for example.
Clinical examination serves to assess the upper airway including the nasal and oral cavities alongside the anatomical segments of the pharynx and larynx. A general inspection is initially invaluable however to assess for features such as dental malocclusion, retrognathia, craniofacial abnormalities and body habitus. Body mass index BMI and neck collar size should be measured. Nasal examination with anterior rhinoscopy, misting testing and rigid endoscopes will enable evaluation for rhinological factors contributing to SRBDs.
Visualisation of the oral cavity and oropharynx provides information regarding the grade of the palatine tonsils, the dimensions of the soft palate and uvula, and evidence of redundant pharyngeal tissue. In addition, clinicians can evaluate tongue position using Friedman or Mallampati gradings, which have been shown to correlate strongly with predicting OSAHS Figure 1 18 - Furthermore, there is evidence that patients with Friedman tongue position 1 are more likely to benefit from palatal surgery whilst those with tongue positions 3 or 4 are unlikely to benefit The optimal examination technique is flexible nasopharyngolaryngoscopy and allows visualisation and assessment of the pharynx and larynx including the tongue base.
Despite evidence that these manoeuvres correlate with Epworth scores and sleep study findings, there are difficulties in standardising this effectively subjective assessment 22 - The gold standard investigation to differentiate between simple snoring and OSAHS is hospital-based polysomnography.
Due to financial constraints, patient preference and availability, ambulatory sleep studies are often performed. Recorded parameters include oxygen saturation, nasal and oral airflow, respiratory effort via chest and abdominal movements and sleep architecture, the latter of which is not possible with home or ambulatory sleep studies Further investigations have been proposed ranging from imaging, acoustic analysis, pressure transducers and sleep nasendoscopy but all have limitations and thus have not been universally accepted Drug-induced sedation endoscopy DISE or sleep nasendoscopy has been tested most thoroughly since its introduction by Croft and Pringle in The main criticism remains that drug-induced sleep differs from natural physiological sleep alongside the inherent subjectivity in assessment and lack of standardised grading systems.
This is countered by the suggestion that these drugs would affect different segments equally and thus still allow evaluation of obstruction at each anatomical level. Alongside this, recent studies have confirmed superiority to awake assessment by flexible nasopharyngolaryngoscopy in outpatients and correlation with AHI, mean oxygen desaturation alongside surgical outcomes with good inter-rater reliability 26 , 28 - Moreover the recent European congress meeting has met in an attempt to standardise nomenclature and data capture from these procedures As a corollary to this standardisation, the advent of a neurophysiological bispectral index monitoring device may indicate at which juncture DISE should be performed, potentially allowing for the development of clearer protocols Sleep is a natural periodic state of rest characterised by reduced or absent consciousness, reduced sensory activity and voluntary muscle inactivity.
Although humans spend about one third of their lives asleep and deprivation can lead to serious physiological consequences, the function of sleep remains to be fully elucidated. Slow-wave or NREM sleep is characterised by four stages with distinct neurophysiological features. Its duration and frequency decreases with age. Stage 1 sleep is the transition between sleep and wakefulness and lasts minutes with a reduction of alpha waves, indicative of wakefulness, transitioning to low voltage, mixed frequency waves.
Electroencephalograms EEG demonstrate sleep spindles, K complexes and relatively low-voltage, mixed frequency activity Figure 3. Stages 3 and 4 sleep show low frequency delta waves with reducing sleep spindles. Snoring will tend to occur in the latter stages. REM sleep is defined by the presence of desynchronised brain wave activity similar to wakefulness , muscle atonia and bursts of REM.
Ventilation and respiratory flow change during sleep and become increasingly faster and more erratic during REM sleep. In addition, the efficacy of adaptive responses is reduced during sleep. The cough reflex, hypoxic ventilatory drive and arousal response to respiratory resistance are all suppressed in various stages of the sleep cycle, in part due to reduced muscle tone.
Polysomnography is a comprehensive recording of biophysiological changes during sleep with recorded parameters including oxygen saturation, nasal and oral airflow, respiratory effort via chest and abdominal movements and sleep architecture, the latter of which is not possible with home or ambulatory sleep studies Numerous attachments are therefore required for electroencephalography, electro-oculography, electromyography, electrocardiography, pulse oximetry, recording of snoring, body position, leg muscle activity, pressure transducers for nasal and oral airflow alongside belts to assess chest and abdominal movements.
Polysomnography allows the diagnosis of both sleep and movement disorders Objective values often analysed from these studies include AHI, mean oxygenation and oxygen desaturation index. The lack of a high level of evidence has been highlighted by numerous authors for this topic but also surgery in general. Many therefore recommend larger scale clinical studies 14 , However, an oft-neglected caveat is the lack of standardisation of nomenclature not only in DISE but also in the definition of success and outcomes 14 , 36 - As a corollary to this, the technique modifications amongst similar surgical procedures is myriad and makes comparison difficult and of little clinical value.
A recent Cochrane review underlined this issue and further work needs to be done to ensure improved data collation and analysis along with formulation of tangible and answerable trial hypotheses 39 , Management strategies are generally primary and adjunctive in that they may be used alone or in combination with other treatment modalities. Lifestyle modifications can be sufficient to reduce snoring significantly. Reducing body weight, alcohol intake and positional therapy by avoiding sleep positions precipitating symptoms such as supine are of value.
Recent studies have indicated that sleep position therapy can be highly efficacious 41 - Medications such as those to aid in weight loss or treat contributing conditions such as allergic rhinitis or hypothyroidism may also be of use. Nasal dilators are reserved for those patients suffering from simple snoring and nasal obstruction; these patients may benefit from reconstructive nasal surgery if there is a significant improvement.
MAS efficacy can be predicted by DISE and function by protruding the hyoid bone anteriorly along with the mandible, contracting genioglossus and thus increasing the retroglossal distance MAS is contraindicated in those with uncontrolled epilepsy, poor dentition and edentulous patients 47 - Further complications include dermatitis, rhinitis, epistaxis, aerophagia and barotrauma. Addressing these factors either medically or surgically may facilitate the use of CPAP with lower pressure requirements.
The primary aim of surgery is either to bypass upper airway obstruction or to increase the upper airway anatomical dimensions. Despite the limitations outlined above and criticisms regarding possible overenthusiastic use of surgery, there is evidence that surgical outcomes are good if patients are selected diligently 38 , 54 - Patient selection is therefore integral in ensuring successful outcomes and surgical options should be offered judiciously, with an underlying principle of site-specific surgery.
In these cases, surgery may serve to reduce CPAP pressures and hence patient compliance. Patients with a high BMI tend to do less well. To allow effective patient selection and site-specific surgery, DISE is invaluable 27 , 29 , 33 , It is worth highlighting that although in some cases a single procedure can resolve symptoms, in the main, patients display multilevel obstruction requiring careful assessment and treatments.
Nasal surgery, including septoplasty, turbinate reduction, endoscopic sinus surgery and septorhinoplasty or nasal valve surgery, can be efficacious for simple snorers and in facilitation of CPAP usage by reducing pressure requirements along with patient discomfort 16 , 63 - Palatal surgery incorporates a wide range of procedures and is the most common surgery performed for these patients. Conservative procedures are usually initially favoured over more aggressive surgery.
Minimally invasive surgeries maintain the anatomy of the soft palate but aim to scar or stiffen the soft palate by, for example, chemical injections e. The evidence base and long term efficacy of these procedures is questionable, particularly in the OSAHS group 66 - The most promising recent research, including a meta-analysis, has however highlighted the efficacy of radiofrequency applications to the soft palate for both simple snorers and OSAHS patients 38 , 55 , Radiofrequency thermoablation has few complications although ulceration and fistula formation has been reported, with NICE guidance highlighting this safety profile In addition, it can be performed under local or general anaesthetic Figure 4 38 , 55 , 69 - Radical palatal surgery involves altering the anatomy of the soft palate by removing excess tissue e.
Uvulopalatopharyngoplasty was developed by Fujita in the s but has significant associated morbidity and even mortality and as such, has fallen out of favour. Moreover, although the underlying theory is to augment the retropalatal dimension, success rates for OSAHS are low 73 , Subsequently, further options have developed such as modified Z-palatoplasty and laser-assisted palatoplasty 75 , There has also been increasing interest in relocation and lateral pharynoglasty procedures.
These surgeries focus on tissue repositioning, which can be extensive, rather than resection. In selected patients expansion sphincter pharyngoplasty a type of lateral pharyngoplasty and relocation pharyngoplasty have demonstrated promising results 79 , In the paediatric subgroup, adenotonsillectomy has conclusively been shown to improve OSAHS and improve long term quality of life 59 , 81 , The clinical picture in adults is typically more complex and multifactorial however.
The contribution of the tongue base and epiglottis to snoring and OSAHS is underappreciated and underlines the relevance and importance of a dynamic visualisation of patient snoring cycles with DISE to assess for multilevel collapse Surgery in this area can be quite challenging however.
Minimally invasive options such as radiofrequency ablation to the tongue base have been shown to be efficacious 55 , 57 , 69 , 83 , More aggressive procedures such as midline glossectomy and hyoid suspension have also been described with varying success rates 56 , 85 , Hypoglossal nerve stimulation synchronised with inspiration via the surgical introduction of an electrical implant has shown recent promise with the underlying theory that reduced upper airway muscle activity is fundamental to OSAHS.
Further research is required however as serious complications have been reported 87 , The advent of the da Vinci system has led to the development of transoral robotic surgery to address hypopharyngeal collapse, with initial promising reports 89 - Apart from tracheostomy, the highest success rates for snoring surgery have been achieved by maxillomandibular advancement MMA which increases retropalatal and retroglossal dimensions 92 -
Nasal Involvement in Obstructive Sleep Apnea Syndrome
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Sleep-related breathing disorders comprise of a wide range of conditions, including obstructive sleep apnoea OSA , where recurrent partial or complete cessation of breathing occurs. This spectrum of disorders is common and negatively impacts patient health alongside conferring a significant socio-economic burden 1. In addition, with the ensuing obesity epidemic, many of these conditions are increasing in prevalence. There is robust evidence demonstrating that moderate to severe OSA correlates independently with a large increased risk of all-cause mortality, alongside with an increased risk of, amongst others, cardiac arrhythmias, myocardial infarction, insulin resistance, pulmonary and systemic hypertension, stroke, impaired cognition and road traffic accidents 6 - CPAP was first developed in the s and its underlying principle is that of continuous mild air pressure which serves to stent open the airway, and thereby overcome anatomical areas of collapse or obstruction.
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Download Rhinologic And Sleep Apnea Surgical Techniques 1St Edition Online
Sleep-related breathing disorders SRBD encompass a wide range of conditions in which there is recurrent partial or complete cessation of breathing, including simple snoring, upper airway resistance syndrome, central sleep apnoea-hypopnoea syndrome, obesity-related sleep hypoventilation syndrome and obstructive sleep apnoea-hypopnoea syndrome OSAHS 1. This spectrum of disorders is common and not only negatively impacts on patient health but also induces a significant social and economic burden 2 - 4. SRBD, particularly OSAHS, can increase the risk of cardiac arrhythmias, pulmonary and systemic hypertension, myocardial infarction, type 2 diabetes mellitus, cerebrovascular accidents, impaired cognition and road traffic accidents 8 - Furthermore, there is evidence that moderate-to-severe OSAHS independently correlates with a large increased risk of all-cause mortality
Numerous studies have reported an association between nasal obstruction and obstructive sleep apnea syndrome OSAS , but the precise nature of this relationship remains to be clarified. This paper aimed to summarize data and theories on the role of the nose in the pathophysiology of sleep apnea as well as to discuss the benefits of surgical and medical nasal treatments. A number of pathophysiological mechanisms can potentially explain the role of nasal pathology in OSAS. These include the Starling resistor model, the unstable oral airway, the nasal ventilatory reflex, and the role of nitric oxide NO. Pharmacological treatment presents some beneficial effects on the frequency of respiratory events and sleep architecture.
This document addresses nasal surgery for the treatment of obstructive sleep apnea OSA and snoring. Note : Please see the following related documents for additional information:. Nasal surgery employing any technique is considered not medically necessary for the treatment of snoring. Nasal surgery employing any technique, including nasal valve surgery, septoplasty, turbinectomy, polypectomy and laser or radiofrequency ablation volumetric tissue reduction of the nasal turbinates is considered not medically necessary for the treatment of obstructive sleep apnea and other sleep related breathing disorders.