ENT Surgery in Jubilee ENT Surgery in Jubilee Hospital TrivandrumHospital Trivandrum

Dr.K.O.Paulose FRCS.DLODr.K.O.Paulose FRCS.DLOConsultant ENT SurgeonConsultant ENT Surgeon

Jubilee Hospital TrivandrumJubilee Hospital Trivandrumweb:www.drpaulose.comweb:www.drpaulose.comwww.snorefreesleep.comwww.snorefreesleep.com

33 years experience in ENT Surgery33 years experience in ENT Surgery

ABOUT MEABOUT ME

1968-1973-MBBS Medical College Trivandrum1968-1973-MBBS Medical College Trivandrum 1968-1969- 1968-1969- Inmate of Louis catholic Hostel(Now Jubilee Hospital)Inmate of Louis catholic Hostel(Now Jubilee Hospital) 1978-1987 UK various NHS Hospital (10 yrs)1978-1987 UK various NHS Hospital (10 yrs) 1981-FRCS UK, 1984 DLO London1981-FRCS UK, 1984 DLO London 1987-2003 Bahrain(Military Hospital-Consultant(17yrs)1987-2003 Bahrain(Military Hospital-Consultant(17yrs) 2003-2004 Bahrain-Kims Hospital (locum Consultant)2003-2004 Bahrain-Kims Hospital (locum Consultant) 2005-2010-SUT Hospital, Trivandrum-Consultant (5 yrs)2005-2010-SUT Hospital, Trivandrum-Consultant (5 yrs) 1616thth Sept 2010- on wards Jubilee Hospital Trivandrum Sept 2010- on wards Jubilee Hospital Trivandrum

LASER EXPERIENCELASER EXPERIENCE

1996- onwards laser surgery started In Bahrain1996- onwards laser surgery started In Bahrain Feb 2008 Laser and Coblator surgery in SUT HospitalFeb 2008 Laser and Coblator surgery in SUT Hospital Total number of Laser surgery in BDF .>1000 cases(Using Sharplan Co2 Total number of Laser surgery in BDF .>1000 cases(Using Sharplan Co2

laser-Germany)laser-Germany) Feb 2008-Sept 2010- 421 cases(Co2 laser and coblator Arthrocare®)in Feb 2008-Sept 2010- 421 cases(Co2 laser and coblator Arthrocare®)in

India+India+ 6 cases in first one week jubilee Hospital- 196 cases in first one week jubilee Hospital- 19thth October onwards October onwards

1616thth September 2010-Blessing of ENT Clinic by Most September 2010-Blessing of ENT Clinic by Most Rev Soosapakyam, Archbishop of TrivandrumRev Soosapakyam, Archbishop of Trivandrum

Blessing Prayer by Fr.Andrews Kosmos MBA, MD of Jubilee Blessing Prayer by Fr.Andrews Kosmos MBA, MD of Jubilee HospitalHospital

ENT Clinic cum Endoscopy roomENT Clinic cum Endoscopy room

Co2 Laser partsCo2 Laser parts

Laser Saftey guidlinesLaser Saftey guidlines

Co2 Laser in Jubilee HospitalCo2 Laser in Jubilee Hospital

Laser Surgery Started in Jubilee 19Laser Surgery Started in Jubilee 19thth October 21010 October 21010For Snoring-OSA and Nasal allergyFor Snoring-OSA and Nasal allergy

Kumbhakarna and snoringKumbhakarna and snoring

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Stop snoring and save your Stop snoring and save your marriagemarriage

Day time sleepinessDay time sleepiness

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Broken marriages-Divorce !!!!Broken marriages-Divorce !!!!

Car accidentsCar accidents

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How Snoring and OSAHow Snoring and OSA

Causes of SnoringCauses of Snoring

Nasal ObstructionNasal Obstruction Enlarged, Uvula, Soft Palate, TougueEnlarged, Uvula, Soft Palate, Tougue Enlrged Ts AdsEnlrged Ts Ads Lack of Muscle tone upper airwayLack of Muscle tone upper airway Air Turbulance in the oropharynxAir Turbulance in the oropharynx Vibration of soft palate and uvulaVibration of soft palate and uvula Venturi Effect-Bernoulli principleVenturi Effect-Bernoulli principle

Causes of Snoring 1Causes of Snoring 1

Causes of Snoring -NasalCauses of Snoring -Nasal

Sleep ApneaSleep ApneaWhat is Sleep apnea?What is Sleep apnea?

Stoppage of breathing while asleepStoppage of breathing while asleep More than 10 secondsMore than 10 seconds 100-500 episode of apneas in one night100-500 episode of apneas in one night Plus HypopneasPlus Hypopneas Cause Hypoxia and HypercarbiaCause Hypoxia and Hypercarbia

Types of sleep apneaTypes of sleep apnea Obstructive Sleep Apnea (OSA)Obstructive Sleep Apnea (OSA) Most common-loud snoringMost common-loud snoring Obstruction of upper airwayObstruction of upper airway Central Sleep Apnea (CSA) Central Sleep Apnea (CSA) Brain stem lesion, stroke, polio, tumorsBrain stem lesion, stroke, polio, tumors No snoringNo snoring Mixed sleep apnea (OSA+CSA)Mixed sleep apnea (OSA+CSA) Chronic respiratory failure>centralChronic respiratory failure>central

Signs and symptoms of sleep apnea Signs and symptoms of sleep apnea

Choking or gasping during sleep Choking or gasping during sleep Loud snoring Loud snoring Sudden awakenings to restart breathing Sudden awakenings to restart breathing Waking up in a sweat during the night Waking up in a sweat during the night Feeling tired in the morning Feeling tired in the morning HeadachesHeadaches Daytime sleepinessDaytime sleepiness Lack of concentration,fatigue,irritableLack of concentration,fatigue,irritable Low O2- Brain and HeartLow O2- Brain and Heart

Diagnosis of Sleep ApneaDiagnosis of Sleep Apnea

Good History from spouse or parentsGood History from spouse or parents Physical examination-Nose and ThroatPhysical examination-Nose and Throat Voice recordingVoice recording Flexible EndoscopyFlexible Endoscopy CT imaging or MRI retropalatal and CT imaging or MRI retropalatal and

pharyngeal airwaypharyngeal airway Sleep study-PolysomnogramSleep study-Polysomnogram Cardiac evaluationCardiac evaluation

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CT Scan Retroplatal Airway-PN RatioCT Scan Retroplatal Airway-PN Ratio

CT adenoid and soft CT adenoid and soft palate.JPGpalate.JPG

CT imagingCT imaging

adenoid.JPGadenoid.JPG

Sagital CT-PN ratioSagital CT-PN ratio Pharyngeal Narrowing Ratio-Its significancePharyngeal Narrowing Ratio-Its significance Soft palate-tongue contact and automatically Soft palate-tongue contact and automatically

calculated pharyngeal narrowing ratio (PNR), calculated pharyngeal narrowing ratio (PNR), defined as a ratio between the airway cross-defined as a ratio between the airway cross-section at the hard palate level and the narrowest section at the hard palate level and the narrowest cross-section from the hard palate to the cross-section from the hard palate to the epiglottis epiglottis

Soft palate should therefore be the target for Soft palate should therefore be the target for causal treatment of snoring, LAUP, CAUP, RF causal treatment of snoring, LAUP, CAUP, RF somnoplasty all aimed at the soft palate in OSA somnoplasty all aimed at the soft palate in OSA surgery. surgery.

Polysomnography - Sleep lab studyPolysomnography - Sleep lab study

Brain electrical activity –EEGBrain electrical activity –EEG ECGECG Eye and jaw muscle movement Eye and jaw muscle movement Leg muscle movement Leg muscle movement Airflow Airflow Respiratory effort (chest and Respiratory effort (chest and

abdominal excursion) abdominal excursion) EKG EKG Oxygen saturationOxygen saturation

CPAPCPAP

CPAP3.jpgCPAP3.jpg

Treatment of Snoring and Sleep ApneaTreatment of Snoring and Sleep Apnea

ConservativeConservative Weight LossWeight Loss Avoid AlcoholAvoid Alcohol Dental devices, dilatorsDental devices, dilators Avoid sleeping pillsAvoid sleeping pills or narcoticsor narcotics before bedbefore bed Stop SmokingStop Smoking Don't sleep on your backDon't sleep on your back

Surgical TreatmentSurgical Treatment GlossectomyGlossectomy Mandibular osteotomyMandibular osteotomy Hyod advancementHyod advancement Nasal surgery, Septal surgery,LAPTNasal surgery, Septal surgery,LAPT RF SomnoplastyRF Somnoplasty UPPP-LAUP+Coblator surgeryUPPP-LAUP+Coblator surgery Ts AdsTs Ads Tracheostomy-last optionTracheostomy-last option

LASER TYPESLASER TYPES

Laser is an acronym that stands for Light Amplification by Stimulated Emission Laser is an acronym that stands for Light Amplification by Stimulated Emission of Radiation. of Radiation. The first concept of the laser was initiated by Albert Einstein in 1917.The first concept of the laser was initiated by Albert Einstein in 1917.

CO2 Laser CO2 Laser

Argon laser Argon laser

The Nd:YAG (Neodymium:Yttrium-aluminum-The Nd:YAG (Neodymium:Yttrium-aluminum-garnet) garnet)

The potassium-titanyl-phosphate (KTP) The potassium-titanyl-phosphate (KTP)

Diode LaserDiode Laser

Co2 LaserCo2 Laser CO2Laser CO2Laser The CO2 laser is the most versatile laser in otolaryngology. The carbon dioxide (CO2) laser The CO2 laser is the most versatile laser in otolaryngology. The carbon dioxide (CO2) laser

emits a colorless, infrared light at a specific wavelength of 10,600 microns, which has an emits a colorless, infrared light at a specific wavelength of 10,600 microns, which has an extremely high affinity for the intercellular water of cells.extremely high affinity for the intercellular water of cells.

A second, built-in, coaxial helium neon laser is necessary to indicate with its red color the A second, built-in, coaxial helium neon laser is necessary to indicate with its red color the site where the invisible CO2 laser beam will impact the target tissue. This laser, then, site where the invisible CO2 laser beam will impact the target tissue. This laser, then, acts as an aiming beam for the invisible CO2 laser beam.acts as an aiming beam for the invisible CO2 laser beam.

Advantages of Laser SurgeryAdvantages of Laser Surgery FastFast Painless Painless Bleeding-nilBleeding-nil Fast recovery Fast recovery No hospitalization if done under LANo hospitalization if done under LA GA for difficult casesGA for difficult cases

Disadvantages of LaserDisadvantages of Laser Cost of equipment and maintenanceCost of equipment and maintenance Special surgical skills Special surgical skills Increased setup time of equipment Increased setup time of equipment Need of safety eyewear Need of safety eyewear Increased care for patient safety - explosion or fire hazard.Increased care for patient safety - explosion or fire hazard. smoke smoke

Other Non surgical treatmentOther Non surgical treatment

Dental splintDental splint Nasal dilatorNasal dilator Nasal dropsNasal drops Treatment of allergyTreatment of allergy CPAP MachineCPAP Machine Yoga breathingYoga breathing Tennis ball on pyjama!!!Tennis ball on pyjama!!!

Laser surgery for snoring and OSALaser surgery for snoring and OSA

LAUP (Laser Assisted LAUP (Laser Assisted Uvulopalatopharyngoplasty)Uvulopalatopharyngoplasty) involves involves removal of the uvula, shorten the soft removal of the uvula, shorten the soft palate and reduce the volume of the palate and reduce the volume of the tonsils using CO2 laser done under-LA / GAtonsils using CO2 laser done under-LA / GA

LAPT-Laser assisted Partial turbinectomyLAPT-Laser assisted Partial turbinectomy LAS-Laser assisted septoplastyLAS-Laser assisted septoplasty LAT-Laser assisted TonsillectomyLAT-Laser assisted Tonsillectomy

Results of Laser surgeryResults of Laser surgery showed the correction of sleep apnea by an average of 70-80% showed the correction of sleep apnea by an average of 70-80%

However, the snoring sound reduction was between 75-95%. However, the snoring sound reduction was between 75-95%.

Side EffectsSide Effects post op infection -rarepost op infection -rare nasal fluid reflux –temporary nasal regurgitation for few days, but nasal fluid reflux –temporary nasal regurgitation for few days, but

rarely permanentrarely permanent no voice changes were noted no voice changes were noted Bleeding-rareBleeding-rare Dryness of throat-rareDryness of throat-rare

Causes of fauilure if anyCauses of fauilure if any mixed apnea-central componentmixed apnea-central component Inadequate excision of tissues-RedoInadequate excision of tissues-Redo Obesity,alcohol,sedativeObesity,alcohol,sedative Lack of muscle tone in the neckLack of muscle tone in the neck Base of tongue factor-coblator reductionBase of tongue factor-coblator reduction Jaw factor-need mandibular advancementJaw factor-need mandibular advancement

laser sugery4.JPGlaser sugery4.JPG

After LAUP-LAAfter LAUP-LA

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Intubation-GAIntubation-GA

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Laser surgery under GALaser surgery under GA

Laser Surgery for OSA in JubileeLaser Surgery for OSA in Jubilee

LAUPLAUP

LAUP+Partial TonsillectomyLAUP+Partial Tonsillectomy

Tonsils,soft palate and uvulaTonsils,soft palate and uvula

Laser Surgery-LAUP GALaser Surgery-LAUP GA

Laser surgery for Nasal allergy/ -LALaser surgery for Nasal allergy/ -LA

Laser Surgery Nose-LALaser Surgery Nose-LA

Laser Surgery for Nasal allergy LALaser Surgery for Nasal allergy LA

““Doubting Thomas”Doubting Thomas”

Laser NoseLaser Nose

Laser noseLaser nose

After Laser SurgeryAfter Laser Surgery

Oldest LAUPOldest LAUP

Post op LAUPPost op LAUP

COBLATOR SURGERYCOBLATOR SURGERY

Cold Ablation-Coblation TechnologyCold Ablation-Coblation Technology a controlled, non-heat driven process — uses a controlled, non-heat driven process — uses

radiofrequency energy to excite the electrolytes in a radiofrequency energy to excite the electrolytes in a conductive medium, such as saline conductive medium, such as saline

Temperature 40-70*C-less thermal damageTemperature 40-70*C-less thermal damage Coblator II, Arthrocare ® USA MachineCoblator II, Arthrocare ® USA Machine

Coblator Surgery done in SUT RoyalCoblator Surgery done in SUT Royal RF turbinate-Turbinoplasty RF turbinate-Turbinoplasty PolypectomyPolypectomy Tonsillothomy-pediatricTonsillothomy-pediatric CAUP –Snoring and OSACAUP –Snoring and OSA Tongue base reductionTongue base reduction

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Coblator machineCoblator machine

2coblator 2coblator machine.JPGmachine.JPG

Coblation TechnologyCoblation Technology

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CAUPCAUP

CAUP01.jpgCAUP01.jpg

CAUPCAUP

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Septal surgerySeptal surgery

septoplasty-nisha5.jpgseptoplasty-nisha5.jpg

coblator-nisha1.jpgcoblator-nisha1.jpg

Coblator stiffening soft palateCoblator stiffening soft palate coblatorcoblator chanelingchaneling

soft palate2-nisha3. soft palate2-nisha3. coblatorcoblator chanelingchaneling soft palate2-nisha3.jpgjpg soft palate2-nisha3.jpgjpg

Laser surgery NoseLaser surgery Nose

Happily living afterHappily living after

Diode laser surgeryDiode laser surgery

Next ? -Harmonic Scalpel and Next ? -Harmonic Scalpel and Starion Tissue weldingStarion Tissue welding

harmonic scalpel1.jpgharmonic scalpel1.jpg

Rhinoplasty ProcedureRhinoplasty Procedure

Rhinoplasty SurgeryRhinoplasty Surgery

Rhinoplasty procedureRhinoplasty procedure

Micro Ear Surgery in JubileeMicro Ear Surgery in Jubilee

Micro ear surgery in Jubilee 2Micro ear surgery in Jubilee 2

Cosmetic Surgery of Cosmetic Surgery of Nose-RhinoplastyNose-Rhinoplasty

Rhinoplasty-PocedureRhinoplasty-Pocedure

Pre and Post op RhinoplastyPre and Post op Rhinoplasty

Pre and Post op RhinoplastyPre and Post op Rhinoplasty

THANK YOUTHANK YOU

For details please visit my web site:For details please visit my web site:www.drpaulose.comwww.drpaulose.com

www.snorefreesleep.comwww.snorefreesleep.com

THANK YOUTHANK YOU