AAO-HNSF Primary Care Otolaryngology Handbook

INTRODUCTION TO CLINICAL ROTATION AND PHYSICAL EXAM OBSTRUCTIVE LEEP APNEA

• OSA with an AHI of 15–65 events/hour • Intolerance or ineffective treatment with PAP therapy • BMI less than 33

• DISE with absence of complete circumferential palate-level collapse Patients typically consider upper airway stimulation after trying PAP therapy for many months or years without success. In the appropriate patient, the results can be quite dramatic, with reported success rates in early trials ranging from 60 to 70 percent and subsequent studies demonstrating even better results with refinement and wider use of the procedure. Surgery includes three incision sites (stimulation lead, generator, and sensor lead). The stimulation lead is placed on a portion of the hypo- glossal nerve that innervates the protrusor muscles of the tongue, typi- cally on the patient’s right side to avoid interference with any future potential cardiac devices. Next, a subcutaneous pocket is created along the right pectoralis major muscle on the chest wall for the generator device. A third incision is made along the right chest flank for insertion of the sensor lead between the internal and external intercostal muscles. The device is tested intraoperatively to confirm good functioning, and patients are typically discharged the same day or kept one night for observation. The device is typically activated one month later. It is turned on nightly by the patient using a hand-held remote control with functionality to control the level of stimulation. The device intermittently turns on and off throughout the night in accordance with the natural breathing cycle. Approximately two months or more after surgery, patients receive a repeat PSG to properly titrate the stimulation level. Once a proper stimu- lation level is determined, patients follow up on a semiannual to annual basis for regular care. Pediatric OSA Enlarged tonsils and adenoids are often the source of airway obstruc- tion in children, and result in sleep-disordered breathing. Unlike in adults, symptoms often include daytime behavioral problems, poor school performance, hyperactivity, growth retardation, and secondary nocturnal enuresis. Similar to adults, some children have daytime sleep- iness, snoring, and witnessed apneas. In severe—but rare—cases, cardiopulmonary disease can result.

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