The
flexible
endoscopy
of
the
upper
airway
is
also
called
Flexible
Naso-Pharyngo-Laryngoscopy
(FNPLS
in
short)
as
it
passes
through
and
visualizes
those
areas.
(naso=nose,
pharyngo
=
throat,
laryngo=voice
box
region)
It
is
an
easily-tolerated
procedure
done
in
the
ENT
clinic.
Usually
a
local
anesthetic
spray
would
be
administered
into
both
nostrils
a
few
minutes
before
the
procedure
to
reduce the discomfort.
Much
information
can
be
gathered
from
this
endoscopy.
Certain
manoeuvres
eg.
Muller’s
manoeuvres
may
be
useful.
Vincent’s S.C.A.N.S
Ear, Nose and Throat (ENT), Head and Neck Surgery
Specialist Clinic
OBSTRUCTIVE SLEEP APNEA (OSA)
Part 2 - Diagnosis & Treatment
How does my doctor diagnose me with OSA?
1.
History - the patient and sleep partner (looking for symptoms as mentioned in the previous page)
2.
Physical Examination adn endoscopy
3.
Polysomnography- Full or ambulatory
From
your
history
(your
symptoms
and
your
bed
partner's
input),
he
will
also
examine
you
physically
to
look
for
signs
suggestive
of
OSA.
An
endoscopy
of
the
upper
airway
(i.e
nose
and
throat)
is
almost
always
mandatory
to
understand
the
anatomy
of
your
airway
better.
The
endoscopy
can
also
yield
information about the likely level of obstruction contributing to your OSA.
Physical examination and endoscopy
Copyright Vincent Specialist Solutions Sdn Bhd 2016. All rights reserved
Last update: 10/1/13
To
read
from
OSA
Part
1
-
What
?
How?
Who ? Am I the one ?
Sleep study [polysomnography (PSG)]
A sleep study [polysomnography (PSG)] is mandatory to confirm the nature of your sleep apnea.
This
can
be
done
in
the
hospital
environment
for
Level
I
full
polysomnogram,
where
you
sleep
in
the
hospital
with
real-time
monitoring
by
the
sleep
technicians. Wires and monitors would be attached to your body and remain there throughout your sleep duration.
Full PSG monitors the following
1.
Electro-encephalo-gram, EEG [monitors your brain waves-indicate which depth of your sleep]
2.
EOG (e-oculography) [monitors your eye movement, to know the stage of sleep your are in i.e Rapid-Eye-Movement (REM) sleep stage]
3.
EMG submental & anterior tibialis [detects movement eg. in restless limb syndrome]
4.
ECG [monitors your heart rhythm -to detect stress on heart and irregular heart beats]
5.
oxygen saturation [monitors your blood oxygen level, indicating how low the level is and for how long the duration is ]
6.
nasal and oral airflow
7.
respiratory muscle effort [whether breathing effort is present during sleep, differentiates CSA from OSA]
8.
sleep
position
[whether
your
severity
of
airway
obstruction
is
dependent
on
your
sleeping
position,
whether
sleeping
on
your
back
(supine)
or
facing downwards (prone)]
Parameters derived include:
•
Apnea index : no. of apnea episodes per hour
•
Apnea-Hypopnea index (AHI) or respiratory disturbance index (RDI)
o
=
no.
of
apneas
or
hypopneas
10
seconds
or
longer
occurring
per
hour
of
sleep
o
normal RDI : < 5
o
Mild SDB : 5-15
o
moderate SDB : 16-35
o
Severe SDB : > 35
•
Arousal index
•
apnea duration
•
no. of oxygen dips, degree of desaturation
•
sleep disturbance index - arousals per hour
•
ECG: stress on the heart
Clinically,
OSA
is
defined
by
the
occurrence
of
daytime
sleepiness,
loud
snoring,
witnessed
breathing
interruptions,
or
awakenings
due
to
gasping
or
choking
in
the
presence
of
at
least
5 obstructive respiratory events (apneas, hypopneas or respiratory effort related arousals RERA) per hour of sleep.
The
presence
of
15
or
more
obstructive
respiratory
events
per
hour
of
sleep
in
the
absence
of
sleep
related
symptoms
is
also
sufficient
for
the
diagnosis
of
OSA
due
to
the
greater
association
of
this
severity
of
obstruction with important consequences such as increased cardiovascular disease risk
Alternatively,
you
can
choose
to
undergo
the
ambulatory
type
where
the
patient
brings
the
monitoring
system
back
to
his/her
own
home
(yes,
it
is
small
enough
for
you
to
carry
it
back
home).
The
test
parameters
are
recorded
into
the
device
as
you
sleep.
The
data
will
be
downloaded
by
your
doctor/sleep
technician
the
next day.
Ambulatory
or
home
sleep
testing
is
now
recognized
in
the
medical
policies
of
most
insurers
in
the
US
as
appropriate
for
patients
with
a
high-likelihood
of
OSA
as
well
as
for
patients
that
need
to
undergo
follow-up
studies
to
confirm
the
effects
of
therapy,
lifestyle
changes
or
surgery
in
the
treatment
of
their
OSA.
It
is
also
useful
for
screening
out
the
highly
debilitating
condition
of
OSA
for
patients
that
are
considering
treatments
for
snoring,
as
snoring
is
often
an
indicator
of
OSA,
and
it
is
highly
recommended
to
diagnose
prior
to
undergoing any procedure or therapy for snoring.
Depending
on
which
device/system
used,
there
will
be
slight
variation
in
the
technical
usage
and
specifications. Please ask your doctor/sleep technician for more details.
In
both
sleep
studies,
whatever
the
environment
you
are
in,
it
is
important
that
you
sleep
like
you
NORMALLY do.
Some differences between full PSG and ambulatory PSG:
What treatment is avaiiable?
1
.
Non-surgical
approach [eg.
behavioral change
,
continuous positive airway pressure (CPAP)
,
oral appliances
] and,
2
.
Surgery
Briefly,
CPAP
is
considered
the
goal
standard
and
most
effective
nonsurgical
treatment
for
OSA,
especially
the
moderate
and
severe
group.
(read
more below)
Your doctor would weigh the pros and cons and customize the treatment according to each patient with your interest at heart.
Behavioral therapy/change
Weight loss
Get below "trigger weight" (loss below 20% of body wt)
•
Diet
-reduce
oily,
high-fat,
high-calorie
diet
eg.
fried
food.
Consume
more
vegetable,
low-fat,
low-calorie
food -be aware of the
Food Pyramid
•
Exercise -Active exercise at least 30minutes 3 times a week
There
is
a
need
to
balance
calorie
input
(how
much
we
eat,
depending
on
type
of
food,
intake
frequency)
and
output
(how
much
we
‘burn
the
fat’
eg.
exercise,
sedentary
lifestyle)
-importantly,
to
lose
weight,
calorie
OUTPUT MUST BE MORE THAN INPUT.
•
Medications -under a physician’s supervision
Sleep hygiene
Avoidance of alcohol before sleep
Avoidance of sedatives (eg.sleeping pills) before sleep
Positional changes
•
patients should sleep on their sides, on their stomachs, or propped up 60 degrees
lying supine allows gravity to assist in pulling lax tongue muscles back toward the Posterior Pharyngeal Wall, back portion of throat)
•
Avoidance
of
supine
sleeping
can
easily
be
accomplished
with
a
sock,
tennis
ball,
and
safety
pins.
The
tennis
ball
in
a
sock
is
pinned
to
the
back
of
the
pajamas,
positioning
the
tennis
ball
between
the
scapulae.
When
the
patient
rolls
into
the
supine
position
during
sleep,
this
lump
is
uncomfortable enough that the position is immediately shifted, usually without the patient awakening
Limit intake of caffeine, chocolate, smoking
Surgery
Surgery
can
improve
your
OSA
by
customising
your
surgical
treatment
according
to
the
level
of
obstruction
based
on
the
doctor's
clinical
and
endoscopy assessment.
Surgical
options
are
aplenty,
targeted
at
the
different
level
of
obstruction
eg
the
nose,
soft
palate,
lateral
wall,
tonsils,
base
of
tongue,
tongue
itself,
jaw bone.
Generally,
it
ranges
from
the
least
invasive
options
(to
a
specific
site
of
obstruction
eg.
the
nose
only,
the
soft
palate
only)
to
the
invasive
and
multilevel
surgery
(eg.combining
nasal,
tonsil
and
soft
palate
surgeries).
It
works
well
for
mild
to
moderate
OSA,
but
much
less
effective
for
severe
OSA.
Different procedures can be done under local anesthesia (LA) or may require General Anaesthesia (GA)
For
those
with
nose
blockage,
surgical
options
are
also
available
to
reduce
the
nasal
obstruction
depending
on
the
cause
of
obstruction
(see
the
chapter on '
Nose Block
' ). Reducing the nasal blockage may also be a prerequisite before embarking on the CPAP therapy.
For more details on adenoid and tonsil surgery, please go
here.
Bariatric
surgery
refers
to
a
variety
of
surgical
procedures
performed
on
obese
people.
Different
procedures
can
be
done
under
General
Anaesthesia
(GA)
by
the
general
surgeon
who
undertakes
bariatric
surgeries
or
a
bariatirc surgeon .
Weight
loss
is
achieved
by
reducing
the
size
of
the
stomach
with
an
implanted
medical
device
(put
a
band
around
the
stomach
-gastric
banding)
or
through
removal
of
a
portion
of
the
stomach
or
resecting
and
re-routing
the small intestines to a small stomach pouch.
Continuous Postitive Airway Pressure (CPAP) therapy
CPAP
works
by
quietly
delivering
gentle
air
pressures
through
the
nasal
passages
to
keep
the
airways
open
(acting
as
a
pneumatic
splint), allowing a person to breathe uninterruptedly during sleep.
C
=
continuous
=
the
machine
works
continuously
while
you
sleep
to
deliver the preset pressure
PAP = positive airway pressure = The positive pressure will keep the
upper airway passage open
(think of it as blowing air into a balloon, where the air you blow
serves as the positive pressure and it keeps the balloon from
collapsing)
lt is administered through a mask (also called 'interface') that seals either the nose, mouth or both the nose and the mouth.
There are different types of interfaces to suit different needs. They include:
•
Nasal masks (for nose breathers),
•
Nasal pillows (for nose breathers),
•
Full face masks (for nose and mouth breathers),
•
Oral-nasal masks (for nose and mouth breathers) and
•
Oral masks (for mouth breathers).
It
is
very
important
to
try
out
the
different
interfaces
to
find
a
comfortable
fit.
This
will
greatly
increase
CPAP
therapy
compliance
and
the
quality
of
your life.
The
pressure
delivered
can
either
be
fixed
or
automatic.
Fixed
CPAP
therapy
provides
one
constant
air
pressure
throughout
the
night
while
automatic CPAP automatically varies the pressure throughout the night with night-to-night variations.
For severe OSA, CPAP will provide the best treatment option.
Less common treatment options include wearing
oral appliances
during sleep.
They
can
keep
the
lower
jaw
in
a
forward
position
and
prevent
the
tongue
from
falling
backwards,
thus
reducing tenarrowing of the upper airway during sleep.
How does effective treatment benefit me ?
Effective
treatment
of
SDB
has
been
shown
to
reduce
mortality,
lower
blood
pressure,
improve
heart
function
and blood sugar level.
•
Reduction or elimination of apnea and snoring.
•
Feeling more rested and alert during the day.
•
lmproved blood oxygen levels, reducing health risks caused by sleep apnea.
•
Lowers blood pressure in hypertensive people 24 hours a day.
•
Less strain on the heart.
•
Sleep patterns return to normal.
Indeed,
OSA
is
a
large
topic
and
treatment
options
are
very
much
customised
to
each
individual patient. Please discuss with your doctor regarding treatment options.
Here's wishing that you sleep well at night and waking up fresh in the next morning...
(as
recommended
by
Sleep
1999,
American
Academy
of
Sleep Task Force)
S
© Vincent Tan ENT
The Telltale Signs of OSA
(mouse over for description or click for larger image)
Full PSG monitoring -wires and monitors that you wear to sleep in a hospital environment
An oral appliance
This patient education is provided in good faith to help patients and their families learn more about their medical conditions, the options available to them and the possible consequences of
their decisions. This information is not intended to be used for diagnosis, or treatment of any specific individual. Please consult with your ENT doctor regarding your particular circumstances.
Keen to know more about
OSA
Disorder
Services
provided here ?
The CPAP analogy
(
Mouse over to zoom in on selected image)
(
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© Vincent Tan ENT
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Talks about SNORING & O.S.A on 12/1/16
(for educational purposes)
D
R.
V
INCENT
T
AN
Consultant Ear, Nose and Throat, Head and Neck Surgeon,
MD (UKM), MS ORL-HNS (UKM), DOHNS RCS Edinburgh (UK), MRCS Edinburgh (UK), Postgrad. Cert.in Allergy (UK), A.M. (Mal),
Fellowship in Rhinology (Singapore)
Fellowship in Head and Neck Oncology & Surgery (Amsterdam)
+603-3377 7864
+6012-3760 728
ENTdrvincenttan@gmail.com
