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Oral Surgery 2 > Obstructive Sleep Apnea > Flashcards

Obstructive Sleep Apnea Flashcards

1
Q

Normal sleep is a delicate balance between ___ and ___. Regulation of the sleep-wake-cycle is complex in nature involving what things?

A

Hypersomnia and insomnia

Light-dark cues

Retinothalamic tract

Suprachiasmatic nucleus

Cortisol

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2
Q

What is the difference between NREM and REM?

A

NREM: steady slow HR and respiratory rate. Low BP

REM: rapid eye movement, increased autonomic activity and dreaming, stimulated brain activity, decreased muscular activity

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3
Q

What are the physiologic changes during sleep in normal pts?

A

Decreased tidal volume, decreased minute ventilation, increased pCO2

Decreased SaO2

Increased upper airway resistance

10-20% decrease in metabolic rate

Decreased HR and BP

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4
Q

Name 6 sleep apnea syndromes

A

Obstructive sleep apnea syndrome (OSA) - absence of airflow with continued respiratory effort

Central apnea (nothing you can really do about this) - lack of airflow from absence of respiratory effort

Mixed apnea - combination of obstructive and central

Obesity hypoventilation syndrome

Pickwickian syndrome

Sudden infant death syndrome

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5
Q

Define obstructive sleep apnea

A

Periodic obstruction of upper airway during sleep that is marked by either apneic or hypopneic events

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6
Q

What is the difference between apneic and hypopneic ecents?

A

Apneic - cessation of ventilation for 10 seconds or longer, leading to an arousal (these occur normally)

Hypopneic - tidal volume decreased by >50% for greater than 10s. Decreased airflow with arousal or desaturation of 2-4%

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7
Q

To be diagnosed with obstructive apnea you must have more than ___ apneic events per hour

A

5

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8
Q

__% of the adult population has OSA. __% of OSA pts have HTN. __% of HTN pts have OSA.

A

5%

50%

25%

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9
Q

Describe the pathophysiology behind OSA

A

Anatomic narrowing/pharyngeal collapse

Decreased airway patency

Increase inspirations pressures

Abnormal neuromuscular control

Reflex activation of dilatory in response to airway obstruction often fils

Becomes a viscous cycle

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10
Q

What is a definitive event?

A

Occlusion of upper airway

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11
Q

Apnea leads to progressive ____ until brief arousal form sleep occurs and airflow resumes

Up to ___times or greater per night in some patients

This leads to sleep fragmentation

A

Asphyxia

400

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12
Q

Why does the airway collapse in osa?

A

Sleep reduces activity of airway dilator muscles and their reflex response to subatmospheric airway pressures

OSA pateints demonstrate high airway compliance (floppy airway)

Some patients have obvious anatomic problem

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13
Q

Where do most sites of obstruction occur in osa?

A

50% occur at base of tongue

18% occur at soft palate

Most are due to combination

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14
Q

What tools are used to diagnose osa?

A

History (abnormal snoring, excessive daytime fatigue, restless sleep, impaired cognitive function, morning headaches, personality changes, sexual dysfunction, poor job performance)

Physical exam (vitals, head and neck exam, flexible endoscopy) males >17.5” color size with snoring have a 50% likelihood of OSA

Radiographs

Polysomnogram

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15
Q

What are some things you may find in a head and neck exam that may lead you to think the pt has osa?

A

Mandibular retrognathia

Macroglossia

Adenotonsillar hypertrophy

Large neck circumference

Airway anatomy (mallampati classification)

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16
Q

What is a nasopharyngoscope used for?

A

Evaluation of the nose, oropharynx, and hypopharnx is best accomplished using a flexible nasopharyngoscope

17
Q

What is muller’s maneuver?

A

Inspire against closed nostrils and mouth, reveal the site and degree of obstruction (use a nasopharyngoscope)

Measured from 1-4 (total collapse)

Measured at soft palate and at base of tongue

Done in the supine and upright positions

18
Q

What are some cardiovascular manifestions of osa?

A

Hypoxemia, hypercarbia result in multiple problems..

Tachycardia/bradycardia

MI

Ventricular ectopic

Systemic and pulmonary HTN

Decreased CO

Polycythemia

Ventricular hypertrophy

Congestive heart failure

19
Q

What are some non-surgical treatment options for osa?

A

Weight loss
Sleep hygiene
Oral appliances
CPAP, BiPAP

20
Q

What are some surgical treatment options for osa?

A

Uvulopalatopharyngoplasty

Radio frequency ablation of tongue base/palate

Tongue reduction

Genial surgery

Maxillomandibular advancement

Nasal surgery

Tracheostomy

21
Q

What is the gold standard non-surgical treatment for osa?

A

CPAP (continuous positive airway pressure)

Subjective symptoms and long-term sequence eliminated if CPAP used

Patient compliance is a problem

22
Q

True or false… CPAP is effective for part-time use

A

False

23
Q

What is the goal of oral appliances that are used to treat osa?

A

Advance the mandible

Retain the tongue anteriorly

Most helpful in cases of mild disease

24
Q

Oral appliances for osa are best in which cases? What are some side effects?

A

Most effective in non-obese patients with retro or micrognathia

Better for mild-moderate cases (less likely in severe disease)

Side effects: TMJ symptoms, excess salivation, occlusal changes

25
Q

Surgical treatment for osa is guided depending on…

A

Area of obstruction

Retro palatal obstruction: UPPP, LAUP

Retrolingual obstruction: tongue surgery, genial surgery, mma

26
Q

What is the most commonly performed surgical procedure for OSA?

A

Uvulopalaopharyngoplasty (UPPP)

Removes redundant tissue from the palat and tonsillar regions

Snoring improved or cured in 76-95% of patients

27
Q

What is LAUP?

A

Laser assisted UPPP

28
Q

What is radio frequency ablation of the palate/tongue base? (RFA)

A

Used as an alternative to UPPP/LAUP

Complications are common: mucosal sloughing, tongue base neuralgias, abscesses, and hematomas

Secondary to maxillary osteotomy blood supply effects

It creases limited zones of coagulation beneath the tissue surface. As lesions resorb, they stiffen and reduce the tissue in the soft palate/base of tongue

29
Q

Name some different tongue reduction surgeries used for treatment of OSA

A

Lingual tonsillectomy

Midline partial glossectomy

Glossopexy

These have minimal research and have poor results

30
Q

What are some genial procedures used to treat OSA?

A

Genial tubercle advancement - advancing the lingual cortex beyond the labial cortical plate and rotating it 45-90 degrees. (Pulls mylohyoid)

Advancement genioplasty

Studies suggest combining UPPP w/genial advancement has an 80-85% success rate

31
Q

Maxillomandiublar osteotomy and advancement (MMA) is usually reserved for pts with ___ disease. It has effects on…

A

Severe

All pharyngeal levels

Nasopharynx
Oropharynx
Hypopharynx

Creates a larger pharyngeal airway
Rigid fixation is important
Bone grafting to maximize stability

32
Q

What does MMA do?

A

Pulls soft palate forward and upward

Moving the mandible forward results in a more anterior position of the tongue base

Increases tension of pharyngeal wall musculature and tissue

Hyoid position poorly understood but MMA results in more anterior and superior position

33
Q

What are some nasal surgeries used for OSA?

A

Septoplasty

Turbinate reduction

Functional nasal reconstruction

34
Q

When would you use a tracheostomy to treat OSA?

A

Only when severe/emergencies…

1) Temporary procedure during airway reconstruction
2) severe osa when CPAP refused, ineffective, or not tolerated or if other conditions exacerbated by the apneas

Virtually 100% effective

Bypasses all areas of obstruction

35
Q

True or false.. osa is ossociated with significant long-term morbidity and decreased life expectancy

A

True

36
Q

Multi-level surgical reconstruction of the airway today provides ___% chance of long-lasting cure to osa

A

95%

Oral Surgery 2 (9 decks)

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