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Algorithm for Multilevel Treatment: The Riley, Powell, and Liu Stanford Experience

1 Introduction Obstructive sleep apnea syndrome (OSAS), upper airway resistance syndrome, and snoring are collectively referred to as sleep-related breathing disorders (SRBDs). SRBD involve repeated partial or complete obstructions of the upper airway during sleep, and the etiology is multifactorial with derangements associated with respiratory arousal threshold, airway critical closing pressure, muscle tone, and loop gain. Loss of airway patency can be central, obstructive, or mixed…

Algorithm for Surgery: Palatopharyngoplasty First and Foremost

1 Goals and Considerations Multiple mechanisms underlie upper airway obstruction in obstructive sleep apnea (OSA). Although a small upper airway size is fundamental to OSA, muscle tone, tissue factors, lung volume, loop gain, and arousal threshold are important additional determinants. It is therefore not surprising that treatments that aim to enlarge or stabilize the upper airway such as sleep surgery, oral appliance therapy, hypoglossal neurostimulation, positional…

Friedman Tongue Position and the Staging of Obstructive Sleep Apnea/Hypopnea Syndrome

1 Introduction Obstructive sleep apnea/hypopnea syndrome (OSAHS) is often the result of obstruction at multiple anatomic sites. Nasal, palatal, and hypopharyngeal obstruction, acting alone or in concert, are frequently identified as the cause of snoring and OSAHS. Even in cases where a single site is primarily involved, the increase in negative pressure may induce further obstruction in other areas. When surgical management of OSAHS is considered,…

Perioperative and Anesthesia Management

1 Introduction Obstructive sleep apnea/hypopnea syndrome (OSAHS) is a growing health care concern with many potentially detrimental consequences and important anesthetic implications. A rise in obesity among the population of the United States corresponds with an upswing in the prevalence of OSAHS. Over the last two decades, the prevalence of OSAHS increased from 26.4% to 33.9% in males and from 13.2% to 17.4% in females. An…

Perioperative Monitoring in Obstructive Sleep Apnea/Hypopnea Syndrome

1 Introduction Obstructive sleep apnea/hypopnea syndrome (OSAHS) is a common condition resulting from a decrease in upper airway size and patency during sleep. Apneas, hypopneas, and episodes of airflow limitation occur during sleep, resulting in physiologic changes, including reductions in oxygen saturation and arousals from sleep. Arousals lead to cessation of the respiratory event, only to be followed by repetitive airflow obstructions and arousals. The arousals…

Rationale and Indications for Surgical Treatment

1 Background and Rationale for Surgical Therapy The rationale for and the objectives of surgical treatment for obstructive sleep apnea (OSA) are fundamentally analogous to those of medical management: to improve sleep-related symptoms and quality-of-life measures and to reduce cardiovascular morbidity and other health consequences associated with untreated moderate to severe OSA. The potential success of primary airway reconstructive surgery has a unique advantage over most…

Oral Appliances for OSA

1 Introduction Intraoral mandibular advancement devices (MADs) have become an acceptable and common treatment for the signs and symptoms of obstructive sleep apnea (OSA) in the United States. Oral appliances can be employed as a first-line modality for OSA and primary snoring or in patients who are intolerant of or need concurrent treatments with other modalities. MADs are usually not as efficacious as positive airway pressure…

Analysis of CPAP Failures

1 Introduction Arguably, the goal of treatment of obstructive sleep apnea (OSA) is (1) elimination or improvement of symptoms, (2) normalization or improvement of sleep study parameters, and (3) cardiovascular risk reduction in the longer term. The latter is especially true for severe OSA or for mild to moderate OSA, starting at a younger age. In 1981, continuous positive airway pressure (CPAP) was introduced as a…

CPAP, APAP, and BiPAP

1 Introduction Positive airway pressure (PAP) therapy is the standard modality for treating moderate and severe obstructive sleep apnea (OSA) in adults. It was first described by Colin Sullivan, an Australian pulmonologist, in 1981. There are several theories as to how PAP therapy relieves airway obstruction. Intuitively, it makes sense to think of it as a pneumatic splint that keeps the airway open by increasing the…

Obstructive Sleep Apnea: Decision Making and Treatment Planning

1 Introduction Numerous treatment options for obstructive sleep apnea (OSA) presently exist. These treatments range from noninvasive behavioral modifications to nightly use of continuous positive airway pressure (CPAP) devices to numerous pharyngeal expansion procedures that either alter airway anatomy or modify airway physiology. This chapter seeks to provide a framework to help guide physicians to a synthesis and evaluation of treatment options in this disease. It…

Drug-Induced Sleep Endoscopy (DISE)

1 Introduction Drug-induced sleep endoscopy (DISE) was introduced by Croft and Pringle in 1991 and over time has increased in popularity and is applied worldwide. The evaluation requires pharmacologic induction of sedation and flexible fiber-optic endoscopy to visualize upper airway obstruction and/or snoring. As opposed to most surgical evaluation techniques, DISE not only uniquely offers a dynamic evaluation of the upper airway during conditions that ideally…

Home Sleep Testing

1 Introduction Testing for obstructive sleep apnea (OSA) outside of the sleep laboratory setting has become increasingly common in the United States. Since 2008, when the Centers for Medicare and Medicaid Services (CMS) began reimbursing for the use of home testing, many other insurance companies have accepted, and in many cases, demanded, that testing in the home be used as the preferred method of diagnosis. The…

Clinical Polysomnography

1 Introduction The assessment of patients for snoring and sleep apnea includes a comprehensive sleep history, physical examination, and a diagnostic sleep study. The compilation of this information allows for the formulation of a treatment plan that is tailored to the patient's specific issues and needs. There is much more information on a sleep study report than just the Apnea/Hypopnea Index (AHI) and Respiratory Disturbance Index…

Airway Evaluation in Obstructive Sleep Apnea

1 Methods of Airway Evaluation As the interest in sleep-disordered breathing (SDB) has increased, various attempts have been made to assess upper airway anatomy in patients with this relatively frequent disorder. From the very beginning, researchers and clinicians used a multitude of different techniques not only to reveal potential differences in upper airway anatomy to better understand the origin and the pathophysiology of the disease, but…

Signs and Symptoms of Obstructive Sleep Apnea and Upper Airway Resistance Syndrome

1 Obstructive Sleep Apnea Obstructive sleep apnea (OSA) is characterized by repetitive episodes of complete or partial obstructions of the upper airway during sleep. The spectrum of these obstructive respiratory events during sleep occurs on a continuum ranging from hypopnea (reduced airflow during sleep) to apnea (complete airflow cessation during sleep). According to the International Classification of Sleep Disorders, 3rd edition, a diagnosis of OSA is…

Surgical robotics: safety, legal, ethical and economic aspects

Safety and normalization in surgical robotics B. Lombard Despite their complexity, ultra-specialization and intrinsically invasive nature, legislation worldwide considers surgical robots as medical devices at the same level as bandages or contact lenses. Regulations largely remain to be established, harmonized and internationalized; having so recently been introduced in the world of surgery, the norms, safety requirements and even certification of these devices are as yet based more…

Surgical simulation and training for ENT surgery

Surgical simulation: gadget, teaching tool, or surgical strategy aid? S.J. Daniel Introduction Many people wonder whether surgical simulation really is just a gadget: some think it is an important educational tool, while others see it as an aid to surgical strategy. There is, in fact, sufficient hard evidence to show that simulation improves knowledge and skill acquisition, although this obviously means that the simulation has to target…