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SLEEP APNEA
Stephen A. Schendel, M.D., D.D.S.
Richard L. Jacobson, D.M.D., M.S.
Joseph A. Broujerdi, M.D., D.M.D.
Prepared by Jenny R. Armstrong, B.A.
STEPHEN A. SCHENDEL, M.D., D.D.S.
 Surgical interests are craniofacial and maxillofacial surgery, including sleep apnea and orthognathic surgery
 Professor of Surgery Emeritus at Stanford University Medical Center and Lucile Packard Children’s Hospital
EDUCATION AND TRAINING:
 Graduate of University of Minnesota Dental School in 1973
 Residency at Parkland Memorial Hospital in Dallas
 Studied as a Fulbright Fellow at the University of Nantes in France
 Emphasis of cleft lip & palate surgery and dentofacial orthopedics under the tutelage of Dr. Jean Delaire
 Graduate of University of Hawaii Medical School in 1983
 Assistant to Dr. Paul Tessier 1987 to 1988 in Paris, France
 General Surgery internship at Baylor University Medical Center, Dallas
 General Surgery and Plastic Surgery training at Stanford University Medical Center
ACHIEVEMENTS:
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Recipient of a Chateaubriand French Research Fellowship
Full-time faculty of the Division of Plastic and Reconstructive Surgery at Stanford University Medical School from 1989 until 2007
Leader in the field of distraction osteogenesis for the correction of facial deformities.
Board-certified in Oral and Maxillofacial Surgery and Plastic Surgery
Fellow of the American College of Surgeons
Fellow in the American Academy of Pediatrics
Former President of the American Society of Maxillofacial Surgeons
Former board member of the American Society of Plastic Surgeons from 1992 to 2002
Former Chief of Plastic Surgery at Stanford University Medical Center and Chief of Pediatric Surgery
Chairman of the Department of Functional Restoration from 1994 to 2001
Director of The Craniofacial Anomalies Center at Lucile Packard Children’s Hospital from 1994-2007
Full-time faculty of the Division of Plastic and Reconstructive Surgery at Stanford University Medical School from 1989 until 2007
PUBLICATIONS
 He has published over 100 articles and chapters including a textbook on maxillofacial surgery.
RICHARD L. JACOBSON, D.M.D., M.S.
 Board certified orthodontist practicing in Pacific Palisades for 30 years
 Additional areas of interest and expertise include orthognathic surgery and temporomandibular joint disorders
 Part-time instructor at UCLA School of Dentistry Department of Orthodontics
EDUCATION AND TRAINING:
 UCLA School of Dentistry Department of Orthodontics 1981
 M.S. in Oral Biology UCLA 1979-1983 TMJ Department
 American Institute of Bioprogressive Education
 Mentored by Robert M. Ricketts, D.D.S., M.S., and Tom Graber, D.D.S., M.S, PhD.
SERVICE
 Director of the Foundation for Orthodontic Research and Education 1990-2000, elected President in 2000
 Director of the Western Orthogmorphic Diagnostic team
 Service on the UCLA/St. John's Cleft Palate and Craniofacial Team
 President of the UCLA Orthodontics Alumni Association 1985, 2001
 Reviewer for the American Journal of Orthodontics and World Journal of Orthodontics (2011)
 International Review Board approval for an airway study on 1300 patients (May 2011)
PUBLICATIONS
 Textbook: Radiographic Cephalometry: From Basics to 3-D (Quintessence)
 American Journal of Orthodontics, Journal of Clinical Orthodontics, Journal of Oral and Maxillofacial Surgery
JOSEPH A. BROUJERDI, M.D., D.M.D.
 Dual training in Plastic & Reconstructive surgery and Oral & Maxillofacial Surgery
 Sub-specialty and surgical interests: Cranio-Maxillofacial Surgery and Surgical Treatment of
Sleep Disorders
EDUCATION AND TRAINING:
 Graduate of the University of Pennsylvania School of Dental Medicine
 Craniofacial/Pediatric Plastic Surgery fellowship at Stanford University Medical Center, Lucile
Packard Children’s Hospital
 Plastic & Reconstructive Surgery at Wayne State University/Detroit University Medical
Center
 General Surgery and Oral & Maxillofacial Surgery at SUNY Downstate/Kings County
Hospital Center
ACHIEVEMENTS:
 Recipient of Henry M. Goldman award from the University of Pennsylvania
PUBLICATIONS:
 Dr. Broujerdi has written many papers covering new developments in the field of Plastic &
Reconstructive Surgery, contributed to peer-reviewed journals, and co-authored a book
chapter on Maxillofacial Surgery. He has given presentations and spoken at national and
international conferences.
RELEVANT TERMINOLOGY
Sleep-Disordered Breathing (SDB)
Obstructive Sleep Apnea (OSA)
Upper Airway Resistance Syndrome
(UARS)
Apnea
Hypoapnea
Snoring
• All encompassing term for abnormal sleep patterns and disturbances
• Includes OSA and UARS
• Re-occuring partial or complete collapse of the upper airway during sleep, resulting in arterial
desaturation
• Occurs 5 or more times per hour in sleep (AHI>5)
• Patients symptomatic
• Patients symptomatic
• Evidence of nocturnal sleep fragmentation
• AHI <5
• No oxygen desaturation
• Cessation of breathing during sleep
• Reduction of airflow, abnormally low respiratory rate, shallow breathing lasting for 10 or more
seconds
• Indication that airway is partially obstructed
EPIDEMIOLOGY
EPIDEMIOLOGY OF SNORING
 Affects 90 million adults in the
USA
 37% of adults self-report
snoring a few nights a week in
previous year
 27% of adults self-report
snoring every night
 Studies indicate that a more
reasonable estimate is 50% of
adults snore
 Men slightly more likely to
snore than women
National Sleep Foundation, 2002. Sleep in America. www.sleepfoundation.org, 4 May 2011
Powell N., Riley R., Schendel S. California Sleep Institute, 2009. www.calsleep.com, Snoring. 4 May 2011
EPIDEMIOLOGY OF UARS
 No gender bias
 Non-obese (BMI <25)
 Younger patient
 Mean age 37.5 years
Guilleminault C., Takaoka S. 2009, Signs and Symptoms of Obstructive Sleep Apnea And Upper Airway Resistance Syndrome.
Friedman M., ed. Sleep Apnea and Snoring: Surgical and Non-Surgical Therapy, Saunders Elsevier, Chicago, p 3-8.
EPIDEMIOLOGY OF SLEEP APNEA
 2-5% of the population
 18 million people in the USA
 More males than females until
menopause
 25% of adult men
 9% of adult women
 Typically presents between ages
of 40-60
 1/3 of those with OSA have
cases severe enough to warrant
immediate treatment
Stevens, Damien R. Sleep Medicine Secrets. Hanley & Belfus, Inc.: Philadelphia, 3004. p 3
Powell N., Riley R., Schendel S. California Sleep Institute, 2009. www.calsleep.com, Snoring. 4 May 2011
EPIDEMIOLOGY OF SLEEP APNEA
Worsens with
increasing age
Enlarged tonsils
and adenoids
Dentofacial
deformities
• High narrow palate
• Elongated soft palate
• Small or deficient jaw
Family history of
sleep apnea
2 men with OSA for
each woman
(4% men
vs. 2% women
Obesity with BMI
greater than 25
(60%-90% of
OSA are obese)
Neck size greater
than 17 inches
Friedman et al, 2009. pp 3, 51.
EPIDEMIOLOGY OF SLEEP APNEA: WOMEN
More ‘vigilant’ sleepers (more concerned about
bed-partners sleep)
More likely to have REM-related apneas and
therefore tougher to diagnose
Tend to be more obese and have lower AHI than
men
Some studies suggest women with OSA may have
higher mortality
Post-menopausal women are 3x more likely to
have OSA than pre-menopausal women
Increased risk of sleep apnea during pregnancy
National Sleep Foundation, Women and Sleep. http://www.sleepfoundation.org/article/sleep-topics/women-and-sleep 4 May 2011
SYMPTOMS
Excessive daytime
sleepiness
Apneas or loud
snoring observed
by bed partner
Choking
sensations upon
awakening
Gastroesophageal
reflux
Reduced ability to
concentrate
Memory loss
Personality
changes
Mood swings
Nocturia
Dry mouth
upon awakening
Morning
headache
Impotence
Friedman et al, pp 1
NON-SPECIFIC SYMPTOMS: WOMEN
Insomnia
Disrupted
sleep
Chronic
fatigue
Depression
Anemia
Fatigue
Fibromyalgia
Menopausal
changes
Friedman et al, pp 8
EPIDEMIOLOGY OF SLEEP APNEA
An individual with
untreated apnea is up
to 4 times more likely
to have a stroke & 3
times more likely to
have heart disease
(National Sleep Foundation)
People suffering from
sleep apnea are 6 times
more likely to be involved
in a car crash (as a result
of drowsiness) than those
without sleep disorders.
(New England Journal of Medicine,
March 18, 1999)
Treatment with CPAP
was found to lower
blood pressure and
reduce risk of stroke
by 20%
(The Lancet 2002, 359: 204-210)
The NHTSA estimates that
each year drowsy driving
is responsible for at least
100,000 automobile
crashes, 40,000 injuries,
and 1550 fatalities
(National Sleep Foundation)
EPIDEMIOLOGY OF SLEEP APNEA:
MEDICAL COMPLICATIONS
Increased
risk of:
• Heart problems
• CHF
• cardiac arrest
• stroke
• high blood pressure
• type II diabetes
• constant fatigue
• personality changes
• headaches
• decrease in sexual desire/impotance
• increased risk of accidents
ANATOMY
AIRWAY ANATOMY
Upper
Airway
Space
(UAS)
• Posterior of post-nasal spine (PNS) to superior point of
hyoid bone
• Retropalatal Space (RP)
• Posterior of PNS to edge of the soft palate
• Retroglossal Space (RG)
• Edge of soft palate to superior point of hyoid bone
• Epiglottis
Nasal
Airway
Space
(NAS)
• Internal Nasal Valve
• External Nasal Valve
• Pharynx
• Hard palate
• Uvula
• Turbinates
• Septum
AIRWAY ANATOMY
Friedman et.al, 2009. pp 96
ANATOMY: NASOPHARYNX
ANATOMY: NASOPHARYNX
 Airflow of Inspiration
 Parabolic curve
 directed superiorly through
the nostril
 Up through the nasal cavity
passing the turbinates
 Posteriorly passes through
the nasopharynx
ANATOMY: INTERNAL NASAL VALVE
 4 structures
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SUPERIOR: Upper lateral cartilage
MEDIAL: Nasal septum
INFERIOR: Pyriform aperture
POSTERIOR: Head of inferior turbinate
 Narrowest part of the nasal passage
 Source of nasal resistance
 Narrowest portion of IV is region
between septum and near the posterior
border of the upper lateral cartilage
 10-15 degrees in Caucasians
 Wider in African Americans and Asians
 IV angles < 10 degrees more prone to
nasal valve collapse
Friedman et.al, 2009. pp 120
ANATOMY: TURBINATES
 Filter and heat air from 0 to 36 and humidify it
 Special air flow receptor cells on surface of inferior turbinates
 Secretes mucous that keeps nose moist and limits drying
Friedman et.al, 2009. pp 120
ANATOMY: EXTERNAL NASAL VALVE
 Nares
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Alar margin
Soft tissue triangle
Columella
Nasal sill
 Nasal vestibule
 Inside the external naris
 Septum and Columella are located
medially
 Alar sidewalls are lateral to the vestibule
 Vibrissae
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Located within vestibule
Filter air
Direct air posteriorly into nasal cavity
Limit rate of inspired air
Friedman et.al, 2009. pp 120
ANATOMY: NASAL MUSCULATURE
 Elevator muscles
 Procerus
 Levator labii superioris alaeque
nasi
 Anomalus nasi
 Depressor muscles
 Alar nasalis
 Depressor septi nasi
 Compressor muscles
 Transverse nasalis
 Compressor narium mino
 Dilator muscles
 Alar muscles
 Dilate the IV to keep the lumen
open
AIRFLOW: NASAL STRUCTURES
 IV and EV function together to
deliver smooth air current
 Inspiration:
 Nostrils flare
 EV is increased
 Bernoulli Principle
 Intraluminal pressure in the IV
decreases when airflow is
increased
 cartilage in nose counterbalances
tendency towards IV collapse
 IV area should remain
unchanged during normal nasal
function
CAUSES FOR NASAL OBSTRUCTION
• Normal nose contributes to 50% of upper airway resistance
Structural
3 Causes
• Septal deviation
• Hypertrophy of the inferior or
middle turbinates
• Inspiratory or fixed nasal
valve collapse
• 13% of adults with chronic
nasal obstruction
• Polyps
Mucosal
Neuromuscular
•
•
•
•
Allergic rhinitis
Vasomotor rhinitis
Chronic sinusitis
Upper respiratory infections
STRUCTURES OF THE NOSE OFTEN
INDICATING NASAL OBSTRUCTION
Narrow or Weak Upper
Cartilaginous Vault or
weak lateral nasal walls
Narrow IV
Collapse in the resting state
Small decreases in cross-sectional area of IV can be substantial
EV collapse due to
insufficient support of the
alar rim and alar lobule
Short nasal bones and
long upper cartilagious
ault
Narrow, projecting nose
Slit-like or small nostrils
Pinching of the lateral wall
with inspiration
Thin cartilage
Nasal obstruction may
result in mouth
breathing
Tongue gets pushed back
Limited growth of mandible
Adenoid Face Syndrome
Pouseille’s Law
ANATOMY: OROPHARYNX &
HYPOPHARYNX
ANATOMY: RETROPALATAL SPACE
 Hard Palate
 Bony structure
 Separates nasal and oral cavities
 Occupies 2/3 of total oral palate
 Soft Palate
 Occupies 1/3 of total oral palate
 Uvula
 Prevents air escape into nasal cavity
during speech
 secretes mucus for swallowing and
digestion
 prevents choking and regurgitation of
liquids
 controls gag reflex
 prevents passage of food/liquids into
nasal passages
 Tongue
ANATOMY: PALATE
 Soft Palate
 Fibromuscular tissue
 Separates oral and nasal cavities
 Ends posteriorly with the uvula
 Musculature:
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Levator veli palatini
Tensor veli palatini
Palatopharyngeus
Musculus uvulae
Palatoglossus
 Nerve
 Pharyngeal Plexus
 CN V2
 Function:
 Mucous secretion
 Prevents regurgitation of food into
nasal cavity
ANATOMY: RETROGLOSSAL SPACE
 Epiglottis
 Base of Tongue
 Hyoid
 Genioglossus, geniohyoid, and middle pharyngeal constrictor
muscles insert on hyoid bone
 Tonsils
 Mandible
 Genioglossus
CAUSES OF POTENTIAL AIRWAY OBSTRUCTION
Relaxation of
the throat
muscles
Anatomical
abnormalities
of the nose
and throat
Obesity
Causes:
Muscle
relaxers and
other
medications
Sleep position
Alcohol
MOST COMMON CAUSE IS ANATOMIC ABNORMALITY LEADING TO OBSTRUCTION
MAJOR SITES OF POTENTIAL AIRWAY
OBSTRUCTION
 Nose
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Septum
Nasal valve
Turbinate
Polyp
 Palate
 Oropharynx
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Tonsils
Lateral pharynx
Tongue
Mandible
Hyoid
Epiglottis
SLEEP ARCHITECTURE
 Sleep Stages:
 REM – Rapid Eye Movement
 20-25% of total sleep time
 Memorable dreaming occurs as well as atonia
 NREM – Non-Rapid Eye Movement
 3 Stages:
 N1
 Somnolence
 Sudden twitches/jerks can occur with onset of sleep
 Loss of muscle tone
 N2
 Muscular activity decreases
 Awareness of external environment disappears
 45-55% of total sleep in adults
 N3 – Delta Sleep or Slow-Wave Sleep
 Parasomnias occur
 NREM-REM Cycle
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N1  N2  N3  N2  REM
Each cycle lasts from 90 to 110 minutes on average
Deep sleep is stage N3 and occurs earlier in cycle
REM is later in sleep cycle before awakening
DIAGNOSTICS
DIAGNOSING SLEEP APNEA IN OUR PRACTICE
Clinical
examination and
patient symptoms
Excessive daytime
sleepiness
Airway analysis
Identify region of
abnormality and
obstruction
Polysomnogram
AHI
• Upper Airway Space
• Nasal Passages
Decreased
concentration and
work performance
Oxygen Desaturation
Loud snoring
EKG
Dentofacial
abnormalities
Sleep Architecture
Epworth Sleep Scale
Nasal Endoscopy
Identify region of
abnormality and
obstruction
Meuller’s
Manuever
Identify region of
abnormality and
obstruction
CLINICAL EXAMINATION
Ht., Wt., BMI, Neck Circ.
•greater than 17 inches
Nose
•Cottle test, septum, turbinate
Palate
•U vs. V shape
Uvula
•Thickness & Length
Tonsil size
•Size 0, 1, 2, 3, 4
Lateral Pharyngeal tissue
•Ant. & Post. tonsil pillars U vs. V shape
Tongue size
•Mallampati classification I, II, III, IV
CLINICAL EXAMINATION: BMI
Grade 0 - < 20
• Underweight
Grade 1 – 20-25
• Normal
Grade 2 – 25-30
• Overweight
Grade 3 – 30-40
• Obese
Grade 4 - >40
• Morbidly
Obese
CLINICAL EXAMINATION: NASOPHARYNX
Cottle Test
• cheek is retracted laterally and patient breathes quietly
• determines if should correct septum or valve
• positive result if Cottle test improves breathing and indicates valve problem
Septum
• image of normal vs. deviation
• Cause airflow turbulance and dryness/bleeding if deviated
Turbinate
• Enlarged vs. normal image
Alar collapse
Polyps
CLINICAL EXAMINATION: NASOPHARYNX
CLINICAL EXAMINATION: OROPHARYNX
AND HYPOPHARYNX
Palate
• U vs. V Shape
Lateral Pharyngeal Tissue
• anterior and posterior tonsil pillars
• U vs. V shape
Uvula
• thickness and size
Epiglottis
• position and character
Laryngeal view
•
•
•
•
I Full view of VC
II Partial View of VC
III Epiglottis only
IV No epiglottis
Hyoid
• position
Dentofacial Characteristics
• periodontal condition
• dental occlusion
• skeletal proportions
CLINICAL EXAMINATION: TONGUE SIZE
 Mallampati Position of Tongue
 Based upon patient sticking tongue out
 3 grades
 Friedman Tongue Postions (FTP)
 Method to approximate obstruction at
hypopharyngeal level
 Evaluate tongue in neutral, natural position
inside mouth
 Repeat procedure 5 times
 5 Positions
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I – Tonsils, Uvula, Pillars
IIa – Uvula
IIb – Most of soft palate, base of uvula
III – Some of soft palate
IV – Only hard palate
Friedman et al., 2009, pp 106
CLINICAL EXAMINATION: TONSIL SIZE
 0 – surgically absent
 1 – less than 25%
 hidden within pillars
 2 – 25-50%
 extending to pillars
 3 – 50-75%
 Extending beyond pillars
 4 – 75-100%
 Extending to midline
CLINICAL EXAMINATION: OSAHS SCORE
FTP
(O-IV)
Tonsil
Size
(O-4)
BMI
Grade
(0-4)
OSAHS
Score
INTERPRETING RESULTS
• >8 Positive OSAHS
• 74% effective in predicting severe OSAHS (AHI >45)
• <4 Negative OSAHS
• 67% effective in predicting AHI <20
Friedman et al., 2009, pp 109
CLINICAL EXAMINATION: CRANIOFACIAL CHARACTERISTICS
Short anterior
cranial base
Less obtuse
cranial base
flexure angle
Mandibular
retrusion,
hypoplasia
Maxillary
retrusion,
hypoplasia
Steep mandibular
plane,
dolicocephalic
facial pattern
Long soft palate
Decreased airway
space
Lowered position
of hyoid bone
Increased anterior
facial height
Adenoid face
syndrome
CLINICAL EXAMINATION:
EPWORTH SLEEPINESS SCALE (ESS)
Scaled questionnaire
intended to measure
daytime sleepiness
• Developed in 1991 by
Dr. Murray Johns of
Epworth Hospital in
Melbourne, Australia
Requires patient to
rate probability of
falling asleep on a
scale of increasing
probability between
0-3 for 8 situations
SCORE
INTERPRETATION:
The sum of the
scores for each
question is the
patients total score
• 0-9 Normal
• 10-24 Expert medical
advice should be sought
CLINICAL EXAMINATION:
EPWORTH SLEEPINESS SCALE (ESS)
CLINICAL EXAMINATION:
MUELLER MANEUVER
Forced inspiratory
effort against
obstructed airway with
fiberoptic endoscopic
visualization of airway
Evaluate pharynx
4 degrees of airway
obstruction defined
Describe any visible
obstruction linked to
the epiglottis
•Exposes UAS to negative
intraluminal pressure
• THERE IS SOME EVIDENCE THAT
MUELLER MANEUVER DOES NOT REFLECT ACTUAL
SITES OF OBSTRUCTION DURING SLEEP
Friedman et al., 2009, pp 104, 224
UPPER AIRWAY ANALYSIS
Volumetric
(cm3)
Surface Area
(mm2)
•
•
•
•
• Choke points
• Area of smallest
surface area
• Identify
independently
in Retropalatal
Space and in
Retroglossal
Space
UAS
RP
RG
NAS
Length (mm)
Height (mm)
• 2-dimensional
length parameters
of the choke
points
• Transverse
dimension
• Anteriorposterior
dimension
• 2-dimensional
height of the
airway
• Retropalatal
height
• Retroglossal
height
HISTORICALLY:
2-D CEPHAMALOMETRIC ANALYSIS
 Standardized lateral x-ray of H&N for
skeletal and soft tissue assessment
 Multiple bony and soft tissue
measurements
 Skeletal Class I, II, III
 Good estimate of A-P dimension
 No estimate of transverse dimension
 Performed upright when patient is
awake
 muscles are active
 Head position is different than when
resting
 may underestimate degree tissue falls
HISTORICALLY:
2-D CEPHALOMETRIC ANALYSIS
 SNA 82
 SNB 80
 Posterior airway space (PAS)
11mm
 Soft palate length (35 mm)
 Mandibular plane to hyoid
(MP-H) 15
 Patients with OSA have
decreased SNB, narrow
PAS, and high MP-H
AIRWAY ANALYSIS: 2-D VS. 3-D
PATIENT WITH NORMAL AIRWAY
AIRWAY ANALYSIS: 2-D VS. 3-D
PATIENT WITH SDB
AIRWAY ANALYSIS: 2-D VS. 3-D
PATIENT WITH OSAHS
ANATOMICALLY NORMAL PATIENT RESEARCH:
CLINICAL EXPERIENCE
390 patients total
13 age groups,
30 patients per group
Any malocclusion could
be corrected with
orthodontics alone
203 females,
187 males
TOTAL UPPER AIRWAY VOLUME (CM3)
35
30
Upper Airway Volume (cm3)
25
20
15
10
5
0
6-8
9-11
12-14
15-17
18-20
21-25
26-30
31-35
Age
Min Outlier
Max Outlier
36-40
41-45
46-50
51-55
56+
AVERAGE UPPER AIRWAY VOLUME (CM3) BY SEX
18.00
16.00
Male UA
volume is
generally
greater than
female UA
volume
14.00
Average Volume (cm3)
12.00
10.00
8.00
6.00
4.00
Female UAS (cm^3)
2.00
0.00
0.00
Male UAS (cm^3)
10.00
20.00
30.00
40.00
Age (Average)
50.00
60.00
70.00
INDEX (TOTAL VOLUME CM3/HEIGHT MM) BY SEX
0.35
0.3
Female index is
greater than male
index between
the ages of 20
and 40
Index (cm3/mm)
0.25
0.2
Male Index
Female Index
0.15
0.1
0.05
0
0.00
10.00
20.00
30.00
40.00
Age (Average)
50.00
60.00
70.00
TABLE OF DATA
Average UAS (cm3)
Average Index (cm3/mm)
Age
Female
Male
Age
Female Index
Male Index
6-8
5.29
6.33
6-8
0.12
0.14
9-11
6.75
7.20
9-11
0.15
0.15
12-14
10.21
9.98
12-14
0.20
0.18
15-17
12.47
15.57
15-17
0.23
0.25
18-20
13.75
14.97
18-20
0.25
0.23
21-25
13.83
14.18
21-25
0.27
0.21
26-30
15.74
14.97
26-30
0.29
0.21
31-35
14.41
13.80
31-35
0.26
0.21
36-40
15.23
15.34
36-40
0.26
0.22
41-45
12.91
15.58
41-45
0.23
0.22
46-50
13.29
14.94
46-50
0.22
0.22
51-55
11.87
12.15
51-55
0.21
0.17
56+
11.57
13.37
56+
0.20
0.20
RETROPALATAL VS. RETROGLOSSAL SPACE
AS AGE INCREASES
10.00
Retropalatal
space is greater
in volume on
average than
retroglossal
space in normal
patients
9.00
8.00
7.00
Volume (cm3)
6.00
5.00
Retropalatal Space (v cm^3)
Retroglossal Space (V) cm^3
4.00
3.00
2.00
1.00
0.00
0.00
10.00
20.00
30.00
40.00
Age (average)
50.00
60.00
70.00
CHOKE POINT RETROPALATAL VS. RETROGLOSSAL
250.00
The choke point
(smallest surface
area) of the
airway generally
lies in the
retroglossal
space
Surface Area (mm2)
200.00
150.00
Choke point retropalatal (mm^2)
Choke point retroglossal (mm^2)
100.00
50.00
0.00
0.00
10.00
20.00
30.00
40.00
Age (Average)
50.00
60.00
70.00
CHOKE POINTS MALE VS. FEMALE
300.00
Female choke
points are
greater in
surface area
than males
between ages
20-40
250.00
Choke Points (mm2)
200.00
150.00
100.00
Female Choke Pt Retropalatal (mm^2)
50.00
Female Choke Pt Retroglossal (mm^2)
Male Choke Pt Retropalatal (mm^2)
Male Choke Pt Retroglossal (mm^2)
0.00
0.00
10.00
20.00
30.00
40.00
Age (Average)
50.00
60.00
70.00
OSA PATIENT PRE-TREATMENT DATA
VS.
NORMAL PATIENT DATA
UAS (cm3)
OSA: 8.64 cm3
Normal: 13.67 cm3
Retropalatal Space
(cm3)
Retroglossal Space
(cm3)
Choke-Point
Retropalatal (mm2)
OSA: 3.92 cm3
Normal: 7.95 cm3
Percent Difference: 50.7%
OSA: 4.59 cm3
Normal: 5.76 cm3
Percent Difference: 20.3%
OSA: 78.04 mm2
Normal: 166.8 mm2
Choke-Point
Retropalatal
Transverse (mm)
OSA: 18.19 mm
Choke-Point
Retropalatal A-P (mm)
OSA: 3.94 mm
Normal: 23.37 mm
Normal: 6.33 mm
Choke-Point
Retroglossal (mm2)
Percent Difference: 36.8%
Percent Difference: 53.2%
Percent Difference: 22.2%
Percent Difference: 37.8%
OSA: 84.8 mm2
Normal: 152.89 mm2
Choke-Point
Retroglossal
Transverse (mm)
OSA: 18.01 mm
Choke-Point
Retroglossal A-P (mm)
OSA: 5.41 mm
Normal: 23.87 mm
Normal: 7.59 mm
Percent Difference:44.5%
Percent Difference: 24.5%
Percent Difference: 28.7%
POLYSOMNOGRAM
The gold standard in diagnosing apneas
No patient should undergo airway surgery without a sleep
study
Used to diagnose or rule out sleep disorders
•
•
•
•
•
OSA
Narcolepsy
Periodic Limb Movement Disorder
REM Behavior Disorder
Parasomnias
Split Night Study
• Patient is woken after 2-3 hrs if demonstrating obstructive sleep apnea
and CPAP is applied for remainder of study
• Aides in determining best levels for CPAP titration
POLYSOMNOGRAM INTERPRETATION
Apnea/Hypoapnea
Index - AHI
Oxygen Desaturation
• <5 NORMAL
• 5-15 MODERATE OSA
• >15 SEVERE OSA
• 3% oxygen desaturation constitutes an apnea or hypoapnea
EKG
• Analyze for abnormalities that might be indicative of heart
irregularities
• P Wave
• QRS Complex
• T Wave
Sleep Architecture
• Sleep Onset Latency
• Usually less than 20 minutes
• Sleep Efficiency:
• # of minutes of sleep/# of minutes in bed
• Normal is 85% to 90% and higher
• Sleep Stages:
• Majority of sleep is stage 2
• REM sleep normally occupies 20-25% of sleep time and
decreases with age
• Stage 3 deep sleep decreases with age
CONSERVATIVE
MEASUREMENTS
CONSERVATIVE MEASUREMENTS
CPAP
Bipap
Nasal CPAP
Oral Devices (Dental Appliances)
• Mandibular Posturing Device
Nasal Devices
Oropharyngeal Exercises
Weight loss
Behavior modification
CONSERVATIVE MEASUREMENTS:
CPAP
Indications:
• individuals with AHI >15 or >5 with existing co-morbidities
The “Gold Standard” of OSA Tx
•
•
•
•
•
•
Reduction of stroke by 20%
Compliance rates make success rates near 50%
Reduction in depressive symptoms
Eradication of snoring
Decreased cholesterol and blood pressure
Improvement in quality of life
Auto adjusting and fixed pressure
Disadvantages
• Poor patient compliance
• Loud and cumbersome
• Dry nose, mouth
Friedman et al., 2009, pp 60-67
CONSERVATIVE MEASUREMENTS: BIPAP
Biphobic Continuous Airway Pressure
Two pressure levels
• One for inspiration
• One for expiration
Rare – those with high CPAP pressures who
have trouble breathing against the pressure
CONSERVATIVE MEASUREMENTS:
NASAL CPAP
 Long-term compliance rates ranging
from 46%-89%
 Successful if accepted by the patient
Friedman et al., 2009, pp 69-71
CONSERVATIVE MEASUREMENTS:
MANDIBULAR POSTURING DEVICES
 Indicated for use in:
 patients with primary snoring and mild to moderate OSA
 patients who do not respond to CPAP or failed tx with CPAP
 Some studies indicate as being as effective as CPAP in certain patients
CONSERVATIVE MEASUREMENTS:
ORAL APPLIANCES
 RX for Oral Appliances:





Oral examination
Orthodontic evaluation
Periodontal evaluation
Temporomandibular joint evaluation
Craniofacial skeletal evaluation
 PURPOSE:
 Create more airway by posturing the
airway forward
 Adjustable screw allows variable posture
(create more space if necessary)
 DISADVANTAGES:
 Can move teeth/create malocclusion if not
properly designed and monitored
 Can be bulky
 Success in 52% of patients
 Success defined as no more than 10
apneas or hypoapneas per hour of sleep
Friedman et al., 2009, pp 73-75
CONSERVATIVE MEASUREMENTS: ORAL APPLIANCES
 Upper and lower impressions
 Facebow in centric relation
 2 wax bites
 Normal bite
 Posturing edge-edge, lower jaw
forward
 Pour in die-keen
 Mount models
 Set occlusion in forward postured
bite
 Add acrylic to upper and lower
models until flat bite
 Add screws to adjust bite
 Add lateral wings
 Polish
CONSERVATIVE MEASUREMENTS:
NASAL DEVICES
 Nasal devices are a good predictor of
success with IV/EV reconstruction
 PROVENT
 Prosthetic nasal device placed in each
nostril acts as a valve
 Uses patients own breathing to keep
nasal airway open
 Breathe Right strips
CONSERVATIVE MEASUREMENTS:
OROPHARYNGEAL EXERCISES
Exercises that strengthen and tone the
oropharyngeal muscles
DISADVANTAGES:
• Limitations on amount can improve symptoms of OSA
• Only recommended for a very select group of patients who are
also on CPAP therapy
• Patient compliance
• Time consuming
• Referral to specialists to teach exercises
CONSERVATIVE MEASUREMENTS:
WEIGHT LOSS
 Improvement in:




SDB
Oxygen hemoglobin saturation
Sleep fragmentation
Daytime performance
 Loss of 9-18% weight associated
with AHI reduction of 30-75%
 Surgical weight loss tx have
shown greater improvements in
AHI than dietary tx
Friedman et al., 2009, pp 55-59
CONSERVATIVE MEASUREMENTS:
BEHAVIOR MODIFICATION
Sleep position
therapy
Weight loss
• Patient sleeps on side or stomach
• Pillows, positioners
• Reduces bulk tissue in neck
• exercise
Avoidance of
sedatives, alcohol, • Loss of muscle tone
large meals
DISADVANTAGES:
• Not a stand-alone treatment
• Only mitigates the effects of OSA
HISTORICAL TX OF OSA
HISTORICAL TREATMENT OF OSA
 CPAP and Traecheostomy are goldstandard of OSA Treatment
 50% reduction of AHI is standard of
success
 Two-phase surgical protocol
 Powell-Riley Protocol
 Avoid unnecessary surgery
 Objective is to alleviate obstruction
equivalent to CPAP management
 Fujita Classification
 Type I Palate – Mild OSA
 Type II Combined – Severe OSA
 Type III Hypopharynx – Moderate to
Severe OSA
TRAECHEOSTOMY
 1st modality used to treat OSA
 Eliminates sleep apnea
permanently
 Is sometimes used temporarily
pre-surgically
Friedman et al., 2009, pp 343-348
SURGICAL
INDICATIONS/CONTRAINDICATIONS
Indications
 AHI >20
 May be performed if <20 if has a
comorbidity or decreased
cognition due to OSA
 Oxygen desaturation <90%
 Esophageal Pressure (PES)
more negative than -10 cm H2O
 EDS
 Neurobehavioral symptoms
 CPAP/Conservative Treatment
Failure
 Anatomical sites of obstruction
Contraindications
 Severe pulmonary disease
 Unstable cardiovascular
disease
 Morbid obesity
 Alcohol or drug abuse
 Psychiatric instability
 Unrealistic Expectations
Friedman et al., 2009, pp 81
PRE-OPERATIVE PLANNING
Physical evaluation by
PMD and optimization
for surgery
Pre-Operative CPAP
• Reduce risk of
postobstructive pulmonary
edema
• Reduce sleep deprivation
PHASE I SURGERY
 Surgery directed at site of obstruction
 Conservative surgery targeting the soft-tissues




Nasal Reconstruction
Soft Palate
Base of tongue
Epiglottis
 60% of all patients are cured with phase I surgery
 Less than successful outcome predicted by AHI greater than
60, oxygen desaturation below 70%, and morbid obesity
 Re-evaluate patient with polysomnogram 3-4 months postoperatively
Friedman et al., 2009, pp 80-84
PHASE II SURGERY
 Maxillo-mandibular advancement
 Enlarges the hypopharyngeal and
pharyngeal airway by advancing
the skeleton
 Creates more space for tongue
anteriorly
 Documented success rates >90%
Friedman et al., 2009, pp 80-84
SURGICAL
INTERVENTION
NASAL RECONSTRUCTION
CPAP TITRATION LEVELS
BEFORE AND AFTER
NASAL SURGERY FOR OSA
3
Goals
• Reduce nasal
obstruction
• Reduce severity of
or eliminate SDB
• Facilitate SDB
treatment by
allowing nose to be
used in positive
airway therapies
Mean CPAP
(cm H2O)
OSAHS
Patients
Pre-Op
Post-Op
Total (n=22)
9.3
6.7
Severe (n=13)
10.07
7.42
Moderate
(n=4)
9.5
6.5
Mild
(n=5)
7.2
5
Friedman et al., 2009, pp 128
NASAL RECONSTRUCTION
Septoplasty
Turbinectomy
Radiofrequency reduction
Internal nasal valve reconstruction
External nasal valve reconstruction
Spreader grafts
NASAL RECONSTRUCTION:
SEPTOPLASTY
 TARGET: deviated septum
 PROCEDURE:
 Incisions are made in the lining
of the septum
 Repositioning of the cartilage
and/or bone of the nasal cavity
 May be stabilized with splints or
sutures internally
NASAL RECONSTRUCTION:
TURBINECTOMY
GOAL:
• Partial or
complete removal
of enlarged
turbinates
DISADVANTAGES:
• Can cause
dryness
• High postoperative
bleeding rates
• “Empty Nose”
Syndrome
NASAL RECONSTRUCTION:
RADIOFREQUENCY REDUCTION
 GOAL: Turbinate reduction
to increase airflow
 PROCEDURE:
 Uses RF energy to create
submucosal tissue controlled
shrinkage leading to
reduction of tissue volume
 ADVANTAGES:
 Performed in office with
topical anesthetic
 Procedure duration is 2-4
minutes
 Improvement 10-14 days
following treatment
Friedman et al., 2009, pp 141
NASAL RECONSTRUCTION:
INTERNAL NASAL VALVE RECONSTRUCTION
 Nasal Valve Suspension
 Spreader Graft
 GOAL: correct internal nasal
valve collapse by lateralizing
superior segment of upper lateral
cartilage
 Cartilage Spanning Graft
 Splay Conchal Graft
Friedman et al., 2009, pp 135
NASAL RECONSTRUCTION:
EXTERNAL NASAL VALVE RECONSTRUCTION
 Alar Batten Graft
 Columelloplasty
 Nasal Valve Suspension
Friedman et al., 2009, pp 135-136
NASAL RECONSTRUCTION: CASE I
E
M
PreUAS
Post –
UAS
PreRP
PrePost
PrePost- Pre- Post Choke Choke Choke
RP
RG
RG
Pt RP Pt RP Pt RG
PostChoke
Pt RG
10.37
11.39
5.05
5.66
123.57
4.72
 Age: 27
 Diagnosis:
 Nasal Obstruction and Snoring
 Procedures:
 Nasal Reconstruction
 Septoplasty
 Radiofrequency Inferior
Turbinates
 Spreader Grafts
 Palatopharyngoplasty
4.93
115.2
126.72 128.43
NASAL RECONSTRUCTION: CASE I
Before
After
NASAL RECONSTRUCTION: CASE I
NASAL RECONSTRUCTION
 Isolated correction of the nasal passages does not always improve OSA
 Study performed by Friedman





50 patients with nasal airway obstruction
98% subjective improvement in nasal breathing
66% did not notice significant change in snoring
PSG results did not show significant change in AHI or LSAT
CPAP levels decreased
 Medical tx resolved OSA in 9%
 Surgical tx resolved OSA in 18%
Friedman et al., 2009, pp 116
SOFT PALATE RECONSTRUCTION:
RADIOFREQUENCY SOFT PALATE
 GOAL:
 Reduce tissue volume of soft
palate and stiffen remaining tissue
leading to the reduction of snoring
and sleep apnea without surgery
 ADVANTAGES:
 In-office procedure
 Local anesthesia
 Minimal patient discomfort
 RESULTS:
 Significant improvement in ESS
 Significant reduction in snoring by
patient and bed partner
 Immediate reduction in palatal
tissue volume
 Continual symptomatic
improvement over time due to
tissue shrinkage and stiffening
Friedman et al., 2009, pp 233
SOFT PALATE RECONSTRUCTION:
BASE OF TONGUE
 GOAL:
 Reduce volume of the tongue to
increase airway volume
 ADVANTAGES:
 In-office procedure
 Local anesthesia
 procedure duration is 15-20
minutes
 Results in 3-6 weeks
 DISADVANTAGE:
 Treatment often needs to be
repeated over multiple sessions
to achieve desired results due to
tongue size and limited RF
energy that can be applied to
tongue
Friedman et al., 2009, pp 244
SOFT PALATE RECONSTRUCTION:
RADIOFREQUENCY SUCCESS RATES
 Steward: Combined reduction of palate and base of tongue
 Success Rate: 59%
 Fischer et al: Palate, Tonsil, Tongue Base
 AHI changed from 32.6 +/- 17.4 Pre-Op to 22 +/- 15 Post-Op
 Success Rate: 33%
 Stuck: Palate and Base of Tongue
 Success rate 33.3%
 Success was AHI reduction of 50% and value <15
Friedman et al., 2009, pp 233-247
SOFT PALATE RECONSTRUCTION
Radiofrequency
Uvulopalatopharyngoplasty (UPPP)
Tonsilectomy
Lateral Pharyngoplasty
Palatal Pharyngoplasty
Pillar Procedure
SOFT PALATE RECONSTRUCTION: UPPP
 Historic procedure
 TARGET:




Retropalatal soft tissue obstruction
Uvula
Pharyngeal Walls
Tonsils, Adenoids if present
 GOALS:
 Creates more space in the width of the airway at the throat’s opening, improving the ability of the airway to remain
open, and the movement and closure of the soft palate
 PROCEDURE:
 Removes uvula, (tonsils, and adenoids if present), positions soft tissues of the palate and lateral pharyngeal walls
 SUCCESS RATE: 39%
 Success defined by:
 AHI reduction of 50%and postoperative AHI <20
 Or AI reduced by 50% and postoperative AI <10
 DISADVANTAGES:
 Aggressive procedure
 Throat dryness
 Velopharyngeal Insufficiency (VPI)
 Hypernasal speech
 Changes in voice




Regurgitation of fluids through the nose or mouth
Does not address other sites of obstruction in the airway
Impaired sense of smell
Failure and recurrence of apnea
Friedman et al., 2009, pp 83, 180
SOFT PALATE RECONSTRUCTION: UPPP
Friedman et al., 2009, pp 151, 178-180
SOFT PALATE RECONSTRUCTION: TONSILECTOMY
 GOAL:
 Create more lateral airway
space through removal of
the tonsils and adenoids if
necessary
 DISADVANTAGES:
 Failure to improve nasal
airway or resolve snoring,
sleep apnea or breathing
 VPI
 Painful procedure
 Bleeding
SOFT PALATE RECONSTRUCTION:
LATERAL AND PALATAL PHARYNGOPLASTY
 GOAL:
 Widening of the airway by placing the lateral throat walls in tension
and reducing the soft palate
 ADVANTAGES:
 Higher degree of success and lesser degree of complications in
comparison to UPPP
 Produces greater radius of opening in soft palate and throat providing
a wider area for air exchange than UPPP
 Preserves much of the soft palate and uvula function so less chance
of VPI or regurgitation of fluids into nasal cavity in comparison to
UPPP
 DISADVANTAGES:
 Failure and recurrence of apnea
Friedman et al., 2009, pp 224-231
SOFT PALATE RECONSTRUCTION:
LATERAL AND PALATAL PHARYNGOPLASTY
Friedman et al., 2009, pp 151, 178-180
SOFT PALATE RECONSTRUCTION:
TRANSPALATAL ADVANCEMENT PHARYNGOPLASTY
 GOAL:
 Enlarges upper oropharyngeal
airway to improve respiratory
function through advancement of
the hard palate
 Soft palate is mobilized, not
removed
 SUCCESS RATES:
 5.77% more successful than UPPP
Friedman et al., 2009, pp 217-222
SOFT PALATE RECONSTRUCTION:
PILLAR PROCEDURE
 GOAL:
 Palatal implant of 3 polyester filaments into
uvula to extend hard palate and reduce
vibrating parts of palate
 PROCEDURE:
 In-office procedure
 Local anesthesia
 30 minutes duration
 DISADVANTAGES:






Partial extrusions of implants in 25%
complete extrusion
dry mouth
sensation of a foreign body
sore throat
Failure to improve snoring or sleep apnea
 SUCCESS RATE:
 Snoring reduced from 7.1 to 4.8 on VAS
scale, but could still be heard
 90% of patients and bed partners would
recommend the procedure to others
Friedman et al., 2009, pp 169-175
BASE OF TONGUE RECONSTRUCTION:
Genioglossal Suspension
Genioglossal Advancement
Tubercle Advancement
Genioplasty with Genioglossal Suspension
Hyoid Myotomy with Suspension Sutures
BASE OF TONGUE:
GENIOGLOSSAL SUSPENSION
 GOAL:
 Create more space for the
tongue in the A-P dimension
and prevent tongue from
falling posteriorly
 PROCEDURE:
 Suture is passed through
tongue in an inverted
triangle
 Suspended to the tubercle
of mandible
Friedman et al., 2009, pp 258-263
BASE OF TONGUE:
TUBERCLE ADVANCEMENT
Friedman et al., 2009, pp 268-277
BASE OF TONGUE:
GENIOGLOSSAL ADVANCEMENT
 TARGET:
 Base of tongue, Retroglossal Airway Space
 GOAL:
 Limit posterior displacement of tongue
 PROCUDURE:
 Rectangular osteotomy in mandible
 Advance genial tubercle, genioglossus muscle and tongue base
anteriorly
 Suspension sutures
 LIMITATION:
 Does not change dental occlusion or jaw position
 Does not create additional room for tongue
 Failure or recurrence of sleep apnea
 SUCCESS RATES:
 30-65%
 Increases to 80% when combined with soft palate procedures
Friedman et al., 2009, pp 268-277
BASE OF TONGUE:
GENIOGLOSSAL ADVANCEMENT
GENIOPLASTY/TUBERCLE ADVANCEMENT
 Class II
 Correct facial profile
 Creates more anterior space
for tongue
HYOID MYOTOMY WITH SUSPENSION
SUTURES
TARGET:
• Advance Hyoid
Complex,
Epiglottic
Reconstruction
Myotomy to:
• Thyroid
cartilage
• Anterior
mandible
(retroglossal
airway space)
Results:
• 71% of
patients did not
need further
treatment
Friedman et al., 2009, pp 268-277
PHASE I SURGERY: CASE I
GK
PreUAS
Post –
UAS
11.6
12
PreRP
3.91
PostRP
4.37
• Age: 54
• Diagnosis:
• Loud snoring
• Moderate OSA
• Nasal Obstruction
• Procedure:
• Nasal Reconstruction
• Septoplasty
• Inf Turbinates
• Spreader Grafts
• Palataopharyngoplasty
• Spreader Grafts
PreRG
7.16
Post RG
PreChoke
Pt RP
PostChoke
Pt RP
PreChoke
Pt RG
6.88
99.27
96.03
113.85
PostChoke
Pt RG
109.53
PHASE II SURGERY: CASE I
GK
PreUAS
Post –
UAS
12
16.44
PreRP
4.37
PostRP
5.77
 Presented with severe
OSA 1 year post-op
 Phase II MMA
 RESULTS:
 AHI <5 Normal
PreRG
6.88
Post RG
PreChoke
Pt RP
PostChoke
Pt RP
PreChoke
Pt RG
10.67
96.06
158.5
109.53
PostChoke
Pt RG
152.01
REASONS THE AIRWAY NARROWS
Age
• Soft tissue collapses
as we age
• Muscle fibers elongate
and thin
• Chronic
vibration/hypoxemia
result in fibrous,
scarred tissue
Weight
• Excess tissue,
accumulate fat as we
age
NEED FOR A NEW STANDARD
50% Reduction in AHI of
a patient with severe
OSA, could still have
severe OSA
Multiple surgeries to atrisk patients with
compromised health from
sleep apnea
• Example:
• PT with pre-phase I
AHI of 70, reduction
by 50% has AHI of 35
• PT still has severe
OSA
• Surgery is considered
a success
• Phase I Success Rate:
• 60%
• Phase II Success Rate:
• 90%
• MMA Success Rate :
• 70-100% (some
studies indicate >90%
success rate)
Patients do not tolerate
CPAP well
• 50% success rate
• “Darth Vader mask”
• “Snorkeling in my sleep”
SUMMARY: CURE RATES
 UPPP: 39%
 UPPP + Genioglossus Advancement + Hyoid Myotomy (+
Radiofrequency of the Tongue Base)
 Success rate: 60% (study of 223 patients)
 PHASE I: 60%
 PHASE 2: 90%
Friedman et al., 2009, pp 112
MAXILLOMANDIBULAR
ADVANCEMENT
OSTEOTOMY
MAXILLOMANDIBULAR ADVANCEMENT
 70-100% cure rate
 Patients with AHI indicating severe OSA pre-operatively have
normal AHI post-surgery
 Only surgery that creates more space for tongue
 Expand facial framework of mandible and maxilla
CANDIDATES FOR MAXILLOMANDIBULAR ADVANCEMENT
Moderate to severe OSA
indicated by high AHI during
polysomnography
Narrow or bottlenecked
airway
Mandibular deficiency or
retrognathia
Obesity
Patients on CPAP
Patients whom other sleep
apnea procedures have
failed
POST-OPERATIVE MANAGEMENT
 OSA patient is more complicated than usual orthognathic patient
1. ICU stay first night





Patient’s condition may dramatically change when overly sedated or asleep
Careful use of analgesics and antihypertensives
Use of a patient-controlled analgesia pump is not recommended
Sensitivity to respiratory depressant drugs is variable
Recommend IV does by ICU nurse who is constantly evaluating respiratory rates
2. Nasal CPAP recommended




maintains airway
controls edema
lessens use of narcotics
Nasal trumpet airways must be used to apply CPAP
3. IV medication is seldom needed after first post-operative day
4. Patient is encouraged to be out of bed ambulating and oral liquids on first
post-op day
TOTAL HOSPITAL STAY IS 2-3 DAYS
POST-OPERATIVE FOLLOW-UP
 Frequent follow up suggested
 DAY 1-3
 Surgical edema will peak at 72 hrs
 Concerns about airway swelling significant
 Seen in office day 3 or 4 and then weekly until healed
 CPAP use is continued until 1-2 weeks before follow-up PSG
 4-6 MONTHS POST-OPERATIVELY
 Follow-up PSG obtained
 Allows for weight stabilization and neurologic equilibration
 If post-operative PSG and EDS are resolved, follow-up is at 6 months
and then yearly as necessary
RESEARCH
CLINICAL EXPERIENCE
Patient Demographics
• 7 Patients with Obstructive Sleep Apnea
• 6 Male
• 1 Female
• Age at time of Maxillomandibular
Advancement
• 35-56 years old
• Average 46.4 years old
• Pre-Operative AHI
• Ranged from 18-54.6
• Average 38.27
CLINICAL EXPERIENCE
CBCT Scan
Nasal
Endoscopy
Model
Surgery/
Fabrication
of Splints
3D Ceph
Analysis
PreOperative
Work-Up
Virtual
Treatment
Objectives
3dMDVultus
Airway
Analysis
Sleep
Study
Orthodontics
Dental
Models
• 3 ortho patients
with brackets
• 4 non-ortho
patients –
archbar used
SURGICAL TECHNIQUE
 LeFort I Maxillary
Osteotomy Advancement
 Bone grafting
 +/- Septoplasty and/or
turbinectomy
 Bilateral Sagittal Split
Osteotomy of the Mandible
Advancement
 +/- Genioglossal
Advancement
POST-OPERATIVE CARE
Patients admitted to ICU for 1-2 nights
Transferred to surgical floor for +1-2 nights prn
Discharged
Surgical follow-up
Post-operative CBCT scan and airway analysis obtained 3-6 months post-operatively
Sleep study obtained 3-6 months post-operatively
PRE- AND POST-OPERATIVE DATA: AHI
PT
SEX
AGE
BMI
PRE-AHI
POST-AHI
NB
M
51
27
42
3.8
CD
M
36
30.5
31
0
KG
M
51
29
48
0
RJ
M
35
28
54.6
1.5
SD
M
47
23
18
4
VE
F
49
19.8
53.5
28.4
TM
M
56
29.2
21
5
PRE- AND POST-OP DATA:
MOVEMENT
• Average Mandibular Movement: 9.57 mm
• Average Maxillary Movement: 9.86 mm
• Average Genio Movement: 6 mm
PT
SKELETAL
PATTERN
MAND
MOVEMENT
(MM)
MAX
MOVEMENT
(MM)
GENIO
MOVEMENT
(MM)
NB
II
9
9
8
CD
I
9
9
0
KG
II
9
9
0
RJ
II
8
12
6
SD
II
11
8
0
VE
II
10
11
4
TM
I
11
11
0
PRE- AND POST-OP VOLUMETRIC
ANALYSIS
PT



Average % Change UAS
 236.99%
Average % Change RP
 361.97%
Average % Change RG
 164.56%
NB
PREUAS
POST
- UAS
VOL
VOL
%
CHN
GE
cm3
cm3
UAS
3.35
21.46
PRERP
POST
- RP
VOL
VOL
%
CHN
GE
cm3
cm3
RP
1.33
8.46
540.60%
CD
7.56
10.22
11.6
3.97
16.44
4.49
3.46
3.91
30.9
10.27
20.56
4.92
12.39
29.48
11.88
7.44
20.49
1.89
13.00
587.83%
5.73
59.61%
10.67
1613.33
%
49.02%
2.26
9.34
313.27%
5.41
5.53
16.04
2.22%
4.82
8.02
115.59%
4.70
72.47%
RG
80.69%
137.93%
TM
cm3
7.16
8.89
37.97%
VE
cm3
47.57%
1.20
14.17
VOL
3.59
5.77
793.06%
SD
VOL
%
CHN
GE
13.10%
41.72%
RJ
POST
-RG
536.09%
35.19%
KG
PRERG
10.69
66.39%
7.00
127.45%
12.15
73.57%
PRE- AND POST-OP SURFACE AREA ANALYSIS
PT

Average Choke Point RP Pre


Average Choke Point RP Post


154.55 mm2
PostChoke
Point
Retrogloss
al
mm2
49.68
155.34
%
Chnge
PreLocation
of
Chke
Pt
PostLocati
on of
Chke
Pt
NB
873.47%
P
G
CD
74.52
61.83
P
P
P
G
P
G
P
G
G
G
G
G
212.68%
88.65
116.01
-17.03%
30.86%
100.98%
Location of Choke Pt Pre-Operatively


84.80 mm2
Average % Change RG


191.87
PreChoke
Point
Retrogloss
al
mm2
664.22%
Average Choke Point RG Post


19.71
%
Chnge
Average Choke Point RG Pre


237.45 mm2
PostChoke
Point
Retropalata
l mm2
Average % Change RP


78.04 mm2
PreChoke
Point
Retropalata
l mm2
KG
103.80
158.85
109.89
152.01
53.03%
5 Patients Retropalatal, 2 Patients Retroglossal
38.33%
Location of Choke Pt Post-Operatively

6 Patients Retroglossal, 1 Patient retropalatal
RJ
8.37
273.5
44.28
156.60
3167.62%
SD
104.84
187.83
253.66%
107.46
161.10
79.16%
VE
139.70
400.58
49.92%
133.65
268.46
186.74%
TM
95.36
387.69
100.87%
60.00
306.55%
72.32
20.53%
PRE- AND POST- OP TRANSVERSE ANALYSIS

Average change in the transverse dimension
 Retropalatal: 11.64 mm
PT
 Retroglossal: 7.11 mm
PreChoke
Pt RP
Transverse
(mm)
PostChoke Pt
RP
Transverse
(mm)
Mm
difference
PreChoke Pt
RG
Transverse
(mm)
PostChoke Pt
RG
Transverse
(mm)
Mm
difference
NB
8.1
30.6
22.5
10.2
23.4
13.2
CD
16.5
16.8
0.3
19.8
19.2
-0.6
KG
24.0
29.7
5.7
21.9
27.3
5.4
RJ
1.8
28.2
26.4
12
30
18
SD
28.5
34.8
6.3
23.7
32.4
8.7
VE
26.4
37.5
11.1
26.1
28.8
2.7
TM
22.0
31.2
9.2
12.4
14.8
2.4
PRE- AND POST-OP A-P ANALYSIS

Average change in the A-P dimension
 Retropalatal: 6.40 mm
 Retroglossal: 2.61 mm
PT
PreChoke
Pt RP
A-P
(mm)
PostChoke
Pt RP
A-P
(mm)
Mm
difference
PreChoke
Pt RG
A-P
(mm)
PostChoke
Pt RG
A-P
(mm)
Mm
difference
NB
2
5.7
3.7
5.4
6.9
1.5
CD
5.7
6.6
0.9
6
9
3
KG
3
4.5
1.5
6.9
8.7
1.8
RJ
6
25.2
19.2
4.2
6.6
2.4
SD
2.1
6.9
4.8
5.1
6
0.9
VE
4.8
9.6
4.8
3.9
12.6
8.7
TM
4
11.2
7.2
6.4
6.4
0
PRE- AND POST- OPERATIVE HEIGHT ANALYSIS
 Average Change in UAS height
 2.86 mm
 Average Change in RP height
 3.14 mm
 Average Change in RG height
 4.29 mm
PreUAS
(mm)
PostUAS
(mm)
Pre-RP
(mm)
PostRP
(mm)
Pre-RG
(mm)
PostRG
(mm)
NB
80
74
46
44
32
30
CD
70
70
40
38
30
32
KG
74
80
38
32
36
48
RJ
68
66
38
32
30
32
SD
74
72
34
34
40
38
VE
64
62
32
34
32
28
TM
76
78
26
22
50
56
PT
POUSEILLE’S LAW
As radius increases and height decreases,
the resistance of flow decreases
Results
 Volume
 The UAS enlarged significantly
 The shape of the UAS changed from a funnel to a tube like shape
 The retropalatal space increases in volume more than the retroglossal space
 Surface Area
 The surface area at the choke point in the retropalatal space increases by a greater percent change
than the retroglossal space
 The location of the choke point is generally pre-operatively in the retropalatal space and postoperatively in the retroglossal space
 Indication of normalizing the airway and eliminating any bottlenecking/funneling
 The airway enlarges in a rectangular fashion
 Length
 The transverse dimension increases more than the A-P dimension in millimeter change
 The A-P dimension increases more than the transverse dimension in percent change
 The retropalatal space increases more in the transverse and A-P dimensions than the retroglossal
space does
 Height
 The height of the airway measured from the posterior of the post nasal spine to the superior tip of the
hyoid bone generally decreases post-operatively
 The height of the airway was pre-operatively shorter in the retropalatal space than the height of the
retroglossal space
 The height of the airway was post-operatively shorter in the retroglossal space than the retropalatal
space
Case I:
Volume:
Pre-UAS:
3.46 cm3
Post-UAS:
30.9 cm3
% Increase:
790.3
Surface Area:
Pre:
8.37 mm2
RP
Post:
156.60 mm2
RG
% Increase:
177.71
Transverse
Length
Retropalatal
Pre: 1.8 mm
Post:
28.2 mm
MM
Increase:
26.4 mm
Transverse
Length
Retroglossal
Pre: 12 mm
Post: 30 mm
MM
Increase:
18 mm
AnteriorPosterior
Length
Retropalatal
Pre: 6 mm
Post:
25.2 mm
MM
Increase:
19.2 mm
AnteriorPosterior
Length
Retroglossal
Pre: 4.2 mm
Post: 6.6 mm
MM
Increase:
2.4 mm
CASE I
CASE I
CASE I
Pre-Surgical
Post- Surgical
CASE II
Volume:
Pre-UAS:
3.32 cm3
Post-UAS:
21.46 cm3
% Increase:
546.38
Surface Area:
Pre:
19.71 mm2
RP
Post:
155.34 mm2
RG
% Increase:
688.12
Pre: 8.1 mm
Post: 30.6
mm
MM
Increase:
22.5 mm
Transverse
Length
Retroglossal
Pre: 10.2 mm
Post: 23.4
mm
MM
Increase:
13.2 mm
AnteriorPosterior
Length
Retropalatal
Pre: 2 mm
Post: 5.7 mm
MM
Increase:
3.7 mm
AnteriorPosterior
Length
Retroglossal
Pre: 5.4 mm
Post: 6.9 mm
MM
Increase:
1.5 mm
Transverse
Length
Retropalatal
CASE II
CASE II
CONCLUSIONS
 3-Dimensional airway analysis indicates that
maxillomandibular advancement is an effective treatment
option for patients with obstructive sleep apnea by increasing
tension and changing the position of the palatal and
pharyngeal muscles. As a result:
 Airway volume increases
 Shape of airway changes
 Change from a funnel to cylindrical shape
 Height of airway decreases
 Resistance decreases
 Radius of the airway increases
 Height of the airway decreases
SUMMARY
 MMA effective treatment option
 CURES sleep apnea, doesn’t just manage
 The best treatment will depend on good diagnostic values
 Polysomnogram
 Airway analysis
 Clinical condition and patient symptoms
SDB IN CHILDREN
EPIDEMIOLOGY OF SLEEP APNEA:
CHILDREN
 Affects 8% or more of children in the US
 True apnea commonly does not occur
 Symptoms:









Restless sleep
Sweating during sleep
Snoring
Night terror
Sleep walking
Bed wetting
Daytime fatigue
Hyperactive behavior
Poor academic performance and attention
span
 50% of children with ADHD had signs of
sleep disordered breathing compared to
only 22% of children without ADHD
Golan N, Shahar E, Ravid S, Pillar G, Sleep Disorders and Daytime Sleepiness
In Children With Attention-Deficit/Hyperactive Disorder. Sleep, 2004 March 15; 27 (2):261-6
EPIDEMIOLOGY OF SLEEP APNEA:
CHILDREN
 Some children may exhibit poor physical growth
 Dentofacial deformities
 Adenoid face syndrome






Long face
Open bite
Mouth breathing
Underdeveloped lower jaw
Narrow (high arch palate)
Over developed upper jaw (gummy smile)
CAUSES OF PEDIATRIC OSA
 Enlarged tonsils and adenoids
 Nasal obstruction (enlarged turbinates)
 Dentofacial deformities (abnormal jaw growth)
 Congenital birth deformity




Cleft lip & palate
Perre Robin sequence
Hemi Facial Microsomia
Treacher Collins
TREATMENT OF PEDIATRIC OSA
 Target:
 Treatment at site of obstruction
 tonsils or adenoids
 Procedures:
 Tonsilectomy
 Adenoidectomy
 Orthodontics
 Rapid palatal expansion




Nasal CPAP
Radiofrequency
Maxillofacial Surgery at full maturity prn
Distraction Osteogenesis
 SUCCESS RATES: 80%
INSURANCE, BILLING,
AND CODING
INSURANCE: EXAMINATION AND CONSULTATION
 New Patient Examination – 99201-99204
 Consultation: 99214
 Office visit: 99214
 Panorex – 70355
 Cephalometric – 70350
 Frontal – 70250
 TMJ Cuts – 70110
 Laminographs – 70350
 CBCT – use all of the above
INSURANCE: DIAGNOSTIC CODES
 Sleep Apnea - 327.23
 Deviated Septum - 470.0
 Turbinates (hypertrophy) - 478.0
 Maxillary sinusitis - 473.0
 Maxillary/Mandibular prognathism – 524.00
 Maxillary hyperplasia – 524.01
 Mandibular hyperplasia – 524.02
 Maxillary hypoplasia – 524.03
 Mandibular hypoplasia – 524.04
 Maxillary/Mandibular retrognathia – 524.06
INSURANCE: DIAGNOSTIC CODES
 Cephalgia (head/facial pain) – 784.0
 Myalgia/Myositis – 729.1
 Injury to face and neck – 959.09
 Accident, same level – E885
 Accident, fall – E888
 Struck by moving appliance – E919
 Struck in sports – E917.0
INSURANCE: MANDIBULAR POSTURING DEVICES
 Submit 1500 INSURANCE claim to
patients provider
 CODES:
 21085 – Sleep Apnea Device
 21076 – Custom Preparation
INSURANCE: PSG
 A sleep study is usually mandatory, and should be performed
regardless for proper diagnosis of OSA, for insurance coverage of
CPAP or any surgical procedure for sleep apnea
 HMO
 Must be referred for PSG by primary care physician
 Out of network must pay everything out of pocket
 PPO
 Refer patient for PSG
 Submit patient’s insurance to sleep center
 1-2 weeks turn around for results
 Medicare
 Must be referred for PSG by primary care physician
 At home, unattended sleep-study may be performed to qualify for CPAP
INSURANCE: PSG CODES
 95807 – Sleep study, simultaneous recording of ventilation,
respiratory effort, ECG or heart rate, and oxygen saturation
attended by a technoglogist
 95808 – Polysomnography, sleep staging with 1-3 additional
parameters of sleep, attended by a technologist
 95810 – Polysomnography, sleep staging with 4 or more additional
parameters of sleep, attended by a technologist
 Split-Study
 95811 – Polysomnography, sleep staging with 4 or more additional
parameters of sleep, with initiation of CPAP therapy or bilevel ventilation,
attended by a technologist
 Unattended Study
 95806 – Sleep study, unattended, simultaneous recording of heart rate,
oxgyen saturation, respiratory airflow, and respiratory effort
INSURANCE: CPAP
 Sleep Center will usually provide and submit this information









E0601 – CPAP Device
A7027 – Combination oral/nasal mask, used with CPAP device
A7030 – Full face mask used with positive airway pressure device
A7034 – Nasal interface (mask or cannula type) used with PAP device, with or without
headstrap
A7035 – Headgear used with PAP device
A7036 – Chinstrap used with PAP device
A7037 – Tubing used with PAP device
A7038 – Filter, disposable, used with PAP device
A7039 – Filter, nondisposable, used with PAP device
REPLACEMENTS
 A7028 – Oral cushion for combination oral/nasal mask, replacement only, each
 A7029 – Nasal pillows for combiantion oral/nasal mask, replacement only, pair
 A7032 – Cushion for use on nasal mask interface, replacement only, each
 A7033 – Pillow for use on nasal cannula type itnerface, replacement only, pair
INSURANCE: PRE-AUTHORIZATION
 Contact patient’s insurance to begin pre-authorization
process
 They will notify you what you need to submit
 Generally requests are made for:
 A letter documenting patient history
 X-Rays
 EO’s
 IO’s
 Dental Models
 The entire pre-authorization process can take 1 week to
3 months
INSURANCE: PROCEDURE CODES
 Septoplasty: 30520
 Turbinectomy: 30130-50
 Radiofrequency:
 Turbinates: 30802
 Soft Palate: 41530
 Base of Tongue: 0088T
 UPPP/Palatalpharyngoplasty: 42145
 Pharyngoplasty: 42953
 Tonsilectomy and adenoidectomy younger than 12: 42820
 Tonsilectomy and adenoidectomy age 12 and over: 42821
 Removal of foreign body from pharynx: 42809
INSURANCE: PROCEDURE CODES
 LeFort I: 21143
 LeFort I with bone grafts: 21147
 BSSO: 21196
 Genioplasty: 21121
 Genioglossal Advancement: 21191
 Mandible osteotomy with genioglossus advancement: 21199
 Hyoid Myotomy and suspension: 21685
INSURANCE: WHAT TO DO IF DENIED
 Dispute denial of benefits
 Contact insurance and set up a peer-peer review
 Peer-peer review is between submitting doctor and reviewing doctor and takes
place over the phone
 Submit additional diagnostic material
 WE HAVE NEVER HAD A PROCEDURE DENIED AFTER PEER-PEER REVIEW
IMAGE REFERENCES
 Cyber Sarge’s Vietnam Veterens Information. 2006. Sleep Apnea Information.
http://cybersarges.tripod.com/SleepApnea.html 4 May 2011.
 Friedman M., ed. Sleep Apnea and Snoring: Surgical and Non-Surgical Therapy,
Saunders Elsevier: Chicago, 2009, pp. 96, 106, 120
 E-Doctor Online. Nose Anatomy. http://www.edoctoronline.com/medicalatlas.asp?c=4&id=21657&m=1&p=3&cid=1050&s= 4 May 2011
 Cwynar, Justin, 2004. Mouth, Teeth, Tongue, Nose.
http://www.pitt.edu/~anat/Head/Mouth/Mouth.htm 4 May 2011
 Guyuron B. Soft Tissue Functional Anatomy of the Nose. Aesthetic Surgery Journal,
Nov 2006 Vol. 26 No. 6 733-755.
 Rhee J et al. Clinical Consensus Statement: Diagnosis and Management of Nasal
Valve Compromise. Otolaryngol, Head, and Neck Surgery, July 1 2010 vol. 143. no.
1 48-59
 The Snoring Centre, 2009. http://www.snoringcentre.com/images/tonsil_size_sm.gif
4 May 2011
 NY Snoring and Sinus, 2010. Septoplasty. http://www.nysnoringandsinus.com/septoplasty.html 4 May
2011
 Pearl A M.D. Premier Community Health – A.D.A.M., 2006. Tonsilectomy.
http://www.premiercommunityhealth.org/adam/Health%20Illustrated%20Encyclopedia/3/100122.htm 4 May 2011