ENT Lecture in Jubilee Hospital, Trivandrum, South India: 25-10-2011. Dr.K.O.Paulose FRCS DLO Consultant ENT Surgeon

1. ENT Surgery in Jubilee
Hospital Trivandrum
Dr.K.O.Paulose FRCS.DLO
Consultant ENT Surgeon
Jubilee Hospital Trivandrum
web:www.drpaulose.com
www.snorefreesleep.com

2. 33 years experience in ENT Surgery
 ABOUT ME
 1968-1973-MBBS Medical College Trivandrum
 1968-1969- Inmate of Louis catholic Hostel(Now Jubilee Hospital)
 1978-1987 UK various NHS Hospital (10 yrs)
 1981-FRCS UK, 1984 DLO London
 1987-2003 Bahrain(Military Hospital-Consultant(17yrs)
 2003-2004 Bahrain-Kims Hospital (locum Consultant)
 2005-2010-SUT Hospital, Trivandrum-Consultant (5 yrs)
 16th Sept 2010- on wards Jubilee Hospital Trivandrum
 LASER EXPERIENCE
 1996- onwards laser surgery started In Bahrain
 Feb 2008 Laser and Coblator surgery in SUT Hospital
 Total number of Laser surgery in BDF .>1000 cases(Using Sharplan Co2
laser-Germany)
 Feb 2008-Sept 2010- 421 cases(Co2 laser and coblator Arthrocare®)in
India+
 6 cases in first one week jubilee Hospital- 19th October onwards

3. 16th September 2010-Blessing of ENT Clinic by Most
Rev Soosapakyam, Archbishop of Trivandrum

4. Blessing Prayer by Fr.Andrews Kosmos MBA, MD of Jubilee
Hospital

5. ENT Clinic cum Endoscopy room

6. Co2 Laser parts

7. Laser Saftey guidlines

8. Co2 Laser in Jubilee Hospital

9. Laser Surgery Started in Jubilee 19th October 21010
For Snoring-OSA and Nasal allergy

10. Kumbhakarna and snoring
 snoring kumbhakarna.jpg

11. Stop snoring and save your
marriage

12. Day time sleepiness
 daytime-sleepy.jpg

13. Broken marriages-Divorce !!!!

14. Car accidents
 8 car crash.jpg

15. How Snoring and OSA

16. Causes of Snoring
 Nasal Obstruction
 Enlarged, Uvula, Soft Palate, Tougue
 Enlrged Ts Ads
 Lack of Muscle tone upper airway
 Air Turbulance in the oropharynx
 Vibration of soft palate and uvula
 Venturi Effect-Bernoulli principle

17. Causes of Snoring 1

18. Causes of Snoring -Nasal

19. Sleep Apnea
What is Sleep apnea?
 Stoppage of breathing while asleep
 More than 10 seconds
 100-500 episode of apneas in one night
 Plus Hypopneas
 Cause Hypoxia and Hypercarbia
Types of sleep apnea
 Obstructive Sleep Apnea (OSA)
 Most common-loud snoring
 Obstruction of upper airway
 Central Sleep Apnea (CSA)
 Brain stem lesion, stroke, polio, tumors
 No snoring
 Mixed sleep apnea (OSA+CSA)
 Chronic respiratory failure>central


20. Signs and symptoms of sleep apnea
 Choking or gasping during sleep
 Loud snoring
 Sudden awakenings to restart breathing
 Waking up in a sweat during the night
 Feeling tired in the morning
 Headaches
 Daytime sleepiness
 Lack of concentration,fatigue,irritable
 Low O2- Brain and Heart

21. Diagnosis of Sleep Apnea
 Good History from spouse or parents
 Physical examination-Nose and Throat
 Voice recording
 Flexible Endoscopy
 CT imaging or MRI retropalatal and
pharyngeal airway
 Sleep study-Polysomnogram
 Cardiac evaluation

22.  C:Documents and SettingsAdministrato
drpaulose clinic.jpg

23. CT Scan Retroplatal Airway-PN Ratio
 CT adenoid and soft palate.JPG

24. CT imaging
 adenoid.JPG

25. Sagital CT-PN ratio
 Pharyngeal Narrowing Ratio-Its significance
 Soft palate-tongue contact and automatically
calculated pharyngeal narrowing ratio (PNR),
defined as a ratio between the airway cross-
section at the hard palate level and the narrowest
cross-section from the hard palate to the
epiglottis
 Soft palate should therefore be the target for
causal treatment of snoring, LAUP, CAUP, RF
somnoplasty all aimed at the soft palate in OSA
surgery.

27. Polysomnography - Sleep lab study
 Brain electrical activity –EEG
 ECG
 Eye and jaw muscle movement
 Leg muscle movement
 Airflow
 Respiratory effort (chest and
abdominal excursion)
 EKG
 Oxygen saturation

29. CPAP
 CPAP3.jpg

30. Treatment of Snoring and Sleep Apnea
Conservative
 Weight Loss
 Avoid Alcohol
 Dental devices, dilators
 Avoid sleeping pills or narcotics before bed
 Stop Smoking
 Don't sleep on your back
Surgical Treatment
 Glossectomy
 Mandibular osteotomy
 Hyod advancement
 Nasal surgery, Septal surgery,LAPT
 RF Somnoplasty
 UPPP-LAUP+Coblator surgery
 Ts Ads
 Tracheostomy-last option

31. LASER TYPES
Laser is an acronym that stands for Light Amplification by Stimulated Emission
of Radiation.
The first concept of the laser was initiated by Albert Einstein in 1917.
CO2 Laser
Argon laser
The Nd:YAG (Neodymium:Yttrium-aluminum-
garnet)
The potassium-titanyl-phosphate (KTP)
Diode Laser

32. Co2 Laser
 CO2Laser
The CO2 laser is the most versatile laser in otolaryngology. The carbon dioxide (CO2) laser
emits a colorless, infrared light at a specific wavelength of 10,600 microns, which has an
extremely high affinity for the intercellular water of cells.
A second, built-in, coaxial helium neon laser is necessary to indicate with its red color the
site where the invisible CO2 laser beam will impact the target tissue. This laser, then,
acts as an aiming beam for the invisible CO2 laser beam.
Advantages of Laser Surgery
 Fast
 Painless
 Bleeding-nil
 Fast recovery
 No hospitalization if done under LA
 GA for difficult cases
Disadvantages of Laser
 Cost of equipment and maintenance
 Special surgical skills
 Increased setup time of equipment
 Need of safety eyewear
 Increased care for patient safety - explosion or fire hazard.
 smoke

33. Other Non surgical treatment
 Dental splint
 Nasal dilator
 Nasal drops
 Treatment of allergy
 CPAP Machine
 Yoga breathing
 Tennis ball on pyjama!!!

34. Laser surgery for snoring and OSA
 LAUP (Laser Assisted
Uvulopalatopharyngoplasty) involves
removal of the uvula, shorten the soft
palate and reduce the volume of the
tonsils using CO2 laser done under-LA /
GA
 LAPT-Laser assisted Partial turbinectomy
 LAS-Laser assisted septoplasty
 LAT-Laser assisted Tonsillectomy

35. Results of Laser surgery
 showed the correction of sleep apnea by an average of 70-80%
However, the snoring sound reduction was between 75-95%.
Side Effects
 post op infection -rare
 nasal fluid reflux –temporary nasal regurgitation for few days, but
rarely permanent
 no voice changes were noted
 Bleeding-rare
 Dryness of throat-rare
Causes of fauilure if any
 mixed apnea-central component
 Inadequate excision of tissues-Redo
 Obesity,alcohol,sedative
 Lack of muscle tone in the neck
 Base of tongue factor-coblator reduction
 Jaw factor-need mandibular advancement

36.  laser sugery4.JPG

37. After LAUP-LA
 12 after operation.jpg

39. Intubation-GA
 C:Documents and SettingsAdministrato
intubatiC
:Documents and SettingsAdministrator

41. Laser surgery under GA

42. Laser Surgery for OSA in Jubilee

43. LAUP

44. LAUP+Partial Tonsillectomy

45. Tonsils,soft palate and uvula

46. Laser Surgery-LAUP GA

49. Laser surgery for Nasal allergy/ -LA

50. Laser Surgery Nose-LA

51. Laser Surgery for Nasal allergy LA

52. “Doubting Thomas”

53. Laser Nose

54. Laser nose

56. After Laser Surgery

58. Oldest LAUP

59. Post op LAUP

60. COBLATOR SURGERY
Cold Ablation-Coblation Technology
 a controlled, non-heat driven process — uses
radiofrequency energy to excite the electrolytes in a
conductive medium, such as saline
 Temperature 40-70*C-less thermal damage
 Coblator II, Arthrocare ® USA Machine
Coblator Surgery done in SUT Royal
 RF turbinate-Turbinoplasty
 Polypectomy
 Tonsillothomy-pediatric
 CAUP –Snoring and OSA
 Tongue base reduction

61.  IMG_2028.jpg

62. Coblator machine
 2coblator machine.JPG

63. Coblation Technology
 plasma glow.jpg

64. CAUP
 CAUP01.jpg

67. CAUP
 Picture4.jpg

68. Septal surgery
 septoplasty-nisha5.jpg

69.  coblator-nisha1.jpg

70. Coblator stiffening soft palate
 coblator chaneling
soft palate2-nisha3. coblator
chaneling soft palate2-nisha3.jpgjpg

71. Laser surgery Nose

72. Happily living after

73. Diode laser surgery

74. Next ? -Harmonic Scalpel and
Starion Tissue welding
 harmonic scalpel1.jpg

75. Rhinoplasty Procedure

76. Rhinoplasty Surgery

77. Rhinoplasty procedure

78. Micro Ear Surgery in Jubilee

79. Micro ear surgery in Jubilee 2

80. Cosmetic Surgery of
Nose-Rhinoplasty

81. Rhinoplasty-Pocedure

82. Pre and Post op Rhinoplasty

83. Pre and Post op Rhinoplasty

84. THANK YOU

85. THANK YOU
For details please visit my web site:
www.drpaulose.com
www.snorefreesleep.com