T.R. RHEE, M.D. INC
T.R. RHEE, M.D. INC
WELCOME
T. R. RHEE, M.D. INC
12555 Garden Grove Blvd. Suite 408. Garden Grove CA. 92843 TEL:(714)530-1010
DIPLOMATE AMERICAN BOARD OF
OTOLARYNGOLOGY, HEAD AND NECK SURGERY
PRIVATE PRACTICE IN ORANGE COUNTY,CALIFORNIA.U.S.A
GARDEN GROVE OFFICE:12555
GARDEN GROVE BLVD. SUITE 408, GARDEN GROVE, CA 92843
(714)530-1010
OFFICE HOURS:
MONDAY,TUESDAY,THURSDAY,FRIDAY(9AM - 5PM)WEDNESDAY(9A.M. - 1P.M.)
ENDOSCOPIC
SINUS SURGERY Excessive day time sleepiness (EDS) * Restless disturbed sleep *Loud snoring and gasping * wake up gasping for breath *Morning headache * falling asleep while at work *Memory problems * feeling tired no matter how much you've had *Excessive movements while "asleep" * partner sleeps in another room due to snoring *Enuresis * snoring every night *Sexual problems/impotence * falling sleep while driving *Personality, mood changes * falling asleep whenever you sit down in a quiet place
Hypertension--congestive heart failure--arrhythmia---Brain dysfunction by hypercapnea and hypoxemia
GERD(gastroesophageal reflux diseases): globus pharyngeus, cervical dysphagia, chronic coughing, hoarseness, reflux laryngitis.
Snoring is often associated with obstructive sleep apnea, the most common form of this sleep disorder, While sleeping, the normal person's throat relaxes and breathing is steady throughout the night. In the OSA patient structures in the throat block the flow of air in and out of the lungs during sleep. Periods of absent breathing or reduced breathing may last as little as 10 seconds to as long as a minute or more. You may try to breathe but very little air, if any, can go in or out of your lungs because of the "obstruction" in your throat. You then may gasp and snort and awaken for a few seconds and start breathing again. Then you fall back to sleep and the cycle repeats it self occurring up to several hundred times during the night.
Your brain, heart, lungs and other body tissues literally starve for oxygen until your body defense mechanisms take over. If left untreated it can lead to high blood pressure, respiratory failure, heart problems, obesity, and increase the risk for greater possibility of accidents while driving.
Snoring, daytime drowsiness, nocturnal bronchoconstriction, depression, and headaches are common. Other symptoms include irritability, short temper, and non-refreshing or restless sleep.
Nasal obstruction, nocturnal asthma, allergies and reflux can all be responsible for disordered sleep. This translates to approximately 20 million cases that need proper evaluation and treatment.
No! Obstructive sleep apnea is a medical disorder with anatomic and physiological origins. You cannot think your way out of sleep apnea. In the past, people with apnea have been incorrectly diagnosed as being lazy or depressed because of psychological reasons.
Although you may stop breathing and wake up briefly hundreds of times during the night, chances are that you don't remember waking up at all. This is why it is very common for your bed partner or someone who has observed your sleep to first recognize your problems.
An overnight sleep study must be performed with the sleep apnea sensor to determine whether you have sleep apnea, an entirely painless procedure. Sensors are attached to your body to evaluate heart activity, breathing, oxygen level, snoring, respiratory effort and body position.
Yes! Once an accurate evaluation has been made. Your physician will interpret the data which will enable him to correctly evaluate and recommend appropriate treatment. Increased energy and vitality, weight loss, and the feeling of being a "new person" are common following treatment.
Afrin Test: 3 night spray sleep lesser snore than without Afrin= indication of nasal surgery
Presence of HIV DNA in Laser Smoke, but no culture obtained
Snoring: simply defined, snoring represents repetitive vibrations of soft tissue structures.in the upper airway during sleep.
1. Present in 90-95% of patients with OSAS
2. Snoring often 69-80 db; above safe noise level (pneumatic drill smashing concrete: 70-100 dB)
3. Continuos snoring: inspiratory noise associated with almost every breath; tends to maintain a regular frequency and amplitude.
4. Intermittent or cyclical snoring:
a. Intensity of snores wax and wane(may be regular of irregular)
b. Frequent quiet intervals which represent apneic episodes
c. Often terminated by a loud snort or gasp
Habitual(nightly)snorers found in :
1. 19% of unselected pollution
2. More prevalent in men(25%) than women(15%)
3. Increasing prevalence with age:(pharyngeal muscle tone decreased?) ages 41-65 yrs 60% men and 40% women snore
4. Increased prevalence among obese men vs. 34% on non-obese men.
Loudness increases proportionately to weight gain.
PHARYNX AND NASOPHARYNX
1. LASER ASSISTED UVULOPALATOPLASY(LAUP)
2. PARTIAL TONSILLECTOMY
3. TONSILLAR CRYPTOLYSIS
4. TONSILLAR TAG
5. TONSILLAR PAPILLOMA
NASAL
1. POST FESS POLYPECTOMY
2. POST FESS TURBINATE REDUCTION
3. POST FESS NASAL SCAR AND SYNECHIA REDUCTION
4. POSTOPERATIVE ADHESIONS
5. NASAL PAPILLOMA
6. ANTERIOR SEPTAL SPURS
7. NASAL VALVE STENOSIS
8. CHRONIC RECURRENT VESTIBULITIS
ORAL
1. INCISIONAL AND EXCISIONA BIOPSIES
2. RANULA
3. FRENECTOMY
4.MIDLINE LINGUAL TONSILLECTOMY
5. FIBROMA
6.MIDLINE LINGUAL GLOSSITIS
7. APHTHOUS ULCER
8. HAIRY TONGUE 9. EPULIS
10.LICHEN PLANUS
11. MARSUPILIZATION OF SALIVARY DUCT
12.GINGIVOPLASTY
13. MUCOCELE
14. OPERCULECTOMIES
15.VESTIBULOPLASTY
16. PERIODONTAL DISEASES
EAR
1. CUTANEOUS LESIONS OF EAR CANAL
2. MYRINGOTOMY AND TUBE INSERTION
FACIAL COSMETIC
S N O R I N G
HISTORY:
1800'- Nasal Obstruction in Sleep Apnea.
1877- First literature, OSA
1892- Disturbed sleep with impairment of daytime intellectual performace and memory
1950'- Sleep disorders research
1952- PalatoPharyngoplasty(PPP) by Ikematsu
1957- Eye movement during sleep and coined the term REM sleep(Aserinsky)
1959- Sleep stage and postural relaxation(Jouvet & associates)
1960'- Adenoid Hypertrophy with cor pulmonale
1973- Sleep Apnea, first described by Guilleminault et al
1977- Otolaryngologic manifestations of OSAS(Simmons, et al)
1978- Nasal Nocturnal syndrom(restless sleep,snoring & Gasping respiration
with Nasal obstruction.(Cottle)
1978- Tracheostomy to improve SA(Mata)
1981- Uvulopalatopharyngoplasty(UPPP), Fujita, modified by Moran, Koopman
1982- CO2 Laser Uvular Vaporization of Palatopharynx(UVPP) by Prof.Freche
1988- CO2 Laser Resection of Palatopharynx(LRPP) by Yves-Victor Kamami,Paris
PHARYNX: (25 muscles)
* Swallowing, vocalization, breathing ,
Ventilation: 1. stabilizing the palate by contraction of levator veli palatini(IX,X nerve)
(* dimple point of soft palate when say Ha Ha) by contraction of tensor veli palatini
(mandibular branch of V nerve)
2. dilator of pharynx: palatopharyngeus and palatoglossus
3. Tongue position: genioglossus,hypoglossus,styloglossus,chondroglossus
and palatoglossus hyoid bone position: suprhyoid and infrahyoid muscle
OSAS- PSG-FNMM(Fibroptic Nasopharyngoscopy with Muller Maneuver by Borowiecki )
1/3 of life - sleep ,
40 Million - sleep disorder snoring--
OSAS--Heart Failure -- Sudden death
Most common sleep disorder:
insomnia:- occasional I = 90 million
chronic I = 9 million snoring - high b.p., arrhythmia, stroke
"sleep Hygiene"
Theory:
The Pharynx represents a distensible tube, weakly supported by surrounding structures and dilator musculature. With inspiration, the pressure differential created by the diaphragm results in flow, and a negative or subatmospheric intraluminal pressure. This negative intraluminal pressure results in some level of collapse of the compliant soft tissues of the nasal inlet, oropharynx, and hypopharynx. The degree of collapse is dependent on a wide variety of factors including, the compliance of the soft tissue, the cross sectional diameter of the nasopharynx and oropharynx, and the size, shape and position of the tongue and uvula. An additional important factor includes the sensitivity of the feedback loop between Central neural mechanisms and the muscles of the oropharyngeal dilators. The degree of reduction in the intraluminal pressure on inspiration, is a function of the resistance of the upper airway. This includes resistance created by intranasal structures, classically considered to produce 50% of all upper airway resistance, as well as that provided by the oropharyngeal tissues and tongue. As nasal resistance increases, the diaphragm must work harder to create a large negative pressure in order to initiate adequate flow. As this pressure differential increase, the intraluminal pressure decreases and collapse with airway obstruction is more likely. In addition, this process creates an increased turbulence which further contributes to pharyngeal collapse.
It has been well established that the nasal pathway is the preferred pathway for nocturnal breathing. When nasal obstruction becomes severe, then the oral pathway is utilized and mouth breathing occurs. Thus, as long as the nasal pathway is chosen, an increase in nasal resistance will result effectively in a decrease in intraluminal pressure and further collapse of the pharyngeal tissues. If mouth breathing is chosen, there is strong evidence that in the supine position, and during sleep, the work of breathing is substantially increased. Moreover, mouth breathing may trigger so called Naso-Pulmonary reflexes, which results in an increase in peripheral pulmonary resistance. The net effect is alveolar hypoventilation. There is an increasing body of evidence to support the role of nasal obstruction as an important component in the pathophysiology of obstructive sleep apnea syndrome in at least some patients. Nasal airflow obstruction, which creates negative pressure during inspiration causing flaccid tissuers to draw together(Bernoulli effect)
Nonsurgical:
Weight control, D/C sedatives, reduce drinking, Regular Exercise to improve muscle tone
1.medicine: medroxyprogesterone acetate 60-120mg,
protriptyline (vivactil):5-30mg 11/2 before qHS(cardiac arrhythmia) curretab, depo-provera
2.CPAP(continuous positive airway pressure)
3.Antisnoring device(300):nose clip,chin strap,electric shock
USA: snoring, 30 millions
Operation:
1. LAST( Laser Assisted Serial Tonsillectomy)
2. Septoplasty
3. Turbinectomy
4. Tonsillectomy
5. Tracheostomy
6. UPPP( by Fujita,1981, Modified by Moran, Koopmann)
7. LRPP(by Yves-Victor Kamami, Paris, France, 1988, Foch Hospital) CO2 Laser Resection of the Palatopharynx)
* 1952-PPP by Ikematsu and introduce to USA, 1981 by Fujita & Simmons, improved by Dejean & Chonard, France
* 1982 CO2 Laser Uvular Vaporization of Palatopharynx(UVPP) by Prof. Freche
* 15%Lidocaine spray, 2% lidocaine with epinephrine vertical trench, "onion-slice cutting fashion"
new uvula may extend vaporization to palatine tonsil, or posterolateral pharyngeal wall 85% complete success, 12%
improve snoring, 3 % only decrease snoring 3 - 7 session of 5 min : 3 - 5 session for women 4 - 5 session for men " non
OSAS 5 - 7 session for men OSAS 3 - 4 weeks apart, 10 days sore throat.
PMS( periodic movement during sleep)= ant. tibial muscle activity, 0.5-5 sec in 15 to 60 sec interval
MSLT(Multiple Sleep Latency Test)= document impairment of daytime alertness
DBE(disordered breathing event= 50% or greater decrease in the amplitude of airflow lasting a minimum of 10 seconds)
TST(total sleep time) ,PRI(Portable respiratory index) ,QRT(quiet recording time) PRI=total DBE/QRT x 60
1. Apnea rate of 10 or more events/hr may be clinically significant 2. " " greater than 20 is clinically significant
3. O2 desaturation <90% may be significant 4. " < 80% are significant
5. Sleep disturbance index 5< may be significant 6. " 20< is significant
7. average sleep latency of less than 10 min. in MSLT may be significant
8. " less than 5 min " is significant
9.Occurrence of 2 0r more sleep-onset REM periods in the MSLT is significant
SLEEP
* Normal sleep= 4-10 hrs(avg. 73/4 hr)
Characteristics of the Sleep Cycle:
Stage 0(wakefulness) EEG characterized by low voltage pattern: frequency range(4-25Hz),beta wave(>13Hz)
theta wave(4-7Hz),alpha rhythm(sinus wave,8-13Hz) over posterior head region
Stage 1(drowsiness) 1-2% of sleep Alpha rhythm disappears, pupillometry shows slow conjugate constriction and dilation of pupils at 1 to 3 second interval, slow random circular eye movements that may be disconjugate. Patient may feel attentive to surrounding activity but exhibit diminished responsiveness
Stage 2, 45-55% of sleep EEG shows sigma waves or "sleep spindle", rhythmical (Wakefull sleep) clusters of 40 to 100 V waves ranging from 10-16 Hz and lasting about 0.5 to 3 seconds. Patient easily roused but can recognized having been asleep.
Stage 3 & 4 25% of sleep Patient immobile and difficult to arouse. EEG characterized (slow wave or delta sleep,Rock sleep) by high-voltage slow(delta)waves. In stage 3 sleep, wave of <2Hz and >75V occur during 20% to 50% 0f time.
in stage 4 sleep, such delta waves fill more than 50% of the time. The distinction is now seen as somewhat arbitrary.
Stage 5 20-25% of sleep Characterized by rapidly darting conjugate eye movements (REM of dream sleep) under closed lids(saccadic or nystagmoid type), occurring in clusters of 3 to 10 seconds at interval of 30 t0 40 seconds. EEG patterns resemble those of stage 1 with random pattern of mixed frequencies between 4 and 25 Hz
Dreams tend to be vivid, complex, and likely to be remembered;arousal thresholds usually lower than in slow wave sleep
* 1st half of sleep--- slow wave sleep , stage 3,4
* 2nd half of sleep -- REM sleep(delta sleep)
* Older people, sleep less, Quick REM, more dream, 1 hr to reach delta sleep
* Younger children-- 10 min to reach delta sleep, 7 REM cycle, awake 1-3time/night
* Adult -- fewer REM, 2-4 time wake/night
REM to REM -- 90-110 min
Sleep: 1. NREM
2. NREM & REM Cycle 90-110 min
3. Stage I -- 2 - 5% of Sleep
4. Stage II-- 45-55% of Sleep
5. StageIII-- 3 - 8% of Sleep
6. StageIV-- 10 -15% of Sleep
7. REM --- 20-25% of Sleep
Sleep Latency= 30 - 35 min ,
Latency to REM = 90 - 120 min ,
RDI(Respiratory distress index)= Apnea+Hyponea /hr -- normal < 5 ,
During REM Sleep, most muscle relax- more snoring baby, elderly, muscle more weak -- sudden infant death syndrome
,Stop breathing 10" < --- Apnea. 30</7hrs sleep = SAS
Apnea-- Upper airway Apnea- older age more, up to 50yrs man>women after 50yrs man= woman
1.Apnea A :respiratory disturbances during sleep as absence of nasal airflow cessation of airflow at lease 10 seconds
2. Central A: absence of airflow with complete cessation of all respiratory effort Obstructive A: No airflow in presence
of continued respiratory effort
3. Mixed A
Hypopnea:
Maintenance of wakefulness test(MWT):a test of the ability to maintain alertness during the day time. The difference
between the MWT and MSLT(multiple sleep latency test) is that in the MWT the patient is encouraged to relax and fall
sleep.
Multiple sleep latency test(MSLT): a test that measures an individual's ability to fall sleep.
Obstructive Sleep Apnea(OSA):
a disorder characterized by episodes of upper airway obstruction that occur during sleep and are usually associated with
a reduction in the blood oxygen saturation.
Respiratory Disturbance Index:(RDI):
A measure of the number of respiratory events per hour of time. Also known as apnea-hypopnea index.
Apnea Index:(AI): # of apnea / hr of sleep
Sleep Apnea Syndrome: AI= >5/hr or >30/7hrs
Excessive day time sleepiness (EDS) * Restless disturbed sleep *Loud snoring and gasping * wake up gasping for breath
*Morning headache * falling asleep while at work *Memory problems * feeling tired no matter how much you've had
*Excessive movements while "asleep" * partner sleeps in another room due to snoring *Enuresis * snoring every night
*Sexual problems/impotence * falling sleep while driving *Personality, mood changes * falling asleep whenever you sit
down in a quiet place
Hypertension--congestive heart failure--arrhythmia---Brain dysfunction by hypercapnea and hypoxemia
GERD(gastroesophageal reflux diseases): globus pharyngeus, cervical dysphagia, chronic coughing, hoarseness, reflux
laryngitis.
Snoring is often associated with obstructive sleep apnea, the most common form of this sleep disorder, While sleeping, the normal person's throat relaxes and breathing is steady throughout the night. In the OSA patient structures in the throat block the flow of air in and out of the lungs during sleep. Periods of absent breathing or reduced breathing may last as little as 10 seconds to as long as a minute or more. You may try to breathe but very little air, if any, can go in or out of your lungs because of the "obstruction" in your throat. You then may gasp and snort and awaken for a few seconds and start breathing again. Then you fall back to sleep and the cycle repeats it self occurring up to several hundred times during the night.
Your brain, heart, lungs and other body tissues literally starve for oxygen until your body defense mechanisms take over. If left untreated it can lead to high blood pressure, respiratory failure, heart problems, obesity, and increase the risk for greater possibility of accidents while driving.
Snoring, daytime drowsiness, nocturnal bronchoconstriction, depression, and headaches are common. Other symptoms include irritability, short temper, and non-refreshing or restless sleep.
Nasal obstruction, nocturnal asthma, allergies and reflux can all be responsible for disordered sleep. This translates to approximately 20 million cases that need proper evaluation and treatment.
No! Obstructive sleep apnea is a medical disorder with anatomic and physiological origins. You cannot think your way out of sleep apnea. In the past, people with apnea have been incorrectly diagnosed as being lazy or depressed because of psychological reasons.
Although you may stop breathing and wake up briefly hundreds of times during the night, chances are that you don't remember waking up at all. This is why it is very common for your bed partner or someone who has observed your sleep to first recognize your problems.
An overnight sleep study must be performed with the sleep apnea sensor to determine whether you have sleep apnea, an entirely painless procedure. Sensors are attached to your body to evaluate heart activity, breathing, oxygen level, snoring, respiratory effort and body position.
Yes! Once an accurate evaluation has been made. Your physician will interpret the data which will enable him to correctly evaluate and recommend appropriate treatment. Increased energy and vitality, weight loss, and the feeling of being a "new person" are common following treatment.
Afrin Test: 3 night spray sleep lesser snore than without Afrin= indication of nasal surgery
Presence of HIV DNA in Laser Smoke, but no culture obtained
Snoring: simply defined, snoring represents repetitive vibrations of soft tissue structures.in the upper airway during sleep.
1. Present in 90-95% of patients with OSAS
2. Snoring often 69-80 db; above safe noise level (pneumatic drill smashing concrete: 70-100 dB)
3. Continuos snoring: inspiratory noise associated with almost every breath; tends to maintain a regular frequency and amplitude.
4. Intermittent or cyclical snoring:
a. Intensity of snores wax and wane(may be regular of irregular)
b. Frequent quiet intervals which represent apneic episodes
c. Often terminated by a loud snort or gasp
Habitual(nightly)snorers found in :
1. 19% of unselected pollution
2. More prevalent in men(25%) than women(15%)
3. Increasing prevalence with age:(pharyngeal muscle tone decreased?) ages 41-65 yrs 60% men and 40% women snore
4. Increased prevalence among obese men vs. 34% on non-obese men.
Loudness increases proportionately to weight gain.
Definition of SAS:
1. Apneas greater than 10 sec. in duration 2. Greater than 5 apneas/hr
3. Greater than 30 apneas/night 4. Repetitive events
5. Presence of some apneas in NREM sleep
Types of sleep apneas (all last >10 sec)
1. Obstructive Apnea:
Cessation of oronasal airflow but diapragmatic respiratory effort continues.
2. Central Apnea:
simultaneous cessation of both oronasal airflow and respiratory effort during sleep
(bulbar poliomyelitis,degenative neurologic ds,intracranial neoplasm,bain stem infarction,narcotic or sedative overdose)
3. Mixed Apnea:
early in the apnea both oronasal flow and respiratory movements are absent (central component) followed by resumption of unsuccessful respiratory movements (obstructive component)
4. Hypopnea: a partial decrease in ventilation during sleep. Often defined as a fall of > 33% but <75% of measured oronasal airflow accompanied by a >4% oxyhemoglobin desaturation and decreased respiratory effort.
* neg/ oropharynx pressure
* decreased upper airway muscle activity A P N E A S
*small pharyngeal cavity
* high pharyngeal compliance
* high unstream resistance
* baseline arterial PO2 --------------------- decrease PO2
* degree of diffuse airway obstruction-----increased CO2
* lung volume ------------------------------- Decreased pH
*chemoreceptor sensitivity
*CNS arousability AROUSAL FROM SLEEP
Sleep onset -> Apnea-> O2, CO2, pH--> Arousal from sleep--->resumtion of airflow return to sleep.
Vagal bradycardia, ectopic cardia beats--->unexplained nocturnal death , pulmonary vasoconstrition,---> pulmonary hypertension---->Systemic vasocontriction---> systemic hypertension---->acute CO2 retention--->chronic hypoventilation--->cerebral dysfunction, loss of deep sleep, sleep fragmentation,--->excessive daytime ,sleepiness,intellectual deterioration---->personality change, behavioral disorder----->excessive motor activity----> restless sleep
A. Symptoms of OSAS:
1. Suspect sleep apnea in patients who complain of:
*excessive daytime sleepiness *loud snoring *restless, disturbed sleep *witnessed respiratory pauses
2. Excessive daytime sleepiness
a.fall asleep and feel sleepy in increasingly inappropriate places
b.symptoms increase proportionately to mean number of apnea and number of arousals per hour of sleep
c.sleep drunkenness are difficult. Slow to awaken, experience early morning confusion,dullness, can act
drunk with slurred speech, clumsiness
d.automatic behavior syndrome with retrograde amnesia
3. Restless disturbed sleep
a. Noisy snoring,snorts, honks, gasps, and apneas
b. Awaken gasping/short of breath
c. Sleepwalk, sleeptalk, sit up in/on side of bed, fall from bed, wet bed
d. Face and respiratory muscle twitches
e. Heavy nocturnal sweating(60%) [?due to "work" of breathing]
4. Impaired daytime performance
A. Intellectual deterioration difficulty with learning, concentration,verbal memory, visual motor tracking skills,
and changing cognitive sets, Symptoms often worse in morning.
B.Personality change:
1. Often aggressiveness, marked irritability, abrupt outbursts of irrational behavior.
2. Anxiety and depressive reactions, occasionally persecution reactions.
C. Morning Headache(related hypoxia?)
D. Impotence
1. One study found 17% of patients who attend impotence clinics to have sleep apnea
2. High risk: diabetes and pulmonary disease.
Provoke/precipitate other sleep disorders
a. Nocturia(28%) from increased intraabdominal pressure with respiratory efforts
against closed upper airway space
b. Gastroesophageal reflex(mechanism:upper airway obstruction increases esophageal
pressures)
c. Sleeptalking, sleepwalking, sleep drunkenness, vivid dreams, hallucinations.
D. Nocturnal enuresis(majority of children and 5-20% adults)
a.Gastroesophageal reflux b.choking c.laryngospasm d.nocturnal palpitations e.sleeptalking,
f.nocturnal enuresis g.noctural syncope
OBESITY,AGE,CHRONIC FATIGUE,MALE GENDER,ALCOHOL,SMOKING
CNS DEPRESSANTS, ALLERGIC DISORDERS, ENDOCRINE DISORDERS
NEUROMUSCULAR DISORDERS,HEAD & NECK RADIATION.
1.deviated septum 2.nasal polyps 3.allergic rhinitis 4.vasomotor rhinitis 5.hypertrophic turbinates
6.sinusitis 7.tumors
1.tonsillar hypertrophy 2.elongated &/or enlarged uvula 3.palatal hypertrophy 4.lowered palatal arches 5.webbing of palate 6.enlarged tongue
1.enlarged lingual tonsils 2.adipose loading of the tissues 3.abnormal epiglottis 4.laryngeal obstruction 5.posterior mandibular displacement
EXERCISE, SMOKING, ALCOHOL,SLEEPING PILLS, ANTIDEPRESSANT PILLS, ALLERGIES
A. Body habitus:
1.obsity 2.characteristic body habitus, short thick neck, barrel chest, pear shaped abdomen truncal obesity.
B. Oronasomaxillofacial:
mouth,large tongue,dental bite
JAW:
micrognathia ,maxillofacial overbite ,maxillofacial malformations ,retrognathia ,facial trauma/fractures
NOSE:
Fracture,trauma ,nasal congestion ,seasonal allergies, collapse of nostrils upon inspiration
DNS
nasal obstruction ,allergic rhinitis ,Reduntant lateral pharyngeal wall
LARYNX:
omega-shaped floppy epiglottis with redundant aryepiglotic folds
posterior displacement of epiglottis
HYPOPHARYNX:
Lingual hyperplasia ,grade 1(mild) grade2(moderate) grade3(severe)
GENERAL PHYSICAL:
1.systemic hypertension 2.thyroid 3.pulmonary 4.cardiac 5. Neurologic
DIAGNOSTIC TESTING:
1.CBC(Polycythemia) ,2.TSH(hypothyroidism) 3.chest x-ray ,4.chemistry profile 5.EKG with rhythm strip
6.pulmonary functions ,7.allergy testing ,8.cephalometric x-rays
CEPHALOMETRICS:
1.the posterior airway space is the linear space between the base of the tongue and posterior pharyngeal wall on cephalometric x-ray
2a.low position of the hyoid bone with reference to the mandibular plane;
b.posterior airway spaces (PAS):<7mm(often 4-5mm compared to 11mm in controls)and distance from the hyoid to the mandibular plane(MP-H) of >20mm(inferiorly placed hyoid).
OTHER TECHNIQUES:
1. Videofluoroscopy of upper airway.
2. Computerized tomography
3. MRI
ANCILLARY DIAGNOSIIC TECHNIQUE:
*Diagnostic videoendoscopy of upper airway with Mueller's manuever
*observe upper airway patency and collapse at three different levels in both upright
and supine positions
1.nasopharynx
2,oropharynx
3.hypopharynx
*observe the degree and locations of airway collapse especially of:
1.posterior movement of the soft palate, uvula,and tongue
2.medial movement of the lateral walls of the hypopharynx
3.posterior displacement of epiglottis
Type 1.- oropharynx predominant site of airway narrowing (e.g.large tonsils, enlarged uvula,webbed mucosal pillars--95% success with LAUP
Type 2.- low palatal arch, relatively large tongue
2a: predominantly oropharynx:able to see hypopharynx and larynx with mirror.
2b: orohypopharynx involved(difficult to see hypopharynx/larynx with mirror)
Type 3 - Hypopharynx is site of obstruction: oropharynx is normal often see large posteriorly positioned tongue(retrognathia),hypertrophic lingual tonsils, floppy epiglottis with redundant aryepiglottic folds, lateral wall bulge
extending to hypopharynx,(micrognathia) Fujita's patients in whom the stenosis and collapse is confined to oropharynx(type 1,2a) often need staging procedures which involve the oropharynx and hypopharynx, type 3
require hypopharyngeal surgery.
Sher et al reported value of Mueller's maneuver in predicting favorable outcome from LAUP: if selected out patients in whom Mueller's maneuver demonstrates collapse predominantly at the soft palate level, higher success rate for LAUP (87%had >50% in AHI and 40%has postop AHI <5/hr)
POLYSOMNOGRAPHY:
1.sleep onset latency
2.sleep efficiency
3.apnea-hypopnea index=respiratory disturbance index:
*how often and loud patient snores
*effect of position upon patient apnea
*disruption of sleep *arousal index
ASSESSMENT OF APNEAS AND HYPOPNEAS:
1.Detection
2.quantify (range,mean in different sleep stages)
3.identify degree of oxygen desaturation, number of arousals/awakenings
*One can show apneas in a polysomnogram and still be normal!
Nonpathological sleep apneas can be seen in adults, apneas are acceptable when:
1. Less than 30/night or less than a mean of 5/hr of sleep
2. Normal adults often have a few sleep apneas.
A.especially at sleep onset, when changing body position, and during
REM sleep
b. Are usually brief in duration(<10 sec)central in type, and do not cause
significant arterial oxygen desaturation)fall in base line sleep arterial
oxygen)
c. Asymptomatic elderly
Pathological sleep apnea:
1.last > 10 seconds in duration (usually 20 - 40 seconds)
2.frequent, i.e. >5 apneas and hypopneas occur per hour of sleep
Identify and reduce/eliminate predisposing factors:
1.reduce weight
2.thyroid supplement if needed
3.avoid alcohol, hypnotics,sedatives,testosterone, reserpine, propranolol mellaril
4.stop smoking
5.reduce environmental nasal congestants, treat allergic rhinitis and nasal congestion with decongestants.
6.Avoid sleeping supine if postional apnea For patients with moderate to severe sleep apnea:
>20 apneas and hypopneas per hour of sleep especially with symptoms, treatment should include a trial of nasal CPAP
DIVIDE SNORERS IN 2 GROUPS
1. Nonobstructive(nonapneic) asymptomatic= simple snores symptomatic=upper airway resistance syndrome
*excessive daytime sleepiness ,upper airway resistance syndrome:(nonapneic,symptomatic): decrease in daytime alertness,excessive daytime sleepiness increase in arousal index on EEG improvement with CPAP
2. Obstructive(apneic) group: mild: Apneic index(AI) 5 - 20 ,moderate: AI 20 - 30, severe: AI over 30
Laser Smoke- benzene, aldehydes, polycyclic hydrocarbons
- present HIV virus, Hepatitis B virus
AI(Apnea Index),AHI(Apnea-hypopnea index),RDI(Respiratory disturbance Index)
Epidemiology and Natural History of OSA,
Prevalence: AI/AHI,5</hr --- 1-16% adult male
1 - 5% " female ,26-67% elderly male, 20-54% elderly female, , Gender: 85% - male, Age: 1.5% 40th --- 12% 70th
Obesity--- 2/3 of SA-- 20%< IBW, Abnormal Carniofacial Structure, Endocrinological: hypothyroidism, Acromegaly
Congenital Abnormality: Down's syndrome, Prader-willi syndrome, Other Genetic: Family genetics, Morbidity and Mortality: Hypertension,coronary heart disease, myocardial infarction, Stroke, neuropsychiatric problems(depression, cognitive dysfunction,sexual dysfunction), Accident: Virginia Study, 7x more autoaccident with OSA than normal
What is the laser treatment of snoring?
Laser treatment is much like a visit to the dentist. The patient is treated right in the doctor's office- sitting upright and fully awake in a comfortable chair. After local anesthesia(Lidocain) is applied, the laser is used to trim and reshape the uvula, which has no real function. Each session takes about ten minutes, and the full treatment is spread over three to five session spaced about four weeks apart. However the majority cases , only one session is required and severe cases are required more than one session.
What are the advantages of laser treatment?
The multiple sessions keep the pain down to a mild sore throat for a few days; there is no bleeding with laser treatment. Eating and speaking are not affected. Patients go right back to their normal activity after each session. The biggest advantage to treatment with the laser, however, is that it works. An immediate reduction in snoring is common, with significant improvement usually occurring after the second session. In 85% of patients the snoring is cured, while an additional 12% report a reduced level of snoring.
How do I know if laser treatment is right for me?
The initial consultation will include an examination to determine whether laser treatment for snoring is indicated. The procedure is only performed on adults over the age of 16. If doctor decide to go ahead with the laser surgery, a series of appointment will be scheduled.
Will insurance cover the cost of treatment?
Most insurance carriers do not reimburse for treatment of snoring, as is the case for cosmetic procedures.
However, surgery for the treatment of obstructive sleep apnea is often covered. Diagnosis of obstructive sleep apnea must be documented by a sleep study(polysomnography). You should check with your insurance carrier for information about your specific benefits.
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