Current Concepts of Sleep Apnea Surgery

306 Pages·2019·48.492 MB·English

by  Thomas Verse, Nico de Vries

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Verse FM.indd 2 30-Apr-19 6:45:48 PM
Current Concepts of Sleep Apnea Surgery
Thomas Verse, MD
Professor of Otorhinolaryngology
Director of Department of Otorhinolaryngology–Head and Neck Surgery
Asklepios Clinic Harburg
Asklepios Campus Hamburg of Semmelweis University
Hamburg, Germany
Nico de Vries, MD, PhD
Professor of Otolaryngology al.
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Department of Otorhinolaryngology–Head and Neck Surgery at
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OLVG Hospital ed
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Department of Oral Kinesiology yrig
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ACTA Amsterdam o
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Amsterdam, The Netherlands er.
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Department of Otorhinolaryngology–Head and Neck Surgery
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University of Antwerp o
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Antwerp, Belgium ek
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281 illustrations
Thieme
Stuttgart • New York • Delhi • Rio de Janeiro
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Contents
Videos ............................................................................................... xi
Preface .............................................................................................. xii
Contributors ........................................................................................ xiii
1 Introduction and History of Sleep Apnea Surgery ............................................. 1
1.1 Introduction ......................................................................................... 1
1.2 A Short History of Surgery for Sleep-Disordered Breathing: From the Uvula Crusher to the
Stimulation of the Hypoglossus Nerve ............................................................... 3
1.2.1 Antiquity .............................................................................................. 3
1.2.2 Renaissance ............................................................................................ 4
1.2.3 19th Century .......................................................................................... 4
1.2.4 20th Century .......................................................................................... 5
1.2.5 Palatal Surgery ........................................................................................ 6 al.
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1.2.6 Lower Pharyngeal Airway Procedures ................................................................... 7 at
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1.2.7 Devices for the Tongue Base Suspension ................................................................. 7 d
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1.2.8 Laryngeal Obstructive Sleep Apnea ...................................................................... 7 g
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1.2.9 Multilevel Surgery ..................................................................................... 7 p
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1.2.10 Hypoglossal Stimulation ................................................................................ 8 er.
1.2.11 Maxillofacial Surgery .................................................................................. 8 m
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1.2.12 Final Remark .......................................................................................... 8 k
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2 Pathophysiology ................................................................................... 11 ek
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2.1 Epidemiology ........................................................................................ 11 y: t
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2.1.1 Introduction ........................................................................................... 11 de
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2.1.2 Definitions ............................................................................................ 11 nl
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2.1.3 Signs and Symptoms Suggestive of Obstructive Sleep Apnea ............................................... 13 o
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2.1.4 Age and Gender Bias ................................................................................... 17
2.1.5 Symptoms of OSA in Older Subjects ..................................................................... 17
2.1.6 Symptoms in Overlap Syndrome ........................................................................ 18
2.1.7 Focused History ....................................................................................... 18
2.1.8 Screening Questionnaires and Clinical Prediction Models .................................................. 18
2.1.9 Consequences ......................................................................................... 19
2.1.10 Conclusions ........................................................................................... 29
2.2 C auses of Obstructive Sleep Apnea ................................................................... 29
2.2.1 Introduction ........................................................................................... 29
2.2.2 Anatomic Causes of Obstructive Sleep Apnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
2.2.3 Nonanatomic Causes of Obstructive Sleep Apnea ......................................................... 31
3 Diagnosis of Sleep-Disordered Breathing ........................................................ 44
3.1 History Taking ........................................................................................ 44
3.1.1 Conclusion ............................................................................................ 47
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Contents
3.2 C linical Evaluation of Patients with (Suspected) Sleep-Disordered Breathing ........................ 47
3.2.1 Introduction ........................................................................................... 47
3.2.2 Anamnesis ............................................................................................ 47
3.2.3 General Evaluation ..................................................................................... 47
3.2.4 Upper Airway Evaluation ............................................................................... 48
3.2.5 Limitations ............................................................................................ 51
3.2.6 Conclusion ............................................................................................ 54
3.3 Sleep Studies ......................................................................................... 55
3.3.1 Differential Diagnosis in Sleep-Related Breathing Disturbances ............................................ 55
3.3.2 Clinical Investigations .................................................................................. 56
3.3.3 Computer-Based Tests of Vigilance and Attention ........................................................ 58
3.3.4 Evaluation of Sleep and Breathing Disturbances During Sleep ............................................. 58
3.3.5 Parameters of Sleep Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
3.3.6 Case Reports .......................................................................................... 66
3.4 Topo Diagnosis of Obstruction Site(s) ................................................................ 69
3.4.1 Awake Nasopharyngoscopy ............................................................................. 69 al.
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3.4.2 Drug-Induced Sleep Endoscopy ......................................................................... 71 at
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3.4.3 Upper Airway Imaging in Sleep-Disordered Breathing .................................................... 77 d
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3.4.4 Analysis of Snoring Sounds ............................................................................. 81 ht
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4 Nonsurgical Treatment: Lifestyle, Weight Loss, Positional Therapy, Mandibular Advance- C
ment Devices, Continuous Positive Airway Pressure, Multimodality Treatment ........... 89 er.
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4.1 Introduction .......................................................................................... 89 k
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4.2 Lifestyle Intervention ................................................................................. 89 k a
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4.2.1 Didgeridoo and Physical Therapy ........................................................................ 90 ar
4.2.2 Alcohol, Tobacco, and Sedative Abstinence, Sleep Hygiene ................................................. 90 by: t
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4.3 Positional Therapy .................................................................................... 90 a
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4.4 Oral Appliances ....................................................................................... 91 ow
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4.4.1 Mechanism of Action .................................................................................. 91
4.4.2 Outcomes ............................................................................................. 92
4.4.3 Side Effects ............................................................................................ 92
4.4.4 Patient Selection ....................................................................................... 92
4.5 Continuous Positive Airway Pressure .................................................................... 93
4.6 Multimodality Treatment ............................................................................... 94
5 Surgical Principles ................................................................................. 97
5.1 Patient Selection ..................................................................................... 97
5.1.1 Introduction ........................................................................................... 97
5.1.2 Continuous Positive Airway Pressure Washout ........................................................... 99
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Contents
5.2 H ow to Score and Compare Surgical Results with Those of Nonsurgical Treatment ................. 103
5.2.1 Introduction ........................................................................................... 103
5.2.2 How to Compare the Different Treatment Options? ....................................................... 104
5.2.3 Formulas .............................................................................................. 105
5.2.4 Percentage of TST during which CPAP Must Be Used to Meet Sher’s Success Criteria ......................... 107
5.2.5 Percentage of TST during which CPAP Must Be Used to Reduce AHI to Below 10 ............................. 107
5.2.6 Percentage of TST during which CPAP Must Be Used to Reduce AHI to Below 5 .............................. 107
5.2.7 Percentage of TST during which CPAP Must Be Used to Reduce AHI by a Certain Percentage ................. 107
5.2.8 Discussion ............................................................................................ 108
5.3 How to Measure Clinical Success ..................................................................... 110
5.3.1 Surgical Success ....................................................................................... 110
5.3.2 Success in Conservative Treatment ...................................................................... 110
5.3.3 AHI Defines OSA Severity ............................................................................... 110
5.3.4 Clinical Endpoints in OSA ............................................................................... 110
5.3.5 Literature ............................................................................................. 112
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5.4 C ombination Therapy for Sleep-Disordered Breathing ............................................... 113 at
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5.4.1 Combination of CPAP and Other Noninvasive Treatment Options .......................................... 114 e
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5.4.2 Combination of Different Types of Oral Appliance Therapy ................................................ 114 yri
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5.4.3 Combination of Oral Appliance Therapy and Surgery ..................................................... 114 o
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5.4.4 Combination of Positional Therapy and Other Noninvasive Treatment Options .............................. 114 er.
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5.4.5 Combination of Positional Therapy and Surgery .......................................................... 115 m
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5.4.6 Conclusion ............................................................................................ 115 o
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6 Pediatric Obstructive Sleep Apnea .............................................................. 120 ar
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6.1 Diagnosis ............................................................................................. 120 d b
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6.1.1 Introduction ........................................................................................... 120 a
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6.1.2 Prevalence ............................................................................................ 120 w
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6.1.3 Clinical Finding ........................................................................................ 120
6.1.4 Physical Examination ................................................................................... 121
6.1.5 Diagnostic Workup .................................................................................... 122
6.2 Treatment ............................................................................................ 126
6.2.1 Introduction ........................................................................................... 126
6.2.2 Medical Intervention ................................................................................... 126
6.2.3 Oral Appliances ........................................................................................ 126
6.2.4 Surgical Interventions .................................................................................. 127
6.2.5 Anesthesia and Positioning ............................................................................. 128
6.2.6 Operative Technique/Operative Steps .................................................................... 128
6.2.7 Complications (Including Measures for Specific Complications) ........................................... 129
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Contents
6.2.8 Postoperative Care (Including Medication and Drainage) .................................................. 129
6.2.9 Outcome (Including EBM Data for AHI and ESS) .......................................................... 130
6.2.10 Other Pediatric Obstructive Sleep Apnea Surgeries ....................................................... 132
7 Nose ................................................................................................ 137
7.1 Introduction ......................................................................................... 137
7.2 Pathophysiology ..................................................................................... 137
7.2.1 Nasal Breathing during Wakefulness .................................................................... 137
7.2.2 Nasal Breathing during Sleep ........................................................................... 137
7.2.3 Theories, How an Increase in Nasal Resistance Can Induce Airway Collapse ................................. 137
7.3 C onservative Treatment of the Nose ................................................................. 138
7.3.1 Drugs ................................................................................................. 138
7.4 Nasal Surgery ........................................................................................ 139
7.4.1 Nasal Surgery for Snoring .............................................................................. 140 al.
7.4.2 Nasal Surgery for Obstructive Sleep Apnea ............................................................... 140 ateri
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7.4.3 Nasal Surgery to Improve Positive Airway Pressure Treatments ............................................ 142 d
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8 Surgery in Adults .................................................................................. 147 yri
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8.1 Minimally Invasive Surgery ........................................................................... 147 er.
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8.1.1 Interstitial Radiofrequency in the Soft Palate ............................................................. 147 m
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8.1.2 Palatal Implants and Other Stiffening Procedures ......................................................... 150 o
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8.1.3 Uvulopalatoplasty ..................................................................................... 156 k a
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8.2 Invasive Procedures .................................................................................. 160 y: t
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8.2.1 Palate and Tonsils ...................................................................................... 160 ed
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8.2.2 Tongue Base ........................................................................................... 192 o
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8.2.3 Larynx and Trachea .................................................................................... 222 w
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8.3 Maxillofacial Surgeries ............................................................................... 230
8.3.1 Introduction ........................................................................................... 230
8.3.2 Distraction Osteogenesis Maxillary Expansion ........................................................... 239
8.4 Multilevel Surgery ................................................................................... 242
8.4.1 Definition ............................................................................................. 242
8.4.2 Indications, Contraindications, and Patient Selection ..................................................... 244
8.4.3 Diagnostic Workup ..................................................................................... 244
8.4.4 Specific Risks, Patient Information, and Consent .......................................................... 244
8.4.5 Anesthesia and Positioning ............................................................................. 245
8.4.6 Equipment ............................................................................................ 245
8.4.7 Operative Technique/Steps ............................................................................. 245
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