Surgical Treatment for Snoring and Obstructive Sleep Apnea (OSA)
Practice and Services: Sleep Medicine- Snoring and Obstructive Sleep Apnea) surgical treatment
Obstructive sleep apnea (OSA) is a relatively common sleep disorder, affecting an estimated range of 3% to7% of adults. OSA prevalence is directly proportional to the body mass index (BMI), so the disease is more common among obese people. The consequences of untreated OSA might include sudden death, uncontrolled hypertension, coronary artery disease, congestive heart failure, depressive symptoms, social, economic and decreased overall quality of life of the patient and family.
A careful ear, nose and throat (ENT) history of each patient will be taken with particular attention given to sleep history. For all cases, the following data were recorded: (1) AGE (2) SEX (3) Date of Diagnosis, (4) pre-operative and 6 months post-operative Apnea-Hypopnea Index (AHI) and lowest oxygen saturation. Patients are enrolled in conformance with the following inclusion, exclusion criteria:
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Inclusion criteria included:
Patients diagnosed with mild to severe OSA (AHI ≥ 5), having the main site of obstruction at the retropalatal level with or without retrolingual obstruction, patients not accepting or unwilling to use CPAP treatment, failures of previous surgery, age between 21 and 70 years, body mass index (BMI ≤ 35, patients fit for general anesthesia (ASA < 2).
Exclusion criteria included:
Patients >70 years and/or with severe medical illness, patients with significant craniofacial anomalies affecting airway, BMI >35, patients with limited mouth opening (interincisive distance <1.5 cm) and patients unfit for general anesthesia (ASA >2.0).
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Cardio-Pulmonary Clearance and possibly Neurological evaluation
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Polysomnography Sleep Test (PSG); Body Mass Index (BMI); Epworth Sleepiness Scale (ESS); Apnea-Hypopnea Index (AHI) and severity of OSA should be determined.
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Transnasal Flexible Laryngoscopy – To determine the presence of nasal disorder and the presence of palato-pharyngeal collapse (soft palate).
Drug Induced Sedation Endoscopy to determine soft palate collapse
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Barbed Reposition Pharyngoplasty (BRP), Expansion Sphincter Pharyngoplasty (ESP), Uvuloplasty to widen the opening and prevent collapse of the palato-pharyngeal space, Tonsillectomy
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If with Chronic Rhinosinusitis and nasal obstruction (w/ or w/o polyps) Endoscopic sinus surgery can be done with Septoplasty and Turbinoplasty.
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Transpalatal Advancement/Le Fort 1 midfacial advancement is reserved for those with midfacial deformities e.g. Maxillary Cleft palate retrusion and syndromic craniofacial abnormalities like Apert’s.
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Retrolingual tissue volumetric reduction.
Several degrees and patterns of collapse of the upper airway (UA) during sleep have been described in patients with OSA. Attention is mainly focused on soft palatal collapse which is considered the most common site causing OSA and Snoring. Retropalatal space enlargement is one of the main surgical aims for patient with OSA. Although UPPP is commonly performed procedure it has many comorbidities and low success rate (40%). Velopharyngeal dysfunction (VPD), pain, bleeding, abnormal sensation in the throat and difficulty swallowing are the most common problems. To overcome these morbidities, modifications of UPPP have been proposed.
The Lateral Pharyngoplasty (LP) was aimed at addressing the lateral pharyngeal wall collapse in patients with OSA but it carried severe postoperative dysphagia as relevant drawback. Another frequently used technique is Expansion Sphincter Pharyngoplasty (ESP), which involves rotation of the palatopharyngeus muscle and its anchorage to the Pterygoid Hamulus, a partial Uvulectomy and closure of the anterior and posterior tonsillar pillars.
A new palatal surgical technique is the Barbed reposition pharyngoplasty (BRP). This procedure allows the surgeons to achieve widening and stiffening of the nasopharyngeal inlet without any sacrifice by means of a bidirectional barbed suture that is inserted through the fibro-muscular tissues of the soft palate and the posterior tonsillar pillars, and tightened around three steady holds: the posterior nasal spine and the two pterygoid hamuli lateral to the pterygomandibular raphe.
Immediate post-operative care for Severe OSA should be observed in ICU with CPAP for close monitoring of airway obstructions. If patient can tolerate food when fully awake he is given cold soft food and nothing hot. All other medications are first given thru intravenous fluid. A repeat Polysomnography sleep test is required after 6 months post-operative to know the progress and improvement of the patient or will still require CPAP use.