Abstract
Ask the Experts: Sleep Surgery Potpourri
Michael Friedman, MD (moderator); Kathleen Yaremchuk, MD; Eric J. Kezirian, MD, MPH; B. Tucker Woodson, MD; Edward M. Weaver, MD, MPH; Erica R. Thaler, MD; Ofer Jacobowitz, MD
Session Description: Modifications of uvulopalatopharyngoplasty (UPPP), as well as variations in treatment of hypopharyngeal obstruction, are numerous. Selecting the right technique for the right patient often becomes the most difficult decision in treatment planning. It is often unclear if the proponents of a particular technique apply their modifications for every case or if there is a selection process. The purpose of this miniseminar is to present specific cases and hear the opinion of experts on how they would treat the same patient.
Outcome Objectives: (1) Utilize the appropriate patient selection for a classic UPPP. (2) Determine when uvula preservation techniques are appropriate. (3) Examine the current thinking in tongue base reduction.
Cranial Nerve Stimulation for OSA: From Protocol to Practice
B. Tucker Woodson, MD (moderator); Ryan J. Soose, MD; Michael Friedman, MD; Clemens Heiser, MD; Kingman Strohl, MD
Session Description: Cranial nerve stimulation via the hypoglossal nerve is a Food and Drug Administration–approved therapy for treatment of obstructive sleep apnea. Therapy has now transitioned from research protocol to clinical practice. Following this presentation, the participant will be able to (1) describe changes and improvements in surgical implant technique; (2) compare mechanisms of action to other therapies; (3) contrast outcomes and mechanisms of sensor-dependent and -independent implants; (4) describe differences in arousal, polysomnography, and sleep outcomes; and (5) explain algorithms for potential patient selection for implants. The session will allow participants to better understand multidisciplinary implementation of stimulation into clinical practice.
Outcome Objectives: (1) Compare actions of sensor-dependent and -independent cranial nerve stimulation. (2) Assess the upper airway for proper patient selection using knowledge of potential mechanisms of multilevel airway opening. (3) Describe risks and benefits of different surgical approaches for cranial nerve stimulation implantation.
It Is Not Always OSA: Other Common Sleep Problems in Children
Cristina Baldassari, MD (moderator); Stacey L. Ishman, MD, MPH; Norman R. Friedman, MD; Susan Garetz, MD
Session Description: Patients with daytime sleepiness or poor sleep are frequently referred to otolaryngologists for possible sleep-disordered breathing. Many of these patients also have comorbid sleep disorders that have not been adequately evaluated and treated. For example, 10% to 30% of young children have behavioral insomnia of childhood, including bedtime resistance and nighttime awakenings. Other common sleep disorders in children include non–rapid eye movement parasomnias such as night terrors and sleep walking and delayed sleep phase disorder. It is important that otolaryngologists recognize these other disorders, especially in children with persistent sleep disturbances following adenotonsillectomy. We will discuss the presentation of common sleep disorders in children and also review treatment strategies, including extinction, scheduled awakenings, and improving sleep hygiene. The proposed miniseminar will feature a panel discussion of clinical case-based scenarios highlighting sleep disorders commonly seen in pediatric otolaryngology practices.
Outcome Objectives: (1) Recognize common pediatric sleep disorders, including behavioral insomnia of childhood, night terrors, sleep walking, and delayed sleep phase disorder. (2) Describe behavioral interventions for common pediatric sleep disorders, including improving sleep hygiene, scheduled awakenings, phase advancement, and extinction.
Management of the Sleep Patient: Pearls and Pitfalls
Alan Kominsky, MD (moderator); B. Tucker Woodson, MD; Ryan J. Soose, MD; Kathleen Yaremchuk, MD
Session Description: This course will guide otolaryngologists in care of the sleep patient in addition to surgical intervention. Sleep patients with persistent hypersomnia after surgery, patients needing alternative therapies, and patients who are having trouble getting care due to insurance denials will be discussed. In addition, this course will explore the workup of a patient leading to surgery.
Outcome Objectives: (1) Implement comprehensive care of the patient with sleep apnea. (2) Apply new strategies in the workup of obstructive sleep apnea patients. (3) Recognize causes of persistent fatigue in a treated obstructive sleep apnea patient.
Office-Based Snoring Surgery
Brian Rotenberg, MD, MPH (moderator); Kenny P. Pang, MD
Session Description: Snoring is a prevalent problem seen by otolaryngologists. Many patients prefer to have correct work done in the office as opposed to in the operating room. In this lecture, 2 experienced sleep surgeons will review their techniques for office-based snoring surgeries, including sedation, procedure description, postoperative care, and outcomes. Indications for surgery will also be discussed. The purpose of the presentation is to educate attendees as to incorporating office-based snoring procedures into their practice.
Outcome Objectives: (1) Identify which patients are suitable for office-based snoring treatment. (2) Recognize the optimal methods for providing anesthetic in the clinic to facilitate snoring surgery. (3) Comprehend the array of options available to treat snoring in the office setting and how to choose among them.
Palate Surgery in OSA: How to Choose among the Options
Eric J. Kezirian, MD, MPH (moderator); Edward M. Weaver, MD, MPH; Kenny P. Pang, MD; Hsueh-Yu Li, MD; Michel B. Cahali, MD, PhD; B. Tucker Woodson, MD; Brian Rotenberg, MD, MPH
Session Description: A number of palate procedures to treat obstructive sleep apnea have been developed over the past 10 to 15 years as alternatives to classic uvulopalatopharyngoplasty (UPPP). This session includes presentations from surgeons who have developed and/or evaluated these approaches, incorporating the latest evidence and key technique points. The spectrum of procedures will include Robinson’s modified UPPP, expansion sphincter pharyngoplasty, lateral pharyngoplasty, Z-palatopharyngoplasty, palatal advancement, and the Pillar procedure.
Outcome Objectives: (1) Interpret evidence regarding the range of palatoplasty techniques: UPPP, modified expansion sphincter pharyngoplasty (aka functional expansion pharyngoplasty), relocation pharyngoplasty, lateral pharyngoplasty, Z-palatoplasty, and palatal advancement. (2) Assess the technical distinctions between palate procedures. (3) Identify the key patient characteristics to guide the selection among palate surgery techniques.
Pearls and Pitfalls in Perioperative Management of the OSA Patient
Kenny P. Pang, MD (moderator); Brian Rotenberg, MD, MPH; B. Tucker Woodson, MD
Session Description: Patients with obstructive sleep apnea (OSA) are a special group of patients requiring extra care and monitoring due to their anatomical and physiological needs. These OSA patients are commonly undiagnosed when they are undergoing surgery for other parts of their body other than the ear, nose, and throat region; the primary physician may not be aware of their condition. The types of upper airway surgery that these OSA patients undergo are unique because they share the same upper airway region as the anesthesiologist and need good, proper airway management.
Outcome Objectives: (1) Recognize that OSA patients are unique in terms of their anatomy, physiology, pharmacological reaction, and higher complication rate. (2) Identify what are the common perioperative complications that might occur in these OSA patients. (3) Isolate and identify the OSA patients who are more likely to have perioperative complications and how to prevent these complications.
Pediatric Drug-Induced Sleep Endoscopy
Megan Durr, MD (moderator); Norman R. Friedman, MD; Peter Koltai, MD; Sanjay R. Parikh, MD; Kristina Rosbe, MD; Stacey L. Ishman, MD, MPH
Session Description: This panel will address the use of drug-induced sleep endoscopy (DISE) for pediatric obstructive sleep apnea (OSA). The discussion will include patient selection, as well as operative and anesthetic tips for success during pediatric DISE. Our panelists will describe common DISE findings in children with persistent OSA after tonsillectomy and adenoidectomy. The session will also address procedure selection based on DISE findings, including indications for advanced palatal and tongue base procedures in the pediatric population.
Outcome Objectives: (1) Describe proper technique and patient selection for pediatric DISE. (2) Characterize approaches for procedure selection based on DISE. (3) Discuss indications for advanced palatal surgeries and tongue-based surgical options for OSA.
Pediatric Snoring and Mild Obstructive Sleep Apnea: What to Do?
Scott E. Brietzke, MD, MPH (moderator); Cristina Baldassari, MD; Stacey L. Ishman, MD, MPH; Ron Mitchell, MD
Session Description: Pediatric snoring (PS) and mild obstructive sleep apnea syndrome (OSAS) are very common but still poorly understood clinical problems. Recent high level data have brought into question previously accepted treatment algorithms for mild OSAS. In addition, quality of life (QoL) data have been increasingly described for PS/pediatric OSAS that are elucidating an entire new realm of treatment outcomes and clinical management implications. In this scientific colloquium, pediatric sleep experts will discuss recently presented data on PS and pediatric OSAS with a primary goal of guiding the practicing otolaryngologist on how this emerging data should impact their evidence based practice.
Learning Objectives: (1) Understand recently presented data on pediatric snoring and mild pediatric obstructive sleep apnea and its implications on diagnosis and management. (2) Recognize the limitation of using strict polysomnogram based definitions of treatment success in contrast to the dimension added by also considering quality of life–based outcomes. (3) Implement potential changes in the management of pediatric patients with snoring and mild obstructive seep apnea based on recent outcomes data and quality of life data.
State of the Art: Drug-Induced Sedated Endoscopy for OSA
B. Tucker Woodson, MD (moderator); Eric J. Kezirian, MD, MPH; Stacey L. Ishman, MD, MPH; Claudio Vicini, MD; Tracey Stierer, MD
Session Description: Drug-induced sleep endoscopy (DISE) provides a potential evaluation method to assess structure and the dynamics of upper airway collapse in multiple states. The goals of this course are to describe details and controversies of (1) drug selection and anesthetic management, (2) dynamic and static classification schemes (Nose, Oropharynx, Hypopharynx, and Larynx [NOHL]; Velum, Oropharynx, Tongue Base, Epiglottis [VOTE]; and luminal phenotypes), and (3) comparison to other imaging techniques (magnetic resonance imaging) during sleep. The miniseminar will explore both the evidence-based value of the technique in selecting surgical and nonsurgical treatment options in adults and children and its future potential and direction.
Outcome Objectives: (1) Compare and contrast dynamic and static upper airway classification schemes during sedated sleep. (2) Explain key differences in action and outcomes of anesthetic agents used for sedation. (3) Apply evidence-based DISE outcomes to patient surgical selection.
Take the DISE Challenge!
Norman R. Friedman, MD (moderator); Eric J. Kezirian, MD, MPH; Ryan J. Soose, MD; Nico de Vries, MD; Edward M. Weaver, MD, MPH
Session Description: Drug-induced sleep endoscopy (DISE) is a novel technique to identify surgical candidates. DISE interpretation and management are not straightforward. The science of DISE is rapidly expanding, but there are still many gaps. This course will expand beyond the 2014 procedural selection miniseminar. Pertinent clinical information and DISE video will be available prior to the Academy meeting. By visiting http://www.medschool.ucdenver.edu/otolaryngology, Academy members can take the DISE challenge prior to the meeting. During the miniseminar, the experts will provide their interpretation and management. Postoperative outcomes will also be presented. Both the art and science behind the decision process will be discussed.
Outcome Objectives: (1) Evaluate a DISE video and classify the obstruction. (2) Formulate a management plan for a variety of anatomical sites of obstruction. (3) Test diagnostic acumen using a set of actual clinical cases.