Vincent ENT, Head and Neck Surgery Specialist Clinic - Klang, Shah Alam, Subang, PJ, KL and more...

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.

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

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)

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The Telltale Signs of OSA

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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.