Overview Goal of Evaluation Goal of evaluation Pharyngeal anatomy - PowerPoint PPT Presentation

2/15/2014 Disclosures Physical Exam and Identifying the The following personal financial relationships with Pattern of Obstruction commercial interests relevant to this presentation: Medical Advisory Board Apnex Medical Medical Advisory Board ReVENT Medical Eric J. Kezirian, MD, MPH Consultant Inspire Medical Systems Professor Consultant Split Rock Scientific Otolaryngology – Head & Neck Surgery Intellectual Property Rights Berendo Scientific Intellectual Property Rights Magnap Sleep-Doctor.com Eric.Kezirian@med.usc.edu http://sleep-doctor.com/blog http://sleep-doctor.com/blog Overview Goal of Evaluation Goal of evaluation Pharyngeal anatomy and evaluation Characterize disorder to guide effective treatment Importance of identifying the sites of airway obstruction Techniques for identifying the sites of obstruction http://sleep-doctor.com/blog http://sleep-doctor.com/blog 1

2/15/2014 Oral Cavity, Oropharynx, and Hypopharynx Anatomy Major sites of Maxilla Palate (hard and soft) potential airway Uvula obstruction Tonsils – Nose Lateral pharynx – Palate Tongue Mandible/dentition – Hypopharynx Hyoid bone Epiglottis Larynx Neck http://sleep-doctor.com/blog http://sleep-doctor.com/blog Oral Cavity and Oropharynx—Physical Exam Oral Cavity and Oropharynx—Physical Exam Lateral pharyngeal tissue character, redundancy Height, weight, neck Tongue size circumference Modified Mallampati Maxilla Position (tongue size Tonsil size relative to palate and Palate and uvula “space” created by thickness and length mandible and pharynx) --webbing --Samsoon and Young’s (Anaesthesia 1987) --retropalatal space modification of Surgical changes? Mallampati position, with tongue protrusion http://sleep-doctor.com/blog http://sleep-doctor.com/blog 2

2/15/2014 Oral Cavity and Oropharynx—Physical Exam Oral Cavity and Oropharynx—Physical Exam Mandible position Mandible position --may be reflected in dentition Gross assessment Dentition Angle Classification X-ray (lateral cephalogram) Mesiobuccal cusp of maxillary first molar to buccal groove of mandibular first molar http://sleep-doctor.com/blog http://sleep-doctor.com/blog Lateral Cephalogram Lateral Cephalogram Standardized lateral X- Patients with normal ray of head and neck BMI and OSA typically have abnormal lateral Multiple bony and soft cephalogram tissue measurements --decreased SNB – Posterior airway --narrow PAS space, soft palate length, SNA and SNB --high MP-H angles, mandibular plane to hyoid http://sleep-doctor.com/blog http://sleep-doctor.com/blog 3

2/15/2014 Fiberoptic Examination Sites of Obstruction Nose Effective surgery directed at Pharynx site(s) of obstruction Adenoid size Nose Gross assessment of airway narrowing at palate/HP Palate --? grade view of laryngeal visualization (Cormack and Lehane Anesthesia 1984—laryngoscopy) Hypopharynx I = full view of VC; II = partial view (post comm) III = epiglottis only; IV = no epiglottis view Fujita Classification Lingual tonsil hypertrophy Type I Palate Epiglottis position and character Type II Combined Müller/Muller/Mueller maneuver? Type III Hypopharynx Larynx http://sleep-doctor.com/blog http://sleep-doctor.com/blog OSA surgery review (Sher et al. Sleep 1996) Identifying the Sites: – UPPP “successful” in 41% of all OSA patients Ideal Test Characteristics 52% Fujita Type I 5% Fujita Types II and III Easy: technically simple, non-invasive – Conclusion: failure to identify site(s) of obstruction is principal factor in poor results for Low cost surgery Dynamic assessment while breathing Cochrane Collection 2005 review (evidence- Sleeping patient based medicine review database) Accurate – “More research should also be undertaken to identify and standardise techniques to determine the site of airway obstructions.” http://sleep-doctor.com/blog http://sleep-doctor.com/blog 4

2/15/2014 Friedman Stage OSA Severity Modified FS Tonsils Premise: region(s) of upper airway obstruction are Mallampati related to OSA severity (AHI) I 1, 2 3+, 4+ Mild-moderate OSA is most likely due to collapse at the 1, 2 0, 1+, 2+ level of the palate, whereas moderate to severe OSA II most likely includes some component of 3, 4 3+, 4+ hypopharyngeal collapse III 3, 4 0, 1+, 2+ Advantages: easy, low cost, assessment during sleep Disadvantage: inaccurate—not supported by the IV BMI ≥ 40 evidence, and refuted in some studies http://sleep-doctor.com/blog http://sleep-doctor.com/blog Müller Maneuver Friedman Stage Endoscopic evaluation of awake patient with forced Advantages inspiratory effort against closed mouth and nose – Easy, low cost – Associated with UPPP/tonsillectomy outcomes Advantages: simple, low cost Success: Stage I 81% Disadvantage: not accurate or useful by itself Stage II 38% Stage III 8% – Patients with primarily retropalatal obstruction by Corroborated by Li et al. SLEEP 2006 MM had only ~40% cure of OSA after UPPP • Sher et al. 1985, Doghramji et al. 1995 Disadvantages – Petri et al. 1994: MM no predictive value for palate – Only shows patients who are not Fujita type I (most) surgery outcome – Does not identify involved structures other than – Li et al. 2003: MM associated with UPPP outcomes palate/tonsils (to choose possible adjunctive procedures) – Theoretical: not a dynamic assessment of sleeping patient – No information on selection of procedures http://sleep-doctor.com/blog http://sleep-doctor.com/blog 5

2/15/2014 Imaging (CT, MRI, fluoroscopy) Lateral Cephalogram Advantages: easy, low cost, Advantage: Assessment during sleep possible, improve normative data available understanding of abnormal OSA anatomy and changes after IDs patients with less certain treatments favorable outcomes after Lee Laryngoscope 2012: sleep videofluoroscopy suggested first-line procedures multilevel obstruction common (45%; higher in severe OSA) Disadvantages Disadvantages – CT and MRI can be static (although cine-CT) – Two-dimensional image – Awake, upright, and static – Time-consuming and not inexpensive – Does not ID involved structures – Specific equipment and technical assistance and guide selection among – Radiation exposure (CT, fluoroscopy) first-line procedures – Radiation: dental X-rays and – ? association between static dimensions of airway and elevated meningioma risk surgical outcomes—further research (Claus Cancer 2012) http://sleep-doctor.com/blog http://sleep-doctor.com/blog Identifying the Site(s): Natural Sleep Endoscopy Identifying the Site(s): Natural Sleep Endoscopy Fiberoptic scope to Advantage: Dynamic assessment of sleeping visualize airway as patient patient attempts to fall asleep naturally – Directly visualize location of obstruction and involved structures Borowiecki Laryngoscope 1978 Rojewski Laryngoscope 1982 Major disadvantages – Difficult to fall asleep with fiberoptic scope held in place manually or otherwise secured externally (some movement of head relative to scope during sleep onset) – Difficult to move scope without awakening (to visualize multiple potential regions of obstruction) http://sleep-doctor.com/blog http://sleep-doctor.com/blog 6

2/15/2014 Identifying the Sites: Drug-Induced Sleep Endoscopy Velum/Palate Developed in UK in 1991 Pringle MB, Croft CB. Clin Otolaryngol 1991;16:504-9. Used in several centers around the world but less commonly in U.S. Fiberoptic endoscopy of sedated, “sleeping” patient Goal: reproduce SDB seen on sleep study VOTE Classification system (Kezirian, Hohenhorst, de Vries Eur Arch Oto 2011) --some standardization and comparison of findings/outcomes across centers http://sleep-doctor.com/blog http://sleep-doctor.com/blog Oropharyngeal Lateral Walls Tongue http://sleep-doctor.com/blog http://sleep-doctor.com/blog 7

2/15/2014 Epiglottis Drug-Induced Sleep Endoscopy Advantages: Dynamic assessment of sleep – Directly visualize location of obstruction and involved structures – Possible quantification of collapse (Borek Oto-HNS 2012) – Vibration vs. obstruction (Hohenhorst AAO et al.) – Valid: greater collapsibility in OSA vs. snorers (Steinhart Acta Otolaryngol 2000) and SDB vs. controls (Berry Laryngoscope 2005) – Reliability: test-retest (Rodriguez-Bruno Oto-HNS 2009) and inter-rater (Kezirian Archives Oto-HNS 2010) moderate to good http://sleep-doctor.com/blog http://sleep-doctor.com/blog Drug-Induced Sleep Endoscopy Drug-Induced Sleep Endoscopy Advantages: Dynamic assessment of sleep Advantages: Dynamic assessment of sleep – Unique evaluation – “Hypopharynx” contains oropharyngeal lateral walls, tongue, and epiglottis • Not correlated with Modified Mallampati Position (den Herder Laryngoscope 2005) or lateral • Can identify involved structures more precisely cephalogram (George Laryngoscope 2012) and potentially direct surgical treatment – Correlated with outcomes after: • General sense that oropharyngeal lateral wall collapse does not respond as well to surgery; • Palate surgery (Iwanaga Acta Otolaryngol Suppl 2003, Hessel Clin Otolaryngol All Sci 2004) Soares Laryngoscope 2012 • Single and multilevel surgery (Soares Laryngoscope 2012; • Epiglottic contribution not detected by other Koutsourelakis Oto-HNS 2012) evaluations • Hypoglossal nerve stimulation (Vanderveken JCSM 2013) – Nonresponse to surgery: multiple mechanisms • MAD (Johal Eur J Orthodont 2005, Johal J Laryngol Otol (Kezirian Laryngoscope 2011) 2007) http://sleep-doctor.com/blog http://sleep-doctor.com/blog 8