Head & Neck | Surgical Management of Adult OSA | Dr Varun Rai
AOT ENT Education2020-10-17
1K views|3 years ago
💫 Short Summary
In this presentation, Dr. Shailaja Chandra discusses the surgical techniques for sleep apnea, including the Allianza technique and the Bony Opening of the Airway (BOSS) procedure. She emphasizes the importance of individualized treatment and the use of bimodal surgery to address specific anatomical issues. The video also covers the management of sleep apnea in children with maxillary and mandibular hypoplasia and the potential use of orthognathic surgery in certain cases.
✨ Highlights
📊 Transcript
✦
The speaker discusses a surgical technique called Bob (Bony Opening of the Airway) for the treatment of sleep apnea, which involves the expansion of the soft palate.
00:00The Bob technique begins with anterior palatoplasty and extends to other areas of the palate, including the periovular palate of fringes and the hamular region.
Suturing is done to engage the fibers and create lateral expansion in the palate.
Bob is considered advantageous for its modularity, reversibility, and ability to address long-term effects of cutting the palatal pharynx and uvula.
Skeletal malformations affecting the airway may require separate treatment before Bob or any other technique can be effective.
✦
The speaker emphasizes the importance of a multi-disciplinary approach, including the collaboration of various medical professionals, in the management of sleep apnea.
06:14Sleep physicians, chest physicians, dentists, and ENT surgeons should work together to effectively manage sleep apnea.
CPAP and surgery are seen as synergistic and complementary treatments for sleep apnea.
✦
The Q&A session covers topics such as the long-term outcomes of snoring surgery, the effect of surgery on vocal tract resonance for singers, and the management of patients with deviated nasal septum and sleep apnea.
12:19The success of snoring surgery is measured by the improvement in the quality of life for the patient rather than just a reduction in the AHI score.
Raising the baseline oxygen saturation is crucial to prevent long-term sequelae of sleep apnea.
Surgery for singers should take into consideration the potential effect on vocal tract resonance.
In cases of deviated nasal septum without sleep apnea, the approach may involve addressing the nasal issue first or trying CPAP before considering surgery.
✦
The speaker discusses the surgical technique for sleep apnea management, including tonsillectomy and different maneuvers for the palate based on the individual's anatomical features.
18:42Tonsillectomy is a crucial part of the surgical technique for sleep apnea.
Different maneuvers for the palate are chosen based on the individual's anatomy, such as concentric collapse of the palate or the presence of a bulky muscle layer.
The surgical technique is tailored to the specific needs of the patient to ensure the best possible outcomes.
✦
The section covers the technical aspects of sleep surgery, including the use of barbed sutures for palate surgery and the assessment of airway obstruction using drug-induced sleep endoscopy (DISE) and sleep MRI.
24:46Barbed sutures are used in palate surgery for their anchoring and cinching effect, but the placement must be accurate to avoid nasal regurgitation.
Drug-induced sleep endoscopy (DISE) is considered a useful tool for assessing airway obstruction and guiding surgical decisions.
Sleep MRI is preferred for its comprehensive evaluation, but may not be readily available in all centers.
The decision to repeat the barbed sutures procedure after the primary surgery is based on the integration of the sutures with the soft tissue and the development of fibrosis.
✦
The speaker emphasizes the importance of skeletal evaluation in sleep surgery and the need for a tailored approach based on individual anatomy.
30:54Skeletal evaluation is crucial in determining the success of sleep surgery.
A tailored approach based on individual anatomy is necessary, and not all techniques work for every patient.
The decision to pursue sleep surgery should be based on a comprehensive evaluation and a collaborative effort between the patient and the surgical team.
✦
The surgeon explains that the patient who underwent the Allianza Bob technique is now off CPAP and has had their AHI reduced to six, indicating a mild category of sleep apnea.
37:57The success of surgery for snoring is based on the improvement in the patient's quality of life and the reduction of the AHI score.
Surgery for sleep apnea is considered an adjunct to CPAP therapy, and patients are given a CPAP trial before undergoing surgery.
In the case of the patient who underwent the Allianza Bob technique, they are now off CPAP and have had their AHI reduced to six through a combination of surgery and weight loss.
00:03 hello
00:04 my name is ali alami i'm a consultant
00:06 surgeon uh working in east kent and i
00:08 was a fellow at guys and saint thomas's
00:10 uh it is my absolute pleasure
00:14 to introduce to you the speaker today
00:16 for tonight is uh
00:17 dr baron ray who's a consultant tnt
00:21 surgeon based in new delhi in india he
00:24 has very kindly given us a talk
00:25 previously with the gossip library
00:27 um land management
00:31 today he is giving us a talk on surgical
00:33 management of snoring and sleep apnea
00:35 and adults
00:37 just to to in terms of his background
00:40 he's done a fellowship in italy
00:42 in sleep surgery and they're firmly
00:45 looking forward to this talk
00:47 and over to you dr ray for some words of
00:49 wisdom
00:50 thank you thank you so much for having
00:52 me perfect so let me just start off
00:54 without my
00:55 much ado so just the first slide
00:59 is
01:04 this and you can see how it can be
01:09 and yeah you can
01:24 so to speak so uh
01:28 it was one cons once considered a sign
01:30 of prosperity now it's proven to be a
01:32 harbinger
01:33 for various diseases and so now
01:36 we've started taking this seriously and
01:39 the incidence according to various
01:40 meta-analysis and studies
01:42 is quite high and this is a study that i
01:45 found
01:46 of a meta-analysis over the years and we
01:49 see the incidence
01:52 which has risen recently now uh in the
01:55 uk
01:56 the 13 of the adult males do suffer from
01:59 obstructive sleep apnea
02:01 and six percent of that are females and
02:05 recent evidence does suggest that 85
02:07 percent of the people
02:08 are undiagnosed and therefore untreated
02:11 now this has a huge
02:12 impact financial uh and financial
02:15 implications
02:16 on the nhs as well and
02:19 without getting too much into the nitty
02:20 nitty-gritties of it the take home
02:22 message for this slide is basically
02:24 if you treat sleep apnea you save a lot
02:26 of money for your government
02:28 it increases the patient's life's
02:30 lifespan
02:31 and the productivity of the patient as
02:34 well as the partner who gets a sound
02:36 night's sleep and in eventually reduces
02:39 the burden on the health care system
02:41 so it is a thing which is to be taken
02:43 quite seriously
02:47 so understanding sleep apnea so what
02:49 really happens at night when you fall
02:51 asleep
02:51 especially when you lie on your back now
02:54 the first
02:54 thing was the normal airway but once
02:58 the soft tissues of the neck collapse
03:00 that's when you get your ethnic spells
03:03 and that's when you try to push air from
03:05 above
03:06 it just opens up the airway and that's
03:08 the principle of the cpap machine
03:12 so just a brief overview about the
03:14 anatomy which is relevant to us
03:16 so we have our entire airway system
03:18 starting from the nose
03:20 the nasopharynx orifice hypopharynx at
03:22 the larynx
03:23 and heading down into the trachea the
03:25 trachea and the nose are
03:27 the non-collapsible part of the airway
03:31 which can only really give rise to
03:33 static obstructions
03:36 uh the majority of the dynamic
03:39 obstructions
03:40 is the soft palate and it's i just
03:43 need you to make a note of this slide we
03:46 have the two
03:47 uh the levator and the tensor velocity
03:50 and which is responsible for your soft
03:53 palate
03:53 elevation and and basically if you stay
03:56 below this line
03:57 you're never going to cause uh
03:59 velopharyngeal insufficiency
04:02 regarding the symptoms of the patient
04:03 i've just color coded them
04:05 the ones in yellow are for the mild
04:09 sufferers ones in orange you try
04:12 and the symptoms become slightly more
04:14 sinister where you have gasping
04:16 breathing pauses and night awakenings
04:18 and of course you have your consequences
04:20 which are high blood pressure
04:21 uh cardiac issues chest pain at night
04:23 which are really really alarming
04:28 uh for your clinical spectrum you you
04:30 have the entire range of breathing which
04:32 is uh
04:32 from normal to your severe sleep apneas
04:35 and you have a lot of
04:36 uh subtypes along the way and you have
04:39 the occasional snorers
04:41 and the regulars knowledge which have
04:43 just been
04:45 differentiated and as you see below your
04:49 desire of the patient to get treated
04:53 occasional snorers really tran
04:56 transcends to need of intervention as
04:58 you head into the apnea
05:00 so diagnosing obstructive sleep apnea
05:03 was really quite simple earlier
05:04 where you would have the history
05:06 question is you would just do a psg
05:09 or a home based sleep study because you
05:12 were really
05:13 dealing with a single cure option and
05:16 this was
05:16 an example of those questioners these
05:18 are all available online
05:20 we have the effort sleep in a scale
05:22 which was in quite a long period of time
05:24 now we have to stop by the
05:25 questionnaires
05:27 and once you would do the
05:29 polysomnography which was really done by
05:31 our physician colleagues
05:33 you would get this sort of a report
05:35 where you would get the total
05:36 time spent sleeping you would have your
05:39 snoring you would have your
05:40 acne and hypopnea index and apnea is
05:43 basically a cessation of breathing and
05:45 hypopnea is less than 50
05:47 of your breath a chest movement on
05:49 breath and this was
05:51 um calibrated as an index which was used
05:54 as a measure of
05:56 severity for your sleep apnea
05:59 we would uh we had divided them as 5 to
06:02 15 as mild 15 to 30 years moderate and
06:05 greater than 30 was categorized as sleep
06:07 apnea now severe sleep apnea
06:10 and we would really really treat them in
06:13 a single
06:16 way if the physician was the
06:21 contact uh doctor he would
06:24 prescribe the cpap if the patient had uh
06:28 the ent doctor as a source of uh medical
06:31 opinion he would just
06:32 undergo yogurtoplasty which was really
06:35 in work in the 80s
06:36 now a nasal surgery was done with a
06:39 in adjunct to your up3
06:43 so but over the years we saw that up3
06:47 alone gave a 50
06:48 long term success rate and when combined
06:51 with nasa surgery yes it did go up to 73
06:54 but we're not really
06:58 satisfied with those results
07:01 well where did we go wrong we now know
07:04 that it is a
07:05 dynamic and complex condition which you
07:07 cannot have a one-stop solution to all
07:10 uh we obviously needed better diagnostic
07:13 tools to
07:13 really find out what was happening and
07:17 we had to understand the obstructive
07:19 forces at play which were really really
07:21 invisible to the naked eye just on
07:22 clinical examination
07:24 without specialized tools
07:28 so we knew that the psg and your
07:30 question is quantifies the problem we
07:32 know that there is a problem
07:34 but they had we had no information about
07:36 which
07:37 site of the uh nasal of the airway was
07:41 really causative
07:42 of the problem we did not have any idea
07:46 about the types of collapse which really
07:48 occurred during sleep and more
07:50 importantly we
07:52 had no correlation with the sleep cycle
07:53 according to the degree of collapse
07:55 or the sleep apnea now it has now been
07:58 well established that
07:59 you know sleep apneas can really happen
08:02 uh during your rapid eye movement
08:04 uh sleep phase or the non-rapid eye
08:05 movement and
08:07 uh we also knew that there were higher
08:09 dangers associated with brain
08:11 apnea however we know that
08:14 rem uh sleep usually occurs
08:17 later in the night and cpap compliance
08:20 at its best
08:21 was about 70 and the patients would
08:24 usually use it for three to four hours
08:26 at night and that would
08:27 not really cover your rem sleep so these
08:30 patients were not getting treated
08:32 or getting any sort of relief with their
08:35 cpaps
08:36 so surgery should be considered despite
08:38 the bmi or the ah
08:40 of these particular subset of patients
08:45 so when we talk about the types of
08:46 obstruction we have divided them into
08:48 the static and the dynamical apps
08:50 static is something that you can see in
08:52 your opd you look at your nose tonsils
08:55 skeletal malformations your lingual
08:57 tonsils and that's
08:58 really right in front of you the dynamic
09:00 collapse is basically a collapse of your
09:02 normal structures
09:03 during sleep so these were divided into
09:07 three um
09:08 levels which was behind the ballot
09:10 behind the tongue and your laryngeal
09:12 levels
09:14 so really what we were talking about was
09:17 the causes of dynamic collapse why were
09:20 they happening
09:21 well just going into a little bit of the
09:23 physics we have the stalling forces we
09:25 have a
09:26 low pressure above low pressure below
09:28 and a high pressure
09:30 because of increased resistance in the
09:32 nasal part
09:33 and that causes the collapse of your uh
09:36 middle segment
09:37 which leads to your snoring or sleep
09:39 apnea
09:42 well you would uh also have a your
09:46 and this is a video i've just taken off
09:48 the internet and found it really
09:50 interesting when the patient would be
09:53 breathing in through the nose the soft
09:55 palate would be elevated your tongue
09:57 would be
09:57 ahead but once the patient opens the
09:59 mouth there
10:01 is a unstable airway and which leads to
10:05 a vibration of the soft parrot leading
10:06 to the snoring as we know
10:11 uh we also have found out that the nasal
10:14 ventilate about the nasal ventricular
10:15 reflex reflex uh wherein the decrease in
10:19 nasal airflow would
10:21 leads to less activation of the nasal
10:23 receptors and
10:24 consequently there would be inhibition
10:26 of the muscle tone which would lead to a
10:28 flaccid uh soft palate and your tongue
10:31 which would lead to snoring itself
10:34 we also now know about the nitric role
10:37 of nitric oxide
10:38 which leads to a reduced ventilation
10:40 perfusion ratio in the lungs leading to
10:42 a reduced
10:43 oxygenation which really becomes quite
10:46 troublesome
10:48 so uh the present-day sleep surgeon has
10:50 the following investigations in his
10:52 armament
10:53 we have we obviously the basic clinical
10:56 examination is a must
10:58 we have our x-rays for cephalometries we
11:01 are
11:01 we have awake fiber optic laryngoscopy
11:03 specialized laryngoscopy sleep study
11:06 but now we also have the sleep mri and
11:08 the drug-induced sleep endoscopy
11:12 nasal cavities cells for explanatory um
11:15 in your throat examination you have to
11:17 pay a particular
11:18 um attention towards the dentition which
11:21 i would just like to point out
11:23 your tongue position and your tonsils
11:26 and your tongue was its position was uh
11:29 there are various skills to classify it
11:31 we have the friedman trunk position you
11:32 have your malampathy score
11:34 well all these were basically for our
11:37 anaesthetist but the player they have a
11:39 huge implication
11:41 in your sleep apnea as well
11:46 well cephalometric evaluation
11:49 is really really advised in cases
11:51 whoever
11:52 visual hypoplastic or a hypoplastic
11:55 maxilla or a mandible where you would
11:57 really get all these measurements and
11:59 you would plan out
12:01 your intervention in other ways which i
12:03 shall be
12:04 discussing in a bit awake fiber optic
12:08 laryngoscopy was basically done uh it's
12:10 either in a sitting or in a supine
12:13 position
12:14 and the mullious maneuver is basically a
12:16 reverse well salva you
12:18 ask the patient to pinch the mouth and
12:19 the nose you ask the patient to breathe
12:21 in
12:22 and that would slightly stimulate the
12:25 snoring
12:25 um uh the sleep apnea conditions and
12:28 that would give you
12:29 a very nice indicator about what the
12:32 problem
12:33 really was you would also have the end
12:36 expiratory pressure where you would ask
12:38 the patient to
12:40 basically just release all the air from
12:42 the lung and then hold it and you would
12:44 rightly see the tongue movement at the
12:46 end of this
12:47 maneuver
12:51 uh based on your uh levels which i
12:54 discussed about the retro
12:56 palatal lingual and the laryngeal uh
12:59 for purposes of uh
13:03 classification we had divided there was
13:05 a vote classification which was very
13:07 much involved
13:08 where we would have four levels we have
13:10 the vellum the oropharynx the tongue
13:12 base and the epiglottis
13:13 and each of these constitutes a
13:16 clear-cut surgical
13:17 area of interest and
13:21 however now we have the eudis model
13:24 because
13:25 uh we really need to take uh care of
13:28 our static obstructions as well and
13:30 there are
13:31 different patterns of collapse when
13:33 associated with the dynamic conditions
13:36 so this is the model that we follow now
13:38 and they had a very good idea of
13:41 characterizing the percentage
13:43 obstruction as well
13:45 drug induced sleep endoscopy is
13:47 basically done in the or
13:49 and where the patient would be sedated
13:52 with either propofol or dexmedetamine
13:55 and it provides a better understanding
13:57 of the patterns and the levels of
13:58 obstruction multi-level osa
14:00 of course there is a lot of criticism
14:03 because it cannot
14:04 replicate natural sleep and
14:07 of course according to different stages
14:09 of anesthesia
14:12 different patterns of collapse are
14:14 observed
14:16 the next investigation was the sleep mri
14:18 where the patients would be asked to
14:20 sleep in the mri machine
14:21 and the mri would really really
14:24 continuously scan
14:25 and see the soft tissues collapsing
14:29 so the pros were natural sleep you would
14:32 see
14:32 multi-level obstructions happening at
14:34 the same time
14:35 however there were financial
14:37 implications of reserving the mri
14:39 machine for the entire night
14:41 and well who wants to sleep in an mri
14:44 machine so
14:45 there was definitely some issues there
14:48 so when we come to the management yes
14:51 all these are adjuncts
14:52 i would take them as a chance with the
14:55 exception of bad
14:56 therapy fab therapy should go hand in
14:58 hand which i shall be discussing about
15:00 but and the last topic is my topic for
15:03 the day which is targeted surgery
15:04 you try and find out where the problem
15:06 lies and you really really go and get it
15:10 so for your pre-op essentials uh
15:12 psychological counseling is a must
15:14 because patients
15:15 will have some uh sequelae after surgery
15:19 they will have some remnant snoring
15:21 sleep apnea so you really need to get
15:23 them on the
15:24 right frame of mind and be absolutely
15:26 positive about the entire implication
15:29 we really talk about pain because any
15:31 form of surgery is painful
15:33 especially when we talk about your
15:34 palate than your tongue
15:36 we discussed airway fiber optic
15:38 intubation elective tracheostomy consent
15:40 is a must
15:42 and we prepare for all sorts of
15:45 emergency
15:46 complications so coming to the
15:50 surgical management of static
15:51 obstruction i'm just going to run
15:52 through a few videos
15:54 for your nasal surgeries i mean i really
15:56 don't need to
15:57 uh everyone is a qualified
16:00 ent surgeon and there's nothing new that
16:03 i'm offering here but
16:04 the first video is a turbinate stitch
16:06 what we do especially in our sleep apnea
16:08 because
16:09 the terminals are really quite floppy in
16:10 these people so if you just stitch them
16:12 you create a better airway open up the
16:14 middle measures
16:16 septoplasty uh i don't think it needs
16:19 any introduction or explanation so it
16:23 really helps when we talk about a static
16:25 obstruction
16:26 um as an adjunct measure whether there
16:30 it
16:30 is a visible problem or not a turbinate
16:32 reduction or channeling does help
16:35 so the first video the video above is
16:38 the concavalosa
16:39 which is aeration of the middle
16:41 turbinate and we just do a lateral
16:43 laminectomy and that opened up the area
16:45 really nicely
16:46 and the video below is a copolation
16:49 assisted
16:51 turbinated diathermy basically
16:55 where you go some mucously and you
16:58 ablate the soft tissues
16:59 that leads to a reduction of your
17:01 turbinate albeit
17:03 it is uh temporary really lasts for
17:06 about two to three years but
17:08 yeah that's all the time the patient
17:10 needs uh to motivate himself to really
17:12 get better
17:16 so for your adenoid acne and your
17:17 tonsillectomy uh
17:19 we prefer to use copulation and the
17:22 above video is a ton select me below
17:24 video is an adenoidectomy
17:26 we like to use copulation especially in
17:28 sleep apnea because
17:30 these surgeries while they are
17:33 sufficient in itself
17:35 in children in adults usually an
17:38 additional procedure is required and you
17:41 really don't want any bleeding to happen
17:43 when the copulation does for uh give you
17:45 a nice clear vision
17:47 an additional point especially in the
17:49 tonsillectomy while using the cobulator
17:51 we
17:52 leave the capsule in place on the tonsil
17:54 bed and that really helps with all our
17:56 modification
17:57 our suturing techniques are rejection
18:00 techniques it really helps a lot
18:04 so for that yes we like to use the
18:07 correlation well when we talk about your
18:11 dynamic collapse in my mind there are
18:13 basically
18:14 four major uh types of procedures what
18:17 you can do to
18:18 take care of the dynamical apps you have
18:20 your
18:21 i'm sorry i i could not find any
18:25 reference to this online or
18:27 through literature this is just
18:28 something that i personally use
18:31 so they're the four hours uh the first
18:34 is the rejective surgeries then we have
18:36 the restructuring
18:38 we have the remodeling and we have the
18:40 re-enable re-innovation
18:42 so i should just be going uh step by
18:45 step trying to explain trying to talk
18:46 through videos
18:48 so the first and the earliest uh
18:51 procedure
18:52 which was done was the palette of
18:55 plastic where in
18:57 the uvula along with a
19:00 portion of the soft palate which is
19:02 below
19:03 the level of the levator and the tensor
19:05 velar palatini
19:07 was basically cut away now you could
19:09 really really use
19:11 anything there and this just so happens
19:13 there's a video
19:15 where i'm using the copulation but
19:18 that was basically it you would just do
19:20 away with the entire segment that was
19:23 uh collapsing or supposed to you know
19:27 have the maximum collapsible element go
19:29 to your limits of what was safe
19:32 and just take it out so that was what
19:35 was this was happening but this would
19:38 really really not address the lateral
19:40 collapse this of course would not
19:42 um address your tongue collapse and
19:45 which is why we had a lower success rate
19:49 when associated with this procedure
19:51 however for the right indication it is
19:53 still a wonderful procedure
19:55 along but it goes with a lot of
19:57 morbidities
20:00 uh we have the zetaplasty as well which
20:04 is a modification of the up3 where
20:06 we just raise a few flaps and you suture
20:09 in such a way to just to bring the
20:10 pallet up
20:12 forward and above
20:16 so that would create a dilated airway
20:20 well the surgery which has been in vogue
20:23 is the base of tongue rejection wherein
20:25 you would just
20:26 excise uh again with any sort of
20:29 instrument
20:30 this is again just completion because we
20:32 feel it is one of the safer methods
20:34 because
20:35 you're able to visualize your field and
20:38 you
20:38 could really really just reduce the
20:40 midline of the tongue
20:42 especially the lymphoid tissue you would
20:45 really really become
20:46 quite careful once you reach the muscle
20:48 muscular layer of the tongue
20:50 because that's where your lingual
20:51 arteries are and this is quite a complex
20:54 and a dangerous surgery because once the
20:56 lingual artery opens up
20:57 there's really really very limited ways
20:59 you can
21:00 control it and
21:03 so lymphoid tissue not a problem you
21:05 reduce the pace of time
21:07 you open up you do a volumetric
21:09 reduction
21:10 the patient really does quite well but
21:13 we have seen
21:13 eventually almost 20 to 30 percent
21:18 the these structures come back and we
21:20 land up with the same problem
21:25 so we if the epiglottis is the primary
21:28 cause of concern during snoring and the
21:30 epiclot is just falling upon itself
21:33 uh the rejective option was to just take
21:35 off the supra
21:36 portion of the epiglottis you chop that
21:38 off and the collapsibility decreases
21:41 the subsequent fibrosis of the remnant
21:44 of the epiglottis
21:46 also prevents any snoring
21:49 so that is quite a good procedure when
21:51 we talk about a pure
21:52 epiglottitis collapse when we come to
21:55 the least trusting that was really the
21:57 next era
21:58 i think it was uh heralded by
22:01 dr kenny bang and where he brought upon
22:04 the
22:05 procedure which is expansion sphincter
22:08 plastic
22:09 in this the first uh step of the surgery
22:13 is of course a tonsillectomy
22:15 this again just i'll just run through
22:18 this video
22:19 you first do a ton select me and this is
22:21 the end
22:22 of the ton select me so once you have
22:25 done the tonsillectomy
22:26 you basically section off a portion of
22:28 your palative fringes
22:30 muscle right at the junction of the
22:34 upper two third and the lower one third
22:37 once you do that
22:38 you take an absorbable stitch
22:41 through this portion of muscle and you
22:44 try to
22:46 anchor it laterally towards your telego
22:48 mandibular graphic
22:50 which is uh uh which is a oceans hold
22:54 so this was this would really pull up
22:56 the pallet
22:57 uh the soft palate pull up the entire
22:59 pallet of syringes muscle
23:01 and open up the airway laterally so you
23:05 would get an
23:05 excellent lateral expansion at the end
23:09 of this procedure so
23:10 you can see uh you just go back with the
23:13 suture back and forth once or twice
23:15 and you can really see why we like to
23:17 use the correlation because once you're
23:18 doing the
23:19 suturing techniques you do have quite a
23:22 good amount of bleeding now
23:24 in for example if you're doing a
23:25 conventional and you have to cauterize
23:27 this area
23:28 a suturing would really really become
23:30 quite a hassle
23:32 so this is just the same procedure on
23:34 the other side
23:37 sorry modified robinsons is a
23:41 another form where prior to this
23:44 suturing you would really with a
23:45 copulator you would just take off the
23:47 submucosal
23:49 fat and your miners are library clients
23:50 to just do a muscle to muscle
23:53 switching technique you also
23:56 have the tongue advancement procedures
23:58 we have the genoglossal advancement and
24:00 the higher suspension suspension
24:02 and there's just a video of the higher
24:04 suspension suspension
24:05 it's really really quite a simple and
24:07 effective procedure where we just
24:09 make a small neck incision isolate the
24:11 hyoid and the thyroid cartilage
24:13 and just take multiple non absorbable
24:15 sutures through it
24:17 usually we would take proline and just
24:19 stitch and tighten them together
24:21 that would bring the hyoid forward
24:24 and in as a consequence it would just
24:28 pull the gene across the base of tongue
24:30 forward with it
24:32 and with that you would get a good
24:34 retrolingual
24:36 dilatation for your genoglossus
24:39 advancement you just make a window in
24:42 the front
24:42 of your mandible you excise
24:46 where the bone with the drill where the
24:48 junior glasses
24:50 is inserted pull it out
24:53 rotate it 90 degrees and just screw it
24:55 in place and that achieves the same
24:56 effect
24:57 now this is quite a neat surgery
25:00 and but it's really dependent on
25:05 for how long the fibrosis and everything
25:07 would last
25:11 when i would now come to the next part
25:13 which is the remodeling
25:14 the simplest simplest remodeling uh form
25:17 is a lateral cylindroplasty
25:19 where you would
25:23 do a tonsillectomy first
25:27 and you would just suture the pillars
25:29 together at the end of the procedure
25:31 once you do that of course you try to
25:33 incorporate the muscle
25:34 within it so you get your excellent
25:37 lateral
25:38 uh expansion right there and this is one
25:40 of the simplest
25:42 methods but it's really effective
25:49 next uh or the pillar implants which
25:52 were quite invoke i will be discussing
25:54 the anterior palatoplasty in a bit
25:56 the pillow implants really never took
25:59 off but
26:00 it was a wonderful procedure it could be
26:02 done under local anesthesia
26:04 and this is a patient being done under
26:05 local where this patient had
26:08 excessively long soft palate a floppy
26:11 soft palate
26:12 we would just vibrate and the pillow
26:15 implants were basically
26:16[Music]
26:19 just inserted into the soft parrot at an
26:21 angle
26:22 and you would get these teflon pillars
26:26 which would just
26:27 uh provide stiffness to the software and
26:29 prevents it prevent its collapse
26:31 and you can just see we do one in the
26:33 midline one on each side
26:35 and it's a very simple effective
26:37 procedure but however
26:38 it was never fda approved and
26:41 not really never really took off
26:47 i will be talking about the bob roman
26:49 blind switching technique in detail
26:52 but the future also uh
26:55 is the hyperglosses of stimulation where
26:58 you know
26:59 there are a lot of people doing it in
27:01 europe and
27:02 it's still not approved in india yet we
27:05 are still waiting
27:06 for it we have a couple of companies
27:08 based in the us as well
27:10 and with basically the patient would
27:13 whenever there would be a reduced um
27:15 chest movement or a drop in saturation
27:18 this there would be a hypoglossal nerve
27:20 implant which was
27:23 done through a small neck incision in
27:24 the submandibular region
27:26 and it would just give a small stimulus
27:30 for the hypoglossal nerve to contract
27:32 and that would really bring the tongue
27:34 forward and open up the airway
27:36 and prevent apnea
27:39 so uh this part of the lecture i would
27:42 like to dedicate to my mentor as well
27:44 i uh had the pleasure of working under
27:46 him for almost three months
27:48 and we had him here in india as well
27:51 professor mantovani
27:53 and i was introduced
27:56 uh to the barbed suture paletoplasty
27:58 technique
27:59 by him and
28:03 he unfortunately passed away quite
28:05 recently
28:07 so i would really like to dedicate this
28:08 part of the lecture to him
28:13 so uh he put forward this uh amazing
28:16 idea
28:18 where we would use a barbed suture which
28:20 is basically a knotless
28:22 uh non uh sorry absorbable pdo suture
28:26 and we would really uh talk about
28:30 lifting up the soft palate and anchoring
28:32 them to various bony
28:34 and fibroashes holes the bony holes that
28:36 he identified were your
28:38 injections with the heart palette soft
28:40 palate we have the terry got homeless
28:41 right here
28:42 and we add the delegate mandevilla rafi
28:44 so god had given us
28:46 basically a tube within the tube if you
28:48 could just stretch your imagination a
28:50 bit we would have the bony tube outside
28:52 and you have the soft collapsible inner
28:54 tube inside now
28:56 just expand
28:59 and hook these two together we would
29:01 reduce the collapsibility
29:03 so this is just running through the
29:05 anterior posterior collapse pattern the
29:07 first step
29:08 of this procedure would be to do an
29:10 anterior palateoplasty
29:12 then after that we will start switching
29:14 i'm just going to run through it
29:16 we would just start from the heart
29:18 pirates of parrot junction
29:20 go up to the periumula paratophyringes
29:22 insertion come back
29:24 close the anterior palatoplasty
29:28 hook it up laterally towards the
29:29 teleguard hammerless
29:31 and then just all the way back and that
29:34 would really really you know
29:36 uh tent up the soft palate
29:39 just so as to remove uh reduce its
29:41 collapsibility
29:43 and this is a video showing the same now
29:45 i have modified the technique
29:46 a little bit but i'm just going to run
29:49 through it
29:50 the first step is to of course
29:52[Music]
29:53 mark out the structures get your
29:55 markings the first step
29:56 after that is your anterior
29:58 parathyroplasty when a small window is
30:00 made in the soft palate
30:02 basically in the middle one third you
30:05 start
30:06 excising first the mucosa then you have
30:09 the submucosa fat
30:11 and your minus saliva glands till you
30:13 reach your muscle
30:14 muscle layer and that's where you stop
30:18 after that this is the barb technique
30:20 start from the heart palette soft palate
30:22 junction going down of course
30:25 because it's a bob you do not need to
30:27 take any knots so the patient compliance
30:29 is well
30:30 slightly better because the knots can be
30:33 really quite painful
30:35 so we close the anterior palateoplasty
30:37 side in
30:38 layers and this is an extra stretch
30:44 which i was taking right to this
30:47 terrible mandible
30:48 graphic and the beauty of this technique
30:50 is
30:51 it can be modular you can pick and
30:53 choose where you want to place your
30:54 sutures according to you
30:56 the findings that you find on your drug
30:57 and you sleep endoscopy
30:59 and this is basically what we have when
31:01 we've completed both sides
31:03 we do not need to not at the end of the
31:05 procedure you just cut the sutures where
31:06 they are
31:07 and they stay in place because of the
31:09 bark right there
31:11 and that's the beauty of it so you've
31:14 not violated any structure
31:15 at the end of the day you see your
31:17 yogurt pointed in back at me which i
31:19 like to call as the uvula salute to say
31:22 that you've done a decent
31:23 well i hope a half decent job
31:29 uh similar we have according to your
31:32 dice pattern
31:33 if we have a lateral collapse the social
31:35 technique slightly changes
31:37 of course we do it on select me but
31:39 first we go laterally
31:40 just to get your bony and fibrosis holes
31:43 in place
31:44 after that uh with your heart palette
31:47 soft pirate junction your terracotta
31:49 hamlets and your graphe
31:51 and then after that you basically just
31:53 take multiple sutures
31:54 on your posterior tonsil filler come
31:57 back to your rafi
32:00 come back to your hammerless then go all
32:02 the way back just do the same on the
32:04 other side
32:04 and it's really quite simple when you
32:09 see it like this this is a patient where
32:12 of course there is please forgive me for
32:15 some edema there
32:16 this patient had some injury during the
32:18 surgery
32:20 well of course
32:23 again the markings take place of all
32:26 your
32:27 anatomy we again start off with the
32:29 heart palette soft palate junction
32:31 right there we go down head towards a
32:34 uvula
32:35 this was a patient where of course i
32:37 wanted to take
32:38 the periuvular tissue because the
32:40 posterior tonsil
32:41 pillar was really really quite bulky and
32:43 i wanted that upward pull as well
32:48 you can see the period pallet of hinges
32:51 being engaged
32:52 and after that you really come laterally
32:56 you try to engage the periosteum of your
32:59 terry got hammerless
33:00 to get that solid osseous hold
33:05 once you've done that you just travel in
33:07 a swiveling movement along your raphe
33:09 try to get
33:10 as much as of the fibers as possible
33:13 engaged
33:15 once you head down and you've completed
33:18 your
33:19 rafa involvement then you just go
33:22 laterally this is me going to the
33:25 anterior pillar
33:26 the next step would be to engage as as
33:29 much of the
33:30 posterior tonsillar pillow muscle as
33:32 possible
33:37 so this is just re-engaging the muscle
33:38 once more and hooking all this
33:41 laterally
33:46 so the suturing looks quite simple but
33:50 in the confined area and especially in
33:52 the
33:53 case of sleep partners it can be a
33:55 slight issue
33:56 getting a good visualization at all
33:59 times it's definitely easier with a
34:02 headlight
34:02 but of course we don't have the luxury
34:04 of getting recordings then
34:07 so this is done under the microscope and
34:10 at the end
34:11 you can just see that uh
34:14 you see the lateral collapse right there
34:16 if you can appreciate i'm just going to
34:17 run through the starting of the video
34:18 you see the bulky
34:20 tonsillar pillars and you see the end
34:23 result with a good
34:24 natural expansion
34:30 the combination of these two techniques
34:31 is basically the allianza
34:33 technique wherein this is done for your
34:36 concentric collapse of the retropalative
34:38 region
34:39 the first step is your anterior
34:41 palatoplasty and then you just
34:43 start socially again from the familiar
34:46 heart palette soft palate junction go
34:49 back
34:50 periovular palate of fringes close the
34:52 anterior
34:54 paletoplasty site along the way
34:57 once you've done that head to your
34:59 hamless
35:00 then engage your graphic complete your
35:03 uh
35:04 lateral expansion with the similar
35:06 surgery go back to your hammerless
35:09 and then go back to your heart balance
35:11 soft palate junction
35:13 same thing repeated on the other side
35:16 and you get a good
35:17 uh expansion uh holistic exam
35:20 expansion of your soft palate i'm just
35:23 going to let this this just a two minute
35:25 video i'm just going to let this run out
35:27 so this is the first step is your
35:30 ton select me of course we're using the
35:32 corporation again
35:37 so the left one the right one once we
35:40 are done
35:41 uh using the copulator for the anterior
35:44 palatoplasty in this
35:46 we expose the muscle mark out
35:50 our bony landmarks and your raphe
35:55 when you start suturing me being
35:58 right-handed
35:59 it's slightly easier to go on the left
36:01 side first
36:02 the first bite is basically
36:06 hard palate soft palate to your anterior
36:07 palatoplasty close it along the way
36:11 head downwards to your peripheral palate
36:13 of fringes
36:15 hook that muscle fiber right there and
36:18 try and come back towards your alcohol
36:20 hemorrhage trying to
36:21 engage the periosteum next step
36:24 going back to your deregula mandibular
36:27 raphae
36:28 encircling the fibers engaging the
36:30 fibers as much as possible
36:32 in a swiveling movement you see the hand
36:34 movement going right there
36:38 once you go downwards
36:42 then you engage your posterior tonsil
36:44 pillar to really get that good
36:46 um lateral expansion right there
36:52 and you bring those sutures back right
36:54 towards your telegram mandible raffle
36:57 make your way back to your hammers try
36:59 to engage the periosteum once more just
37:01 to get a
37:02 nice firm hold in there
37:06 and you make your way back to your heart
37:09 balance off that junction
37:11 and this just me completing the
37:13 procedure on the other side just cut the
37:15 sutures at the end
37:21 and you can see that uh uvular solute
37:25 sign
37:25 at the end where it's just looking up
37:27 after the expansion and you get a good
37:30 um anterior posterior as well as a
37:32 lateral
37:33 expansion so the advantages of bob
37:37 according to me
37:38 well it's modeler you can really do your
37:41 suturing
37:42 as in where you find the obstruction
37:44 based on your dies
37:45 it is reversible because if the patient
37:47 doesn't tolerate it you can
37:49 simply divide the sugar and just pull it
37:51 out the bob really really engage in one
37:54 direction the other direction they can
37:55 just pull it out
37:57 it's repeatable because uh
38:00 well with a long enough experience in
38:02 sleep apnea surgery you know that these
38:04 patients come back
38:06 they may not come back in six months
38:08 they may not come back in
38:09 a couple of years they put but they'll
38:11 definitely come back within 10 years
38:14 so it's a repeatable process you can
38:17 obviously do that
38:18 it has a lesser modality because you're
38:20 not excising or cutting
38:22 or dividing any muscle and
38:25 there have been plenty of studies based
38:27 uh on that the long-term effects of
38:29 cutting the palatal pharynges
38:31 uh there are quite
38:34 problematic issues of cutting the uvula
38:36 as well
38:38 and the best part is based on multiple
38:40 bony landmarks
38:43 there are quite a few procedures which
38:45 are based on just the pterygomandibular
38:47 raphe
38:48 now terry commander raphae is a fibrous
38:51 um condensation so it's really not
38:55 going to be as good a hold as a
38:58 periosteum of a bone let's say
39:01 so once you have multiple holy landmarks
39:03 you're
39:04 anchoring your soft palate too the
39:07 surgeon
39:08 can have a better sleep at night
39:13 well uh coming to the last part we do
39:15 have the skeletal malformation which
39:17 have to be treated
39:18 so whatever technique you want to
39:21 present
39:21 remodel or re-innovate if the problem is
39:25 a small box
39:26 where you have a smaller airway because
39:30 of maxilla or
39:31 mandibular hypoplasias or retrognathism
39:35 none of these procedures are really
39:37 going to work till you expand the airway
39:39 and once you expand everything really
39:40 opens up
39:41 you don't need to do anything else so
39:44 this is just a schematic
39:48 diagram we i'll also be talking about
39:50 the devices
39:54 the post-op essentials of course
39:56 emergency trick asked me
39:57 it should always be at hand um
40:01 in our center we usually uh whenever we
40:04 do
40:04 that's the base of town we like to keep
40:06 the patient intubated for at least 12
40:08 hours
40:09 wait for the admiral subside and only
40:11 then should extubation be attempted
40:13 with um the preparation for a
40:17 fiber optic laryngoscope as well as a
40:19 tricky osmium at hand
40:20 during extubation npr state for 24
40:24 hours is a must because these patients
40:26 are going to have swallowing issues
40:27 they're going to have as
40:28 mild mild aspiration uh issues after
40:31 extubation pain and swallowing
40:34 management is a must and
40:35 we really really cancel that pain is
40:38 going to be a feature of the surgery for
40:39 at least four weeks
40:41 uh swallowing management of course it
40:43 has to be uh
40:44 calibrated quite slowly and the patient
40:46 should be encouraged liquids first
40:49 either with a slow with a straw sorry or
40:52 going on later to soft diet
40:56 we generally as a matter of protocol we
40:58 repeat the sleep study and assessment
41:00 after three months to really categorize
41:02 what kind of a
41:03 result that we have given
41:06 now coming to uh just devices this is i
41:09 know this is not my topic but i found it
41:11 too interesting
41:13 so especially in children just on a side
41:15 note
41:16 we do have your ad in our tonsils but we
41:18 do have syndromic children where we have
41:20 maxillary and mandibular hyperplasias
41:23 especially and in chronic android kids
41:26 we do see a high arch palette
41:28 we have crowded upper teeth and these
41:31 are
41:31 patients where the maxilla really really
41:34 becomes
41:34 quite hypoplastic so devices are a
41:39 very very interesting and a good way to
41:42 prevent not will not prevent or to treat
41:46 sleep apneas and snoring in children who
41:48 have this
41:49 malformation and of course we take care
41:51 of the future as well
41:53 so 8 to 15 is the idle years
41:56 are the ideal candidates and we have two
41:58 types we have the removable which is the
42:00 first and we have the fixed which is the
42:02 second
42:03 and we have the title ones as well when
42:06 just use a key to basically over the
42:09 years you just expand the
42:10 maxilla
42:13 similarly we have the mandibular
42:15 advancement devices
42:16 uh works on a simple similar dental
42:19 principle where the there's a gradual
42:22 distraction
42:22 of your mandibular to try a mandible to
42:26 try and bring it forward
42:27 once you do that your tongue really
42:30 really
42:30 gets out of the way of the airway and
42:33 these patients also do quite well
42:34 providing
42:35 provide the indication is
42:38 there now these can be quite viable
42:41 alternatives to your pace of tongue
42:43 rejection techniques and your
42:45 distraction techniques however these
42:47 have
42:48 a limit you can only really get
42:51[Music]
42:52 a slight amount of advancement before
42:54 you start having temporomandibular joint
42:57 problems just
43:00 in a nutshell just trying to summarize
43:03 we have
43:04 a modular treatment strategy and this is
43:07 a flowchart that we used to use quite a
43:10 long time back
43:11 where uh surgery cutoff would be would
43:14 be a bmi of 30
43:16 and your lower the ahi the better your
43:20 results mild moderate were the ones who
43:22 were taken up for surgery maybe just to
43:25 beef up our surgery success rates trying
43:28 to compete with the gold standard which
43:29 was
43:30 cpap at the time and in children if you
43:33 see i have not done so you would
43:35 straight away go for surgery
43:37 any other problem giving let's say a 10
43:40 year old tells cpap are we doing
43:42 him or her justice no
43:46 well in the end uh it this really is a
43:49 complex disorder and
43:51 a multi-disciplinary approach which
43:53 includes the sleep physician
43:55 your chest physician your um
43:59 your dentist your ent surgeon
44:02 everyone should really work hand in hand
44:04 to manage
44:06 the patient who's really suffering and
44:08 uh
44:09 cpap and surgery are synergistic and
44:12 complementary to one another just
44:14 as almost all the ent surgeons and you
44:16 know
44:17 once we have a patient with the
44:18 conductive hearing loss the patient
44:21 has the option of a hearing aid
44:22 throughout life
44:25 but on the other hand we can do us a
44:27 simple surgery which is stapes
44:28 and cure the patient so there are
44:31 exceptions but we need to work together
44:36 uh and just to sign off every patient is
44:39 different
44:40 we need to look at every patient as an
44:43 individual
44:45 as a different individual and treat them
44:48 differently with whatever tools you have
44:50 at hand
44:52 and i would like to sign off with this
44:53 wonderful quote by
44:56 shakespeare and thank you so much
45:04 i find it very educational many thanks
45:05 for that um
45:08 you might start with my first question
45:09 i'm not sure if you know or not in the
45:11 nhs we're a bit tight with money
45:14 we're a bit limited in what we can do in
45:16 terms of snoring surgery
45:18 uh partly of that is there was a
45:21 question about the
45:22 long term outcomes of
45:25 surgery what are your thoughts about
45:27 that how do you have the same problems
45:28 in india did you how did you navigate it
45:31 what was your thought well um according
45:34 to every
45:34 um literature source i mean success of
45:38 surgery for snoring is basically
45:40 reduction of 50
45:41 in the ahi score right and that was
45:44 really
45:45 really the um yardstick by which we
45:48 would charge surgery but really that's
45:50 not the case
45:52 uh nowadays we do our
45:55 repeat questionnaires if you could
45:57 really really improve the quality of
45:58 life of the patient i think that's far
46:00 more important than the
46:02 some objective measure like an agile
46:05 the more important index in my
46:08 opinion is to raise the baseline oxygen
46:11 saturation
46:12 because that really prevents any
46:14 long-term uh
46:15 sequelae because once you have that if
46:18 you can improve that a patient who has a
46:20 60
46:21 baseline uh during sleep if you can
46:24 bring it up to 80 85
46:25 well the recommended is 92 however if
46:28 you can bring it to even 8085 that's
46:30 good
46:31 in addition we cancel all our patients
46:34 that you know apart from the static
46:36 obstructions
46:37 your tonsils adenoids where you can
46:38 literally cure the patient
46:40 right rest of the surgeries are adjuncts
46:43 they are meant to be
46:46 a cure in just a few but they're meant
46:49 to be adjuncts to their cpap therapy
46:51 so we always give the patient a cpap
46:53 trial before if the pressures are too
46:55 high
46:56 the physician sends them to us they
46:58 undergo
46:59 some sort of surgery wherein we can
47:01 bring the pressures of the cpap down to
47:03 increase
47:05 the compliance so it's
47:08 it's a mixed bag i mean you know success
47:11 rate it's relative
47:13 that's true that's true and and do you
47:15 manage to get some of these patients off
47:17 the cpap
47:19 well yes yes um so for example uh one of
47:22 the patients that are shown especially
47:24 the
47:26 allianza bob technique now that patient
47:28 is off cpap he was on cpap and he was i
47:31 think on pressures of 12
47:32 if i'm not mistaken i'm sorry might be
47:34 wrong
47:35 but he was off cpap and his ahi dropped
47:38 to six
47:39 which is still well in the mild category
47:41 but he really did not need
47:43 the cpap after that well after that he
47:46 went
47:46 to his um weight loss regimens and lost
47:50 a lot of weight that helped
47:53 great that's good good good to know um
47:55 so a few questions from the
47:57 attendees a question from andrea
48:00 does the barbed treated patients have
48:02 nasal regurgitation
48:05 well uh hi andre that's a wonderful
48:07 question uh
48:08 well really uh if the regurgitation
48:12 happens
48:13 it's going to be temporary because once
48:15 um
48:16 it's never going to be permanent because
48:18 you're not cutting anything
48:19 the tissues are going to remain where
48:21 they are and
48:23 i personally after having well i've done
48:26 about 25
48:27 of these cases i've never had it
48:29 personally but according to all
48:30 literature yes it can be transient in
48:32 nature
48:35 great that's fantastic um the question
48:38 from kian kumar i'm not sure
48:40 maybe you can elaborate on what this can
48:42 is
48:43 d-i-s-e dice is that something you guys
48:46 use
48:47 anyway done post-operatively an osa
48:49 patient perhaps you can tell us what is
48:50 the ise that's the drug-induced sleep
48:53 endoscopy
48:54 in the we're talking about dice in the
48:57 post-operative period
48:58 and post-separatively well i i don't
49:01 think that's really indicated because
49:03 why take the patient to the or once
49:05 again unless and until he has a problem
49:07 if he has a problem or if there's a huge
49:09 failure of your surgery
49:11 then of course it's indicated otherwise
49:13 the awake
49:14 fiber optic laryngoscopy with all your
49:16 maneuvers in the obd
49:18 is as good a diagnostic tool i
49:21 a sleep study is mandatory at least in
49:24 our institution
49:28 and do you have any indications for
49:30 dicing pre-operatively in your in your
49:32 institution we always do that
49:34 that's a matter of protocol we always do
49:36 a dice before taking up a
49:37 uh for surgery to try and understand
49:40 exactly what's going on
49:42 and not rely on indirect measures alone
49:45 okay great a question from muhammad
49:49 if you have a deviated nasal septum and
49:51 the patient doesn't have sleep apnea
49:53 do you address the deviated nasal septum
49:55 first or would you try c
49:56 pipe first so i think the question
50:00 is really about this your single stage
50:02 and your multi-level surgery right
50:05 yes so earlier it was propagated that
50:08 you could do two major sites of surgery
50:12 and one minor wherein the nose would be
50:14 a major of course
50:16 you would have your palette or your
50:17 tongue or your epic lotus so these are
50:19 the four major
50:20 and you could do a minor procedure which
50:22 would just be a channeling or your
50:24 diathermy and you would really do two
50:27 plus one but now
50:29 there's enough uh evidence in literature
50:31 that you can go ahead
50:33 um doing a multi-level me personally
50:37 if i'm doing the nose i would not touch
50:40 the tongue
50:42 because nose i would have to pack in all
50:44 likelihood
50:46 and if i do a tongue base and that area
50:49 undergoes a lot of edema it's really
50:51 really uncomfortable for the patient and
50:54 for the surgeon as well to manage that
50:56 so okay so i would i would do as a
51:00 second
51:01 stage in almost any situation so you
51:03 state your surgery
51:04 to the nose and to the palate separately
51:07 valid
51:08 uh epic lotus everything is fine but
51:10 tongue i would
51:11 do separately that's my difference
51:16 good um a question from maryam shady if
51:19 you have a singer
51:20 and you you're doing snoring surgery for
51:23 that singer do you want
51:24 about vocal tract resonance change does
51:26 it and does it affect the resonance in
51:28 your experience
51:29 well yes it definitely does so these are
51:32 things that you have to
51:33 really really get clear beforehand
51:36 because it could you could have a huge
51:37 lawsuit on your hands if
51:38 you spoil a single voice the resonance
51:41 is really really important to them
51:44 right uh and a question from a doctor
51:49 sin could an orthognathic surgery speed
51:53 up
51:53 the treatment for the patient instead of
51:56 advice and activating it
51:58 daily definitely that was
52:02 what i was touching upon at the end they
52:04 are
52:05 your advancement procedures your
52:07 maxillary and mandible
52:08 they're really really uh wonderful i
52:11 personally being an ert surgeon those
52:13 things are
52:14 being taken care of by a oral surgery
52:17 department
52:18 so i personally don't have videos for
52:20 those procedures
52:22 but they're really really beneficial if
52:24 done for the correct
52:25 indication if you really have a good
52:28 normally placed uh
52:30 maxilla or a mandible you can't really
52:33 advance it too much
52:34 before you cause a problem so i mean
52:37 there's a
52:38 fine palace it has to be indicated but
52:40 that's really nice
52:43 good and question from muslim minimum
52:45 age for bob
52:46 pallatoplasty do you have any in mind
52:49 i uh we're talking about bob
52:52 right yeah the minimum i have done is
52:55 four years so
52:57 okay yeah and and from your experience
53:00 how common is being a pharyngeal
53:02 institution in you triple b
53:05 well uh according to literature it's not
53:08 much as long as you stay below
53:11 the level of your
53:15 your levators um
53:18 but in actual practice there is some
53:20 nasal legal station
53:21 about 30 to 35 okay
53:25 and that's usually temporary
53:28 well yes usually yes as long as you stay
53:30 below that level which i'm sure
53:32 most of the surgeons would it's usually
53:34 temporary
53:36 as well i think that's similar as us the
53:38 same sort of
53:39 merriam shady a similar question about
53:41 hypernessality and
53:42 and velopharyngeal sufficiencies along
53:45 the same lines
53:46 um a question from star
53:50 waisi and any indication for posterior
53:53 pharyngeal diathermy
53:57 we did it did not really find too much
54:00 of use because what you
54:01 basically it's it's really really um
54:05 thin muscle layer anyway in your
54:07 posterior tonsillar pillar
54:08 so doing diathermy there is really not
54:10 achieving too much
54:12 so it's either you're cutting that
54:14 muscle dividing the muscle or you're
54:15 rejecting or you're remodeling it in
54:17 some way
54:18 just doing a some mucosal really does
54:21 not
54:22 we did not have any at least personally
54:24 we did not have encouraging results
54:28 and and from the experiences do you find
54:30 is there much of a difference like you
54:32 mentioned tron selecting me is the main
54:33 aspect if it is tons of hypertrophy
54:36 contributing factor and then
54:37 the other maneuvers are sort of adjuncts
54:40 in your experience if you find one
54:41 adjunct
54:42 one of these maneuvers particularly more
54:43 useful than the others
54:45 that you would sort of your go to for
54:47 political side of things
54:49 uh no it really uh it's uh whatever the
54:53 situation
54:54 demands like you know uh let me just
54:58 take an example okay tonsillectomy is
55:00 the cornerstone you have to take out the
55:02 tonsils when you're talking about sleep
55:03 surgeries right
55:04 after that when you concentrate toward
55:06 your palate um
55:08 and let's say you have a concentric
55:10 collapse you know let's take the worst
55:11 case scenario
55:13 if your palate uh is
55:16 collapsing but it's thin and
55:20 there's not too much of muscle bulk then
55:22 i would go with above
55:24 right if there's a lot of muscle layer
55:28 and the muscle is itself quite bulky
55:31 then
55:32 in my personal experience the suturing
55:34 is not the best
55:35 then i would do the expansion sphincter
55:37 or peltoplasty
55:39 plus your anterior paralleloplasty right
55:43 then if you really if i uh find that
55:46 the soft tissue is just too redundant
55:49 you have a lot of
55:50 uh mucosal uh hypotrophy
55:53 of your soft palate you see your muscle
55:55 layer right here and you see your
55:57 mucosa heading almost a centimeter half
56:00 down then that probably in my mind is
56:03 the indication for a
56:05 modified new vp so it's quite a dynamic
56:08 situation and again if there's not one
56:10 clear
56:13 thing that i can advise if that helps
56:16 sure so a couple more questions so one
56:18 is someone's asking wait do you
56:20 are the old videos are your own videos
56:22 or are they
56:23 available on the internet well uh
56:27 apart from the animation they're all
56:29 ours
56:31 okay uh so i suspect maybe youtube will
56:34 have something about the about
56:35 procedure technique if you want to
56:37 educate yourself with that
56:39 and
56:42 one the perhaps last couple so one of
56:46 those is going when are you going to
56:47 repeat
56:48 the above procedure after the primary
56:51 procedure
56:52 if you do need to repeat it okay
56:55 so in theory these sutures uh what we're
56:58 using the pto sutures
57:00 they're supposed to um dissolve at the
57:03 end of six months
57:04 right now um in that
57:07 in in in the intervening period they
57:10 become really quite integrated with soft
57:12 tissue
57:13 so six months absolutely no after that
57:16 you have to give it time to
57:17 develop fibrosis because what you're
57:19 really doing with these sutures
57:20 it's not just the sutures which are
57:22 pulling it's a directed fibrosis
57:24 of the submucosal and your muscle layer
57:28 which will eventually tent up those um
57:31 soft palatal
57:32 um soft tissue and prevent its
57:35 collapsibility so you have
57:36 fibrosis to step in next
57:40 so that takes about a year year and a
57:42 half so you're good to go for
57:43 at least two years till now uh
57:46 i personally have not had to repeat but
57:49 i had a huge
57:50 uh talk with professor mantovani when i
57:53 was there and he said
57:54 uh well give it two years after that if
57:57 you still feel that
57:58 uh you know it's not working then go
58:01 ahead and do it
58:02 so that was his word
58:05 and then a question from kian would
58:08 would you choose between dice or
58:11 sleep on mri which would be or would be
58:13 your problem
58:14 okay in our center sleep mri is
58:17 virtually impossible because
58:19 our hospital um our mri machine is
58:23 barely free
58:24 they won't give it to us for 12 hours
58:26 sending a patient
58:27 outside it's well not feasible
58:31 so we prefer doing the dies and of
58:33 course being surgeons we would like to
58:34 see ourselves what's happening
58:37 holistically when we're talking about
58:39 multi-level obstruction because the
58:40 situation is really quite dynamic
58:42 ideally i would like to have sleep mri
58:47 but that's just not possible for us okay
58:50 great and then uh
58:51 the last question will be a good one to
58:52 end with is
58:54 from tashita what is your advice for a
58:56 junior surgeon who wants to pursue
58:58 sleep medicine and sleep surgery as a
59:00 career how to go forward
59:03 um well well apart from this
59:07 virus thing which has just happened
59:08 recently and there's so many fellowships
59:11 up and about and they're wonderful in
59:13 our country itself we've
59:14 uh had this has we have this association
59:18 for sleep surgeons and we offer
59:20 um fellowships maybe two fellows
59:23 a year and they undergo training around
59:26 the country are at various centers our
59:28 center being
59:28 one of them so uh i would suggest you
59:31 know
59:32 um fellowships are the way to go
59:35 there are a lot of cadaver detection
59:36 courses which are now being offered as
59:38 well
59:39 which are really really help you get the
59:42 feel of things
59:44 and well as with any surgery after that
59:49 just you will just have to take the
59:51 plunge and
59:52 get on to it very true that's kind of
59:55 goes with any surgery really
59:57 uh well i only have time to to thank you
59:59 really for your wonderful talk i mean i
01:00:01 appreciate your time particularly this
01:00:03 late tonight i'm sure it's
01:00:04 way past that time for most people maybe
01:00:07 not for you but for most people as far
01:00:08 as about time in india
01:00:10 um so i'm really grateful for your time
01:00:12 and thank you very much
01:00:14 thank you thank you so much for having
01:00:15 me thank you everybody
💫 FAQs about This YouTube Video
1. What are the key advantages of the BOSS and bimodal sleep surgery techniques for treating sleep apnea?
The key advantages of the BOSS and bimodal sleep surgery techniques for treating sleep apnea are their ability to address upper airway obstruction, the consideration of individual patient anatomy, and the potential for reducing the reliance on CPAP therapy. These techniques offer a comprehensive approach to sleep surgery and can be effective in improving the quality of life for patients with sleep apnea.
2. How important is the evaluation of skeletal factors in sleep surgery, and what are the implications for further treatment?
The evaluation of skeletal factors in sleep surgery is crucial as it helps determine the appropriate treatment options and their potential success. Skeletal factors can have significant implications for further treatment, highlighting the need for a personalized approach based on the specific anatomy and condition of the patient. By considering skeletal factors, surgeons can better tailor their interventions to achieve optimal outcomes in sleep apnea management.
3. What role do devices play in the treatment of sleep apnea, and how are they used in conjunction with surgical interventions?
Devices play a significant role in the treatment of sleep apnea, particularly in cases where surgical interventions are complemented by other modalities. For example, mandibular advancement devices can be used in conjunction with surgery to enhance airway stability and improve breathing during sleep. The coordinated use of devices and surgical approaches reflects the multi-faceted nature of sleep apnea treatment, allowing for customized and comprehensive management strategies.
4. How does the concept of bimodal sleep surgery contribute to a more personalized and effective approach for patients with sleep apnea?
The concept of bimodal sleep surgery contributes to a more personalized and effective approach for patients with sleep apnea by integrating different surgical techniques to address specific anatomical and physiological factors. This comprehensive strategy recognizes the varied nature of sleep apnea and enables surgeons to tailor their interventions based on individual patient needs, ultimately enhancing the success and satisfaction of the treatment outcomes.
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