Ear, Nose & Throat Associates

NON-SURGICAL THERAPY FOR OBSTRUCTIVE SLEEP APNEA
Weight loss in many cases will improve sleep apnea. In milder cases, weight loss may result in significant changes in snoring to the point that apnea episodes would disappear. For the excessively overweight individuals, losing weight is more of a challenge since you may be too tired to exercise until effective treatment for your sleep apnea is established. There is a direct correlation between increasing neck size and sleep apnea. Fat deposition between your chin and "Adam’s apple" may be responsible for pushing your tongue closer to your soft palate, a key area of obstruction.

Medications and alcohol will not cause sleep apnea but it very possible that over use may aggravate an existing obstructive situation. Alcohol and certain medications such as muscle relaxants, sedatives and pain killers will depress the central nervous system. This will lead to further relaxation of the airway and combined with shallow breathing will result in more apnea events. Therefore, avoidance of certain medication close to bedtime would be a wise decision. 

Oral Appliances are suggested to patients who have mild to moderate sleep apnea because there tongue is too close to the back wall of their throat. After making impressions of your bite a device may be fashioned by a dentist to bring your lower jaw into a more forward position for sleep. This will move your tongue forward possibly relieving any obstruction from the back of your tongue. 

CPAP is the most effective, non surgical treatment for obstructive sleep apnea. With the improved air flow to your lungs, your blood oxygen improves and your brain cells "wake up". The result is a more awake and alert individual. There is usually a "break-in" period to build up ones tolerance to the device. 

UPPER AIRWAY SURGERY
Surgery is considered when the more conservative methods of treatment fail. For those patients who snore and may have mild sleep apnea the Pillar Procedure is a consideration. This is an office procedure that is performed under local anesthesia. By inserting three small Dacron stents into the soft palate less vibration of the palate occurs thus reducing the snoring. Another method for reducing the vibrations of the soft palate that produce snoring is Laser Assisted Uvula Palatoplasty or LAUP. This procedure may be performed under local anesthesia and is performed with a laser beam that incises the soft palate in a slightly oblique fashion on each side of the uvula. As the incisions heal the soft palate becomes tighter and the uvula slightly less prominent. However, this technique may improve snoring without improving the sleep apnea. As a result, fewer cases are being performed using this technique. In addition, patients would complain of significant pain post operatively. Radiofrequency tissue ablation, also known as somnoplasty, is a procedure where a temperature controlled radiofrequency current is delivered to the center of the soft palate, above the uvula. This results in tightening of the palate and some reduction in size of the uvula. Advantages of this procedure are that it is an office procedure performed under local anesthesia for snoring and minimal sleep apnea. The same principle of treatment has been applied to treat the base of the tongue enlargement that produces obstruction when you sleep on your back. Somnoplasty of the tongue base is usually combined with another form of surgical treatment. However, it is usually necessary to repeat the procedure more than once at suitable intervals.

In those patients who find it difficult to adjust to CPAP after a suitable period of time, a surgical procedure would be discussed assuming there are no medical problems that would compromise the patient’s well being. Severe cardiovascular disease or morbid obesity would a contraindication. The most widely performed surgery for obstruction involving the area of the soft palate, uvula and tonsils is the uvulopalatopharyngoplasty known as UPPP with removal of the tonsils if present. Success with this procedure depends on many factors. If the sleep apnea is mild but less than moderate, UPPP alone does very well. If the snoring is not completely eradicated, the bed partner often will comment "there is still some snoring, but it’s much improved". If a post surgical sleep study reveals a 50% improvement in the apnea values, this is also considered a successful outcome. However, some patients find it necessary to continue CPAP therapy after their surgery.

Nasal surgery may be necessary for proper breathing through the nose. A deviated septum, enlarged turbinates or nasal polyps may interfere with obtaining maximum benefit from CPAP therapy. Although correction of a compromised nasal airway does not necessarily cure sleep apnea, an improved air flow eliminates one area of resistance. 

LOWER AIRWAY SURGERY
The space between the back of the tongue and the back of the throat may be narrowed by a large tongue or backward displacement of a tongue of normal size. The "Repose" procedure keeps the tongue in a forward position during sleep. A titanium screw is placed behind the front part of the mandible below the mucosal lining of the mouth. A suture is then guided through the tongue from the front to the back and the tongue is gently pulled forward, tying the suture to the screw.

The "Genioglossus Advancement" is another method of advancing the tongue forward. The genioglossus muscle originates from the back of the tongue and attaches to the inside segment of the chin. A rectangular piece of bone is cut out from the chin which includes the area where the muscle attaches on the inside. By pulling on the rectangular segment the muscle is pulling the tongue forward. The piece of bone is rotated and fixed into place.

The space behind the tongue may also be widened by a Hyoid Advancement procedure. Some of the tongue muscles attach to the C shaped hyoid bone which is located above the "Adam’s apple". The bone is actually moved down and forward and the attached to the top of the "Adam’s apple".

A recessed chin is evident when the lower jaw position is behind the line of the upper jaw. In such a case the tongue also assumes a more backward position, thus narrowing the space in the back of the throat. The mandible may be moved forward, thus advancing the chin to a more natural position by performing bone cuts on both sides of the mandible behind the molar teeth. The genioglossus muscle also moves forward. The latter procedure may be combined with a hyoid advancement procedure as well. A "Maxillomandibular Advancement" moves both the upper and lower jaws in a forward position to provide more room for the tongue and increases space between the tongue base and the back of the throat. This procedure also realigns the contour of the face and corrects an abnormal dental occlusion. This procedure is performed by oral surgeons or Ear, Nose and Throat physicians with a dental background.

In severe cases of obstructive sleep apnea, where the patient’s sleep study indicates a marked decrease in his oxygen level associated with many obstructive events, and the patient is not a good candidate for any conventional surgery, a tracheostomy is considered. This procedure involves maintaining an opening into the patient’s windpipe with a special tube to by-pass the severe obstruction responsible for his apnea.