Management of Snoring and Obstructive Sleep Apnea: A Practical Guide

Contents
List of Figures
List of Tables
1: Introduction
	References
2: An Evolutionary Perspective
	2.1	 Evolution of SDB
	2.2	 Evolution of an Otolaryngologist in the Treatment of OSA
	2.3	 Evolution of Diagnosis
	2.4	 Evolution of Treatment
	2.5	 Evolution in Technology
	References
3: Co-Morbidities and Sequelae of OSAHS
	3.1	 Effects of Obstructive Sleep Apnea (Fig. 3.1)
	3.2	 Obstructive Sleep Apnea and Systemic Hypertension
	3.3	 Obstructive Sleep Apnea and Cardiovascular Diseases
		3.3.1	 OSA and Sudden Cardiac Death
		3.3.2	 Obstructive Sleep Apnea and Arrhythmias
		3.3.3	 Obstructive Sleep Apnea and Pulmonary Hypertension (PHT)
	3.4	 Obstructive Sleep Apnea and Central Nervous System
		3.4.1	 Obstructive Sleep Apnea and Cerebrovascular Stroke
		3.4.2	 Obstructive Sleep Apnea and Metabolic Diseases
		3.4.3	 Metabolic Pathways Linking OSA to Type 2 Diabetes
	3.5	 Obstructive Sleep Apnea and Respiratory Diseases
	3.6	 Obstructive Sleep Apnea and Reproductive System
		3.6.1	 Co-Morbidities and Consequences of Pediatric OSA
	References
4: Anatomy of Upper Airway
	4.1	 Anatomy of Nasal Airway
		4.1.1	 Medial Wall/Septum
		4.1.2	 Lateral Wall
	4.2	 Anatomy of the Pharyngeal Airway
		4.2.1	 Anatomy of the Nasopharynx
		4.2.2	 Applied Aspects
		4.2.3	 Anatomy of Oral Airway
		4.2.4	 Base of Tongue
		4.2.5	 Anatomy of Oropharynx
			4.2.5.1	 Soft Palate
			4.2.5.2	 Applied Aspects
			4.2.5.3	 Oropharynx
			4.2.5.4	 Palatine Tonsil
		4.2.6	 Larynx and Laryngopharynx
		4.2.7	 Larynx
	Reference
5: Upper Airway Resistance Syndrome
	5.1	 Definition
	5.2	 Pathophysiology
	5.3	 Clinical Features
	5.4	 Diagnosis
	5.5	 Treatment
	References
6: History, Clinical Examination, and Diagnosis of Snoring and Obstructive Sleep Apnea–Hypopnea Syndrome
	6.1	 History
	6.2	 Anthropometric Measurements in Suspected Patients of OSA
		6.2.1	 Neck Circumference
		6.2.2	 Waist Circumference
		6.2.3	 Craniofacial Factors
	6.3	 Clinical Examination
		6.3.1	 Examination of Nose and Nasopharynx
		6.3.2	 Examination of Oropharynx
	6.4	 OSA Scoring (Table 6.8)
		6.4.1	 Examination of Hypopharynx and Larynx
	6.5	 Fiberoptic Nasopharyngolaryngoscopy with Muller’s Maneuver and End Expiratory Tongue Position
		6.5.1	 Procedure
		6.5.2	 Palatal Phenophype
		6.5.3	 Modified Moores Tonguebase Classifcation
	6.6	 Polysomnography[PSG]
		6.6.1	 Clinical Definitions
		6.6.2	 How to Report a Level 3 Sleep Study
	6.7	 Drug Induced Sleep Endoscopy [DISE]
		6.7.1	 Sedating Agents
		6.7.2	 Procedure
		6.7.3	 Observation/Recordings
	6.8	 Interventional Dise
	6.9	 Dynamic MRI
	6.10	 Apneagraph
		6.10.1	 Procedure
	References
7: Conservative Therapies in OSA
	7.1	 Medical Treatments
	7.2	 Obesity Management
	7.3	 Use of Oral Appliances
	7.4	 Oral Appliance Therapy
	7.5	 Tongue Retaining Device
	7.6	 Mandibular Advancement Devices [Mad]
		7.6.1	 Myofunctional Therapy/Oral Facial Myofunctional Therapy
		7.6.2	 Principle
		7.6.3	 Indications
		7.6.4	 Technique
	References
8: Prosthodontics in OSA
	8.1	 Association of Dentition/Chewing Habits and OSA
	8.2	 Oral Examination
	8.3	 Treatment Options
	8.4	 Oral Appliances
	8.5	 For Children
	8.6	 For Adults
	8.7	 Advantages
	8.8	 Disadvantages/Complications
	References
9: PAP Therapy in OSA
	9.1	 Type of Devices
		9.1.1	 CPAP
		9.1.2	 BiPAP
		9.1.3	 Masks
	9.2	 Servo Ventilation
	9.3	 Volume Assisted Pressure Support
	9.4	 Compliance with PAP
	References
10: Surgeries for OSA
	10.1	 Patient Selection for Surgery
	10.2	 Rationale and Indications for Surgery in OSA
		10.2.1	 Aim
	10.3	 Surgical Indications and Contraindications
		10.3.1	 Surgeries for Snoring/UARS/ OSA
			10.3.1.1	 Protocol for Surgery
	10.4	 Powell–Riley Two-Phase Surgical Protocol: [2]
		10.4.1	 Surgical Procedures
			10.4.1.1	 Nasal Surgery
				Surgery for Nasal Valve (Figs. 10.1 and 10.2)
					Radiofrequency/Coblation Reduction of Inferior Turbinate (Figs. 10.3, 10.4 and 10.5)
						Patient Selection
						Choice of Instruments
					Septoplasty
						Candidates for Surgery
						Technique
			10.4.1.2	 Palatal Procedure
				Minimally Invasive Procedure
					Radiofrequency Assisted Uvulopalatoplasty (Fig. 10.6)
						Candidate Selection
						Procedure
						Contraindications
						Complications
				Partial Uvulectomy (Fig. 10.7)
					Candidate Selection
					Procedure
					Instrumentation
					Complications
				Radiofrequency Assisted Palatal Stiffening Operation [Somnoplasty] (Fig. 10.8)
					Candidate Selection
					Contraindications
					Procedure
					Complications
				Modified Cautery-Assisted Palatal Stiffening Operation [Modified Capso]/Anterior Palatoplasty (Fig. 10.9)
					Candidate Selection: [8]
					Complications
				Injection Snoreplasty (Fig. 10.10)
					Candidate Selection
					Sclerosing Agents: [9]
					Procedure
					Complications
				Palatal Implants (Fig. 10.11)
					Patient Selection: [10]
					Procedure
					Complications
				Barbed Pharyngoplasty/Barbed Snore Surgery [BSS]
					Properties of Barbed Sutures: [12]
					Candidate Selection: [12]
					Advantages: [12]
					Complications: [12]
				Barbed Lateral Pharyngoplasty (Fig. 10.12)
					Indications: [12]
					Procedure
				Barbed Anterior Palatoplasty (Fig. 10.13)
					Indications: [12]
				Barbed Roman Blind Technique (Fig. 10.14)
					Indications: [12]
				Barbed Alianza Technique: Alianza (BRBT + BAPh)
					Indications: [12]
			10.4.1.3	 Invasive Palatal Surgeries
				Uvulopalatopharyngoplasty [UPPP] (Figs. 10.15 and 10.16)
					Candidate Selection (Table 10.4)
					Procedure
				UPPP with Fair Banks Modification (Figs. 10.17 and 10.18)
					Complications: [14]
				Zetapalatopharyngoplasty [ZPP] (Figs. 10.19, 10.20 and 10.21)
					Indications: [15]
					Contraindications: [15]
					Procedure
					Advantages: [15]
					Disadvantages: [15]
					Complications: [15]
					Improvement after ZPP: [15]
					What to do with Failure Cases of ZPP
				Expansion Sphincter Pharyngoplasty (Figs. 10.22, 10.23 and 10.24)
					Candidate Selection: [16]
					Procedure
						Principle: [16]
					Complications: [16]
			10.4.1.4	 Tongue Base Surgeries
				Minimally Invasive Tongue Base Surgeries
					Radiofrequency Assisted Reduction of Tongue Base Reduction (Fig. 10.25)
						Candidate Selection: [17]
						Procedure
							Probe
					Technique
						Complications: [17]
					Coblation Channeling of Tongue/Coblation Midline Glossectomy (Figs. 10.26 and 10.27)
						Candidate Selection [18]
						Contraindications: [18]
						Procedure: [18]
						Complications: [18]
					Tongue Base Stabilization (Fig. 10.28)
						Candidate Selection
						Procedure
						Complications: [19]
					Lingual Tonsillectomy
						Procedure: [20]
				Invasive Tongue Base Surgery
					Genioglossus Advancement (Figs. 10.29 and 10.30)
						Candidate Selection: [21]
						Procedure
						Complications: [21]
					TORS [Transoral Robotic Surgery]
						Candidate Selection: [22]
						Contraindications: [22]
						Instrumentation: [22]
						Surgical Team
						Procedure: [22]
						Postoperative Care and Complications: [22]
				Supraglottoplasty (SGP) (Fig. 10.31)
					Indications: [22]
					Contraindications: [22]
					Procedure: [22]
				Hyoid Suspension (Fig. 10.32)
					Candidate Selection: [23]
					Surgical Procedure: [23]
						Principle
						Procedure
					Complications: [23]
				Epiglottis Management
					Indication
					Instruments
					Procedure
					Complications
				Maxillary Mandibular Advancement
					Candidate Selection
					Procedure [25]
					Post-operative Management
					Complications: [25]
				Tracheostomy
					Candidate Selection
					Procedure [26]
					Complications
				Speech Ready Long-Term Tube-Free Tracheostomy
					Indication [27]
					Technique [27]
					Advantages [27]
					Disadvantages of Tube Dependent Techniques
				Hypoglossal Nerve Stimulation
					Indications
					Contraindications [28]
					Procedure [28]
					Stimulation Protocol [28]
					Complications [28]
	References
11: Perioperative and Postoperative Considerations in Management of Patients with OSA
	11.1	 Preoperative Consideration
	11.2	 Intraoperative
		11.2.1	 Drugs and Monitoring
	11.3	 Intubation Technique
	11.4	 Extubation
	11.5	 REM Sleep Rebound
	11.6	 Postoperative Monitoring
		11.6.1	 Keys to Anesthetic Management of OSA Surgeries
	References
12: Definition of Success in OSA
	References
13: Pediatric Obstructive Sleep Apnea
	13.1	 As per American Academy of Pediatrics: Spectrum of Pediatric Obstructive SDB in Increasing Order of Severity Encompasses [1]
	13.2	 Levels of Obstruction
	13.3	 Pediatric OSA Is Associated with
	13.4	 Symptoms and Signs of OSA
	13.5	 Diagnosis of OSA in Children
		13.5.1	 Even a Single Apnea is Pathological in Children
	13.6	 Treatment of OSA in Children
	13.7	 Indication for Adenotonsillectomy in SDB
	13.8	 Contraindications for Adenotonsillectomy
	13.9	 Tonsillectomy Techniques
	13.10	 Adenoidectomy Techniques
		13.10.1 Risk Factors for Residual OSA after Adenotonsillectomy: [2]
		13.10.2 Postoperative Complications of Adenotonsillectomy [7]
	13.11	 Lingual Tonsillectomy
		13.11.1 CPAP or Non-Invasive Positive Pressure Ventilation (NIPPV) for Nocturnal Hypoventilation
		13.11.2 Surgeries for Pediatric OSA
	References
14: Preventive Aspects in Obstructive Sleep Apnea
	14.1	 Breastfeeding Is Emerging as a Protective Factor Against Childhood Snoring
	14.2	 Early Diagnosis with Screening of Children to Prevent Them Transform into Adult OSAS
	14.3	 Myofunctional Therapy in Prevention of OSAS
	14.4	 Biomarkers for OSA
15: Newer Technological Tools in Obstructive Sleep Apnea
	15.1	 Radiofrequency in Snoring and OSA
	15.2	 Mechanism of Action
	15.3	 Radiofrequency Usage in Osahs
	15.4	 Coblation in OSA Surgeries
		15.4.1	 Mechanism of Action
		15.4.2	 Applications of Coblation in ENT
	15.5	 Radiofrequency V/S Coblation V/S Electrocautery (Table 15.1)
	References
16: COVID-19 and Obstructive Sleep Apnea
	16.1	 Similarities Between COVID-19 and OSA
	16.2	 The Effects of Lockdown and Home Isolation
	16.3	 The Way Forward
		16.3.1	 Virtual History and Physical Examination
17: Medicolegal Aspects and Consent for OSA Surgeries
	17.1	 What Is a Consent?
	17.2	 What Should a Consent for Sleep-Disordered Breathing Surgery Include?
	17.3	 The Anesthetic Consent Should Include
	17.4	 Additional Parts of Consent [To Be Taken whenever Necessary]
	17.5	 There Are 6 “P” for a Consent
	17.6	 Counselling
	17.7	 Medical Counselling
	17.8	 Financial Counselling
	17.9	 Psychological Counselling
18: Future in Sleep Medicine
	18.1	 Sleep Board Is the Demand of the Day!
		18.1.1	 To Qualify as SDB Specialist
	18.2	 Role of Sleep Board
		18.2.1	 Is it Practical to Have a Sleep Board?
19: Case Discussions
	19.1	 Case I
		19.1.1	 Case Discussion
	19.2	 Case II
		19.2.1	 Case Discussion
	19.3	 Case III
		19.3.1	 Case Discussion
	19.4	 Case IV
		19.4.1	 Case Discussion
	19.5	 Case V
		19.5.1	 Case Discussion