OSA—DANIEL TODD, MD Hx: PRIMARY Sx IS SNORING (NOCTURNAL STERTOR), PRIMARY SIGN IS APNEA—40% OF SNORERS HAVE SOME DEGREE OF OSA! 70% OF SNORERS WITH HYPERSOMNELENCE HAVE OSA! SNORES LOUDLY, APNEA, ETOH, DRUGS, HYPERSOMNELENCE—FALL ASLEEP WHILE DRIVING, NAO, AM HA’S (HYPERCARBIA), NOCTURNAL ENURESIS, INTELLECTUAL DETERIORATION, ABNL MOTOR ACTIVITY DURING SLEEP—RESTLESS, RARELY AWAKEN DURING SLEEP, HYPERACTIVITY DURING DAY, PERSONALITY CHANGES, DECREASED LIBIDO–SOME SAY IF YOU DO NOT HAVE A SEXUAL DYSFUNCTION YOU DO NOT HAVE OSA, DECREASED PRODUCTIVITY, LETHARGY, DEPRESSION, SLOW EATERS, NIGHTMARES, BIZAAR POSITIONING DURING SLEEP, ATTENTION DEFICIT, FTT—SLOW EATERS-DECREASED APPETITE, DYSPHAGIA—DECREASED REM–DECREASED GH SECRETION—-FTT, MOUTH BREATHER, HYPONASALITY, HOT POTATO VOICE, DECREASED EXCERSISE TOLERANCE, DECREASED GROWTH AND DEV. EPWORTH SLEEPINESS SCALE, MSLT(MULTIPLE SLEEP LATENCY TEST) RISK FACTORS: AGE, MALES, OBESITY, NECK CIRCUMFIRENCE, NAO, Fhx, ETOH, SMOKERS, SEDATIVES, HYPOTHYROID, ACROMEGALLY, AMYLOIDOSIS, TVC PARESIS, MARFANS, DOWN SYNDROME, GLOSSOMEGALLY PREDISPOSE TO: HTN, STROKE, MVA (MOTOR VEHICLE ACCIDENT)—HIGHER INCIDENCE THAN EPILEPSY LARYNGOTRACHEOMALACIA > B VC PARALYSIS ARE PRIMARY CONG CAUSE OF OSA—-BEWARE OF GENETIC COMORBIDITIES–STICKLER AND PIERRE ROBIN SEQUENCE—MAY TRY LIP ADHESION–DO BETTER PRONE DOWN SYNDROME, AMYLOID, AND STORAGE DISEASES—MACROGLOSSIA PMHx: MEDS, ETOH—–PROBABLY LINKED TO SIDS AND GERD IF PT OR PARENTS NOT SURE—-POOR MAN’S PSG–TAPE OR VIDEO RECORDER—-PARENTS NOTE: PRESENCE OF APNEA, DURATION, FREQUENCY, QUALITY OF 1ST POST APNEIC BREATH PE: “DESC. CURTAIN SIGN”(VELUM INF TO HORIZONTAL BOT), TONSILLAR HYPERTOPHY, HYPONASALITY, HOT POTATO VOICE, ENLARGED LINGUAL TONSIL, ADENOID, AND FAUCIL PILLARS, ?SEPTAL DEVIATION, POLYPS—?CF, ADENOID FACIES, HTN, OBESITY—-CHILDREN–PECTUS EXCAVATUM, UMBILLICAL HERNIA, DS(DOWN SYNDROME)—HYPOTONIA NAO PROBABLY HAS LITTLE TO DO WITH SNORING, PERHAPS MORE TO DO WITH OSA—–ALL SNORING IS PALATAL ALTHOUGH WE SOMETIMES REFER TO IT AS NASAL OR ORAL EKG–R HEART STRAIN–COR PULMONALE CXR–RVH CBC–SLIGHT POLYCYTHEMIA HOLTER–NOCTURNAL DYSRYTHMIAS FLEXIBLE--MEULLER’S MANEUVER—REVERSE VALSALVA—ALWAYS PREPARE PT--50% PREDICTIVE OF UPPP SUCCESS—GIVES YOU AN IMPRESSION—REALLY A NEG PRESSURE MANEUVER VS WHAT REALLY HAPPENS—-A BOURNOULLI EFFECT—-PROBABLY SHOULD DO IN A SUPINE POSITION—GIVES YOU AN INDIRECT MEASURE OF AIRWAY COLLAPSIBILITY OBSTRUCTION GRADED–I=0-25%, II = 25-50%, III = 50-75%, IV = 75-100%—-PROBABLY EASIER JUST TO USE % SNORING MANEUVER “MODIFIED” FUJITA TYPE I–PALATE ONLY (OP)—–UPPP—20-25%OF PTS AT MOST FUJITA TYPE II–PALATE AND BOT (OP & HP(RETROGOSSAL))—–UPPP + GAHM—PROBABLY GREATER THAN 75% OF PTS FUJITA TYPE III–BOT ONLY (HP(RETROGLOSSAL))—–GAHM—10% OF PTS REALLY MOST OF THE COLLAPSE IS LATERAL TO MEDIAL—-NOT ANT TO POST! PE–MALLAMPATTI AIRWAY CLASSIFICATION OF OC/OP VIEW CEPHALOMETRIC MEASUREMENTS–LAT SOFT TISSUE X-RAY—LOOK AT DISTANCES FROM MANDIBLE TO HYOID–GIVES YOU AN APROXIMATION OF PHARYNGEAL LENGTH—LENGTH TENDS TO CORRELATE WITH COLLAPSIBILITY—REALLY AN EVOLVING ART—PTS WITH HYPO-MAXILLA (PSEUDO-PROGNATHISM) TEND TO HAVE A TREMENDOUS AMOUNT OF TROUBLE FLOUROSCOPY CT OR MRI IMAGING MAY COME INTO PLAY MORE AND MORE WITH 3-D RECONSTRUCTION AND REAL TIME IMAGING CAVEATE—MG MAY PRESENT THIS WAY, R/O HYPOTHYROIDISM, CONSIDER DEPRESSION(CHICKEN OR EGG), ETOH, GERD–IRRITANT VAGALLY MEDIATED APNEA, NEOPLASM OR CONG MASS—-CRANIO-FACIAL MALFORMATION OR HYDROCEPHALUS–ABNL CSR DRAINAGE CORRELATES WITH ABNL SKULL BASE ANATOMY AND OSA PSG: CO2 RETENTION, NOCTURNAL DYSRYTHMIAS, AI, RDI, SLEEP LATENCY (NL=10-15 MIN) DEFINITIONS APNEA = RESP PAUSE > 10 sec “WANT OF BREATH”, >10 TIMES/HOUR DYSPNEA=SENSATION OF SOB APNEA INDEX = AVG # OF APNEAS/HOUR HYPOPNEA–DROP IN O2 SAT WITHOUT APNEA DESAT—<90=ABNL, <80=CRITICAL RDI = RESP DISTURBANCE INDEX = THE MEAN # OF APNEAS + HYPOPNEAS/HOUR NL = < 5 (SOME USE 10) MILD—(RDI 5-20) MOD—(RDI 20-40)
SEVERE—(RDI 40-60) PICKWICKIAN—(RDI >60) CENTRAL APNEA—ONDINE’S CURSE—REQUIRES DIAPHRAGMATIC PACING DEGREES OF DISEASE: SNORING WITHOUT APNEA GRADE I—ETOH OR ON BACK GRADE II—HEAR DOWN THE HALL GRADE III–HEAR EVERYWHERE —-30% OF MALES AGE 30, 60% OF MALES AGE 60, MALE(15) > (1)FEMALE, —OVER 300 DEVICES PATENTED PALATAL SNORING=LOWER FREQUENCY(300-400 HZ) BOT/PHARYNGEAL SNORINING = HIGHER FREQUENCY (800-1000HZ) CORRELATES WITH LIKLIHOOD OF DEV HTN AND CARDIAC Dz AS WELL AS WITH LIKELYHOOD OF MARRITAL PROBLEMS UARS (UPPER AIRWAY RESISTANCE SYNDROME) FREQUENT AROUSALS ABNL NEG INTRATHORACIC PRESSURE NL RDI DAY TIME HYPERSOMNELENCE OSA MILD—(RDI 5-20) MOD—(RDI 20-40) SEVERE—(RDI 40-60) PICKWICKIAN—(RDI >60)—HIGH RISK! MALE 8:1 SEEMS TO CORRELATE DIRECTLY WITH TESTOSTERONE AND INVERSELY WITH PROGESTERONE TREATMENT NON-SURGICAL—TRY FIRST TRIAL OF AFRIN/BREATH-RITE PROGNATHIC MOUTH INSERT–ORAL APPLIANCE O2—DOES NOT HELP–MAY ACTUALLY DECREASE RESP DRIVE–PROLONG APNEA CPAP(+5-20 CM H2O) BIPAP—BETTER TOLERATED—-BETTER FOR COPD METHOXYPROGESTERONE—RESP STIMULANT PROTRIPTYLINE (VIVACTIL) KEEPS PTS OUT OF STAGE 4 SLEEP SURGICAL TREATMENTS NOSE—-START WITH THE NOSE—OS RHINO WITH SPREADERS—-SEPTOPLASTY, BIT’S—-STARLING RESISTOR PRINCIPLE—NAO (USUALLY VALVE REGION)—NECESSITATES HIGHER NEGATIVE PRESSURES PROXIMALLY IN THE OP TO FACILITATE ADEQUATE INSP—LEADS TO PHARYNGEAL COLLAPSE! PALATE-—LAUP—KAMAMI–FANCE IN LATE 1980’S—-USE CO2 LASER IN THE OFFICE RADIOFREQUENCY VOLUMETRIC TISSUE REDUCTION (THREE HITS TO THE PALATE AT 700 JOULES EACH)—SOMNOPLASTY REPOSE—BOT TO INNER TABLE OF MANDIBLE SUTURE—-MANY PROBLEMS SEEN WITH THIS UPPP–ALSO LATERALIZES THE TONSILAR PILLARS TO OPEN THE VP AIRWAYMIDLINE PARTIAL GLOSSECTOMY —–NEVER DO PALATAL WORK WITH AN ADENOIDECTOMY!!!—CICATRICIAL STENOSIS AND VPI PTS WHO HAVE NOT HAD A PRIOR TONSILLECTOMY DO BETTER WITH A UPPP BEWARE OF POSSIBLE VOICE CHANGES, VPI, FAILURE TO CONTROL OSA(50%), AND VERY SORE THROAT BOT—-LINGUAL TONSILLECTOMY–REALLY ONLY GOOD FOR ADULTS—NOT PEDS—THE TONGUE MOVES INDEPENDANT OF THE LAT PHARYNGEAL WALLS—- RADIOFREQUENCY VOLUMETRIC TISSUE REDUCTION OF THE BOT MULTI-LEVEL PHARYNGEAL SURGERY GAHM (GENIOGLOSSUS ADVANCEMENT AND HYOID MYOTOMY)–DO NOT BEVEL YOUR MANDIBULAR OSTEOTOMY—-TAKE A BIG CHUNK—PULL IT ANT AND PUSH IT DOWN AND POSITION IT LIKE A BIG CHIN IMPLANT–PUT A PLATE ACROSS THE APERTURE—USED TO SUSPENT HYOID TO MANDIBLE—-NOW CAREFULLY CUT OFF THE ATTACHMENTS OF THE LESSER CORNU (STYLOHYOID MUSCLE AND TENDON) AND FIX THE HYOID OVER THE THYROID CARTILAGE MAXILLO-MANDIBULAR OSTEOTOMY WITH ADVANCEMENT TRACH = THE GOLD STANDARD