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Headache, TMJ, Sleep medicine Flashcards

1
Q

List 8 differential diagnosis of early morning headache

A
  1. Cluster headache
  2. Glaucoma
  3. Sinusitis
  4. Bruxism in TMJ syndrome
  5. OSA
  6. Cervical spondylosis
  7. Diabetes mellitus
  8. Tumor

Think top-down: head, eyes, nose, teeth, throat, c-spine, pancreas

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2
Q

What are 3 red-flag symptoms for headache?

A
  1. Persistent morning headaches
  2. Associated with emesis
  3. Severe quality
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3
Q

List a differential diagnosis of headache

A

VASCULAR:
1. Migraine - with aura (classic), without aura (common), basilar (complicated)
2. Cluster
3. Mixed Migraine/tension

INFLAMMATORY/INFECTIOUS:
1. Sinusitis
2. Dental

INTRACRANIAL:
1. Traction - space occupying lesion
2. Vascular - Subarachnoid hemorrhage
3. Infectious - meningitis, encephalitis

OCULAR:
1. Oculomotor imbalance
2. Glaucoma

OTHER:
1. Muscular tension
2. Trigeminal neuralgia (Tic Douloureux)
3. TMJ dysfunction

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4
Q

What are the features of a subdural hematoma?

A
  1. Fluctuating LOC
  2. Moderate/severe hearing loss
  3. Associated with head trauma: battle’s sign, raccoon eyes, hemotympanum
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5
Q

What are the features of subdural hemorrhage?

A
  1. Thunderclap headache
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6
Q

What are the features of a headache associated with a brain tumor?

A

30% will have headache at diagnosis

  1. Intermittent, dull aching lateraling
  2. Worse with position changes, cough, straining
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7
Q

What are common causes of headache due to low ICP?

A
  1. Lumbar puncture
  2. CSF leak
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8
Q

Regarding chronic daily headache, discuss:
1. Symptoms
2. Associations
3. Treatment

A

SYMPTOMS:
- Daily, bilateral, frontal/occipital
- Non-throbbing
- Moderate/severe

ASSOCIATIONS:
1. Medications (increase or decrease use)
2. Prior history of migraine or tension headache

TREATMENT:
1. Complete medication withdrawal over 10 day taper
2. Antidepressants

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9
Q

List a differential diagnosis for headaches caused by CNS pathology (non tumor, non-meningitic)

What investigations can be done?

A

DIFFERENTIAL:
1. Epidural abscess
2. Fungal
3. TB
4. Luetic meningitis (syphillis)
5. CNS HIV

INVESTIGATIONS:
1. CSF VDRL
2. Cryptococcal antigen (toxoplasmosis)
3. ACE level
4. Bacterial/fungal/TB cultures

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10
Q

Regarding post-traumatic trigeminal neuralgia, discuss:
1. Pathophysiology / Cause
2. Risk factors
3. Clinical features
3. Treatment

A

PATHOPHYSIOLOGY:
- Post-traumatic/surgical cause of hyperactive sympathetic nervous system
- Sympathetically mediated - increased sympathetic tone

RISK FACTORS:
1. Poor wound closure
2. Infection
3. Fracture
4. Foreign body

CLINICAL FEATURES:
1. Hyperalgesia - pain to light stimulus that is not normally painful (Pain out of proportion to stimulus)
2. Hyperpathia - pain from repeated stimulation
3. Anesthesia dolorosa - Pain in numb area

TREATMENT:
1. Similar to trigeminal neuralgia
2. Bupivicaine injections can also be used

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11
Q

Regarding post-herpetic neuralgia, discuss:
1. Cause
2. Which nerve is most commonly affected?
3. Clinical presentation? What is the timing of post-herpetic neuralgia?
4. What is the treatment?

A

CAUSE: Reactivation of VZV (aka shingles)

LOCATION:
- Peripheral nerves most common
- Trigeminal nerve 2nd most common location

CLINICAL PRESENTATION:
- Neuralgia typically occurs 2 months post infection = post-herpetic
- Dermatomal pain & rash (#1 trunk, #2 trigeminal - look for keratitis, #3 facial - ear, facial paralysis

Treatment:
- TCAs; or
- Anticonvulsants
- Steroids if CN involvement
- Ophthalmology consult if V1 involved, to rule out keratitis/uveitis

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12
Q

What are features of atypical facial pain?
How do you treat this?

A
  1. Chronic burning/aching
  2. Non-focal
  3. Usually bilateral, not shock-like
  4. Psych history in 70%

TREATMENT: Amitriptyline

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13
Q

What is Tolosa Hunt syndrome?
What are the MRI features?
What is the treatment?

A

Tolosa Hunt syndrome (THS) - also known as painful ophthalmoplegia, recurrent ophthalmoplegia, or ophthalmoplegia syndrome - is described as severe and unilateral periorbital headaches associated with painful and restricted eye movements.
- Due to granulomatous inflammation in cavernous sinus, but may have secondary forms

FEATURES:
1. Unilateral headache, localized around eye on same side
2. Paresis of CN III, IV, and/or VI (ipsilateral)

MRI:
- Granulomatous inflammation in cavernous sinus of unknown etiology
- Rule out cavernous sinus thrombosis
- Secondary forms may be due to tumor, vasculitis, meningitis, sarcoid

TREATMENT:
- Responds to steroids in 36 hours

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14
Q

Regarding tension-type headaches, discuss:
1. Causes
2. Features
3. Treatment

A

TENSION-TYPE HEADACHE:
- Stress-related bilateral continuous non-pulsatile headache

CAUSE:
- Associated/precipitated by physical or psychological stress

CLINICAL PRESENTATION:
1. Bilateral squeezing feeling
2. Lasts days to weeks
3. Rare asssociated symptoms (n/v)
4. Can continue ADLs with headache

TREATMENT:
1. Somatic therapy (exercise, biofeedback)
2. Medications (NSAIDs, acetaminophen, NSAID combinations)
3. Preventative (antidepressants, muscle relaxants)

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15
Q

Regarding Cluster headaches, discuss:
1. Differential
2. Cause
3. Clinical presentation
4. Investigations
5. Treatment

A

DIFFERENTIAL:
1. Sluder syndrome (sphenopalatine neuralgia)
2. Trigeminal neuralgia
3. Migraine
4. Tension

CAUSE:
1. Strong male predominance

CLINICAL PRESENTATION:
1. Exposive onset of unilateral periorbital/retroorbital pain
2. Constant with burning quality
3. Lasts 15-180 minutes
4. Associated autonomic symptoms (nasal stuffiness, lacrimation, conjunctival injection)
5. Lacks N/V features

IMAGING: CT/MRI

TREATMENT:
1. Prophylactic
- Antihistamines
- Calcium channel blockers
- Ergotamine
- Lithium
- Methysergide
- Valproic acid
- Ranitidine

  1. Abortive treatment:
    - Sumatriptan
    - Intranasal lidocaine
    - Oxygen
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16
Q

Regarding Trigeminal Neuralgia, discuss:
1. Differential
2. Causes
3. Clinical presentation
4. Investigations
5. Treatment

A

DIFFERENTIAL:
1. Sluder’s syndrome
2. Cluster headache
3. Post-herpetic neuralgia
4. CPA tumor
5. Arachnoid cyst at CPA
6. Aneurysm
7. Trauma

CAUSES:
1. ?Vascular loop of superior cerebellar artery at pons
2. Pain of V2/3 most common

CLINICAL PRESENTATION:
1. Repeated brief attacks of severe, sharp, jabbing or lacinating unilateral facial pain (corner of nose, oral commissure also common locations)
2. Common in 5-7th decades
3. Typically in mandibular trigeminal division, followed by maxillary division
4. Trigger points are common
5. No CN impairment (facial numbness/weakness, loss of corneal reflex, change in taste/small, or others)

INVESTIGATIONS:
1. MRI with contrast
2. LP for patients with negative MRI or other symptoms

TREATMENT:
1. Medical
- Anticonvulsants (Carbamazepine - 1st line, Gabapentin, Phenytoin, Sodium Valproate)
- Baclofen (10-30mg TID)
2. Surgical
- Percutaneous Rhizotomy (surgical severance of nerve roots to relieve pain)
- Microvascular decompression

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17
Q

What is glossopharyngeal neuralgia? How is this treated?

A

Stabbing pain at soft palate, pharynx, ear and mastoid

Treatment: similar to trigeminal neuralgia

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18
Q

Define Sluder’s Syndrome

A
  1. Sphenopalatine neuralgia (V2/V3 + Parasympathetic)
  2. Localized facial pain
  3. Vasomotor abnormalities - lacrimation, rhinorrhea, salivation
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19
Q

What are other types of neuralgias besides trigeminal neuralgia that cause headaches?

A
  1. Post-traumatic neuralgia (2-6 months post injury)
    - Risk factors: Poor wound closure, foreign body, infection, hematoma
  2. Glossopharyngeal neuralgia
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20
Q

Regarding Giant Cell Temporal Arteritis, discuss:
1. What is it?
2. When is the common age of presentation?
3. What are the clinical features?
4. How is it diagnosed?
5. Treatment?
6. What are the complications/risks?

A

GIANT CELL TEMPORAL ARTERITIS:
- Small/medium vessel vasculitis (especially by the temple)
- Common age: > 50 years

CLINICAL PRESENTATION:
1. Headache, unilateral commonly (90%)
2. Tender temporal artery (50%)
3. Jaw claudication (muscle pain) (50%)
4. Lingual claudication (25%)
5. Blindness 1/3 if untreated (begins with amaurosis fugax; transient monocular vision loss with “curtain coming down”)
6. Visual field defects
7. CNIX, X, XII signs

DIAGNOSIS:
1. Temporal artery biopsy, need 1-1.5cm as can have skip lesions (false negative)
2. Elevated ESR (>50mm/hr)

DIAGNOSTIC CRITERIA: (Need 3/5)
1. Age > 50
2. New headache
3. Temporal artery clinical abnormality (ie. tenderness / temporal pain to palpation)
4. ESR > 50
5. Positive biopsy for GCA (must get 1-2cm piece minimum due to skip lesions)
- Histology: giant cells in tunica media; vasculitis

TREATMENT:
1. Systemic corticosteroids 60mg OD x 2 weeks then reassess

COMPLICATIONS:
1. Blindness in 30% if untreated
2. Carotid dissection
3. Vessel aneurysms

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21
Q

Regarding Temporal mandibular joint pain and dysfunction, discuss:
1. What is the epidemiology?
2. Causes/pathophysiology?
3. Symptoms?
4. Examination
5. Imaging workup

A

EPIDEMIOLOGY:
- 5-15% (only 2% seek treatment)
- Most common in 20-40s

CAUSE/PATHOPHYSIOLOGY:
- Normal opening at incisors - 40-55mm, less in women and decreases with age
- Muscle pain more common than intraarticular pain, but interplay of both
- Can develop a chronic pain state (fibromyalgia)
- Intracapsular pain - Disc/condylar fossa problem with joint noise, limited mobility

SYMPTOMS:
1. Facial pain
2. Headaches
3. Otalgia, aural fullness
4. Clicking/popping
5. MIld hearing loss, tinnitus, dizziness
6. Trismus
7. Trouble with chewing and speech
8. Wear of occlusion of teeth
9. Psychosocial - present with pain, stress and depression beyond normally expected

EXAM:
1. Palpation of muscles and joint
2. Document the maximum painless and painful opening, as well as maximum passive ROM (distance between incisors)
3. Opening should be smooth, pain free and wihtout noise or deviation
4. Internal derangement (displacement) - deviation to side of obstruction; if displacement then returns to midline, implies early displacement with reduction; if entire ROM then no reduction
5. Lateral excursion movements - decrease in direction away from pathology if non-reducing; equal movement implies muscular pathology
6. Intraoral inspection and palpation: look at teeth and mucosa of tongue

IMAGING:
1. Panorex (rule out fractures, arthritis, tumors, cysts, or malformations)
2. CT for soft tissues

Vancouver notes page 35

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22
Q

What are the three classes of internal derangements of the TMJ?

A
  • Disruption of the different ligamentous attachments along with the lateral pterygoid vector of force
  • Can be caused by structural weakness, trauma, or hyperextension
  • Scale correlates with outcome prognosis - earlier the click, the less displaced the disk
  1. ANTERIOR DISPLACEMENT WITH REDUCTION ON OPENING THE MOUTH
    - Clicking and popping
    - Can be painful or painless
    - Treat pain with NSAIDs, bite block appliance, muscle relaxant PRN for pterygoid spasm (#1 anterior medial - lateral pterygoid)
  2. ANTERIOR DISPLACEMENT WITHOUT REDUCTION ON ATTEMPTED MOUTH OPENING
    - Locking
    - Treat with arthroscopic lysis and lavage
    - Open mobilization or removal with replacement
  3. DISC ADHESION TO THE ARTICULAR EMINNECE
    - LImitation of mouth opening
    - Treat with arthroscopic lysis of adhesions and lavage
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23
Q

What are 6 causes of mandible ankylosis (stiffening, immobility)?
What are the different types?
What is the main mode of investigation?
What are the treatment options?

A

CAUSES:
1. External trauma
2. Infectious arthritis
3. Rheumatoid arthritis
4. Condylar degeneration
5. Osteoradionecrosis
6. Congenital: Branchial arch anomalies, hemifacial microsomia, condylar aplasia/hypoplasia

TYPES:
1. Fibrous - chronic infection/disease
2. Bony - lateral to zygomatic arch

INVESTIGATIONS:
1. MRI is gold standard

TREATMENT:
1. Arthroscopic vs. open surgical mangement
2. Condylectomy with costochondral cartilage
3. Arthroplasty (fossa) - auricular cartilage, temporal flap, pericranial flap
4. Post-operative physio is essential to achieving favourable outcome

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24
Q

Regarding TMJ hypermobility, discuss:
1. Causes
2. Treatment

A

CAUSES:
- Subluxation or dislocation from yawning, prolonged opening (e.g. seizure, trauma)

TREATMENT:
- Usually self-reduced in subluxation (partial dislocation)
- Dislocation needs manual relocation - urgently as becomes more difficult later
- With repeated subluxation may need a osteotomy of zygomatic arch (Le Clerc procedure) or lateral pterygoid myotomy

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25
Q

Discuss the overall management of TMJ dysfunction

A
  1. Education, set expectations
  2. Most are self-limiting
  3. No good evidence for any one type of treatment
  4. NSAIDs
  5. Muscle relaxants
  6. Dietary
  7. Physical therapy (heat, ice, exercise)
  8. Massage or behavioural (grinding/clenching)
  9. Pain services, dentistry
  10. Botox for hyperactive masticatory system (dystonia)
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26
Q

Describe the surgical options for TMJ dysfunction

A

CLOSED APPROACHES
1. Arthrocentesis
- Can inject steroids or sodium hyaluronate
- Can dilute inflammatory mediators
- Can alleviate negative pressure causing disc adherence

  1. Arthroscopy - diagnostic tool
    - Removes scar
    - Improves ROM and decreases pain
    - Stretch capsular ligament
    - Lysis of adhesions

OPEN APPROACHES
1. Arthrotomy
- Reserved for ankylosis, tumor resection, trauma, growth disturbances or severe degenerative disease

  1. Reconstruction
    - Congenital or developmental deformity, Tumor, Severe degeneration or ankylosis
    - Uses autografts (costocondral) or alloplastic joint replacement
    - Joint replacements have limiited success with few FDA approved
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27
Q

What is Bruxism?
What are the treatment options?

A

BRUXISM:
- Myofascial pain from parafunction
- Parafunction includes activities such as thumb sucking, finger sucking, tongue thrusting or object sucking, teeth grinding

TREATMENT OPTIONS:
1. Positional appliances (have been effective in protecting dentition and offloading)
2. Soft splints for bruxism
3. Repositioning splints - can cause joint noise and pain
4. Bite plane splints - can change occlusion in long term

Cochrane review does not favour appliances either way

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28
Q

Describe the normal sleep architecture stages. How long is sleep time?

A
  • Non-REM: 3 stages, with stage 3 being the deepest (muscle tone maintained)
  • REM: Active or rapid eye movement (characteristic EEG pattern, central and peripheral hypotonia); 20-25% of sleep

Normal latency to REM ~90 minutes
More frequent and longer REM cycles as night progresses

Sleep time:
1. Infants: 14-16 hours
2. Children: ~9 hours
3. Adults: 7-8 hours

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29
Q

What are the theoried functions of sleep?

A
  1. Inactivity (“hide”)
  2. Conservation (“save energy”)
  3. Restoration (“repair and grow”)
  4. Brain development (“plasticity”)
30
Q

Describe the 5 main stages of sleep, their PSG characteristics, clinical characteristics, and % of sleep.

A

W Stage:
- PSG: Beta-waves and alpha waves in relaxed state
- Clinical: Wakefulness and drowsiness
- % sleep: n/a

NREM = 75-80% total sleep time

N1 Stage:
- PSG/EEG: low-amplitude mixed-frequency (LAMF), vertex, and theta waves, slow eye movements
- Clinical: Transitional sleep, drifting off, easily awakened
- < 5% sleep

N2 Stage:
- PSG/EEG: K complexes and spindle waves
- Clinical: Intermediate sleep, awakened by sound
- ~50% of sleep

N3 Stage:
- PSG/EEG: >20% slow wave (delta waves), minimal eye movements
- Clinical: Deep sleep, restorative sleep, first half of the night
- ~10% sleep

R Stage: 25% total sleep time
- PSG/EEG: Decreased EMG tone, ± REM, LAMF (N1 like), saw tooth waves
- Clinical: Easily awakened, stage occurs more often and for longer with more sleep time
- ~25% of sleep

Normal Progression of Sleep: Stage I - II - III - II - REM
Total cycle = 90 minutes, approx 4-5 cycles / night (duration of REM becomes longer as night goes on)

Kevan Gen #67

31
Q

Define the following sleep terms:
1. Apnea
2. Hypopnea
3. AHI
4. RDI
5. Apnea index
6. Respiratory Effort-Related Arousal (RERA)
7. Upper airway resistance syndrome
8. Sleep latency
9. Sleep efficiency

A

APNEA:
- 90-10 criteria: Decreased oronasal thermal sensor ≥ 90% for ≥ 10 seconds
- Obstructive = increased respiratory effort but no respiratory flow
- Central = No respiratory effort and no respiratory flow
- Mixed = Begin with absent resp effort, but effort resumes in the last portion of the event

HYPOPNEA:
1. 30-4 criteria
- Decreased nasal air pressure ≥ 30 % for ≥ 10 seconds, with at least 4% O2 desaturation
- No arousal
2. 30-3/arousal criteria
- Decreased nasal air pressure ≥ 30% for ≥ 10 seconds, with at least 3% O2 desaturation AND arousal

Apnea-Hypopnea Index (AHI):
- Average number of apneas and hypopneas per hour

Respiratory Disturbance Index (RDI):
- Number of apneas, hypopneas, and RERAs per hour period

Apnea Index:
- Average apneas/hour

Respiratory Effort-Related Arousal (RERA):
- 10 or more seconds of progressively increased respiratory effort leading to an arousal
- Gold standard for measuring = esophageal manometry (pattern of progressively increasing negative esophageal pressure following an arousal)

Upper airway resistance syndrome (UARS):
- < 5AHI but >10RERAs/hour, negative esophageal pressure

Sleep latency:
- Time from lights out to stage N1 (normal 10-30 minutes)

Sleep efficiency:
- [Total sleep time]/[total recorded time = 1 night] x 100 (normal 85-90%)

Two Differences between AHI and RDI
- RDI has RERA
- ?RDI calculates arousals in general
- Criteria definition for sleep apnea is different? (5 vs. 15, and symptoms/signs not required)

32
Q

What are the key elements of a sleep history, physical, and investigations?

A

HISTORY:
1. Pattern of sleep disturbance
2. Snoring
3. Apneas
4. Arousals
5. Onset or maintenance troubles
6. Duration of symptoms
7. Bed partner reports
8. Evidence: audio, video, spouse report
9. Consequences: daytime fatigue, memory, MVA, etc.
10. Sleep habits: distractions (E.g. TV), bed partners (kids, pets), naps, number of times out of bed at night, time in bed to go to sleep, time of awakening, total sleep time
11. ROS

PAST MEDICAL HISTORY:
1. Psych
2. Comorbidities (e.g. HTN)
3. Medications: OTC, prescription

SUBTANCES:
1. Caffeine
2. EtOH
3. Smoking
4. Drugs

SCORES:
1. STOP-BANG
2. Epworth Sleepiness Scale

PHYSICAL EXAM:
- Look at areas of potential obstruction: nasal, oropharynx/hypopharynx, larynx, neck, body habitus
- Cardiovascular signs
- Muller maneuver: Patient generates negative pressure by inhaling against a closed glottis with the nose and mouth closed to trigger airway collapse

INVESTIGATIONS:
1. Noctural Polysomnography PSG (gold standard for diagnosing OSA)
2. Multiple sleep latency test (MSLT) - test of sleepiness
3. Maintenance of wakefulness test (MWT) - test of sleepiness

Kevan Gen #69

33
Q

What are the symptoms characteristic of OSA in adults?

A

DAYTIME:
- Somnolence, fatigue
- Morning headache
- Dry mouth, sore throat
- Depression
- Memory loss
- Decreased cognition
- Impotence
- Motor vehicle accidents

NIGHT TIME:
- Snoring
- Witnessed apneas
- Gasping/choking
- Nocturia
- Insomnia
- Restlessness
- Sweating

34
Q

Define the diagnostic criteria for sleep apnea in adults (as per the ICSD-3)

A

A. AHI ≥ 5 with at least one of the following symptoms/signs:
1. Sleepiness, non-restorative sleep, fatigue, insomnia
2. Wakes with breath holding, gasping, choking
3. Bed partner observes habitual snoring, breathing interruptions
4. Systemic: HTN, Mood disorder, cognitive dysfunction, CAD, stroke, CHF, afib, T2DM

B. RDI ≥ 15, symptoms/signs not required

35
Q

Discuss the spectrum of sleep syndromes

A
  1. Primary Non-apneic snoring:
    - No daytime sleepiness or fatigue
    - AHI ≤ 4 with reduced subjective sleep quality
    - RDI < 5, SpO2 > 90%
  2. UARE / Upper airway resistance syndrome
    - As above, plus daytime fatigue
    - Low AHI < 5, ≥ 15 RERAs/hour
    - No desaturations but effortful arousal (SpO2 > 90%)
  3. OSAS
    - AHI > 5, SpO2 < 90%
  4. Obstructive sleep hypopnea syndrome
    - Hypopnea index ≥ 15
36
Q

Discuss Obesity-Hypoventilation Syndrome (Pickwickian Syndrome)

A
  • Diagnosis of exclusion

Diagnosis requires:
- Obesity, BMI ≥ 30kg/m^2
- Awake PaCO2 > 45mmHg

  • Majority of patients have sleep disordered breathing, but this is not required
  • 10-20% of obese patients with OSA have hypercapnea
  • Treatment: BiPAP
37
Q

List 16 risk factors for obstructive sleep apnea in adults

A
  1. Elderly (soft tissue laxity), age > 40 years old
  2. Male sex and post-menopausal femaes (risk equals males)
  3. South Asians
  4. Obesity (BMI > 30kg/m^2)
  5. Family history
  6. Anatomical considerations (e.g. neck circumference > 43cm males, 40cm females); narrow upper airway - large tonsils, retrognathia, large tongue/uvula, small mouth, nasal obstruction
  7. Marfan’s syndrome
  8. Myopathies
  9. Neural disease
  10. Allergies
  11. ApoE4 allele
  12. Left ventricular heart failure
  13. Smoking
  14. Alcohol
  15. Hypothyroidism
  16. Cognitive disorder

Typical phenotype: Obese male, over 40 with HTN and large neck

38
Q

What is the severity spectrum of OSA syndrome in adults vs pediatrics, based on AHI and saturation?

A

ADULTS:
1. Mild = AHI 5-14, sats > 85%
2. Moderate = AHI 15-29, sats 65-84%
3. Severe = AHI ≥ 30, sats < 64%

PEDIATRICS:
1. Normal = AHI ≤ 1, SpO2 nadir < 92%
2. Mild = AHI 1-5
3. Moderate = AHI 6-10
4. Severe: AHI > 10, SpO2 nadir < 80%

39
Q

What are the questions on the Epworth Sleepiness Scale and how do you score them?

A

Scoring:
0: No chance of dozing
1: Slight chance
2: Mild chance
3: High chance

Abnormal > 10
Significant daytime sleepiness > 18

  1. Inactive in a public place
  2. Passenger seat for 1 hour
  3. Watching TV
  4. Lying down in the afternoon
  5. Sitting and reading
  6. Sitting and talking
  7. Stopped in traffic for a few minutes
  8. Sitting quietly after lunch
40
Q

Describe the modified muller maneuvers. What 3 structures are being evaluated using this maneuver?

A

Forced inhaling effort by a patient with both the nose and mouth closed. The pharynx is observed with a scope

  1. Velopharynx (soft palate, lateral/post pharyngeal wall)
  2. Base of tongue
  3. Hypopharynx
41
Q

What are 8 craniofacial abnormalities associated with OSA? What are 4 main significant physical findings?

A
  1. Shortened anterior cranial base
  2. Retrognathia/macroglossia/micrognathia
  3. Increased distance between mandibular plane and low positioned hyoid (normal = 15mm or greater)
  4. Enlarged soft palate (elongated)
  5. Narrow posterior pharyngeal space (normal = 11mm or less)/ post nasal space
  6. Tonsillar hypertrophy
  7. Redundant pharyngeal mucosa
  8. Shortened thyromental distance

Other significant physical findings:
- Collar size ≥ 17 (male) 16 in female
- BMI
- Truncal obesity
- HTN

42
Q

What are 13 parameters that are possibly measured during a polysomnography?

A
  1. EEG (C3 or C4, O1 or O2, F1)
  2. EOG
  3. ECG
  4. EMG (submental and anterior tibial)
  5. O2 saturation oximetry
  6. EtCO2
  7. Nasal/oral airflow monitors (thermistors, nasal pressure transducers, or inductance plethysmography)
  8. Respiratory movement
  9. Body Position monitors
  10. BP
  11. Esophageal pressure (± useful for detection of RERAs)
  12. Thoracoabdominal effort
  13. Tracheal microphone
43
Q

Briefly describe the multiple sleep latency test

A

Test of sleepiness
- 5 scheduled daytime naps - calculate the average time to falling asleep
- More than 20 minutes normal, < 5 minutes severe sleepiness

44
Q

Briefly describe the maintenace of wakefulness test

A

Test of sleepiness
- In sleep lab - asked to stay awake –> time measured to falling asleep
- Less than 8 minutes before falling asleep is abnormal

45
Q

What are the classifications of sleep studies?

A

Type 1: ≥ 7 physiologic parameters monitored and sleep techician in attendance

Type 2: ≥ 7 physiologic parameters monitored, unattended (home portable monitors, full parameters as above)

Type 3: 4-6 physiologic parameters monitored, unattended (home portable monitors, limited parameters - usually airflow, effort, O2, HR)

Type 4: ≤ 3 physiologic parameters monitored, unattended (ie. basically just home oximetry)

Other:
- Whole night vs. Split night testing
- Multiple sleep latency test (historical)

46
Q

What are the indications and contraindications to home polysomnography (PSG) testing?

A

INDICATIONS:
1. Patients with a high pretest probability of moderate to severe OSA
2. Patients who cannot do in-lab PSG testing secondary to immobility, safety, or critical illness
3. To monitor response to non-CPAP treatments for OSA including oral appliances, upper airway surgery, and weight loss

CONTRAINDICATIONS:
1. Patients with significant comorbid medical conditions (moderate to severe pulmonary disease, NM disease, CHF, recent CVS accident, nocturnal hypoxemia requiring oxygen therapy)
2. Patients suspected to have other sleep disorders (CSA, periodic limb movement disorder, insomnia, parasomnias, circadian rhythm disorders, or narcolepsy)
3. General screening of asymptomatic patients

47
Q

What is the Fujita Classification of obstruction levels?

A

Divides the velohypopharynx into description levels:

  1. Type I: Retropalatal, posterior to the soft palate or velopharynx
  2. Type II: Both retropalatal and retrolingual, or velohypopharyngeal
  3. Type III: Retrolingual, posterior to the tongue base or hypopharyngeal
48
Q

Describe the Friedman tongue position scale

A

Based on Mallampati scale, but the tongue is kept INSIDE the mouth
- Ask patient to open mouth minimum 5 times, breathe normally while keeping the tongue in natural position

FTP 1: Entire uvula and tonsil/pillar seen
FTP 2a: Most of uvula but not the entire tonsil/pillar seen
FTP 2b: Uvula base and entire soft palate seen
FTP3: Part of the soft palate seen, distal soft palate not seen
FLP4: Only hard palate seen

Vancouver Page 65

49
Q

What is the Friedman tonsil grading system

A

Grade 0: Absence of tonsillar tissue
Grade 1: Tonsil within the pillars
Grade 2: Extended to the pillars
Grade 3: Extended past the pillars
Grade 4: Extended to the midline

50
Q

Describe the Friedman Staging System for OSA. What are the treatment recommendations per stage? What is the success rate of UPPP by stage?

A

Staging system for patients who have failed CPAP and/or would like to pursue OSA surgery

Consists of 3 variables, which are then assigned a stage based on a chart:
1. Friedman tongue position
2. Friedman tonsil size
3. BMI

STAGES (Chart):
Stage 1
- FTP: I, IIa/b
- Tonsil size: 3/4
- BMI < 40

Stage 2:
- FTP: I, IIa, IIb
- Tonsil size: 0-2
- BMI < 40

OR
- FTP: III or IV
- Tonsil size: 3 or 4
- BMI < 40

Stage 3:
- FTP: III or IV
- Tonsil size: 0-2
- BMI < 40

Stage 4:
- FTP: Any
- Tonsil size: 0-4
- Any patient with significant craniofacial or other anatomic abnormalities
- BMI > 40

TREATMENT RECOMMENDATIONS
1. Stage I: UPPP
2. Stage 2: Consider UPPP
3. Stage 3: Poor success with UPPP alone, evaluate (e.g. DICE) for multilevel OSA surgery
4. Stage 4: Not a surgical canddiate

Success rate of UPPP by stage:
1. Stage 1: 81%
2. Stage 2: 38%
3. Stage 3: 8%
4. Stage 4: Unlikely to have any improvement

Vancouver Page 66

51
Q

What are the 4 pharyngeal dilator muscles?

A
  1. Tensor veli palatini
  2. Genioglossus/hyoid
  3. Sternohyoid
  4. Anterior digastric
52
Q

What does STOP-BANG stand for?

A

Anesthesia tool for estimating risk of OSA

  1. S: Snoring
  2. T: Tired
  3. O: Observed Apnea
  4. P: Pressure (HTN)
  5. B: BMI > 35
  6. A: Age > 50
  7. N: Neck circumference > 16 inches
  8. G: Gender (1 for male)

Score:
1. > 4 - high risk of OSA
2. 3-4 - intermediate risk
3. 0-1 - low risk

53
Q

What is the triad of symptoms to suggest obstructive adenoid hyperplasia?

A
  1. Chronic nasal obstruction (obligate mouth breathing, snoring)
  2. Rhinorrhea
  3. Hyponasal speech
54
Q

What are 4 signs/symptoms of obstructive tonsillar hyperplasia?

A
  1. Enlarged tonsils
  2. Snoring
  3. Obstructive disturbances
  4. Dysphagia and voice changes
55
Q

What are the indications for treatment of OSA in adults?

A
  1. AHI ≥ 5 in presence of symptoms of excessive daytime sleepiness
  2. AHI ≥ 5 in presence of risk factors - cardiac disease, smoking, HTN, high cholesterol
  3. AHI ≥ 20 - associated with increased mortality
56
Q

List the surgical indications for OSA in adults

A
  1. Failed CPAP (claustrophobia, pulling mask off at night, air leak around)
  2. Improve CPAP compliance nasal procedures
  3. CPAP not practical (traveler, noncompliance, unwilling)
  4. AHI > 15, or AHI 5-14 with symptoms or comorbidities
  5. Surgically correctable significant anatomic upper airway obstruction
  6. Oxyhemoglobin desaturation < 90%
  7. Upper airway resistance syndrome (preferable with objective improvement of neurocognitive dysfunction and medical therapy)
  8. Significant cardiac arrhythmias associated with obstructions
  9. Medically stable enough to undergo recommended procedures
57
Q

Discuss 6 relative contraindications to OSA surgery in adults

A
  1. Severe obesity
  2. Severe cardiopulmonary disease
  3. Substance abuse
  4. Age
  5. Unrealistic outcomes
  6. Significant surgically uncorrectable (unfavourable) anatomy
58
Q

Discuss the overall management options for OSA in adults

A
  1. Conservative measures
  2. Nasal optimization (e.g. nasonex, breathe-right strips)
  3. Oral appliances (mild OSA): Tongue retaining or mandibular advancement/dental devices, nasal strips
  4. CPAP/BIPAP (Maximum 20cmH2O gold standard)
  5. Procedures/Surgery
59
Q

List conservative and medical therapy options for OSA in adults

A
  1. Lifestyle modifications: weight loss, smoking cessation, side sleeping, sleep hygiene and avoid triggers (alcohol, sedatives, caffeine, supine posture) - 10% weight loss reduces AHI by 26%
  2. Progesterone - Respiratory stimulant
  3. Acetazolamide - increases hydrogen concentration in blood
  4. Theophylline - increase hypoxic ventilatory drive
  5. Protriptylline (TCA)
  6. Oxygen therapy - CPAP/BIPAP
60
Q

What are the risks of OSA in adults?

A
  1. Increased mortality - 2.5x increase in motor vehicle accidents
  2. Increased CV disease - 3x HTN/CAD/CHF/Cor pulmonale/Arrhythmias/pHTN/Stroke/Sudden death)
  3. Neurocognitive deficits
  4. Increased GERD incidence (secondary to obesity?) - RERA with negative intrathoracic pressure
  5. Increased incidence of Diabetes (secondary to obesity?)
61
Q

What are the cardiopulmonary complications associated with OSA in adults?

A
  1. HTN
  2. MI
  3. Stroke
  4. Coronary artery disease
  5. Cor Pulmonale (right heart failure secondary to pulmonary HTN)
  6. Pulmonary HTN
  7. Chronic alveolar hypoventilation
62
Q

Discuss the nasal optimization options for CPAP

A
  1. Nasal topical corticosteroids
  2. Nasal splints, breathe right strips
  3. Turbinate reduction
  4. Septoplasty
  5. Rhinopalsty (correction of valve collapse)
63
Q

What are the possible reasons for CPAP failure or non-compliance in OSA?

A
  1. Claustrophobia, “suffocatiion”
  2. Insomnia
  3. Noisy
  4. Discomfort (chest, facial, nasal)
  5. Aerophagia (Excessive, repetitive airway swallowing)
  6. Mask issues: poor fit, abrasions, rash
  7. Nasal issues: epistaxis, rhinorrhea, congestion, dryness
  8. Spousal intolerance
  9. Inconvenience
64
Q

Name the different surgical procedure options for OSA in adults. What are some anesthetic considerations that need to be addressed?

A

NASAL:
1. Septoplasty
2. Nasal valve reconstruction
3. Turbinectomy/reduction
4. RFA turbinate reduction
5. Adenoidectomy

PALATAL:
1. Tonsillectomy
2. LAUP (Laser assisted uvula palatoplasty)
3. UPPP (Uvulopalatopharyngoplasty)
4. RAUP (Radiofrequency assisted uvulopalatoplasty with tonsillectomy)
5. Lateral pharyngoplasty
6. Transpalatal advancement pharyngoplasty
7. Tonsillar pillar implant (Dacron)

TONGUE BASE:
1. Genioglossal advancement
2. Hyoid myotomy and suspension
3. Tongue base suspension
4. Tongue base reduction/lingual tonsillectomy
5. Laser midline glossectomy
6. Thyrohyoidpexy
7. SMILE (Submucous minimally invasive lingual excision)

MAXILLOFACIAL:
1. Mandibular advancement
2. Maxillary advancement
3. Palatal expansion

OTHER:
1. Hypoglossal nerve stimulation
2. Tracheostomy
3. Bariatric surgery

ANESTHETIC CONSIDERATIONS:
1. Absolutely no pre-operative sedation
2. Both Anesthesia and surgeon must be present at induction
3. Availability of equipment for jet ventilation
4. Bronchoscopy
5. Oral/nasal airways
6. Tracheostomy

65
Q

What are 5 complications of maxillary mandibular advancement?

A
  1. V3 sensory disturbances
  2. Changes in facial appearance (the advancement performed in OSA surgery is much more greater than in orthognathic surgery)
  3. Hemorrhage
  4. Hardware extrusion
  5. Airway obstruction/pharyngeal edema
66
Q

What are the success rates of LAUP/UPPP procedures for snoring?

A

Immediate results = 85-90%
At 12 months = 45% success (all comers)

Success is higher in thin patients, with only retropalatal collapse, and have tonsillectomy performed

67
Q

What are 8 complications of UPPP?

A
  1. VPI
  2. Voice change
  3. Bleeding
  4. Nasopharyngeal stenosis
  5. Foreign body/globus sensation
  6. Oral candidiasis
  7. Perioperative upper airway obstruction
  8. Death from upper airway obstruction
68
Q

What are 6 contraindications of palatal procedures in mild OSA?

A
  1. VPI
  2. Bleeding disorder
  3. Voice/swallowing considerations
  4. Submucous cleft palate
  5. Prior XRT
  6. For LAUP, hyperactive gag reflux and retrognathia with relative macroglossia
69
Q

What are 8 indications for permanent tracheostomy in OSA?

A
  1. Morbid obesity
  2. Severe apneas with desaturation
  3. No response to weight loss and avoidance of sedatives and alcohol
  4. No response/tolerance to CPAP trial
  5. Cardiac arrhythmia with apneic events
  6. Cor pulmonale
  7. Chronic alveolar hypoventilation
  8. Disabling hypersomnolence
70
Q

What is a test that should be done for suspected sleep apnea, besides PSG?

A

Thyroid function

71
Q

What is the definition of surgical responders in OSA?

A
  1. AHI < 20
  2. Reduction of AHI by > 50% if pre-op AHI < 20
  3. O2 sat > 90%
  4. Systemic disease alleviated
  5. Restoration of normal sleep archiecture
  6. Response equivalent to CPAP on full-night titration

General OTOHNS (9 decks)

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