RUSSAMENTO E OSAS (SNORING AND OSAS)

Obstructive Sleep Apnea Syndrome O. S. A. S Obstructive Sleep Apnea Syndrome

O.S.A.S Sindrome caratterizzata da: russamento episodi apnoici durante il sonno

OSAS Base della patologia è l’apnea che si caratterizza per un interruzione dell’attività respiratoria nasale ed orale per almeno 10 secondi e persistenza dei movimenti toracici ed addominali per vincere l’ostruzione (apnea ostruttiva) Se vi è abolizione dei movimenti toracici si parla di apnea centrale Le apnee costituiscono il sintomo cardine, insieme alle ipopnee, della sindrome delle apnee ostruttive o sindrome OSAS

eziopatogenesi Apnea centrale: disfunzione dei centri del respiro a livello del SNC, con abolizione dei movimenti toraco-addominali e quindi del flusso aereo ( rara ) Apnea ostruttiva periferica: collasso delle vie aeree superiori di varia natura, con persistenza dei movimenti toraco-addominali Apnee di tipo misto periferico-centrale

RUSSAMENTO Rumore che si produce durante il sonno a causa delle vibrazione di parti molli delle prime vie aeree Non si realizza un’ostruzione completa È un disturbo di tipo “sociale” (partner) Non ha effetti secondari immediati sull’apparato cardiocircolatorio È spia di un decadimento anatomico e funzionale delle prime vie aree che può esitare nell’OSAS

Apnea – cessation of airflow >10 sec, ends in arousal Definizione Apnea – cessation of airflow >10 sec, ends in arousal Hypopnea – reduction in airflow with desaturation, ends in arousal Apnea / Hypopnea Index (Respiratory Disturbance Index)

Definizione di OSAS RDI 10<20 = mild RDI > 20 increases risk of mortality RDI 20-40 =moderate RDI >40 =severe Upper Airway Resistance Syndrome (UARS) Shares pathophysiology with OSA No desaturation, continuous ventilatory effort Snoring

Apnea ostruttiva periferica fattori predisponenti obesità stenosi nasale: deviazione del setto polipi nasali ipertrofia dei turbinati ipertrofia adenoidea ostruzioni faringee: ipetrofia tonsillare mega-ugola

apnea ostruttiva periferica stadiazione Stadio 0: forti russatori con sporadiche apnee notturne Stadio 1: forti russatori con apnee ma solo in posizione supina Stadio 2:forti russatori con frequentissime apnee anche dormendo sul fianco Stadio 3: pz. scompensati ipoventilati anche in veglia con gravi apnee notturne

apnea ostruttiva periferica conseguenze ipersonnia diurna cefalea faringodinia mattutina insufficienza respiratoria cuore polmonare > patologie cardio-circolatorie > patologie vasculo-cerebrali > incidenti automobilistici !!!!!!!!!!!!!

Obstructive Sleep Apnea 1-4% of population Pickwick Papers (1837) Osler (1906) Guilleminault (1973) - OSAS

(da Guilleminault nel 1973) O.S.A.S Studiata e descritta in modo scientifico solo di recente (da Guilleminault nel 1973)

Epidemiologia 85% dei pazienti adulti sono di sesso maschile 2% delle donne oltre i 40 anni 4% degli uomini oltre i 40 anni circa 2\3 dei pz è obeso l’incidenza dell’OSAS aumenta con l’età

Physiology of Sleep REM Sleep Latency, REM Latency Arousal Woodson, Tucker “Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment” SIPAC 1996 REM Sleep Latency, REM Latency Arousal

Pathophysiology of OSA Airway size:

Pathophysiology of OSA Sites of Obstruction: Obstruction tends to propagate

Pathophysiology of OSA Findings in Obstruction: Nasal Obstruction Long, thick soft palate Retrodisplaced Mandible Narrowed oropharynx Redundant pharyngeal tissues Large lingual tonsil Large tongue Large or floppy Epiglottis Retro-displaced hyoid complex

Pathophysiology of OSA Sites of Obstruction:

Pathophysiology Pharyngeal collapse Decreased airway patency Increase in negative pressure Becomes a vicious cycle

Pathophysiology Anatomic narrowing Abnormal neuromuscular control Requires increased inspiratory pressures Abnormal neuromuscular control Reflex activation of dilators in response to airway obstruction often fails

Risk factors Obesity (BMI > 30) Drunkenness Smoking ORN Hormonic depletion (estrogeni)

Tests to determine site of obstruction: Muller’s Maneuver Sleep endoscopy Fluoroscopy Manometry Cephalometrics Dynamic CT scanning and MRI scanning

Apnea ostruttiva periferica diagnosi anamnesi e visita ORL tradizionale valutazione endoscopica delle VADS test di Muller ossimetria transcutanea polisonnografia rinomanometria posizionale tests allergici studio del reflusso gastro-esofageo valutazione neurologica e pneumologica

History Snoring* Excessive daytime sleepiness* Restless sleep Personality changes Headaches Sexual dysfunction Job performance Sleep hygiene Bed partner’s input *

Physical Exam Vital signs Head & Neck exam Flexible endoscopy

Vital signs Height Weight Collar size Blood pressure Calculate BMI Wt (kg) / Ht (meters) squared Men >27.8, Women >27.3

Examination Tongue Palate Uvula Tonsils Nasal cavity Hyoid Mandible Maxilla

Classificazione di Mallampati

MALLAMPATI MODIFICATA . Lo score viene calcolato osservando il piano del dorso linguale e il profilo del palato molle a bocca aperta e con la lingua adagiata sul pavimento orale e se ne identificano quattro gradi (vedi figura): o       grado I: tonsille, pilastri e palato molle chiaramente visibili o       grado II: ugola, pilastri e polo tonsillare superiore visibili o       grado III: visibile solo parte del palato molle grado IV: palato molle non visibile, visibile solo il palato duro La classificazione di Mallampati permette una immediata quantificazione del volume linguale e può essere un utile indice di ostruzione faringea; è stata infatti dimostrata una stretta correlazione tra questo indice e la gravità della sindrome OSA. Anche il volume tonsillare è considerato un importante fattore predittivo sia della presenza dell’OSAS che della sua severità ed è stato individuato come fattore predittivo del successo chirurgico in diversi studi.L’ipertrofia tonsillare viene valutata tramite una classificazione che prevede cinque gradi

Test di Muller

Hypo-pharynx collapse Test di Muller BOT collapse Hypo-pharynx collapse

Esame obiettivo

Tests Radiologici Cephalometrics Computed tomography Magnetic resonance imaging

Cephalometrics Standardized lateral radiographs Examines bony and soft-tissue structure Two-dimensional evaluation Lack of volumetric data Maxillomandibular surgery, oral appliances

Computed tomography Supine Volumetric reconstruction Disadvantages Cost Weight limitations Ionizing radiation

Magnetic Resonance Imaging Excellent soft tissue anatomy Multiple planes No ionizing radiation Disadvantages Cost Weight limitations Noisy claustrophobia

Evaluation of Sleep Split-Night Polysomnography Epworth Sleepiness Scale

Evaluation of Sleep Polysomnography EMG Airflow (nasal and oral) EEG, EOG Oxygen Saturation Cardiac Rhythm -- Respiratory movement -- Sleeping position Leg Movements AI, HI, AHI, RDI

Evaluation of Sleep Polysomnography Woodson, Tucker “Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment” SIPAC 1996

Polisonnografia Apnea centrale: disfunzione dei centri del respiro a livello del SNC, durata almeno 10 sec., con abolizione dei movimenti toraco-addominali e quindi del flusso aereo ( rara ) Apnea ostruttiva periferica: collasso delle vie aeree superiori di varia natura, almeno 10 sec. di durata, con persistenza dei movimenti toraco-addominali Apnee di tipo misto periferico-centrale: (caratteristiche di entrambi) Ipopnea: ipoventilazione secondaria ad ostruzione parziale

Polisonnografia Apnea index Apnea-Hypopnea index = respiratory disturbance index Arousal index

Nonsurgical modalities Surgical modalities TERAPIA Nonsurgical modalities Surgical modalities

Nonsurgical Treatment Weight loss Sleep hygiene and sedative avoidance Pharmacotherapy Smoking cessation Nasal continuous positive airway pressure Oral appliances

Apnea ostruttiva periferica terapia Terapia farmacologico-comportamentale: calo ponderale, terapia del GERD, stop fumo, alcool, tranquillanti, modifiche della postura a letto! antidepressivi?

Nonsurgical Treatment Weight loss Get below “trigger weight” Diet, exercise, bariatric surgery, medications Sleep hygiene Avoidance of sedatives Positional changes

Terapia Farmacologica Protriptyline – decreases REM sleep Xanthine based drugs Steroids Antibiotics Nasal medications

Medical Management CPAP since 1981 Very effective Can be modified and used on a trial basis Pressure must be individually titrated Compliance is as low as 50% Air leakage, eustachian tube dysfunction, noise, mask discomfort, claustrophobia

CPAP Titrated to limit all respiratory events 50-90% acceptance – better if daytime symptoms improved Side effects in 40-50%

CPAP

CPAP

CPAP

Nonsurgical Management Oral appliance Advances the mandible Retains the tongue anteriorly

Oral Appliances May be as effective as surgical options, However low compliance rate of about 60% in study by Walker et al in 2002 rendered it a worse treatment modality than surgical procedures Walker-Engstrom ML. Tegelberg A. Wilhelmsson B. Ringqvist I. 4-year follow-up of treatment with dental appliance or uvulopalatopharyngoplasty in patients with obstructive sleep apnea: a randomized study. Chest. 121(3):739-46, 2002 Mar.

Oral appliances Advances the mandible Retains the tongue anteriorly Most effective in nonobese patients with retro or micrognathia Better for mild to moderate cases 51% achieve normal sleep, 61% improved RDI < 20 Consider TMJ dysfunction and occlusal changes

Surgical Management Therapy should be directed toward presumed site of obstruction This does not always guarantee results

Trattamento chirurgico Algorithms Riley et al 1992 Studied 2 phase approach for multilevel site of obstruction (Stanford Protocol): Phase 1: Genioglossal advancement, hyoid myotomy and advancement, UP3 Phase 2: Maxillary-Mandibular advancement in 6 months if phase 1 failed Reported >90% success rate in patients who completed both phases Other studies have lowered this number Testing is done at 6 months

Riley-Powell-Stanford Protocol

Riley-Powell-Stanford Protocol Post operative PSG at 6 months Phase I = 61% success Phase II = 95-100% success

Trattamento chirurgico Measures of success – No further need for medical or surgical therapy Response = 50% reduction in RDI Reduction of RDI to < 20 Reduction in arousals and daytime sleepiness

Trattamento chirurgico Perioperative Issues High risk in patients with severe symptoms Nasal CPAP often required after surgery Nasal CPAP before surgery improves postoperative course Risk of pulmonary edema after relief of obstruction

Trattamento chirurgico Tracheostomy Primary treatment modality Temporary treatment while other surgery is done Thatcher GW. et al: tracheostomy leads to quick reduction in sequelae of OSA, few complications (see table II) Once placed, uncommon to decannulate Thatcher GW. Maisel RH. The long-term evaluation of tracheostomy in the management of severe obstructive sleep apnea. [Journal Article] Laryngoscope. 113(2):201-4, 2003 Feb.

Tracheotomia Bypasses all areas of obstruction Virtually 100% effective Two indications Temporary procedure during airway reconstruction Severe OSA when CPAP refused, ineffective, or not tolerated or if other conditions exacerbated by the apneas Line the tract with skin flaps Lack of social acceptance

Trattamento chirurgico Nasal Surgery Improved symptoms and CPAP Septoplasty Turbinate reduction Functional nasal reconstruction Limited efficacy when used alone Verse et al 2002 showed 15.8% success rate when used alone in patients with OSA and day-time nasal congestion with snoring (RDI<20 and 50% reduction) Adenoidectomy

Trattamento chirurgico Retropalatal obstruction Retrolingual obstruction

ALTERAZIONI DI PALATO MOLLE ED UGOLA

NELL’AFFRONTARE IL PROBLEMA VELARE NELL’OSAS NON SI PUO’ PRESCINDERE DA UNA RISOLUZIONE DEL PROBLEMA TONSILLARE

SITUAZIONE TONSILLARE Grado 0 esiti di tonsillectomia Grado I tonsille atrofiche intraveliche Grado II tonsille appena visibili minimamente debordanti dal pilastro anteriore Grado III tonsille ipertrofiche occupanti uno spazio pari a 3/4 dell’istmo delle fauci Grado IV tonsille completamente ostruenti l’istmo delle fauci (kissing tonsils)

Grado 0 esiti di tonsillectomia Grado I tonsille atrofiche intraveliche Grado II tonsille appena visibili minimamente debordanti dal pilastro anteriore Grado III tonsille ipertrofiche occupanti uno spazio pari a 3/4 dell’istmo delle fauci Grado IV tonsille completamente ostruenti l’istmo delle fauci (kissing tonsils)

Trattamento chirurgico Uvulopalatopharyngoplasty (UPPP) The most commonly performed surgery for OSA Severity of disease is poor outcome predictor Levin and Becker (1994) up to 80% initial success decreased to 46% success rate at 12 months Friedman et al showed a success rate of 80% at 6 months in carefully selected patients Friedman M, Ibrahim H, Bass L. Clinical staging for sleep-disordered breathing. Otolaryngol Head Neck Surg 2002; 127: 13–21.

UPPP Fujita (1981) Most common procedure 1st line tx for retropalatal collapse 10-50% success

UPPP

UPPP – Fujita / Ikematsu

Uppp PRE E POST

UPP

Trattamento chirurgico UP3 Complications Minor Transient VPI Hemorrhage<1% Major NP stenosis VPI

Trattamento chirurgico Cahali, 2003 proposed the Lateral Pharyngoplasty for patients with significant lateral narrowing: Cahali MB. Lateral pharyngoplasty: a new treatment for obstructive sleep apnea hypopnea syndrome. Laryngoscope. 113(11):1961-8, 2003 Nov.

Trattamento chirurgico Lateral Pharyngoplasty

Trattamento chirurgico Lateral Pharyngoplasty Median apnea-hypopnea index decreased from 41.2 to 9.5 (P = .009) No control group No evaluation at 12 months

LAUP Laser Assisted Uvulopalatoplasty High initial success rate for snoring Rates decrease, as for UP3 at twelve months Performed awake

COMPLICANZE LAUP- STENOSI

Surgical Management Radiofrequency Ablation – Fischer et al 2003 Radiofrequency device is inserted into various parts of palate, tonsils and tongue base at various thermal energies Fischer et al 2003 At 6 months Showed significant reduction of: RDI (but not to below 20) Arousals

TERAPIA INTERSTIZIALE RVFR palatale

TERAPIA INTERSTIZIALE: Coblator - Cold Ablation (ablazione fredda). E’ un sistema bipolare che lavora ad una frequenza di 10 KHz. L’ablazione dei tessuti avviene per dissociazione molecolare, anziché per vaporizzazione od esplosione cellulare. I tessuti vengono quindi ridotti in molecole di idrocarburi ed ossidi, Lavora tra i 40 ed i 70°.

IMPIANTI PALATALI: procedura semplice ed efficace consiste nell’inserimento nello spessore del palato molledi tre barrette di materiale sintetico (poliestere) a lento riassorbimento; lo scopo della procedura è causare un irrigidimento velare e di conseguenza minori vibrazioni del palato, monoseduta

Tongue reduction Lingual tonsillectomy Laser midline glossectomy Lingualplasty Radiofrequency volumetric tissue reduction

Trattamento chirurgico Tongue Base Procedures Lingual Tonsillectomy may be useful in patients with hypertrophy, but usually in conjunction with other procedures

Trattamento chirurgico Tongue Base Procedures Lingualplasty Chabolle, et al success rate of 77% (RDI<20, 50% reduction) in 22 patients in conjunction with UPPP Complication rate of 25% - bleeding, altered taste, odynophagia, edema Can be combined with epiglottectomy

Trattamento chirurgico Lingual Suspension:

Trattamento chirurgico Lingual Suspension:

Trattamento chirurgico Hyoid Myotomy and Suspension Advances (the tongue base ) hyoid bone anteriorly and inferiorly Advances epiglottis anteriorly Enlarges retrolingual airspace Performed in conjunction with other procedures Dysphagia may result

Trattamento chirurgico Mandibular Procedures Genioglossus Advancement Rarely performed alone Increases rate of efficacy of other procedures Transient incisor paresthesia

Mandibular Osteotomy with Genioglossus Advancement Enlarges the retrolingual airway without disturbing dentition Prevents retrolingual collapse

Maxillary-Mandibular Advancement Trattamento chirurgico Maxillary-Mandibular Advancement

Maxillomandibular Osteotomy and Advancement Severe disease Failure with more conservative measures Midface, palate, and mandible advanced anteriorly Limited by ability to stabilize the segments and aesthetic facial changes

Trattamento chirurgico Maxillary-Mandibular Advancement Performed in conjunction with oral surgeons

Pediatric OSAS Many features are different 2% of children Males = Females Peak at age 2-5

Pediatric OSAS Snoring – severity not predictive Many are mouth breathers Adenoid facies (15% have OSAS) Excessive daytime sleepiness Obesity vs. FTT Increased respiratory effort

Pediatric OSAS Parasomnias Restless sleep Aggressive behavior Learning disabilities Enuresis

Pediatric OSAS Impaired growth Cor pulmonale Associated with GERD Possible impairment of release or end-organ response to GH Increased caloric effort with respiration Difficulty with eating Cor pulmonale Associated with GERD

Diagnosis History * Physical exam * The child who always snores, has restless sleep secondary to obstruction, & has apneic episodes per the parents virtually always has PSG confirmation (Brouillette)

Polisonnografia Not cost effective Considerations CNS disease Age < 2 Increased surgical risks Family desires Discordant exam

Polysomnogram

Diagnosis Lateral neck radiographs Chest x-rays EKG

Terapia Tonsillectomy & adenoidectomy

Down Syndrome OSAS = 54-100% Physical factors Small midface and cranium Narrow nasopharynx Large tongue Muscular hypotonia Obesity Small larynx Congenital heart disease / cor pulmonale UPPP

Trattamento chirurgico Algorithms Friedman et al developed a staging system for type of operation:

Surgical Management Algorithms: Friedman et al:

Surgical Management Algorithms: Friedman et al: Success = RDI<20 and RDI reduced 50% Friedman, Michael MD; Ibrahim, Hani MD; Joseph, Ninos J. BS Staging of Obstructive Sleep Apnea/Hypopnea Syndrome: A Guide to Appropriate Treatment. Laryngoscope. 114(3):454-459, March 2004.

Algorithm Weight loss CPAP Consider oral appliances for milder cases

Conclusions Physiology of Sleep Evaluation of Sleep Definition of Obstructive Sleep Apnea (OSA) Prevalence of OSA Pathophysiology of OSA Medical Treatment of OSA Surgical Treatment of OSA