Sleep Disorders ENT Flashcards
Overview of sleep disorders?
Approximately one in seven North Americans have a chronic sleep/wake disorder.
Excessive daytime sleepiness afflicts up to 5% of western society.
Over half of severely hyper-somnolent patients report loss of job, or disruption of family life.
Excessive daytime sleepiness has been associated with an increased rate of automobile accidents.
What is OSA?
Cessation of airflow with ongoing respiratory effort.
Symptoms of OSA?
Daytime hyper-somnolence: Impaired work performance, Decreased quality of life, Increased rate of automobile accidents
Hypertension
Snoring: Witnessed apneic episodes, Choking or gasping episodes
Other symptoms: Nocturnal headaches, enuresis, gastroesophageal reflux, impotence, respiratory failure, and psychiatric disorders
Assessment of OSA?
History
Questionnaires: Snoring, Witnessed apneic episodes, Daytime hyper-somnolence, Nocturnal choking
Physical exam of OSA?
Alertness
BMI
Neck circumference
Blood pressure
Enlarged or crowded oral structures
Nasal passages
Consequences of OSA?
Subjective complaints: snoring, sleepiness
Neuropsychological sequelae
Metabolic Derangements
Hypertension
Heart and Vascular Disease
Neurobehavioral effects of OSA?
Sizable effect of OSA on the ability to sustain attention over time, particularly on the quality of the performance rather than simple reaction time
Moderate to severe OSA negatively impacts memory and executive performance—although presence and degree of deficit in these categories is controversial
QOL studies indicate that pts with OSA have significantly impaired QOL and social functioning and a high prevalence of minor psychiatric morbidity
Improvements in both subjective and objective tests of sleepiness are seen with CPAP therapy for OSA. These improvements are moderate to large. Subjective scores improve to a larger degree than objective scores.
Evaluation of attention-based cognitive outcomes, there is a much more modest improvement of functioning with CPAP
QOL: the large impairments in sleepiness and energy related QOL scores show substantial improvement with CPAP—those with the most severe OSA reap the most benefit
Metabolic effects of OSA?
Insulin Resistance: hyperglycemia resulting from both an impaired insulin secretory response to glucose and decreased insulin effectiveness in stimulating glucose uptake by skeletal muscle and in restraining hepatic glucose production
Metabolic Syndrome: hyperinsulinemia, glucose intolerance, dyslipidemia, central obesity and hypertension; all risk factors for vascular disease
Diagnosis of OSA?
A polysomnogram measures the following parameters during sleep:
EEG
EOG
Leg movement
EKG
EMG
Oxygen saturation
Airflow
Chest movement
Abdomen movement
Polysomnogram interpretation for OSA?
Sleep staging
RDI/AHI
Oxygen Saturation
Central vs. obstructive apnea
Mild, moderate, severe apnea
Periodic leg movements
Other sleep related difficulties
Treatment options for OSA?
Weight loss
Avoidance of alcohol
Smoking cessation
Alteration of body position during sleep
Treatment of nasal obstruction
CPAP
Oral appliances
Surgery
Explain the CPAP for OSA?
Positive pressure maintains airway patency
Titration
100% effective
Patients often not compliant.
Oral appliances for OSA?
Oral appliances
Mandibular repositioning devices
Fit by a dentist
Hold the jaw and tongue forward
what do we do for pediatric OSA?
Tonsillectomy and Adenoidectomy is 97% curative in the pediatric population.
Tonsillectomy for OSA has become the most common reason to perform a tonsillectomy.
Standardization of of tonsil size?
History of Tonsilectomy?
In U.S.
1959: 1.4 million tonsillectomies performed
1979: 500,000
1985: 340,000
1996: 287,000
In 1950s and 1960s chronic infection primary surgical indication
Now, airway obstruction and obstructive sleep apnea more common indications
Improvement in medical management with Abx
Complications of Tonsilectomy?
2% post-operative hemorrhage: Most common 5-10 days after surgery
Dehydration
POPE—Post-obstructive pulmonary edema.
Velopharyngeal insufficiency.
Adult treatment options for OSA?
Surgical options are many, but uvulopalatopharyngoplasty (UP3) has been most commonly employed in adults
what is a Uvulectomy?
A patient with a large uvula who snores and has few or no symptoms of apnea may benefit from uvulectomy. The patient can be given local anesthesia, and uvulectomy can be performed as an office procedure by using cautery or a carbon dioxide laser. In 1993, laser-assisted uvulopalatoplasty was first described as a procedure for individuals who snore and have mild OSA. The procedure consists of incising the inferior rim of the soft palate and uvula. The tonsils are not removed.
Explain nasal reconstruction?
Relief of nasal obstruction alone rarely cures OSA; however, patient tolerance and response to nasal CPAP are often improved. Septoplasty, septorhinoplasty, and turbinate reduction may be indicated in patients who have predisposing anatomy. Turbinates can be reduced in a number of different ways, including traditional total or partial turbinectomies, submucous resection, cryotherapy, laser vaporization, bipolar radiofrequency coblation, and radiofrequency ablation.
Explain a permanent tracheotomy for OSA?
cures OSA
indicated most often for severe apnea associated with life-threatening cardiac arrhythmias.
less frequent indications:
morbid obesity
obstruction with severe hypoxia
disabling daytime somnolence
Not commonly used today.
in a multidisiplinatarian approach to OSA who should be consulted?
ENT
Neurology (Sleep)
Pulmonary (Sleep)
Oral Surgeon
Sleep Lab
Explain UP3?
UP3 Success rate=40% (20%-90%)
Is it a valued procedure? Isolated Combined with other procedures
UP3 cannot be the only treatment for obstruction Nasal Palatal Tongue base
is severity of disease an indicator of successful UP3?
Severity of disease is NOT a prognostic indicator of successful UP3.
AHI (5-15)=40% success rate
Full options to treat OSA?
CPAP Oral appliance Nasal Nasal Valve UP2 (radiofrequency) UP2 (pillar) UP2 (surgical)
UP3 TBRF Genioglossus advancement Thyro-hyoid suspension Maxillo-mandibular advancement (MMA)
UP3 failure rate?
60% failure rate with UP3 Unchanged Many actually worse
Surgical treatment for OSA?
Surgical treatment
Strive to avoid failure
Multiphase treatment should be identified
Mild disease requires what sort of resection?
UP3 failures Conservative resections for mild disease
BMI grading for OSA?
Grade 0 (<20kg/m2)
Grade I (20-25 kg/m2)
Grade II (25-30 kg/m2)
Grade III (20-35 kg/m2)
Grade IV (>40 kg/m2)
