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Staging and Treating Snoring and Obstructive Sleep Apnea
From: ENT Today, January 2007
by Pippa Wysong
TORONTO-Obstructive sleep apnea (OSA) needs to be addressed as a multilevel disease, especially in patients who fail or can't tolerate continuous positive airway pressure (CPAP). But more than that, often minimally invasive techniques and technology will solve the problem, rather than using aggressive surgery on only one level.
It's not about the palate and tonsils only-it's about the nose, palate, the tongue base, and sometimes the epiglottis. We have to address it with a multiple level of treatments, said Michael Friedman, MD, Professor of Otolaryngology at the Rush University Medical Center in Chicago, who moderated a session on the treatment of snoring and OSA at the annual meeting of the AAO-HNS.
Panelists included B. Tucker Woodson, MD, Professor of Otolaryngology at the Medical Collage of Wisconsin; David Terris, MD, Chair of Otolaryngology at Medical College of Georgia; and David L. Steward, MD, Director of Clinical Research in Otolaryngology-Head and Neck Surgery at the University of Cincinnati Medical Center.
According to Dr. Friedman, the first step is to determine how severe the disease is, and the otolaryngologist needs to take several factors into account in order to stage it. Staging is based on the anatomic site, and the type and severity of deformity. The extent of treatment-whether it's minimally invasive, no treatment, or maximally invasive-is based on a combination of the deformity and severity of the disease.
A minor deformity causing a minor problem may typically call for a minor procedure, whereas a more significant deformity causing problems beyond just snoring may demand a more aggressive procedure, he said.
Dr. Friedman uses a classification system that incorporates three levels of staging for disease severity: 0, 1, and 2. Level 0 would be no disease (or possibly an anatomical variation that falls within the normal, healthy range), level 1 would be mild disease that could benefit from a minimally invasive technique, and level 2 is severe and would require an aggressive approach.
He discussed how the classifications and treatment rankings would work with the nose, palate, tonsils, hypopharynx and tongue base, and body mass index (BMI) of the patient.
With the nose, N0 would require no treatment. An N1 case could benefit from radiofrequency (RF) of the turbinate, or nasal valve repair. For N2, septoplasty is needed.
At this point, panelists were asked how they would treat a patient with an obvious nasal deformity such as a deviate septum or turbinate, and who had significant sleep apnea but no daytime symptoms.
In general, most would do septoplasty. Apnea is a manifestation of airway obstruction and increased resistance, said Dr. Woodson.
However, Dr. Terris said he wouldn't necessarily treat it. I would probe the patient regarding their nasal symptoms, in particular congestion when they are supine. Many times, when they wake up they are congested. That would be enough for me to recommend surgery. If they deny any problems with their nose at all, I wouldn't recommend treatment, he said.
Continuing with the classification system, Dr. Friedman said that with the palate, P0 would mean no treatment; P1 would entail minimal treatments such as RF, Pillar implant procedure, laser-assisted uvulopalatoplasty (LAUP), or uvulectomy. P2 would require UPPP. Tonsils would range from T0, no treatment; to T1, needing coblation; to T2, which would need tonsillectomy.
Clinical staging of the hypopharynx would range from the H0, no treatment level, to H1, needing minimal treatments such as RF, coblation, tongue base suspension, or use of oral appliances. H2 cases would take more aggressive treatments such as genioglossus advancement, thyroid suspension, or bimaxillary advancement.
When it comes to the patient's BMI, B0 (meaning within a normal healthy range) would not need any treatment. Heavy patients would fall into a B1 category and should undergo weight loss, while B2 could mean a more aggressive approach such as bariatric surgery.
However, patients whose BMI is over 40 are not good candidates for upper airway surgery, Dr. Friedman said.
Pros and Cons of Pillar Implants
Panelists discussed Pillar implants, and agreed that it's a procedure they don't use frequently. Drs. Steward and Terris both said they use it occasionally in patients to help treat snoring.
Dr. Friedman described a recent study that showed subjective success rate of 60% reduction in snore levels, and an objective cure rate of 40%.
He suggested that Pillar implants can be used in combination with other procedures. Some evidence suggests that nasal surgery alone leads to a worsening of apnea-hypopnea index (AHI) in most patients, but if combined with Pillar implants there was a 40% success rate.
For patients without tonsils, Z-palatoplasty (ZPP) can be used. In a study where patients also received tongue base treatment, it led to almost as high a subjective success rate as UPPP, but a higher objective success level when compared to UPPP.
When it comes to problems in the nose, most resistance is due to problems in the nasal valve, according to Dr. Woodson. There are various procedures to expand the air space. In particular, the goal of palatopharyngoplasty with palatal advancement is to make the retropalatal space bigger.
The first time you do it, you'll the effect on the retropalatal space is remarkable, Dr. Woodson said.
Dr. Steward described RF ablation treatments for OSA. The advantage of RF over surgery is that there is less morbidity, lower complication rates, less pain for the patient, does not require general anaesthesia, and it can be done as an outpatient procedure. The downside with RF ablation is that it requires multiple procedures and is less efficacious than nasal CPAP, he said.
He provided some tips for tongue base RF ablation. These included using a dilute local anesthetic that is buffered with sodium bicarbonate, treating the patient immediately after each injection, using a Peridex oral rinse and systemic antibiotics, not reusing handpieces, and targeting patients whose BMI is less than 34.
Dr. Terris discussed the use of tongue suspension in hypopharyngeal sleep surgery. Before performing surgery for tongue base obstruction, a full assessment should include an upper airway examination, polysomnography, and a trial of CPAP; in addition, the physician must have informed consent from the patient, along with preoperative clearance.
The tongue suspension procedure (Repose) was originally designed for bladder suspension, but was adapted for use on the mandible. There have been early, promising results from a Stanford study on a total of 19 patients who also had concomitant UPPP, Dr. Terris said.
Indications for the procedure include moderate to severe OSA (AHI over 20); tongue base obstruction observed on a flexible airway examination; failure of CPAP (or refusal to use), and no medical contraindications to surgery.
One study showed a 60% success rate of tongue suspension plus UPPP. In some cases CPAP usage is still required, but can be tolerated at lower pressures, he said.
However, there are some caveats with the tongue suspension. Patients with microgenia or substantial enlargement of the tongue are not good candidates, and other surgical options should be shared with the patient, Dr. Terris said.
To avoid complications, Dr. Terris offered a few tips. One was to stay in the midline to avoid Wharton's ducts. Right-handed surgeons should put the temporary suture loop on the right, and avoid making the suture too tight. Patients should be observed in the recovery room for a couple of hours to determine the level of care they may need.
©2007 The Triological Society