It should be A Snoring Clinic Management Algorithm Proposal for Snoring and Obstructive Sleep Apnea: A Multidisciplinary Approach Concept with Possible Treatment Models
- 1. Department of Otolaryngology, Cairo University, Egypt
ABSTRACT
Objective: Introduce a multidisciplinary snoring and obstructive sleep apnea (OSA) management algorithm proposal with possible treatment models.
Conclusion: Snoring& OSA multidisciplinary management team is the key to success in this group of patients. Interaction between different specialty clinics with a planned algorithm and outcome treatment modules seems to be clinically sound and promising in the management of these cases.
KEYWORDS
• Snoring
• OSA
• Management algorithm
• Multidisciplinary team
CITATION
Eldin Elbassiouny AMM (2020) It should be A Snoring Clinic Management Algorithm Proposal for Snoring and Obstructive Sleep Apnea: A Multidisciplinary Approach Concept with Possible Treatment Models. Ann Otolaryngol Rhinol 7(4): 1248.
INTRODUCTION
Obstructive sleep-disordered breathing (OSDB) represents a group of physio pathologic conditions characterized by an abnormal respiratory pattern during sleep that can be isolated or coexist with other respiratory, nervous, cardiovascular, or endocrine diseases. In general, snoring is at one end of a clinical continuum with the opposite extreme of severe OSA. So, everyone suffering from OSDB snores but not everyone who snores has OSDB [1].
OSDB is a multifactorial and multilevel condition. The risk factors that may cause OSDB include obesity, increased neck circumference, craniofacial abnormalities, hypothyroidism, and acromegaly. Levels of upper airway obstruction include different causes of nasal obstruction, nasopharyngeal masses, hypertrophied tonsils, elongated and/or thickened palate and uvula, lingual tonsillar hypertrophy, macroglossia, acromegaly and micrognathia [2].
Treatment approaches include non-surgical and surgical modalities aiming at relieving the upper airway obstruction [3]. As for obesity-related sleep apnea, weight reduction may reduce obstructive episodes, improve blood oxygenation, and reduce daytime drowsiness [4,5].
The current proposal aims at addressing a management algorithm for snoring and OSA patients with patients’ categorization into possible treatment models for better outcome
DISCUSSION
Snoring and OSA management algorithm is a multi-disciplinary step by step approach that asses the different etiological factors and comorbidities and directs surgical treatment toward the specific regions of obstruction during sleep. The benefits of the management algorithm include: 1-Decreases possibility of incomplete preoperative assessment, 2-Categorize patents in a clear precised treatment models, 3- Decreases possibility of unnecessary operations and improves cure rates. Generally, it is accepted by most patients.
Traditionally, the otolaryngologist has been the primary medical reference for patients suffering from OSDB. Patients may lose their way during referral from one specialty clinic to the other. For proper diagnosis and management, the interaction of the multidisciplinary team members is deemed necessary and essential [6,7]. Stepnowsky C. in 2019 concluded in his study that, given the recent advances in OSA phenotyping and the large numbers of therapeutic options available across a wide variety of specialty areas, multidisciplinary management through dedicated sleep centers (and/or clinics) appear to represent the future of sleep apnea management .The American Academy of Sleep Medicine (AASM) recommended in its guidelines for OSA patients in 2009 that OSA should be approached as a chronic disease requiring long-term, multidisciplinary management [9].
Preoperative accurate history taking and clinical assessment (Figure 1)
Figure 1: Outpatient snoring sheet.
and a multi-disciplinary step by step algorithm (Figure 2)
Figure 2: Snoring and OSA clinical pathway.
are the keys to success in snoring and OSA patients.
A planed pre-operative protocol, treatment models, must be individualized for each patient. The preoperative clinical assessment includes a history with points of stress related to snoring and OSA including Epworth sleepiness score (ESS). The multi-disciplinary team should include many professionals from different areas; ENT evaluation, obesity evaluation, maxillofacial evaluation, internal medicine evaluation, and sleep laboratory specialist.
The multi-disciplinary step by step algorithm starts with the ENT clinic evaluation. Patients having body mass index (BMI) more than 25 will be referred to an obesity clinic for assessment and decision making either to keep on dietary protocols or to have bariatric surgery. Patients with possible maxillofacial abnormalities will be referred to the maxillofacial clinic to evaluate the patency of the post-lingual space and the need for any possible surgery. Patients with a BMI less than 25, with no maxillofacial abnormality and complaining from simple habitual snoring will be categorized as treatment model I (Figure 3).
Figure 3: Treatment model I. *BMI: less than 40with no comorbidity ** DISE: Two scenarios were discussed, either to do DISE immediately prior to the proposed snoring /OSA surgery or DISE and nasal surgery and then perform the definitive surgery after the sleep endoscopy discussion in clinic
Patients with maxillofacial abnormalities will be categorized as treatment model II (Figure 4).
Figure 4: treatment model II. * DISE: Two scenarios were discussed, either to do DISE immediately prior to proposed snoring /OSA surgery or DISE and nasal surgery and then perform the definitive surgery after the sleep endoscopy discussion in clinic
Patients with a history suggestive of OSA will have polysomnography (PSG) and internal medicine consultation to control any associated medical problems. Mild OSA patients will be included in treatment model I. Mild OSAHS is defined as a respiratory disturbance index (RDI) of 5 t0 15 per hour, lowest oxygen saturation 86% to 92% and mild or no daytime sleepiness [9]. Moderate OSA patients will undergo drug-induced sleep endoscopy (DISE) and will be categorized as treatment model IV (Figure 5).
Figure 5: Treatment model IV. * BMI: less than 40 with no comorbidity ** DISE: documentation of site of obstruction for any future upper airway surgery
Moderate OSAHS is defined as a respiratory disturbance index (RDI) of 15 TO 30 per hour, lowest oxygen saturation 70% to 85% and moderate daytime sleepiness [9]. Severe OSA patients will be categorized as a treatment model III (A, B &C) (Figure 6).
Figure 6: Treatment model III (A). *BMI: 40 or more /BMI 35 or more with comorbidity ** DISE: documentation of site of obstruction for any future upper airway surgery
(Figure 7)
Figure 7: Treatment model III B and C. * BMI: less than 40 with no comorbidity ** DISE: documentation of site of obstruction for any future upper airway surgery
Sever OSAHS is defined as a respiratory disturbance index (RDI) more than 30 per hour, oxygen saturation below 70%, and severe daytime sleepiness [9]. Treatment model III, will be categorized according to the presence of morbid obesity. Treatment model IIIA was concerning with severe OSA associated morbid obesity (figure 6). For patients suffering from severe OSA without morbid obesity, will be categorized as model III B&C. Patients with nasal blockage will have nasal surgery with DISE to evaluate the upper airway and will fix the CPAP and followed up (Figure 7A). Patients who refused or cannot tolerate the CPAP, will undergo DISE and included in treatment model IV (Figure 7B). OSA patients, model III & IV, will be treated according to the results of the PSG and DISE.
The case is then discussed with the entire multidisciplinary team. Opinions from all members on the diagnostic hypothesis and the treatment to be made are obtained, as well as the necessary complementary examinations. From this point, the patient is referred to the specialties to continue the proposed singular therapeutic project.
As for all the patients who are candidate for nasal surgery, DISE will be performed to assess the upper airway collapse. Two scenarios were discussed, either to do DISE immediately before the proposed snoring /OSA surgery [10] or DISE and nasal surgery and then perform the definitive surgery after the sleep endoscopy discussion in the clinic. The ease and high success rate of nasal reconstruction make this procedure a very valuable technique for those with nasal obstruction and OSDB. Although it is very unlikely to cure OSDB as a stand-alone procedure, correction of any defects at this level minimizes mouth breathing and can decrease negative pressure breathing during sleep. The palatal and lateral pharyngeal tissues have been found to be the most compliant of the upper airway, and documentation of collapse at this level in OSDB is well established. However, results vary with the experience of the surgeon, the patient’s anatomy, the severity of the OSDB, and the technique selected. The careful removal or repositioning of obstructive soft palate tissues is essential to the improvement of OSDB at this level [11]. Tongue base surgery may be needed. Tongue base surgery is rarely done alone but usually, it is a part of multilevel surgery. Tongue base procedures are an integral part of multilevel surgery for the treatment of OSA. A lot of surgical approaches have been described for the treatment of tongue base obstruction. The midportion of the tongue base can be directly reduced in size, or it may be addressed by making more room for the tongue using skeletal advancements [12-16]. Obstruction at the tongue base may be bypassed by tracheotomy [17].
Oral appliances are indicated for patients with mild to moderate OSA and for patients with severe OSA who are intolerant or choose not to use CPAP therapy. In addition to less severe disease, other predictors of a more favourable response to oral appliance therapy include younger age, lower BMI, smaller neck circumference, and those with more positional OSA [18].
The rationale for treatment model I is to improve the nasal airway patency and reshape the redundant soft palate. This can be performed as a single-stage nasal and palatal surgery or as staged operations. DISE will be performed as a routine step to assess the upper airway collapse. The rationale for treatment model II is to open the retro lingual pharyngeal airway. DISE will be performed immediately before the maxillofacial surgery and the patient will be followed up with a postoperative PSG and re-evaluated for possible 2nd stage palatal or palatopharyngeal surgery. Santos JF et al., 2007 concluded in their study that genioplasty for genioglossus advancement is an option in patients with OSAHS and mandibular retrognathia. Metes A et al., 1991 described a patient with retrognathia causing airway obstruction at the base of the tongue, in whom sagittal mandibular osteotomy with hyoid bone advancement resulted in the resolution of snoring and sleep apnea. The rationale for treatment model III is to treat severe OSA either conservatively with CPAP or surgical treatment for the tongue base alone or as a part of multilevel surgery. Bariatric surgery can be considered. Severe OSA patients, treatment model III A, Bariatric surgery Will be indicated in patients with BMI 40 kg/m² or those with BMI 35kg/m² and comorbidities and in-home dietary attempts at weight control have been ineffective [21].A lot of studies found that OSA significantly improved after bariatric surgery.Haines KL et al., 2007 concluded in their study that OSA is prevalent in at least 45% of bariatric surgery patients, Preoperative BMI correlates with the severity of OSA and surgically induced weight loss significantly improves obesity related OSA and parameters of sleep quality. Zhang Y et al., concluded in their study that Bariatric surgery is effective at improving nocturnal hypoxemia in obese patients with OSA; it also reduces body weight and the number of apnea events. For patients suffering from severe OSA without morbid obesity, model III B&C, continuous positive airway pressure (CPAP) will be considered as the first line of treatment. Patients will be followed up to assess CPAP tolerance. Safe and acceptable CPAP compliance is defined as regular use of CPAP 4hours/day and at least 5 days /week [23]. If intolerance was detected in such cases, patients will be included in model IV to be scheduled for DISE & surgical intervention or oral appliances according to DISE results. Oral appliances may be useful in selected patients with sleep apnea who cannot tolerate CPAP or do not want to undergo surgery [24]. Related medical problems were assessed and controlled. Nasal surgery improves the nasal airway and at the same time facilitates the use of postoperative CPAP [25].
CPAP remains the most effective and the first line of treatment for OSA [26].
Despite its effectiveness in resolving sleep-disordered breathing, adherence to CPAP therapy is approximately 50%. Advanced technology PAP devices, such as auto PAP (APAP) and bi-level therapies, have not been shown to consistently improve adherence in patients who have been intolerant to standard CPAP therapy. This coincides with the rationale of treatment model III B&C. Rationales for treatment model VI are to treat the nasal obstruction, locate the site of upper airway obstruction by DISE in one session, and proceeds either for oral applicants or upper airway surgery. The author′s technique for palatal surgery ,Soft palatal webbing flap Palatopharyngoplasty without tonsillectomy is a good surgical alternative for patients having both soft palatal.
and lateral pharyngeal wall collapse and non-collapsing tonsils, mostly grade 1, with promising surgical outcomes [27]. The author applied the same technique for tonsil sizes 2, 3, and 4 by performing extracapsular coblation tonsillectomy down to the capsule in conjugation with the original technique [28].
Surgical outcomes can vary, and it is therefore essential that all patients be re-evaluated after each phase is completed. This minimizes the possibility of unnecessary additional surgery and readily identifies those who require further attention. To determine the outcome, each patient who underwent one of the treatment models will be re-evaluated by PSG if needed and reassessed clinically at 4 to 6 months.
Finally, this study aimed to introduce a management algorithm with treatment models and establish the concept of snoring multidisciplinary teams for better patient service and avoidance of unnecessary surgical procedures.
CONCLUSION
Snoring and OSA multidisciplinary management team is the key to success in this group of patients. Interaction between different specialty clinics with a planned algorithm and outcome treatment modules seems to be clinically sound and promising in the management of these cases.
