Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Obstructive Sleep Apnea It is estimated that at any given time one-third of the United States' population suffers fromsleep-related problems. The most commonly diagnosed sleeping disorder that involves otolaryngologists is obstructive sleep apnea (OSA). Obstructive sleep apnea is not a benign disease. Bonekat (1990) estimated that in 1990 alone, 58,000 motor vehicle accidents involved a sleep apnea patient. These patients also have a higher incidence of stroke, right heart failure, and an increased mortality rate when there are greater than 20 apneic episodes per hour of sleep. OSA may be defined as the absence of airflow combined with persistent respiratory effort during sleep. It has been determined that the site of obstruction in these patients is within the pharynx. The exact site, however, usually cannot be determined in any given patient. The average patient is obese, middle age, male, and a loud snorer. Often the patient presents with his spouse who is keenly aware of the snoring and "pauses" in breathing (apneic episode). Other signs and symptoms include: excessive daytime somnolence, morning headaches, hypertension, personality changes, nocturnal arrhythmias, and even cor pulmonale. The formal diagnosis of OSA requires a sleep study to document the number of apneic episodes, associated arrhythmias, and the severity of the problem. The treatment regimen must be tailored to the individual, his symptoms, sleep study results, and physical findings. Therapeutic options may be divided into four categories: (1) identification and elimination of aggravating factors (alcohol, sedatives) coupled with sustained weight loss; (2) use of medications such as protriptyline; (3) use of mechanical devices such as continuous positive airway pressure (CPAP) or a newer modality, bilevel positive airway pressure (BiPAP); and (4) surgical intervention such as uvulopalatopharyngoplasty (UPPP), tracheostomy, or a newer method termed transtracheal oxygen therapy (TTO). The advantages and disadvantages of each treatment option are discussed, as well as The Methodist Hospital experience with UPPP. Case Presentation A 31-year-old, overweight, normotensive, white male presented for evaluation of a three-year history of excessive daytime fatigue and sleepiness. The patient's wife noted that he is a loud snorer and that his snoring could be heard through a closed door. She also noted that he appeared to stop breathing on multiple occasions during the night. These episodes lasted approximately 30 to 90 seconds and then, with a loud snort, the patient began to breath again. Physical examination was significant for a deviated septum, a high arched palate, but no redundant pharyngeal mucosa. A sleep study was performed which indicated numerous episodes of obstructive apnea (AI=46) and partial obstructive events with an oxygen desaturation below 90 percent on 673 occasions. No cardiac arrhythmias were noted during the study. The patient underwent septoplasty and the institution of nasal continuous positive airway pressure (CPAP) treatments at night, with resolution of both night and daytime symptoms. Bibliography Bonekat HW, Krumpe PE. Diagnosis of obstructive sleep apnea. Clin Rev Allergy 1990;8:197-213. Burgess LPA, Derderian SS, Morin GV, Zajtchuk JT. Postoperative risk following uvulopalatopharyngoplasty for obstructive sleep apnea. Otolaryngol Head Neck Surg 1992;23:81-86. Chauncey JB, Aldrich MS. Preliminary findings in the treatment of obstructive sleep apnea with transtracheal oxygen. Sleep 1990;13:167-174. Dickins QS, Jenkins NA, Mrad R, Schweitzer PK, Walsh JK. Nasal continuous positive airway pressure in the treatment of obstructive sleep apnea. Operative Techniques Otolaryngol 1991;2:91-95. Farney RJ, Walker JM, Elmer JC, Viscomi VA, Ord RJ. Transtracheal oxygen, nasal CPAP and nasal oxygen in five patients with obstructive sleep apnea. Chest 1992;101:1228-1235. Fujita S, Conway WA, Zorick FJ, Siclesteel JM, Roehrs TA, Wittig RM, et al. Evaluation of the effectiveness of uvulopalatopharyngoplasty. Laryngoscope 1985;95:70-74. Goode RL. Sleep disorders. In: Cummings CW, Schuller DE, editors. Otolaryngology - head and neck surgery, Volume 1. St Louis: CV Mosby, 1986:449-457. Goodnight-White S. Obstructive sleep apnea - a chronological overview. Respir Ther 1988;4:14-23. He J, Kryger MH, Zorick FJ, Conway W, Roth R. Mortality and apnea index in obstructive sleep apnea. Chest 1988;94:9-14. Heimlich HJ. Respiratory rehabilitation with transtracheal oxygen system. Ann Otol Rhinol Laryngol 1982;91:643-647. Hudgel DW. Mechanisms of obstructive sleep apnea. Chest 1992;101:541-549. Kaplan J, Staats BA. Obstructive sleep apnea syndrome. Mayo Clin Proc 1990;65:1087-1094. Kimoff RJ, Cosio MG, McGregor M. Clinical features and treatment of obstructive sleep apnea. Can Med Assoc J 1991;144:689-695. Koopmann CF, Moran WB. Sleep apnea - an historical perspective. Otolaryngol Clin North Am 1990;23:571-575. Koopmann CF, Moran WB. Surgical management of obstructive sleep apnea. Otolaryngol Clin North Am 1990;23:787-808. Kuna ST, Sant'Ambrogio G. Pathophysiology of upper airway closure during sleep. JAMA 1991;266:1384-1388. Maisel RH, Antonelli RJ, Iber C, Mahowald M, Wilson KS, Fiedler B, et al. Uvulopalatopharyngoplasty for obstructive sleep apnea: a community's experience. Laryngoscope 1992;102:604-607. Metes A, Cole P, Hoffstein V, Miljeteig H. Nasal airway dilation and obstructed breathing in sleep. Laryngoscope 1992;102:1053-1055. Mishoe SC. The diagnosis and treatment of sleep apnea syndrome. Respir Care 1987;32:183-201. Philip-Joel F, Rey M, Triglia JM, Reynaud M, Saadjian M, Saadjian A, et al. Uvulopalatopharyngoplasty in snorers with sleep apneas: predictive value of presurgical polysomnography. Respiration 1991;58:100-105. Riley RW, Powell NB. Maxillofacial surgery and obstructive sleep apnea syndrome. Otolaryngol Clin North Am 1990;23:809-826. Riley RW, Powell NB, Guilleminault C. Maxillofacial surgery and nasal CPAP. A comparison of treatment for obstructive sleep apnea syndrome. Chest 1990;98:1421-1425. Scharf MB. Sleep disorders. In: Paparella MM, Shumrick DA, Gluckman JL, Meyerhoff WL, editors. Otolaryngology. Volume 1: basic sciences and related principles, 3rd edition. Philadelphia: WB Saunders; 1991:865-876. Shepard JW, Gefter WB, Guilleminault C, Hoffman EA, Hoffstein V, Hudgel DW, et al. Evaluation of the upper airway in patients with obstructive sleep apnea. Sleep 1991;14:361-371. Shepard JW, Olsen KD. Uvulopalatopharyngoplasty for treatment of obstructive sleep apnea. Mayo Clin Proc 1990;65:1260-1267. Sher AE. Obstructive sleep apnea syndrome: a complex disorder of the upper airway. Otolaryngol Clin North Am 1990;23:593-608. Strelzow VV, Blanks RHI, Basile A, Strelzow AE. Cephalometric airway analysis in obstructive sleep apnea syndrome. Laryngoscope 1988;98:1149-1158. Wittels EH, Thompson S. Obstructive sleep apnea and obesity. Otolaryngol Clin North Am 1990;23:751-760.
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