TITLE: Surgical Management of Sleep Apnea
SOURCE: Grand Rounds Presentation, Department of Otolaryngology
The University of Texas
Medical Branch (UTMB Health) <=
/span>
DATE: April 25, 2012
RESIDENT PHYSICIAN:
FACULTY PHYSICIAN: Farrah Siddiqui, MD
SERIES EDITOR: Francis B. Quinn, Jr., MD
ARCHIVIST: Melinda Stoner Quinn, MSICS
=
"=
This
material was prepared by resident physicians in partial fulfillment of
educational requirements established for the Postgraduate Training Program =
of
the UTMB Department of Otolaryngology/Head and Neck Surgery and was not
intended for clinical use in its present form. It was prepared for the purp=
ose
of stimulating group discussion in a conference setting. No warranties, eit=
her
express or implied, are made with respect to its accuracy, completeness, or
timeliness. The material does not necessarily reflect the current or past
opinions of members of the UTMB faculty and should not be used for purposes=
of
diagnosis or treatment without consulting appropriate literature sources and
informed professional opinion."
“For the purposes of the following discussi= on, it is useful to define the breathing events being examined. These breathing ev= ents include the following:
· Apnea
· Hypopnea
· Respiratory effort–related arousal (RE= RA)
Apnea is defined by the American Academy of Sleep Medicine (AASM) as the cessation of airflow for at least 10 seconds. Apnea may last for 30 seconds or e= ven longer.
Hypopnea is defined as a recognizable transient reduction (but not complete cessation) of breathing for 10 seconds or longe= r, a decrease of greater than 50% in the amplitude of a validated measure of breathing, or a reduction in amplitude of less than 50% associated with oxy= gen desaturation of 4% or more. An arousal is unnecessary to score a hypopnea. =
An RERA is an event characterized by increasing respiratory effort for 10 seconds or longer leading to an arousal from sleep but one that does not fulfill the criteria for a hypopnea or apnea. The criterion standard to measure RERAs is esophageal mano= metry, as the AASM recommends. However, esophageal manometry<= /span> is uncomfortable for patients and impractical to use in most sleep centers.” 3
Sleep apnea severity is graded based on the AHI: = the number of apneas, plus the number of hypopneas measured while the patient is aslee= p, divided by the time spent asleep to give an average number per hour of respiratory events. An AHI of= less than 5 events per hour is considered normal in adults. Mild sleep apnea is an AHI of 5-15, Moderate is AHI of 15-30, Severe is AHI greater than 30 events per hour, or= an average of one hypopnea or apnea every 2 minutes or less.
Treatment options include behavioral modification,
devices that can be worn, or surgical options. Some patients with mild sleep
apnea need only to sleep on their sides.&n=
bsp;
Alcohol avoidance and weight loss can also help some mild cases
resolve. There are a variety =
of
oral devices that can be worn to advance the jaw or tongue during sleep.
For preoperative evaluation of the sleep apnea pa= tient, a good Sleep History should be taken. The Physical exam should include a thorough head and neck exam inclu= ding Friedman scores for palate and tonsils, Neck circumference, BMI, and the Mu= ller Maneuver. Imaging may include Xray, CT, MRI for= cephalometrics. Polysomnography is necessary to make the diagnosis of sleep apnea and assign a severity. Identifying the site of obstructio= n on physical exam is challenging. “Numerous other methods have been used to predict the location of the upper airway obstruction--including physical examination, computed tomography, magnetic resonance imaging, and fluoroscopy. As with cephalomet= ric studies, these studies all are valuable in research studies but have not be= en shown to be of clinical value. The most commonly used test is he Muller man= euver (MM). Borowiecki and Sassi= n first described this maneuver for the preoperative assessment of SDB. The MM consists of having the patient perform a forced inspiratory effort against = an obstructed airway with fiberoptic endoscopic vi= sualization of the upper airway. The test is widely used and simple to perform. Despite this, its use is controversial and certainly no studies have been able to associate the maneuver as a tool to select patients who are likely to succe= ed with UPPP.” 7
Friedman has developed a staging system to predict success rates of uvulopalatopharygnoplasty (UPP= P) in achieving cure of sleep apnea predicted with grading systems based on physical exam a= nd BMI for mouth opening and tonsillar size. The Friedman tongue position (FTP) describes several grades of mouth opening.= “FTP I allows visualization of the entire uvula and tonsils/pillars. FTP IIa allows visualization of most of the uvula, but the tonsils/pillars are absent. F= TP IIb allows visualization of the entire soft plate to = the base of the uvula. In FTP III= some of the soft palate is visualized but the distal structures are absent. FTP IV allows visualization of the = hard palate only.”5 The tonsil grading scale is similar: “Tonsils, size 0, s/p tonsillectomy.= Tonsils, size 1, within the pillars= . Tonsils, size 2, extend to the pill= ars. Tonsils, size 3, extend past the pillars. Tonsils, size 4, extend to the midline.” 5 Combining these grades stages the patient for probability for cure. Lower s= tages predict higher success rate of UPPP alone to treat OSA
|
Stage
|
FTP
|
Tonsil
size |
BMI
|
|
I
|
I,
IIa, IIb |
3
or 4 |
<40
|
|
II
|
I,
IIa, IIb |
0,
1, or 2 |
<40 |
|
III
or IV |
3
or 4 |
<40 |
|
|
III
|
III
or IV |
0,
1, or 2 |
<40 |
The Friedman algorithm for treatment is as follow= s: Mild (AHI 5-15) sleep apnea can be treated in two ways. For symptomless patients, behavior modification is often all that is needed.&= nbsp; For patients exhibiting symptoms like daytime sleepiness and inabili= ty to concentrate, behavior modification, adding a worn device like a mouthpie= ce or CPAP, or you may consider surgery. For moderat sleep apnea, (AHI 15-3) with no sym= ptoms, consider behavior changes or adding a device. For patients with symptoms, a device, usually CPAP should be trialed, and consider surgery for device fai= lures. For severe (AHI >30) OSA patien= ts, devices are first line therapy, consider surgery as adjunct to help with tolerance = of CPAP (help to achieve cure at a lower setting), refer for bariatric surgery= for patients with BMI>40. As usually a last resort, consider tracheostomy. <= /p>
Another way of approaching this issue is to consi= der the indications for surgery. Apnea/Hypopnea Index (AHI) >20, Oxygen desaturation nadir <90% during the sleep study, esophageal pressure (PES) more negative than –= ;10 cm H2O during polysomnography, Cardiovascular derangements (arrhythmia, hypertension), neurobehavioral symptoms (excessive daytime sleepiness), failure of medical management, and clear anatomical si= tes of obstruction (nose, palate, tongue base) are all indications for surgical management. 5
Powell and Riley have outlined a protocol for pha=
sing
sleep apnea procedures. In th=
eir
phase I, the following procedures may
be considered alone or in combination to alleviate anatomical
obstructions. Nasal surgery
(septoplasty, turbinate reduction, nasal valve grafting), Tonsillectomy,
Nasal Surgeries
Nasal surgery is well described to alleviate nasa= l obstruction even without sleep apnea, including septoplasty and inferior turbinate reduction. Alar batten grafts= or spreader grafts may be placed during rhinoplasty to relieve internal valve collapse. Tonsillectomy and adenoidectomy are indicated especially in children with OSA to relieve posterior nasal and oropharyngeal<= /span> obstruction. 5
Palatal Surgeries
Many palatal surgeries may be considered for reli= eving obstruction involving the upper oropharynx. Snare Uvul= ectomy is simple removal of the uvula for upper airway resistance syndrome and sim= ple snoring, but has no studies comparing AHI pre and post procedure. Cautery assisted palatal stiffening may be considered for upper airway resistance syndrome, simple snoring, or mild OSA. One study shows AHI improvement from 12.3 to 5.2 with this method. Injection sno= replasty is indicated for simple snoring caused by palatal flutter. In one study, 76.7 to 92% of patie= nts experienced improved snoring. One downside to this procedure is that it does not last long term; however, it = may be repeated if the first time is successful.5
Palatal Implants (Pillar®) may be considered.= These are minimally invasive and l= ess painful than other palatal surgeries and consist of woven cylindrical impla= nts inserted to stiffen palate and reduce palatal flutter causing snoring. They are indicated for simple snor= ing and therefore are not usually covered by insurance as snoring procedures are considered cosmetic. Patients that benefit from this have small tonsils more than 2 cm apart, no signs of tongue base collapse, FTP I or II, and redunda= nt palatal tissue . Implantation= can be performed under local anesthesia in the office. Extrusion rate per patient is about= 10%. The Pillar reduces snoring sound intensity, but does not completely eliminate snoring. A recent 4 year longitudinal study showed that subjective improvement degrades over time to nearly baseline.5
UPPP is resection of part of the anterior tonsillar pillars, the bilateral tonsils, and the uvu= la in an arched curve. The pillars = are then approximated with suture to promote wound healing and scarring. Succes= s is defined as reduction in AHI by 50% to less than 20 events per hour. For Friedman stages, success rates= are Stage I, 81% Stage II, 37% Stage III, 8%.
Fairbanks technique, which involves a more aggres= sive lateral and superior palatal resection in more of a rectangular resection i= s reported to improve on traditional UPPP by improving lateralization of pillars. This technique minimizes shortening of the soft palate to maintain velopalatine valvular pat= ency. Reported results are similar to traditional UPPP.5
Zetapalatopharyngoplasty is a technique indicated for patients with prior history of tonsillectomy with OSA. It is indicated for Frie= dman Stage II and III patients with moderate to severe OSA. The uvula is transected medially a= nd lateral palatal flaps are demucosalized. The flaps created by the transected uvula are rotated up to cover the demucosalized palate. The healing process c= reates tension lateral and cranially instead of the tension of UPPP healing which = can be medial and caudally. ZPPP therefore is theorized to widen the retropalatal space.&= nbsp; This technique does carry a greater risk for VPI, but cure rates for stage II patients who also undergo tongue base RF with ZPPP is reported as = 70%. 5
A uvulopalatal flap h= as been performed where the anterior surface of the medial soft palate and uvula ar= e demucosalized and the uvula is rotated up to the pala= te and sutured. This procedure can be performed under local anesthesia and is initially reversible if desired out= come is not achieved. 5
Palatal advancement pharyngo= plasty shortens the bony palate with osteotomy to increase the nasopharyngeal open= ing. This technique has the advantage of maintaining the structural attachments = of the soft palate constrictors to the posterior edge of the hard palate while shortening the overall hard palate length. Studies of this technique report= a decreased RDI from average of 52.8 to 12.3 in responder group, and success = rates improved over UPPP alone for Stage III patients. 5
Tongue Base Surgeries
Tongue base reduction uses radiofrequency electro= des to create scar tissue contraction and therefore volume reduction in the base of the tongue. It can be an in-o= ffice procedure done under local with minimal side effects, and may be repeated to optimal effect. It is more effective when used in conjunction with UPPP. 5
Submucosal Lingualplasty utilizes an open approach to address
A percutaneous variation on this technique called= SMILE (Intraoral submucosal minimally invasive lingual excision) has been reported to have good success in Down’s syndrome children. Initially, neurovas= cular bundles are identified with ultrasound.&nb= sp; Then the tongue base is approached percutaneous= ly with coblation followed by copious irrigation t= hrough endoscope until sufficient volume is removed. 5
The tongue base may be suspended to the mandible = for anterior traction during sleep. The Re= pose system provides a minimally invasive approach to this procedure. A screw is implanted into the mand= ible above the genial tubercle and nonabsorbable sut= ures are drawn through the tongue base and tightened to create a sling which hol= ds the tongue base anteriorly. T= his is not indicated for OSA caused by retropalatal up= per airway obstruction. Relative contraindications include macroglossia and poor= oral hygiene. Success rates are reported as 51-78%, some in combination with UPP= P or other palatal techniques. 5
Lingual tonsillectomy may be performed if lingual tonsil hypertrophy is considered to be contributing to hypopharyngeal collapse. Definition of this condition is subject to some debate as the lingual tonsils do not have clear anatomical boundaries or sizing criteria. One study proposes lingual tonsillectomy is indicated if they are 10 mm in diameter and abutting both = the posterior border of the tongue and the posterior pharyngeal wall. 5
Multilevel pharyngeal surgeries
Hyoid myotomy and sus= pension is a variation on the Repose tongue base suspension technique where the anchoring screw above the genial tubercle retains suspension sutures that p= ass around the middle portion of the hyoid bone and are tightened to create anterior traction on the hypopharyngeal walls.<= span style=3D'mso-spacerun:yes'> One study shows improvement in AHI= from an average of 40 to an average of 19. 5
Genioglossus advancem= ent with mandibular osteotomy uses an intraoral approach to the anterior mandible to create an osteotomy that is pulled forward and secured to the remaining mandible. This technique crea= tes traction on the tongue base by advancing the genioglos= sus muscle with the osteotomy. Shapes can vary but rectangular osteotomies tend= to be less invasive and better preserve mandibular integrity. The success rate= of this method is variable from 22-67%. 5
Other surgeries
Maxillomandibular adv= ancement osteotomy with rigid fixation is a Phase II procedure. It involves mandibular osteotomies= and plate placement to advance the mandible plus advancement of the maxilla via= a surgical Lefort osteotomy resulting in advancem= ent of the entire oral cavity. Docum= ented success rates of >90% make this complicated procedure valuable as a secondary consideration if other techniques have failed. 5
The only 100% successful procedure to correct OSA= is tracheostomy. The lifestyle c= hanges required by this procedure make it less attractive to patients than others,= but some techniques are practiced to create hands-free stomas using strap muscl= es that reduce the usual burdens of tracheostomy dependence. 5
Bariatric surgery has been utilized to reduce BMI, which reduces AHI. A recent meta-analysis of bariatric surgery effect on AHI found that with an average= BMI change from 55 to 37 after surgery, average AHI was reduced from 55 to 16. = Bariatric surgery therefore meets criteria for a successful OSA intervention and should be kept in mind for t= he appropriate patients. 11=
In conclusion, sleep disorders are multifactorial= and often multilevel. Milder cases respond more readily to single intervention or lifestyle changes. In general, the more severe the sl= eep disorder, the more involved the intervention. It is important to note that surgi= cal cure usually only provides reduction in severity and CPAP will likely still necessary, but can be more tolerable to patients with sleep apnea.
References
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National Sleep Foundation. How much sleep do we really need? Washington, DC:
National Sleep Foundation; 2010. Available at http://www.sleepfoundation.org/article/how-sleep-works/how-much-slee=
p-do-we-really-need.
Accessed February 22, 2011.
2.
CDC. Unhealthy sleep-related behaviors—12 states, 2009. MMWR
2011;60:233–8.
3
http://emedicine.medscape.com/article/295807-overview
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Sur=
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Management of Sleep Apnea &nbs=
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April 2012