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Chapter 130 - Surgery for obstructive sleep apnea
- from Section 25 - Otolaryngologic Surgery
- Edited by Michael F. Lubin, Emory University, Atlanta, Thomas F. Dodson, Emory University, Atlanta, Neil H. Winawer, Emory University, Atlanta
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- Book:
- Medical Management of the Surgical Patient
- Published online:
- 05 September 2013
- Print publication:
- 15 August 2013, pp 761-763
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Summary
Obstructive sleep apnea (OSA) is a serious and chronic condition affecting as many as 15–20 million American adults. Resulting sleep deprivation has been linked to motor vehicle and workplace accidents. The incidence of OSA is increasing with the obesity epidemic, and it is increasingly recognized as a mediator of cardiovascular disease including atrial fibrillation, stroke, myocardial infarction, and sudden cardiac death. The importance of appropriate diagnosis and timely treatment thus cannot be overstated.
Obstructive sleep apnea manifests by repeated episodes of apnea or hypopnea during sleep. During deeper levels of sleep, especially that characterized by rapid eye movement (REM), there is loss of the normal tone of the pharyngeal and tongue muscles that keep the pharynx open, resulting in collapse of the oropharyngeal and nasopharyngeal airway. In the majority of the population this decrease in airway diameter is clinically insignificant. However, in OSA patients the varied degree of airway obstruction can have clinical consequences. Narrowing of the airway causes increased velocity of inspiratory airflow in the pharynx, causing decreased intraluminal pressure, further tissue collapse, and increased airway obstruction (Bernoulli's principle). In instances of complete airway obstruction, the patient will experience apnea, a cessation of breathing for at least 10 seconds. Incomplete obstruction may result in hypopnea, a reduction in airflow with associated oxygen desaturation, which is more common. Each apnea or hypopnea episode continues until the patient awakens to a more shallow level of sleep, which results in a recovery of pharyngeal muscle tone and recovery of airway integrity. The more frequent the apnea and hypopnea, the more fragmented the sleep, which results in greater sleep deprivation due to the lack of adequate REM activity.
121 - Uvulopalatopharyngoplasty
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- By John M. DelGaudio, Emory University, School of Medicine, Atlanta, GA
- Edited by Michael F. Lubin, Emory University, Atlanta, Robert B. Smith, Emory University, Atlanta, Thomas F. Dodson, Emory University, Atlanta, Nathan O. Spell, Emory University, Atlanta, H. Kenneth Walker, Emory University, Atlanta
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- Book:
- Medical Management of the Surgical Patient
- Published online:
- 12 January 2010
- Print publication:
- 10 August 2006, pp 755-756
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Summary
Uvulopalatopharyngoplasty (UPPP) is a procedure performed on adults for the treatment of obstructive sleep apnea (OSA). UPPP involves removing the posterior aspect of the soft palate including the uvula and lateral pharyngeal mucosa (or tonsils if present) to reduce redundant tissue, thereby enlarging the oropharyngeal and nasopharyngeal airway.
OSA is a condition affecting 4% of the adult population and manifests by repeated episodes of apnea or hypopnea during sleep. During deeper levels of sleep, especially that characterized by rapid eye movement (REM), there is loss of the normal tone of the pharyngeal and tongue muscles that keep the pharynx open, resulting in collapse of the oropharyngeal and nasopharyngeal airway and varying degrees of airway obstruction. Narrowing of the airway causes increased velocity of inspiratory airflow in the pharynx, causing decreased intraluminal pressure, further tissue collapse, and increased airway obstruction (Bernoulli's principle). In instances of complete airway obstruction, the patient will experience apnea, a cessation of breathing for at least 10 seconds. Incomplete obstruction may result in hypopnea, a reduction in airflow with associated oxygen desaturation, which is more common. Each apnea or hypopnea episode continues until the patient awakens to a more shallow level of sleep, which results in a recovery of pharyngeal muscle tone and recovery of airway integrity. The more frequent the apnea and hypopnea the more fragmented the sleep, resulting in greater sleep deprivation due to the lack of adequate REM activity.
120 - Tonsillectomy and adenoidectomy
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- By John M. DelGaudio, Emory University, School of Medicine, Atlanta, GA
- Edited by Michael F. Lubin, Emory University, Atlanta, Robert B. Smith, Emory University, Atlanta, Thomas F. Dodson, Emory University, Atlanta, Nathan O. Spell, Emory University, Atlanta, H. Kenneth Walker, Emory University, Atlanta
-
- Book:
- Medical Management of the Surgical Patient
- Published online:
- 12 January 2010
- Print publication:
- 10 August 2006, pp 753-754
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- Chapter
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Summary
In the past, tonsillectomy and adenoidectomy (T & A) was one of the most frequent surgical procedures performed on children, the most common indication being recurrent sore throat, though these procedures are performed much less often today. Currently, the most common indication for tonsillectomy in children is tonsillar hypertrophy with upper airway obstruction that results in snoring and sleep apnea. Other indications include recurrent tonsillitis and chronic tonsillitis. In adults, the most common indications are sleep apnea (as part of a uvulopalatopharyngoplasty), chronic tonsillitis, and concern for malignancy.
The adenoids are lymphoid tissue located in the nasopharynx. Adenoid hypertrophy results in nasal airway obstruction, mouth breathing, rhinorrhea, and sleep apnea. Due to the natural atrophy that occurs by puberty, adenoidectomy is usually only performed in children. It is frequently, but not always, done in conjunction with a tonsillectomy. The presence of significant adenoid tissue in an adult raises the concern for neoplasm or HIV infection.
T & A is performed under general anesthetic, usually in the outpatient setting. A careful preoperative history is necessary to rule out coagulation disorders. Bleeding is usually mild but can be considerable. Procedures are done using a combination of electrocautery and cold dissection; the use of electrocautery can reduce bleeding but may increase postoperative pain.
Usual postoperative course
Expected postoperative hospital stay
Patients are usually discharged on the day of surgery following a couple of hours of postoperative observation to assure that they can drink and hold down liquids.