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.
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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
Snoring   Obstructive Sleep Apnea (OSA) EDUCATION
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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...
Flexible endoscopy of the upper airway. The black tube represent the scope (source of unlabelled diagram: Netter Atlas of Anatomy) NASAL CAVITY TONGUE POSTNASAL SPACE BRAIN SOFT  PALATE HARD  PALATE BASE OF TONGUE EPIGLOTTIS WINDPIPE/TRACHEA TONSIL CERVICAL SPINE VOCAL CORDS LOWER JAW/ MANDIBLE POSTERIOR PHARYNGEAL WALL  Vincent Tan ENT Flexible endoscopy of the upper airway in a real ENT clinic setting.
(as   recommended   by   Sleep 1999, American Academy   of Sleep Task Force)
Cross section of the upper airway deviated nasal septum (S) with spur No Turbinate hypertrophy/DNS
S
Normal postnasal space Mass in the postnasal space Enlarged base of tongue (red arrow) Normal base of tongue Non-snoring throat configuration Small lower jaw in a syndromic child Large tongue (macroglossia) Vocal cords paralysed on both sides-see the narrow gap Normal vocal cords opening Lateral wall collapsing inwards Normal lateral wall overjet Short thick neck
© Vincent Tan ENT
The Telltale Signs of OSA
enlarged tonsils (red arrows)
(mouse over for description or click for larger image)
Full PSG monitoring -wires and monitors that you wear to sleep in a hospital environment
Some of the sample portable ambulatory devices that you can wear to sleep in your own bed. Various surgical techniques and modifications to improve OSA have been described and used over the years.
An oral appliance
Different masks available for the best comfort to ensure long-term compliance. This is connected to the CPAP machine (red arrow) (graphic source: http://cpap-masks.info)
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.
(source of unlabelled diagram: Netter Atlas of Anatomy)
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The food pyramid as recommended by the Malaysian Ministry of Health
The CPAP analogy
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© Vincent Tan ENT
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Talks about SNORING & O.S.A on 12/1/16 (for educational purposes)
ENT
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)
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