Nelson Powell MD
MANAGEMENT OF SLEEP-DISORDERED BREATHING

June 29th 2013
Sleep Dentistry and Otolaryngology Head and Neck Surgery

General Introduction:
Sleep-disordered breathing (SDB) is a collective term which includes snoring, upper
airway resistance syndrome (UARS) and obstructive sleep apnea syndrome (OSAS). Simply put,the term is descriptive of the effects of an anatomic partial collapse or obstruction of the upper
airway during sleep which may cause sleep fragmentation.
Surgical management was the first treatment modality available for SDB. Some of
the first subjects to undergo surgery for an anatomic narrowing or blockage of the upper airway
during sleep were those afflicted with the Pickwickian Syndrome (obesity-hypoventilation
syndrome). Tracheotomy was the sole surgical procedure available during this period andsince it was lifesaving in these circumstances, tracheotomy was also used for others withnocturnal upper airway obstruction.1 Morbidity and mortality were not established except for
the very severely affected, and the tracheotomy was not well tolerated or accepted by mostpatients even as a method to improve the quality of life, or extend life itself.
In the early 70’s the term used to describe nocturnal airway obstruction was
hypersomnia with periodic apnea (HPA), later revised to be called obstructive sleep apnea
syndrome (OSAS), and now better known collectively as Sleep-Disordered Breathing (SDB).
Over thirty years have passed and our knowledge of sleep disorders has evolved to suchan extent that sleep disorders is now a recognized specialty in medicine and should be, in the
future, a specialty in surgery. The coupling of medicine and surgery for the definitive
management of SDB is necessary due to the fact that upper airway narrowing or blockage
during sleep was thought to be an anatomic problem and thus the surgeon’s domain.
In addition, not all patients will accept medical management as the primary first
choice, and vice versa, the same holds true for surgical acceptance. Granted, there is surely acentral nervous system (CNS) mediator associated with this syndrome that no one has beenable to identify. However, medical management, the present treatment of choice, is now
suffering with compliance problems and resistance from the younger subset of patients, whohave debilitating daytime somnolence due to upper airway resistance syndrome (UARS), and do
not want to wear a nasal device (CPAP/BiPAP) six to eight hours a night for the next forty or
fifty years. Hence, between the two modalities we may offer alternatives as is appropriate.
What we have learned about the obstructive process in sleep disorders, with the imputof the combined efforts of our surgical and medical colleagues, is that nocturnal narrowing or

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obstruction may be localized to one or two areas, or may encompass the entire upper airway
passages to include the nasal cavity, oropharynx and hypopharynx. Conservative medical
therapy is usually recommended first. Treatment centers on sleep hygiene, weight loss, dental
splints and nocturnal nasal pressure devices (CPAP/BiPAP). There are surgical procedures
presently available to provide for a logical upper airway reconstruction of this region.2-3This usually will encompass multiple surgical procedures or sites, in such a manner as tominimize risks and complications, and to subsequently relieve the patient of this problem.
Current established surgical procedures offer reconstruction of the airway from the nose andpalatal level to the tongue base.
Rationale for Surgery:
Nearly all patients with documented SDB are candidates for surgical intervention. This
mandates that the patients are medically and psychologically stable and wish to undergo asurgical procedure. They should be informed of the various treatments both medical andsurgical along with current treatment philosophies. Surgical indications should include thetwo major parameters of OSAS, the neurobehavioral and cardiopulmonary derangements
caused by nocturnal obstructions during sleep.
Patients with UARS usually present with marked excessive daytime sleepiness (EDS).
Since there are numerous other causes of EDS such as narcolepsy, insomnia and sleep
deprivation, a nasal CPAP trial, in this group, can be diagnostic and therapeutic thus helping toestablish that EDS is secondary to upper airway resistance and sleep fragmentation (SDB). The
cardiopulmonary risks of OSAS have been documented when the apnea hypopnea index (AHI) is
greater than 20 events per hour of sleep and a nadir oxygen saturation is below 90%.4 This
severity of disease necessitates treatment to lower the risk of cardiopulmonary sequela and theincreased mortality rate.
Specific Indications for Surgery:
Excessive daytime sleepiness,(EDS) or with a AHI ≥ 20 events per hour of sleep,
oxygen desaturation ≤ 90%, arrhythmias, negative esophageal pressures (Pes > -10 cmH20) andfailure of medical management or desire of patient to select treatment modality whereappropriate. In patients with an AHI < 20 events per hour of sleep and associated excessive
daytime somnolence that interferes with daily functioning, surgery is considered appropriate
on a case by case basis. Our existing Stanford Protocol (Powell-Riley) is predicated on evidence
based medicine for these treatments. Clinical outcomes for all existing surgical procedures arelisted below under current surgical techniques and have been validated over time by othercenters in the United States and Europe and Asia.
Pre-Surgical Evaluation:
A standard should include polysomnography, a comprehensive history with head andneck physical examination, fiberoptic nasopharyngoscopy and 3D-CT imaging analysis where
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available. This will give sufficient data base information to help in directing surgical therapy andaddressing the possibilities for treatment or clinical outcomes. It is recommended andcautioned that no one test or procedure is to be relied on to make such decisions. Thissystematic medical and surgical review will support the establishment of the following
guidelines: determine sleep disorder type, establish parameters of severity, identify
comorbidity factors and probable sites of obstruction, decide if treatment isemergent or elective and assess the risks and benefit ratios.
Contemporary Surgical Techniques for SDB:
Nasal reconstruction
Tracheotomy
Retropalate UPPP /Tonsils
Retrolingual Tongue advancement
Genioglossus Advancement-Hyoid (GAHM)
Bi-Maxillary Advancement (MMA/BMA)
Current Surgical Techniques:
The Airway Bypass: Tracheotomy
Rationale:

Immediate resolution of obstructive breathing during sleep in most subjects.

Indications:
Where an emergent airway is necessary or where there is neither the specialized
equipment or surgical expertise to offer an alternative, morbid obesity (BMI > 33 kg/m2), severe
hypoxemia (Sa02 ≤ 70%) severe arrhythmia, asystole, PVC’s, uncontrolled hypertension andwhere surgery to alleviate upper airway obstruction may compromise the airway secondary to
edema or drug therapy and CPAP is not available or tolerated by the patient. In reality
tracheotomy is usually, but not always, poorly tolerated or accepted. This is especially true now
since nasal CPAP has been used so successfully for severe OSAS that tracheotomy has taken asecond position in the treatment of OSAS.
Techniques: Temporary or permanent tracheotomy methods may be employed to maintain the
airway.
Clinical outcomes:
The tracheotomy should be considered a conservative modality of airway
protection in severe OSAS and especially in those who are morbidly obese. It is considered a
100% cure in most instances.
Nasal Obstruction:

Reconstruction

Rational:
An open nasal airway establishes physiologic breathing and may minimize the useof the open oral airway. It should be remembered that when the mouth is open the lower jaw
auto-rotates open and allows the tongue to fall back into the posterior airway space. In some
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patients improvement of the nasal airway may also improve CPAP tolerance and /orcompliance.
Indications: Nasal airway blockage caused by bony, cartilaginous or hypertrophied tissues thatinterfere with nasal breathing during sleep.
Techniques: Septal and /or bony intranasal reconstruction, alar valve or alar rim
reconstruction, turbinectomy.
Clinical outcomes: The ease and high success rate of nasal reconstruction makes thisprocedure a very valuable technique for those with nasal obstruction and SDB. By itself it is
not likely to make a significant impact on moderate or severe SDB as palatal or tongue base
surgery can.
However, it is still an essential part of the upper airway that should not be ignored in the overall
treatment of SDB. Correction of any defects at this level assures the ability for minimizing oral
breathing and certainly should decrease the possibilities of elevated nasal negative pressure
breathing during sleep.5-9
Retropalatal Obstruction:

Reconstruction

Rationale: The palatal and lateral pharyngeal tissues have been found to be the mostcompliant of the upper airway and documentation of the collapse at this level in SDB is wellestablished.
Indication: A long soft palate, narrow inlet to the nasopharynx, hypertrophic tonsils andredundant lateral pharyngeal mucosa. This level of obstruction is classified as a Fujita Type 1.
Techniques: There are multiple methods to control this region and range from the traditional
UPPP first described in the United States by Doctor Fujita as well as the many variations of his
original procedure. Surgical flaps, lasers, caurtery or radiofrequency have also been used.
Clinical outcomes: Individual results vary with the skill of the surgeon and the techniqueselected. The safe clearance of the tissue blockage at this level is essential to the improvementof SDB and the standard techniques are excellent in accomplishing this goal. The technique
has not gained widespread popularity over the years due to the pain and discomfort after
surgery and the fact that cure rate was so varied.10 This was due, in part, to the fact that during
the time that UPPP was first introduced there was not an appreciation for the possibility of
tongue base obstruction. Many UPPP’s did clear the pharyngeal level of obstruction and were
unfairly credited with failure due to the unrecognized tongue base problem (hypopharyngeal).
In patients who have been carefully selected for upper airway reconstruction and whose site ofprimary obstruction is at the oropharyngeal level (Fujita type 1) the cure rate may be 80 to
90 %.11 In unselected patients this rate will fall to a low of 5 to 30%.10

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Classification of Obstructive Region by S. Fujita
Type lPalate (normal tongue base)Type ll Palate and base of tongue
Type lll Base of tongue (normal palate)
Retrolingual Obstruction: Reconstruction
Rationale: Tongue base obstruction has been documented in SDB by EMG studies, fiberoptic
exams, radiographic cephalograms, CT, MRI scans and vidiofluoroscopy. In addition, the basic
anatomy and physiology of the skeletal relationships and genioglossus-hyoid complex as it
relates to airway size awake and asleep have led to a better understanding of how to surgicallyapproach the base of tongue level (Fujita type 3).
Indications: Those of the general indications for surgery with findings of clinical tongue baseobstruction.
Techniques: The obstruction of the hypopharyngeal (base of tongue) region is a very complex
problem since there is a large mass of tongue tissue with varied elasticity during sleep,
compared to the nasal and palatal levels, coupled with other accessory hypopharyngeal dilatorsthat must be managed in order to successfully open this region during sleep. This region may be
bypassed by tracheotomy or approached logically by either making more room for the tongue
or reducing the tongue size. There are soft tissue techniques to remove the mid portion of the
tongue base using laser midline glossectomy and lingualplasty 12, partial glossectomy 13 orvolumetric shrinkage by radiofrequency.14
In addition, there are skeletal advancements that attempt to place tension on the
tongue so during sleep the tongue may not fall as far back. This procedure is referred to as
Phase one of the Powell-Riley phased protocol 15 (inferior sagittal mandibular osteotomy andgenioglossus advancement, hyoid myotomy and suspension). This is a simple technique that
does not move the teeth or jaw and therefore does not interfere with the dental bite.
A more aggressive procedure, usually saved for failure of the more conservative surgery
above, is the forward movement of the lower jaw and midface for Maxillary-Mandibular
Advancement (MMA)/BMA. This procedure is referred to as Phase two of the Powell-Riley
phased protocol,15 and gives the tongue more room and also places additional tension on the
tongue base. There are various additional technologies for control of the tongue base which
include radiofrequency volume reduction, electrical stimulation of the tongue by a pacing
device, and a recently described suture technique to the tongue base. All of thesetechnologies may be applied depending on their respective merits and published clinicaloutcomes.
Clinical outcomes: A tracheotomy is usually curative in that it bypasses the obstructive region
regardless of the site. It is generally used in subjects with refractory (failures of medical andother surgical management) base of tongue obstruction and in those with medical conditions
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that contraindicate more extensive surgeries. The techniques using soft tissue and skeletal
procedure for the hypopharyngeal level have been used by our group in a staged manner sothat the most conservative treatment is offered as an entry level management. We have named
this approach to upper airway reconstruction the Powell-Riley phased surgical protocol andover the years it has proven to be an effective and safe method for controlling upper airway
collapse in sleep-disordered breathing. It has additionally minimized the possibility that
unnecessary surgery would be done. Our published clinical outcomes cure rate for phase one is
42% to 75% depending on the severity of the disorder. 16-18 Similar results have been
confirmed by others.19-21 Phase two has documented cure rates of greater than 90%.10,17,22
Reported studies using BI-Maxillary Advancement surgery for the treatment of SDB gives results
similar to our work.23-26 Others have used laser midline glossectomy and lingualplasty or partial
glossectomy with varied results depending on the definition they have reported for cure.
Definition of Responder or Cure: (Powell-Riley) Criteria must include 1-3 below or 4.
1. AHI ≤ 20 and /or at least a reduction in the AHI of 50% ( for example if the AHI is 25 then it
must be by definition 12.5 after treatment to call a cure )2. Sa02 ≥ 90% or a minimal fall below 90%
3. Normalization of sleep architecture
4. Equivalent comparison to nasal CPAP/BiPAP results on the second night of titration
Definition of Phase One: (Powell-Riley ) Three regions of the upper airway are treated as
directed by the clinical work up using the most conservative surgery for each but only including
treatment at that level if it was considered sufficiently obstructed.
Nasal: Correct nasal obstruction depending on anatomical deformity (septum, turbinates ornasal valve deformities).
Pharyngeal: UPPP or equivalent and tonsillectomy if tonsils present.
Hypopharyngeal: Inferior sagittal mandibular osteotomy and genioglossus advancement, hyoid
myotomy and suspension, or laser midline glossectomy and lingualplasty, or partial
glossectomy.
After phase one is completed a period of 4-6 months is allowed for sufficient healing, weightstabilization and neurologic equilibration. Then a repeat polysomnogram accompanied with asleep assessment and clinical examination is done to assess the clinical outcomes.27 Thosepatients who are unchanged or incompletely treated are offered either further surgery (Phasetwo) or medical management (CPAP).
Definition of Phase Two: (Powell-Riley)
If our protocol was used previously the only region that should be left incompletely
treated is the hypopharynx (base of tongue) and Maxillary Mandibular Advancement (MMA).
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A choice now is to be made to consider the remaining methods which are Maxillary Mandibular
Advancement (BMA) surgery, tracheotomy or nasal CPAP. Other techniques that could beconsidered to make addition room for the tongue are the laser midline glossectomy andlingualplasty or partial glossectomy. These procedures are seldom used by our center for phasetwo. Base of tongue reduction using Temperature Control Radiofrequency (TCRF) to become analternative to MMA/BMA surgery in some patients.28
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