Surgical options for Obstructive sleep apnoea syndrome

SURGICAL OPTIONS FOR
OBSTRUCTIVE SLEEP APNEA (OSA)
DR. GIRISH. S

American Academy of Sleep Medicine (AASM)

DEFINITION OF OSA
• Sleep disorder that involves cessation or significant decrease in airflow through the
upper airway in the presence of breathing effort.
• Most common type of sleep-disordered breathing (SDB)
• Associated with recurrent oxyhemoglobin desaturations and arousals from sleep.

OSAS
• OSA associated with excessive daytime sleepiness (EDS) is commonly called
obstructive sleep apnea syndrome (OSAS)
• also referred to as obstructive sleep apnea-hypopnea syndrome (OSAHS)
• with severe OSA – more than hundreds of apnea can occur.

OSAS
• OSA is defined by five or more respiratory events—apneas, hypopneas, or
respiratory effort– related arousals—in association with excessive daytime
somnolence; waking with gasping, choking, or breath holding; or witnessed reports
of apneas, loud snoring, or both.

PATHOPHYSIOLOGY
• Upper airway is a compliant tube and, therefore, is subject to
collapse.
• OSA is caused by soft tissue collapse in the pharynx.

ROLE OF THREE FACTORS
A. a reduction in the dilating forces of the pharyngeal dilators,
B. the negative inspiratory pressure generated by the diaphragm &
C. abnormal upper airway anatomy, the element most effectively addressed by
surgery.

• TRANSMURAL PRESSURE - difference between intraluminal pressure and the
surrounding tissue pressure.
• If transmural pressure decreases the cross-sectional area of the pharynx decreases.
• If this pressure passes a critical point (Pcrit), pharyngeal closing pressure is reached
.The airway is obstructed.
• OSA duration is equal to the time that Pcrit is exceeded.

PATHOPHYSIOLOGY
• The three major areas of obstruction are the nose, palate, and
hypopharynx.
• NASAL / RETROPALATAL / RETROLINGUAL

NASAL OBSTRUCTION
• Nasal obstruction contributes to increased airway resistance and may worsen OSA.
• Leads to open-mouth breathing during sleep, which increases upper airway
collapsibility and may decrease the efficacy of dilator muscles.
• Snoring can be caused by nasal obstruction.

PATHOPHYSIOLOGY OF OSA
• Findings in Obstruction:
• Nasal Obstruction
• Long, thick soft palate
• Retrodisplaced Mandible
• Narrowed oropharynx
• Redundant pharyngeal tissues
• Large lingual tonsil
• Large tongue
• Large or floppy Epiglottis
• Retro-displaced hyoid complex

DIAGNOSIS
• History
• Physical examination
• FIBEROPTIC NASOPHARYNGOSCOPY
• Multiple positions
• In awake & asleep patients
• With Mullers maneuver – awake pt – generates negative pressure by inhaling against a
closed glottis with mouth & nose close – triggers airway collapse.

Fiberoptic view of the
hypopharyngeal airway before the
Müller maneuver
Fiberoptic view of hypopharyngeal
collapse during the Müller maneuver.

DISE
• Drug-induced sleep endoscopy (DISE) - guide more effective surgical intervention.
• DISE involves the use of fiberoptic nasopharyngoscopy to evaluate the site of airway
collapse during pharmacologically induced sleep.
• Useful tool for assessing the location, severity, and pattern of airway obstruction
during sleep.

CEPHALOMETRIC RADIOGRAPH
• 2D representation of the airway, a standardized evaluation system with broad
availability and relatively low cost.
• These films provide information on both the bony skeleton and the overlying soft
tissues.
• Inferior displacement of the hyoid, a smaller posterior airway space, and longer soft
palates.

• AWAKE COMPUTED TOMOGRAPHY
• MRI
• FLUOROSCOPY / SOMNOFLOUROSCOPY
• NOCTURNAL PSG – gold std for the diagnosis of OSA.

PSG
 Simultaneous recordings of multiple physiological signals during sleep.
 Electroencephalogram (EEG)
 Electrooculogram (EOG)
 Electromyogram (EMG)
 Electrocardiogram (ECG)
 Oronasal airflow
 Chest wall effort
 Snore microphone
 Oxyhemoglobin saturation

MEDICAL TREATMENT
• Weight loss – Bariatric Surgery
• Continuous positive airway pressure (CPAP)
• Gold std for moderate to severe OSA
• Pneumatic splint – prevents collapse
• Provides constant +ve intraluminal pressure during respiration.

MEDICAL TREATMENT
• Bilevel positive airway pressure (BiPAP)
• delivers a separately adjustable, lower expiratory positive airway pressure and higher
inspiratory positive airway pressure.
• Autoadjusting positive airway pressure (APAP)
• Autotitrate the pressure depending on the variations of airflow to select an effective
level of CPAP.

MEDICAL TREATMENT
• ORAL APPLIANCES – TRD, MPD
• PHARMACOLOGIC THERAY
• MODAFINIL

OSAS
• Includes a wide variety of procedures that vary in their invasiveness and success
rates.
• Generally, success is defined as a drop in the RDI by either 50% or 20 total points.

INDICATION
• Factors for surgical treatment of OSA include the
patient’s wishes,
CPAP tolerance,
severity of symptoms,
severity of disease,
patient comorbidities,
site and severity of upper airway collapse.

CLINICAL STAGING OF OSAS
• In earlier days the sole treatment option for OSAS was UPPP.
• Surgeons were planning treatment based on the severity of disease, avoided severe
dse.
• Now we know that OSAS is a multilevel obstruction dse & UPPP is only useful for
oropharyngeal obstruction.

CLINICAL STAGING OF OSAS
• An anatomically-based staging system is made to identify areas of obstruction, and
helps in tailoring the appropriate surgical treatment for each individual.
• The severity of disease is a secondary factor, which plays a role in determining the
need for treatment.

FRIEDMAN STAGING SYSTEM
• Parameters
• TONGUE POSITION
• TONSIL SIZE
• BODY MASS INDEX

FRIEDMAN TONGUE POSITION
• FTP I - the entire uvula, tonsils, and tonsillar pillars.
• FTP II allows visualization of the uvula, but not the tonsils.
• FTP III allows visualization of the soft palate, but not the uvula
• FTP IV allows visualization of the hard palate only

TONSIL SIZE
• TS 0 - post-tonsillectomy patients.
• TS 1 implies tonsils hidden within the pillars.
• TS 2 represents tonsils that extend to the pillars.
• TS 3 refers to tonsils that extend beyond the pillars, but not all the way to the
midline,
• TS 4 tonsils (‘‘kissing tonsils’’) reach the midline.

STAGING OUTCOMES
• Successful treatment of OSAHS with UPPP was most likely achieved in stage I
patients because of the predominant palatal and tonsillar component.
• Stage II and III patients were least likely to achieve a cure after UPPP, with an overall
objective cure rate of 37.9 and 8.1%, respectively.
• Stage III patients have a predominant base of the tongue obstructive component,
thus making single level surgery useless.

PRECAUTIONS
• OSA patients are frequently overweight, hypertensive, and have other cardiac risk
factors.
• These patients must be cautiously screened with a comprehensive medical
examination before considering surgery.
• The surgical planning should include a discussion between the anesthesia team and
the surgeon.

PRECAUTIONS
• Stepwise algorithm frequently used - using an oropharyngeal airway to prevent
airway obstruction by the tongue, refraining from using paralyzing agents until the
patient can be easily ventilated with a mask & preparing alternative methods of
ventilation in case intubation is unsuccessful.
• Possibility of tracheotomy.

SURGICAL MANAGEMENT
• Staged, stepwise surgical protocol.
• site of obstruction - to determine the type and extent of surgical intervention.
• Before therapy is initiated, patients should be counselled regarding the possible
need for multiple surgical procedures.
• Patients with laryngeal obstruction should be considered for tracheostomy if
improvement is not achieved surgically or with CPAP.

NASAL SURGERY
• Nasal obstruction  poor sleep quality, snoring, and OSA.
• Septoplasty, turbinate reduction, nasal valve surgery, and sinus surgery .
• However, nasal procedures are unlikely to significantly improve OSA when used
alone.
• Improving nasal patency help to restore physiologic breathing and may allow for
the use of nasal CPAP in patients previously unable to tolerate it.
• Initial step in OSA management so as to facilitate better CPAP adherence.

PALATAL SURGERY
• 1981 – Fujita &colleagues – 1st palatal surgery – UPPP
• Ikematsu: 1985  UPPP
• Stiffens the soft palate & increases the space behind the soft palate.
• Complications : temporary nasal reflex ( 12-15%) , post operative bleeding, infection
& rare altered speech.

UVULOPALATOPHARYNGOPLASTY (UPPP)

UPPP STEPS
• Rose’s position
• Partial uvulectomy – excessive mucosa of uvula tip cutoff without touchin musculae
uvulae. Tip sutured
• Incision into the mucosa of the anterior pillar is performed in the oral fold of the
palatoglossus muscle.
• Fibers of the M. palatoglossus are dissected from the tonsil. Tonsillectomy follows.
• Posterior tonsilar pillar is partially incised.
• Lengthened posterior pillar edge sewed together with the anterior pillar.

Semi-elliptical soft palate with a
functioning uvula.

COMPLICATIONS
• Change in voice (rhinolalia aperta)
• Pain with swallowing and pain with speech, usually for 1-2 weeks postoperatively
• Hemorrhage (2-4%)
• Swallowing difficulties, particularly regurgitation of food
• Velopharyngeal Insufficiency
• Disturbance in taste
• Numbness of tongue
• Nasopharyngeal stenosis
• Creation of silent apnea

MODIFICATIONS OF UPPP
• Stanford - Uvulopalatal flap [UPF]
• Woodson et al – Transpalatal Advancement Pharyngoplasty
• Friedman – Z Palatoplasty
• Extended Uvulopalatal flap [ EUPF]

UVULOPALATAL FLAP
• Tonsillectomy.
• Incisions into the soft palate bilaterally on both sides.
• Tip of uvula grasped & excessive mucous membrane resected.
• Now extend of UPF is assessed by rotating the uvula upwards.
• Removal of the antr palatine arch, fat n salivary glands with preservation
of muscles
• Uvula is loosely folded into the defect & sutured

TRANSPALATAL ADVANCEMENT
PHARYNGOPLASTY (TAP)
• Aims to decrease retropalatal obstruction by altering the bony hard palate and the
soft tissue attachments of the posterior maxilla.
• A 1-cm portion of the hard palate is removed, and the soft palate is then advanced
and secured medially and laterally in the tensor aponeurosis, which enlarges the
retropalatal region.

Transpalatal Advancement Pharyngoplasty (TAP)
For moderate to severe OSA

A, Drill holes are placed from the oral cavity to the nose
and are anterior to bone removal (orange). A strong rim of
bone supports the sutures. The anterior extent of the
middle flap is placed in the thinner palatal mucosa.
Mucosa is thicker posteriorly (asterisk).
B, After osteotomy, sutures are placed through the drill
holes, and the bone fragment with attached tendon
and ligaments is advanced.

Z–PALATOPLASTY (ZPP)
• Outline two adjacent flaps on the palate – together they look butterfly-shaped –
only the mucosa of their anterior aspect is removed.
• Then, the two flaps are separated from each other by splitting the palatal segment
down the midline.

Z–PALATOPLASTY (ZPP)
• A two-layered closure brings the midline all the way to the anterolateral margin of
the palate.
• The final result creates 3–4 cm of distance between the posterior pharynx and the
palate.
• The uvula muscles are preserved within the new palate.

LASER ASSISTED UVULOPALATOPLASTY
• LAUPP
• Kamami : 1993
• Stiffens the soft palate & there by minimizes the
palatal flutter& snoring.
• CO2 / Nd:YAG / KTP

LAUP
• Laser produces pyrolysis and tissue vaporization by heating the target tissue to a
temperature up to 750–900C with consequent considerable collateral thermal tissue
damage.
• In the oral cavity/oropharynx, the potassium titanyl-phosphate crystal laser (KTP
laser) is the laser of choice.

LAUP
• The uvula is partly or totally removed.
• Then, two paramedian full-thickness, through-and-
through trenches are made over the soft palate, on either
side of the uvula, to a height of 1–2 cm.
• LAUP is performed under local anesthesia in an outpatient
setting.

COBLATION ASSISTED UVULOPALATOPLASTY
(CAUP)
• Electro-dissociation.
• A medium rich in sodium is dissociated into free ions, which are responsible for the
destruction of intercellular bonds, resulting in tissue dissociation.
• This reaction is achieved at temperatures between 60 - 70C with minimal collateral
thermal tissue damage.
• Advntg – faster tissue healing & decreased postop pain.

OTHER PALATAL SURGERIES
• SNORING  PALATAL FLUTTER – LENGTH - STIFFNESS
• PALATAL IMPLANTS
• MUCOSAL STRIP TECHNIQUE (MST)
• CAPSO
• INJECTION SNOREPLASTY

PALATAL IMPLANT
• minimally invasive, single-step procedure
• useful for mild OSA.
• Polyethylenterephthalat (PET)
• Three rod-shaped implants are inserted in the soft palate.
• The implants themselves and the surrounding scarring induce a stiffening of the soft
palate, reduce snoring sounds.

Applicator : The implants are 18 mm long and have a diameter of 1.5 mm. Delivered in a 14G
hollow needle which has three markings at the curved end of the needle

PALATAL IMPLANT
• Developed to reduce pain, cost & morbidity of UPPP , in mild OSA
• Complication – partial implant extrusion
• Advantage – single office visit, minimal morbidity, reduce snoring.

MUCOSAL STRIP TECHNIQUE
• Using LASER
• Central longitudinal strip of mucosa is removed from
the surface of soft palate.
• Heals by fibrosis, produces reqd stiffening.

CAUTERY ASSISTED PALATAL
STIFFNESS OPERATION
• Diamond style incision
• Using electrocautery
• Mucosal removal
• Uvula trimming

INJECTION SNOREPLASTY
• Injection of sclerosing agents into the soft palate
• 3% sodium tetradecyl sulphate (STS)
• 2ml 1%STS – single needle penetration – midline soft palate
• After 2min – purple h’gic color
• For repeated rx – 3%STS

OROPHARYNGEAL SURGERY
• Tonsillar hypertrophy - tonsillectomy
• Newer methods
• Radiofrequency tonsil reduction by intracapsular tonsillotomy.
• Minimally invasive and has limited morbidity.
• Used in the treatment of OSA in children.

TONSILLOTOMY
• Less surgical alternative to ATE.
• Partial tonsillectomy, intracapsular tonsillectomy, subtotal tonsillectomy
• Saving the psudocapsule – resection within the tonsil
• More or less tonsil tissue remains in the patient.
• Bipolar scissors / radiofrequency ablation / lasers / microdebrider.
• Less pain and less morbidity
• C/I chronic tonsillitis

LATERAL PHARYNGOPLASTY
• Lateral pharyngoplasty – Cahali in 2003 as an alternative to UPPP.
• The technique involves
• Bilateral Tonsillectomy,
• Longitudinal Incision Of The Superior Pharyngeal Constrictor,
• Diagonal Incision Through The Superior Palatopharyngeus,
• Z-plasty Closure Of The Superior Aspect Of The Tonsillar Fossa, &
• Suturing Of The Anterior And Posterior Pillars Together At The Inferior Aspect Of The
Tonsillar Fossa.

EXPANSION SPHINCTER
PHARYNGOPLASTY
• variation of the lateral pharyngoplasty
• Pang and Woodson in 2006
• This involves bilateral tonsillectomy, transection of the inferior aspect of the
palatopharyngeus, and superolateral rotation and figure-eight suturing of the
mobilized muscle to the arch of the anterior soft palate

A. Preoperative view of the oropharynx.
B. Exposure of the palatopharyngeus (vertical fibers).
C. Elevation of the palatopharyngeus.
D. Rotation and tunnelling of the palatopharyngeus
toward the hamulus.
E. Suture suspension and approximation.
EXPANSION SPHINCTER PHARYNGOPLASTY TECHNIQUE.

HYPOGLOSSAL NERVE STIMULATION
• Because OSA is primarily associated with relaxation of the pharyngeal musculature
during sleep, electrical stimulation of the hypoglossal nerve improve the
neuromuscular tone of the pharynx during sleep, particularly the genioglossus.

• Implantable hypoglossal nerve-stimulating device
• Reliably detect the onset of the inspiratory phase of respiration through chest wall
pressure sensors, allowing the electrical stimulation of the hypoglossal nerve to be
timed with inspiration.
HYPOGLOSSAL NERVE STIMULATION

TONGUE BASE PROCEDURES
• PARTIAL MIDLINE GLOSSECTOMY (PMG)
• Removal of a midline rectangular strip of the posterior half of tongue.
• LINGUALPLASTY
• Additional tongue tissue removed posteriorly n laterally
• RADIOFREQUENCY TONGUE BASE ABLATION (RFA / RFT)
• Lingual Tonsillectomy - Laser Lingual Tonsillectomy (LLT)

TONGUE BASE PROCEDURES
• TONGUE BASE SUSPENSION
• SUBMUCOSAL PARTIAL GLOSSECTOMY TECHNIQUES
• PERCUTANEOUS SUBMUCOSAL TONGUE BASE EXCISION
• SMILE
• SMELL Submucosal midline endoscopic lingual base lysis

RADIOFREQUENCY TONGUE BASE
ABLATION (RFA)
• decreases upper airway collapse by producing a volumetric reduction in tongue-
base tissue
• An insulated probe that delivers RF energy at 465 KHz is introduced into several
areas of the tongue base and produces coagulation necrosis and healing by scar.
• OP setting under LA
• Require multiple treatments to achieve the desired results.

TONGUE BASE SUSPENSION
(REPOSE SYSTEM)
• AHI>20 , moderate base of tongue obstruction
• Fixes the tongue forward, thereby preventing collapse
into the airway.
• Intraoral incision made in the frenulum
• Periosteum is elevated over genial tubercle

REPOSE TONGUE SUSPENSION
• A titanium screw is placed at the lingual cortex of the
geniotubercle of the mandible
• Permanent suture is passed through the paramedian tongue
musculature along the length of the tongue, through the
tongue base, and then back through the length of the tongue
musculature.
• It is then anchored to the screw to pull the tongue base
anteriorly.

SUBMUCOSAL MINIMALLY
INVASIVE LINGUAL EXCISION
• Maturo & Mair 2006 – macroglossia in pediatric pts.
• Small incision in the anterior portion of dorsal tongue, advance in posterior
direction, moving superior and inferior fashion.
• Plasma wand / coblator
• Avoid injury to muscles
• Always stay medial to the lingual arteries – newly created cavity.
• Incision is not closed to let the drain.

HYPOPHARYNGEAL PROCEDURES
• Procedures designed to prevent tongue collapse into the airway during sleep.
• GENIOGLOSSAL ADVANCEMENT (GA)
• HYOID MYOTOMY (HM)

GENIOGLOSSAL ADVANCEMENT (GA)
• Genial tubercle of the mandible (anterior attachment of
the genioglossus muscle) is mobilized by means of limited
osteotomy.
• The segment is then advanced, rotated and fixed into
place at the inferior aspect of the osteotomy.

GENIOGLOSSAL ADVANCEMENT PROCEDURE:
The rectangular geniotubercle osteotomy modification offers excellent tension on the genioglossus
muscle with a minimal fracture risk. The geniotubercle fragment is rotated enough to allow bony
overlap. A single inferiorly placed miniscrew is used to fix the fragment.

HYOID SUSPENSION
• Retrolingual obstruction
• Moderate – severe OSA
• Hyoidthyroidpexia (HTP)
• Stabilization of hyoid bone inferiorly and anteriorly by attachment to superior
border of thyroid cartilage
• Tongue base move anteriorly and caudally.

HYOID MYOTOMY (HM)
• Result in an enlarged retrolingual airway by fixing the major dilators of the
pharyngeal airway forward.
• Usually done along with GA
• Problems: external incision on neck, infection, temporary dysphagia & seroma

COMPLICATIONS OF GA & HM
• Permanent numbness
• Infection
• Seroma
• Risk of mandibular fracture , aspiration & death

MAXILLOMANDIBULAR
ADVANCEMENT
• Maxillomandibular deficiency results in diminished airway dimension, which leads to
nocturnal obstruction.
• MMA expands the skeletal framework that encircles the airway, thus enlarging the
entire airway, including the nasal, pharyngeal, and hypopharyngeal airway.

MMA
• Mobilizing the maxilla and mandible to achieve anterior displacement, after intraoral
osteotomy.
• The maxilla and mandible are stabilized with titanium plates in the advanced
position.

MAXILLOMANDIBULAR
ADVANCEMENT (MMA)
• Increases the retropalatal and retrolingual airway.
• Usually performed when other surgical intervention fails.
• Complications include malocclusion, relapse, nerve paresthesia, nonunion or
malunion, TMJ problems, infection, bleeding, and the need for subsequent dental
work.
• Success rate of this procedure approaches 90%.

MMA is the most effective sleep apnea surgical procedure
currently available.

DISTRACTION OSTEOGENESIS (DOG)
• Accepted procedure in the treatment of severe maxillomandibular deficiency in
syndromic and nonsyndromic patients.
• As grossly retropositioned mandible or midface causes a narrow pharyngeal airway,
OSA is often found in these cases.

DISTRACTION OSTEOGENESIS
• An osteotomy of the mandible or midface without advancement is followed by a
short latency period of 4 days.
• Then the two or more bony segments are slowly moved apart (mostly at 1 mm/day)
using some kind of distraction device.
• Thus the unmineralized tissue filling the osteotomy gap is slowly stretched until –
after cessation of distraction – it will turn into bone during the 4–10 weeks lasting
consolidation period.

Midfacial distraction in a Crouzon`s disease case

OSA
• MULTILEVEL SURGERY(moderate-
severe OSA)
• nasal surgery
• uvulopalatopharyngoplasty (UPPP),
• transoral tongue surgery,
• genioglossus advancement (GA),
• maxillomandibular advancement
osteotomy (MMA).
• MINIMALLY INVASIVE MULTILEVEL
SURGERY
• palatal implants and interstitial
radiofrequency treatments (RFT) of the
SP, base of tongue, and tonsils.

LARYNGEAL OSA
• Rare condition.
• occurs in adults and children.
• Laryngeal OSA has to be diagnosed endoscopically during sleep or sedation.
• ›› In children, laryngeal OSA is caused by malformations, tumors, and laryngomalcia;
the latter especially in preterm infants.
• ›› In adults, laryngeal OSA mainly occurs in elder men due to a floppy epiglottis.
More rare conditions are laryngeal and hypopharyngeal tumors.

TRACHEOSTOMY
• traditional gold standard of surgical management of OSA.
• relieves OSA by completely bypassing the portion of the airway that most
commonly collapses during sleep.
• should be considered in patients who have failed all other OSA treatments, in those
who have life-threatening OSA and are unable to tolerate CPAP, or in patients who
are neurodevelopmentally impaired.
• best option for the morbidly obese or as an interim measure for patients
undergoing base of tongue surgery.

TORS
• da Vinci robotic surgical system
• involve the precise excision of oral, pharyngeal and laryngeal tissue with a surgical
robot.
• The robot facilitates these procedures with its articulated instruments and 3-D,
high definition camera.

TORS
• TONGUE BASE REDUCTION (TBR)
- removal of a part of the base of the tongue from the foramen cecum to the vallecula,
include removal of lingual tonsillar tissue, tongue base musculature, or both.
• SUPRAGLOTTOPLASTY (SGP)
- surgical management of collapsible epiglottic, arytenoid and/or aryepiglottic tissue.

SUPRAGLOTTOPLASTY (SGP)
• ameliorate the inward inspiratory collapse of floppy and/or redundant epiglottic,
aryepiglottic, and arytenoid mucosa.
• two most common techniques performed are the Vertical Midline Suprahyoid
Epiglottic Split and the Horizontal Epiglottic Transection.

POSTOP MANAGEMENT
• In multisite surgical treatment of OSA  increased chance of postoperative airway
obstruction because of resultant edema in multiple sites in the upper airway.
• In addition, postanesthesia sedation along with altered respiration secondary to
narcotic pain medications can be additive in patients with an already compromised
airway.

• It is recommended that patients with severe OSA use CPAP for the first 2 weeks
after surgery.
• In addition, it is recommended that postoperative PSG be carried out in 3 to 4
months to evaluate the response to surgery.
POSTOP MANAGEMENT

BARIATRIC SURGERY
• Bariatric surgery encompasses a variety of surgeries.
• The most important ones are adjustable gastric banding, vertical banded
gastroplasty, sleeve gastrectomy, intragastric balloons, jejunal bypass,
biliopancreatic diversion, and Roux-en-Y gastric bypass.
• Bariatric surgery is recommended for patients with a BMI > 35 kg/m2 and an
obesity related concomitant disease or for patients with a BMI > 40 kg/m2.

OTHERWISE SNORE AND THIS WILL
HAPPEN TO YOU….
Or sleep
alone….

Surgical options for Obstructive sleep apnoea syndrome

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Surgical options for Obstructive sleep apnoea syndrome