One of the biggest challenges for sleep apnea surgeons is in figuring out where in the upper airway obstructions are happening, especially when patients are sleeping. The problem with looking in the office is that the patient is awake, and your muscles won’t be as relaxed as when you’re in deep sleep. 

A new study out of Baylor University described a procedure where patients are placed under sedation, but still breathing on their own. While the patient is sleeping, a thin flexible camera (fiberoptic endoscopy)is placed through the nose into the throat and the various structures are examined, including the soft palate, tongue, epiglottis, and tonsils.

Although this may seem like a novel idea, it was already described as early as 2000, with some other studies that followed. 

After reading the 2000 paper, I began performing sleep endoscopy on a dozen or so patients just before they underwent surgery. It literally took only a few minutes immediately before the endotracheal tube was placed. In all cases, the findings didn’t reveal anything more than what was already known before the procedure. As a results of these findings, I stopped looking while the patient was asleep.

An alternative to this procedure is to place a pressure catheter with multiple sensors at different levels (soft palate and tongue) while the patient sleeps at night. This can be performed along with a routine sleep study.

Various CT and MRI studies also report finding significant areas of narrowing and collapse.

My current way of discovering where obstruction is happening is to do a thorough history, exam and physical, and then perform the flexible fiberoptic exam with the patient sitting up as well as lying down flat on his or her back. This way, you’ll see the soft tissue structures collapse due to gravy. In many cases, tongue or palate collapse can be dramatic. If there is significant tongue collapse, I then have the patient thrust the lower jaw forward and in most cases, the space behind the tongue base opens up dramatically. This maneuver can predict whether or not thy can benefit from a mandibular advancement device. 

In my experience, except in severe sleep apnea situations, the palate is usually less of an issue than the tongue. By addressing the nose, the palate and tongue simultaneously, surgical success rates can be as high as 80%, rather than 40% for operating on the soft palate alone. 

When you went to your ENT for your sleep apnea, were you ever examined with the camera lying down? Please enter your experience below in the box.

8 Responses to “Sleep Endoscopy for Sleep Apnea Surgery: Where’s the Obstruction?”

1. Anna on November 2nd, 2009 11:13 am

   “you’ll see the soft tissue structures collapse due to gravy”

   I would collapse from gravy, too .

   Seriously, I have very much enjoy reading your blog and I’m nearly through reading your book.

   I haven’t had a sleep study, but I’d like to do one, though I suspect I would be one of those people who are either borderline or without enough serous sleep issues now to qualify for treatment (in terms of what my insurance would approve and cover). When I’ve mentioned sleep apnea to my various doctors their eyebrows go up, as my BMI is 22, snoring isn’t a problem, I’m not a mouth-breather, etc. On the surface I just don’t look like a typical sleep apnea sufferer.

   But I’m quite sure when before I was treated for hypothyroidism a few years ago, I was experiencing frequent sleep apnea that caused me to awaken very suddenly and sit or stand upright with extremely violent coughing attacks to catch my breath, which probably was a significant contributing factor in developing pelvic organ prolapse. Once the first coughing episode would start, the night, the night would be a serious of continual clearing of my throat/sleep/wake to violent coughing. Not only is is disruptive to my sleep, but also to my husband’s. The coughing attacks have occasionally occurred in daytime, too, especially during the first trimester of pregnancy nearly 12 years ago. I don’t usually experience the coughing attacks now if my thyroid hormone dose is at an effective level, but they recur in the fall when other symptoms return and a seasonal dose adjustment is in order. It took a few years to figure that pattern out. My husband is the one who connected the coughing attacks with my thyroid condition.

   Reading your blog and book have prompted further thought on how I can improve my sleep quality with better breathing. I rarely get colds anymore (with low carb diet for 5+ years and keeping my Vit D 25 (OH)D level above 60 ng/mL) but when I do, I use BreathRite Nasal strips instead of cold meds for the nasal congestion at night. Recently after many consecutive days where I awoke feeling really unrested (almost “hung-over” despite no alcohol consumption the night before), and I remained unusually tired throughout the day, despite thinking I slept soundly through the night. I started applying the nasal strips before bedtime, even though I wasn’t ill.

   Wow! I woke up feeling far more refreshed and alert throughout the day. I continued using the strips and each time wake up feeling far more refreshed than without. I almost don’t want to remove the strip in the morning, either, and oftne leave it on a while, as it really reduces the amount of nose blowing and runny nose symptoms I sometimes experience in the first hour or two after rising.

   After a couple weeks of wearing the strips every night, even though I use the strips formulated for sensitive skin, my nose skin started to suffer from the adhesive, so I stopped. Sure enough, I didn’t feel as alert and rested in the mornings and throughout the day. So I’m trying to find a balance of how often I can wear these without damaging the skin on my nose. I’ll use one for sure if I know the next day is a demanding one.

   I’ve also consulted with Dr. Hang about orthodontic work for my grade school son. He’s quite a distance from us (2.5-4+ hour drive each way, depending on So Cal traffic! ) plus there are other considerations we need to take into account if we choose him for the treatment, but you and he have really focused my attention on making sure any orthodontic treatment we choose takes into account my son’s breathing, airway spaces, and his full facial/cranial development. I knew I needed to chose a plan that did more than simply remove his overbite and smooth out the crowding (which is probably why I hesitated last year when we initially consulted orthodontists in our dental plan who only recommended pulling his upper front teeth back with conventional braces and without forward jaw development guidance), but I didn’t have the specific details of what to discuss and ask about during the treatment proposal consultations.

   I thank you very much for your informative and thought-provoking writing!

2. Steven Park on November 2nd, 2009 12:42 pm

   Thanks for your thoughtful comments, Anna. Optimizing nasal breathing is very important in people with mild sleep-breathing disorders, such as upper airway resistance syndrome. If you’re having trouble with the Breathe Right strips, take a look at Nozovents, or Sinus Cones. They work much better since they push the nostrils out from the inside. Having any degree of nasal congestion can aggravate further tongue collapse downstream.

   I’d really appreciate your feedback when you’re finished reading my book.

3. Steven Park on November 2nd, 2009 2:13 pm

   Thanks for your thoughtful comments, Anna. Optimizing nasal breathing is very important in people with mild sleep-breathing disorders, such as upper airway resistance syndrome. If you’re having trouble with the Breathe Right strips, take a look at Nozovents, or Sinus Cones. They work much better since they push the nostrils out from the inside. Having any degree of nasal congestion can aggravate further tongue collapse downstream.

   I’d really appreciate your feedback when you’re finished reading my book.
   BTW I love your blog!

4. Sara on November 3rd, 2009 6:48 am

   I asked my ENT and my sleep dentist about airway evaluation in supine (based on what I had read in your book), and neither of them uses this approach. It just seems like a common sense to evaluate in the position of concern.

5. Jeff on November 6th, 2009 10:36 am

   Dr. Park,

   I am a dentist in Lynnfield , Ma., I treat sleep apnea patients, we also screen all of our patients for the red flags, that we as dentists are on the front lines of being able to recognize…(large tongue,scalloped tongue,high vaulted palate,signs of bruxism,edematous and elongated uvula,acid erosion of teeth (GERD),retruded mandible,neck circumference,BP,BMI,Epworth,…and we also have a cone beam
   ct xray machine that allows us to visualize the airway in three dimensions throughout…However we also use a piece of equipment known as a Pharyngometer, and The Muller Procedure…the procedure replicates what happens to the airway “tissues” during sleep while the device sends sound waves down the airway and they are reverberated back and a mapping of the airway is made helping us to visualize the narrowest areas and thus the areas most prone to collapse…we can then retest these with our oral appliance in place..we also use a Rhinometer for the nose…

   Anna, I would do whatever I could to bring my child to see Dr. Hang (he is one of my mentors) Jeff

6. Steven Park on November 6th, 2009 12:43 pm

   Jeff,

   What you’re already doing just goes to show that dentists in general are much more aware of the importance of proper breathing while sleeping, compared with most of my fellow physicians. Are you performing these procedures with the patient sitting and lying flat? You’ll see major differences in the caliber of the airway.

   Are you also doing pre and post appliance sleep studies?

7. Anna on November 13th, 2009 11:02 am

   Thanks for the Sinus Cones tip, Dr. Park. I never would have known about these.

   I ordered the newer, softer version called Max-Air nose cones and have used them three nights. I chose a pack each of both the small and medium sizes and it turns out I need the small size, so I’ll return the medium and exchange it for another pack of small cones. The guarantee and exchange policy is very good.

   The first night I didn’t think I’d like the nose cones. I was very aware of them when they were in place and though I could breath freely, it felt like they might pop out when I exhaled. They fell out three times in the night, but I was awake enough to locate and replace them. But the second night I was less aware of the cones and they stayed in place, with perhaps just a quick readjustment or two needed. Last night was the third night I used them and I barely noticed the cones. Perhaps I’m also positioning them better now.

   The strange thing is that I noticed with these nose cones in place, I’ve begun breathing through my mouth a few times while sleeping. It might be with the nasal passages open and clear, I am now able to sleep on my back, but that position also allows my jaw to go slack and open up. For years I slept mostly on my sides, which I alway thought was better for my spine. I never thought of it in terms of my sleep breathing until reading your book.

   The other downside to the nose cones is looking like Miss Piggy . But the skin on my nose is much happier from not having BreathRight nasal strips stuck on every night.

   Thanks again.

8. Anna on November 13th, 2009 11:09 am

   Jeff,

   Thanks for your note. My inclination is for Dr. Hang, too. We had an excellent consult appt with him a couple weeks ago. However, we also saw Dr. Sack (not far from Dr. Hang) the same day and my son seems to prefer Dr. Sack’s approach (which is somewhat similar but with Crozat appliances and spring attachments at the back that guides the jaw forward). Dr. Sack also expressed a focus on the breathing and overall facial bone development. I think my son is concerned about the need to keep the mouth closed so much during the Biobloc phase, which is necessary for the Hang treatment to work.

   If you have any insight you can share that would help us make the decision, I’m all ears.

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