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ASEAN Sleep Surgical Society Nov 2009

The Chinese University of Hong Kong ENT/Sleep Conference
& The 26th Congress of Pan Pacific Surgical Association
– Japan Chapter

Management Principles of OSAS Patients (as were discussed at the Workshop)

Present at the Conference / Contributing Authors
(Founding Members of the Asean Sleep Surgical Society):

    • Dr Victor Abdullah (Hong Kong) - Organizer
    • Dr Kenny Peter Pang (Singapore) - President, ASEAN Sleep Surgical Society
    • Prof David Terris (USA) - Chief, Otolaryngology, Medical College Georgia
    • Dr Michael Sarte (Philippines)

    • Prof Siow Jin Keat (Singapore)
    • Prof Abdullah Sani (Malaysia)
    • Prof Damayanti Soetjipto (Indonesia)
    • Dr Kuljit Singh (Malaysia)
    • Dr Gil Vicenti (Philipines)
    • Dr Rusdian (Indonesia)

    Note:
    Certain principles of management were discussed with a view to develop an Asian-Pacific Management framework of OSAS patients. This is a preliminary discussion and the final draft of this consensus statement would take more time and further rounds of discussions in the near future as more participants join the discussion and as more evidence of sleep apnea surgery emerges from the literature.

    The following framework for assessment and management of OSAS patients is not meant to be a practice algorithm but serves more as a guide in the hope of improving patient diagnosis, patient care and in achieving better surgical results.

Patient History

Documentation of the following : Snoring. Gasping. Witnessed apneas. Excessive
Daytime Sleepiness, Morning Headaches, Hypertension, Coronary Disease.
Questionnaires - Epworth. SF36. QOL score. Snore score (VAS). Berlin Questionnaire.

Physical Exam

Documentation of the following : BMI. Neck circumference. Nasal exam. Turbinates. Septum. Tonsil size. Soft palate redundancy. Tongue size. Tongue type (Moore’s classification). FTP. Mallampati Grade. Jaw size. Hyoid position. Mueller’s Manuever. End Expiratory Phase Manuever. Jaw Thrust Manuever. Friedman’s Clinical OSA Staging.

Investigations

Sleep test (PSG). Attended hospital (PSG). Home based (PSG). OPG. Lateral cephalometry. Dynamic Cine MRI (optional). Drug Induced Sleep Endoscopy (optional). Please note : Whenever possible, a sleep test or some form of attempt to diagnose or document sleep apnea (subject to the availability of sleep diagnostic equipment available in the country of practice) is recommended.

Treatment
Management of Sleep Apnea Patients
Based on the following basic principles:

  1. Trial of Nasal CPAP is explained, offered and introduced to all patients
  2. Overweight and obese patients are given nutritional advice and weight loss guidance.
  3. Fujita levels of obstruction are identified during examination. Identify Palatal and/or Tongue collapse (with Mueller’s and/or End Expiratory Maneuver)
  4. Friedman’s Clinical OSA Staging to help prognosticate surgery
  5. Drug Induced Sleep Endoscopy (DISE) – may be helpful and may be considered
  6. According to Stanford Phases of Surgery, soft tissue surgery first, followed by bony surgery (after soft tissue surgery options have been exhausted and/or failed)
  7. Nose Surgery – is essential for symptomatic patients and/ or those who have narrowed nasal passage (turbinate or septum)
  8. Nose Surgery alone (as stand alone surgery for patients with proven moderate to severe sleep apnea) – is NOT successful, and is not recommended. Nose surgery alone for patients with sleep apnea has a success rate of 15.7% at best. 
  9. Palate Surgery is recommended for patients with sleep apnea (in the form of UvuloPalatoPharyngoPlasty, UvuloPalatal Flap, Expansion Pharyngoplasty, Anterior Palatoplasty, TransPalatal Advancement, Lateral Pharyngoplasty)
  10. Tongue Surgery is required for patients with Tongue Base collapse and/or obstruction. (in the form of Radiofrequency Tongue Base, Genioglossus Advancement, Hyoid Suspension, Sliding Genioplasty, Tongue Suspension Suture, Midline Glossectomy, Lingual Tonsillectomy)
  11. Patients with Severe Sleep Apnea are more likely to have Tongue Base obstruction; however, patients with mild to moderate sleep apnea may also require Tongue Base surgery for better surgical results. Proven mild or moderate sleep apnea in patients does NOT exclude Tongue Base obstruction (as this would be noted on careful clinical examination).  
  12. Bi-Maxillary Advancement Surgery would be offered to patients who fail and/or have exhausted soft tissue sleep apnea surgery.  

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Sleep Specialist
Director, Pacific Sleep Centre
Singapore
 
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