Management of Sleep Disordered Breathing

Sleep-disordered breathing (SDB) is a collective term which includes snoring, upper airway resistance syndrome (UARS) and obstructive sleep apnea syndrome (OSAS). Simply put, the term is descriptive of the effects of a partial collapse or obstruction of the upper airway during sleep which may cause sleep fragmentation.

Surgical management was the first treatment modality available for SDB. Some of the first subjects to undergo surgery for an anatomic narrowing or blockage of the upper airway during sleep were those afflicted with the Pickwickian Syndrome (obesity-hypoventilation syndrome). Tracheotomy was the sole surgical procedure available during this period and since it was life saving in these circumstances, it was also used for other patients with nocturnal upper airway obstruction. Morbidity and mortality were not established except for the very severely affected, and the tracheotomy was not well tolerated or accepted by most patients even as a method to improve the quality of life, or even to extend life itself. In the early 70’s the term used to describe nocturnal airway obstruction was hypersomnia with periodic apnea (HPA), later revised to be called obstructive sleep apnea syndrome (OSAS), and now better known collectively as Sleep-Disordered Breathing (SDB).

Over thirty years have passed and our knowledge of sleep disorders has evolved to such an extent that the field of sleep disorders is now a recognized specialty in medicine and a specialty in surgery. Not all patients will accept medical management as the primary first choice, and visa versa, the same holds true for surgical acceptance. Granted, there is surely a central neurologic mediator associated with this syndrome that is not yet identified. However medical management, the present treatment of choice, is now suffering with compliance problems and resistance from the younger subset of patients, who have debilitating daytime somnolence due to Upper Airway Resistance Syndrome (UARS, a mild form of sleep disorder), and do not want to wear a nasal device (CPAP/BiPAP) six to eight hours a night for the next forty or fifty years. Hence, between the two modalities we may offer alternatives as is appropriate.

What we have learned about the obstructive process in sleep disorders through the combined efforts of our surgical and medical colleagues, is that nocturnal narrowing or obstruction may be localized to one or two areas, or may encompass the entire upper airway passages to include the nasal cavity (nose), oropharynx (palate) and hypopharynx (tongue base). Conservative medical therapy is usually recommended first. Treatment centers around sleep hygiene, weight loss, dental splints and nocturnal nasal pressure devices (CPAP/BiPAP). There are also surgical procedures presently available to provide for a logical upper airway reconstruction (UAR) of these regions.2-3 This will usually encompass multiple surgical procedures or sites, in such a manner as to minimize risks and complications, and to subsequently relieve the patient of this problem. Current established surgical procedures offer reconstruction of the airway from the nose and palatal level to the tongue base.

Current Methods of Management:

Medical:

• CPAP/BIPAP *
• Weight loss
• Sleep hygiene
• Dental splints or tongue retaining devices
• Nasopharyngeal tubes

*This modality has become the mainstay of treatment in most patients with SDB

Surgical:

1. Tracheotomy
2. Nasal
3. Palatal
4. Tongue reduction
5. Genioglossus advancement-Hyoid ( GAHM )
6. Bimaxillary advancement ( MMO )

Rationale for Surgery:

Nearly all patients with documented SDB are candidates for surgical intervention. This mandates that the patients are medically and psychologically stable and wish to undergo a surgical procedure. They should be informed of the various medical and surgical treatments, along with current treatment philosophies. Surgical indications should include the two major pathophysiologic parameters of SDB: neurobehavioral and cardiopulmonary derangements caused by nocturnal obstructions during sleep. Patients with the diagnosis of UARS usually present with marked excessive daytime sleepiness (EDS). Since there are numerous other causes of EDS such as narcolepsy, insomnia and sleep deprivation, a nasal CPAP trial, in this group, can be diagnostic and therapeutic thus helping to establish that EDS is secondary to upper airway resistance syndrome and sleep fragmentation (SDB). The cardiopulmonary risks of OSAS have been documented when the respiratory disturbance index is greater than 20 and their lowest oxygen saturation level is below 90%.4 This severity necessitates treatment to lower the risk of cardiopulmonary sequelae and the increased mortality rate.

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