By Dr.K.O.Paulose FRCS DLO Consultant ENT Surgeon, Jubilee Hospital, Trivandrum, South India.www.drpaulose.com www.snorefreesleep.com Presentation in Indian Medical Association meeting on 07102011, Trivandrum Chapter.

1. Snoring and Sleep Apnea
Management
Dr.K.O.Paulose FRCS.DLO
Consultant ENT Surgeon
Jubilee Hospital Trivandrum
web:www.drpaulose.com

2. About me
 2010-Consultant ENT Surgeon Jubilee
Hospital, Trivandrum
 2004-2010-Consultant ENT Surgeon SUT
Hospital, Trivandrum
 1987-2003-Consultant ENT Surgeon Bahrain
Military Hospital
 1978-1987-UK NHS Teaching Hospitals
 1973-MBBS Trivandrum Medical College
 1980-DLO RCS London UK
 1982-FRCS RCS Glasgow UK
 35 years of ENT Experience

3. Kumbhakarna and snoring
 snoring kumbhakarna.jpg

4. How Snoring and OSA

5. Causes of Snoring
 Nasal Obstruction
 Enlarged, Uvula, Soft Palate, Tongue
 Narrow retroplalatal, retrolingual
area
 Enlarged Ts Ads in children
 Lack of Muscle tone upper airway
 Air Turbulence in the oropharynx
 Vibration of soft palate and uvula
 Venturi Effect-Bernoulli principle

6. Causes of Snoring

7. Causes of Snoring -Nasal

8. About 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


9. 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

10. 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-Home Sleep
Study
 Cardiac evaluation

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. Flexible Endoscopy
 C:Documents and SettingsAdministrato

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

17. CT Imaging
 adenoid.JPG

18. 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.

20. Dynamic Sleep MRI ?

21. 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

22. Home Sleep study

23. Polysomnogram

24. 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

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

26. CPAP
 CPAP3.jpg

27. 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

28. 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

29. 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

30. LAUP LA
 laser sugery4.JPG

31. LAUP in OPD

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

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

34. Intubation Contd

35. Laser surgery under GA

36. Laser Surgery for OSA in Jubilee

37. LAUP GA

38. Tonsils,soft palate and uvula

39. LAUP and LAPT

40. LAUP GA

41. Laser nose

42. Laser surgery Nose

43. LAPT -LA

44. Septal Surgery
 septoplasty-nisha5.jpg

45. Post op LAUP

46. Oldest LAUP

47. OSA in Children –Ts Ads

48. Tonsil Adenoid Causing OSA

49. Tonsillectomy in Children

50. OSA in Children-Ts Ads Surgery

51. 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
 RF turbinate-Turbinoplasty
 Polypectomy
 Tonsillothomy-pediatric
 CAUP –Snoring and OSA
 Tongue base reduction

52. Coblator Machine
 2coblator machine.JPG

53. Coblation Technology
 plasma glow.jpg

54. CAUP
 Picture4.jpg

55. Coblation Surgery
 IMG_2028.jpg

56. Coblation Surgery

57. CAUP GA

58. Coblation Surgery-GA

59. Coblation Soft Palate
 coblator-nisha1.jpg

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

61. Diode laser surgery

62. Number of OSA Surgery
 1980s-UPPP
 1996-2003 Laser Surgery-1000+cases
(approx)
 2004-2010-SUT Hospital- 422 Cases
(LAUP+LAPT+LAS+Ts+Ads+CAUP)
 2010- Jubilee Hospital-86 cases
(LAUP+LAPT+TS+Ads etc)
 Result-70-80% cure OSA, 80-90% cure
Snoring
 Redo-3-4 cases per year
 Causes of Failure-Retrognathia, Large
Tongue,Obesity,Hypothyroid, Central apnea,
Hypotonia, Medications etc

63. Results of Laser surgery
 showed the correction of sleep apnea by an average of 70-80%
However, the snoring sound reduction was between 80-90%.
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

64. Happily living after

65. Thank You
For details please visit my web site:
www.drpaulose.com
www.snorefreesleep.com