Surgery for Snoring and Sleep Apnea
April 6, 2008
This is an edited transcription of a previously recorded podcast
Thanks for joining me today. I’m Dr. Steven Park and I’m an otolaryngologist, or an ear, nose & throat physician and surgeon, interested in sleep-related breathing disorders. Today’s topic will be: Surgical Treatment of Snoring and Obstructive Sleep Apnea. Before we get to the “meat” of the matter, a brief review is in order.
Obstructive sleep apnea is a condition where one stops breathing repeatedly through the night due to obstruction in the throat area. So if untreated, it is associated with high blood pressure, depression, obesity, heart disease, as well as many other medical conditions. This diagnosis is based on a formal overnight sleep study, where one has to stop breathing at least 10 seconds per each episode. If this occurs more than 5-15 times every hour, you are told you have sleep apnea.
Upper airway resistance syndrome, on the other hand, is a condition where you don’t officially meet the criteria but are still tired and groggy with many other caveats. For a more thorough discussion of upper airway resistance syndrome and obstructive sleep apnea, please refer to the other articles in this series.
If you are found to have obstructive sleep apnea, there are a number of treatment options available. First of all, you need to consider conservative options including weight loss, sleep positions and just good diet and lifestyle habits. Weight loss, however, is easier said than done because most people are very tired and unmotivated to exercise. So it’s a very difficult proposition. Furthermore, you don’t have to be overweight to have sleep apnea. It’s been found that even young, thin women who don’t snore can have obstructive sleep apnea.
There are three major categories of treatment options. We’ll start with dental devices, which are oral devices or oral appliances. These are appliances that dentists make these by making a mold of your teeth where the bottom part of this device slides out gradually thereby pulling on the lower jaw and your tongue. Tongue collapse is the cause of many cases of people with sleep apnea. These devices do work for most people and they have been shown to be effective in people with mild to moderate sleep apnea. However, you need to choose these patients carefully because not everyone who has sleep apnea has tongue collapse. As discussed in my previous article, there are different anatomic reasons which can aggravate, if not cause sleep apnea including the nose, the palate and the tongue. So patients who are candidates for oral appliances have to be selected very carefully based on history and a very thorough physical examination.
Some of the problems with dental devices are: excessive salivation, dry mouth, TMJ pain or jaw discomfort and sometimes it can even cause bite changes, so it is very important to be evaluated and followed by a dentist who specializes in these devices.
The next treatment option that is available is CPAP, or Continuous Positive Airway Pressure and this is typically the first line treatment that’s offered to people with significant sleep apnea. Basically, it’s a mask that fits tightly over your nose and a machine at the bedside blows some gentle air pressure through your nose via the mask to sort of stent your airway open while you’re sleeping at night. The exact pressure setting has to be calibrated in the laboratory where you had the sleep study done, and for the most part, people tolerate this very well and get significant improvement in their quality of sleep.
The issues of compliance and efficacy with CPAP are a huge topic in itself and maybe we’ll discuss that another time. Unfortunately, for many people, no matter how hard they try to use the CPAP machine and after multiple, ongoing trials of different masks, headgear and tubing and different pressure settings, some people just can’t tolerate using the CPAP at home every night. So for these few people who have tried everything, surgical management is the only other option available to them.
Now, looking at the whole range of surgical options, you need to look at the entire anatomy from the tip of the nose all the way to the tongue base and the voice box. As I’ve said before, sleep apnea is usually due to a combination of nasal congestion, palatal collapse or tongue collapse and any combination of the above— you can have one, two or three different levels. More commonly, patients will have tongue collapse along with some mild palatal collapse. Some people can have palatal level of obstruction, especially if they have large tonsils. So, we need to look at the entire pathway and then decide what to do.
Starting from the nose, if they have any degree of nasal obstruction, we need to address this area. So, if they have allergies, we treat that first; if they have a deviated septum and if allergy treatment doesn’t work, then we can offer a septoplasty. There is also surgery to reduce the turbinates, which are these wing-like structures on the side of the nose that swell when you have a cold or allergy and there’s one other condition called nasal valve collapse that is frequently undiagnosed. This is a condition where the sidewall nostrils of your nose tend to collapse due to just natural weakening or due to previous surgery. Now these are the people that benefit very well from Breathe-Rite strips, or those nasal dilator strips. It obviously doesn’t work for everyone.
The next level to address is if you have very big tonsils or if you have a very redundant palate. This is getting into the area of an operation called uvulopalatopharyngoplasty, or UPPP. Going further down the airway, if you have any degree of tongue collapse, then that needs to be addressed, as well. So, there are options available for each of these three different levels.
One more comment on a historical note: before CPAP was available in the early 80’s, as well as the UPPP operation in the early 80’s, the only other option that was available for sleep apnea was a tracheotomy, which is where a surgeon places a breathing tube below the voice box. Basically, you’re bypassing the voice box in order to allow you to breathe at night. Obviously, this was a cure in 100% of the cases but not very socially acceptable for obvious reasons.
The key to success in sleep apnea surgery is in choosing the right type of patients to offer this surgery to. If you are severely overweight, these operations will not work as well. If you have any other major medical problems, such as heart disease, then you’re at a higher risk for complications. So there are many other issues that need to be addressed before you decide whether or not you even want to consider surgery. In my practice, I usually insist on trying one of the other conservative non-surgical options first but for the few who can’t tolerate these other treatment options and want something more definitive, then I have a long discussion with these patients face to face, after a thorough re-evaluation of their upper airway anatomy. Once the decision is made to look at surgical options, then we have a discussion about which areas need to be addressed.
As I mentioned before, one of the first options that was made available for sleep apnea patients is called a UPPP or a uvulopalatopharyngoplasty. When it was first offered in the 80s, surgeons were pretty successful in terms of results but with time, what we found was that the success rate kept dropping and dropping and eventually, it leveled off at about 40%. So this is the most widely quoted statistic for the success rate of uvulopalatopharyngoplasty surgery and as a result, it’s gotten quite a bad reputation within certain fields. But if you look at the flip-side of the coin, in 40% patients did respond whereas in 60% they didn’t. Now, with further research we realize that one of the most common reasons for failure was that the surgeons did not address tongue base collapse. So, now, if you address both levels, both the tongue and the palate, the success rates can be as high as 75%-80%.
A few years ago, there was a paper by Dr. Friedman in Chicago, who looked at patients undergoing the UPPP procedure and what he found was that certain patients with certain anatomic features responded to this operation alone better than others. The bottom line is that if you have very large tonsils and you can see most of your palate by looking inside your mouth—in other words, if the top of the tongue sits very low in the mouth and you can see pretty much the entire edge of your soft palate along with large tonsils—then you have about an 80% success rate. There are some other details and other factors associated with the staging criteria but if you don’t meet these criteria, then you have a pretty poor prognosis. So, if you came to me with sleep apnea and you were found to have large tonsils and I can see the free edge of your soft palate, then you would be a good candidate for the UPPP alone. However, there’s still the possibility – about 20%, that despite undergoing this operation, you may still have persistent sleep apnea. If this happens, it usually means that the palatal operation was not either aggressive enough or there was underlying tongue collapse that was not properly addressed.
These days there are a number of different varieties of UPPP procedures; some more invasive and some less invasive and some designed to be less painful. The bottom line is you need to do this operation properly and not be so concerned about what kind of instruments you use and what kind of techniques that you use. As long as you do the basic operation properly, that is the most important part.
One of the variations that I do quite frequently is called a uvulopalatal flap, where there is no muscle cut whatsoever. Instead, I remove a portion of the mucous membrane in the soft palate and then I flap, or flip the uvula and the soft palate up onto the upper part of the soft palate thereby kind of tightening the soft palate as it heals. I’ve also been using a new cutting tool, called a Coblator, which I use routinely for tonsillectomies but I’ve also applied for the palatal operation and there seems to be significantly less pain with this cutting tool, as well. One other note about the laser procedure for sleep apnea—the laser procedure for sleep apnea was originally brought forth 10-20 years ago as a lesser invasive form of surgery for sleep apnea, especially since it could be done in the office. There have been many, many studies published looking at the results and they’ve all been mixed, so the pendulum has been swinging away from offering the laser procedure for sleep apnea, especially since there have been some cases where the sleep apnea got worse following palatal surgery. Needless to say, in these patients where the sleep apnea got worse, they probably had underlying tongue collapse as well. For many people, they will have tongue and voice box collapse as well, and you need to address both if you want success. There are a number of different ways of addressing this.
The one protocol that I began to follow, many years ago, was that from Stanford and what they do is something called a genioglossus advancement, along with a mandibular osteotomy. It’s just a fancy word meaning that they cut out a small, rectangular piece of bone in the lower jaw in the front, which attaches to the lower front part of the tongue, so if you pull on that bone, it pulls the tongue forward, thus opening up the airway space in the back. Along with this, they pull down what’s called the hyoid bone, which is a c-shaped bone on top of your voice box, which attaches to your tongue and your voice box. By pulling that down onto your voice box, it acts as an adjunctive procedure to open up your airway space. So the combination of the hyoid procedure, the genioglossus advancement and the palatal operation are where they get the 75% success rate for people who have mild to moderate sleep apnea. And over the years, there have been various modifications of this—in general the success rate is 75-80%.
One thing to note, and I mentioned this in a previous podcast, is what the definition of success is. As surgeons, our definition of success is when the apnea-hypopnea index (the number of times you stop breathing every hour) drops by 50% and the final number has to be less than 20. So if you start off with 50, you need to be under 20 to be called a success. Obviously, that still has its shortcomings because you still have mild sleep apnea but it’s better than not treating it at all. Many patients feel significantly better. In many cases, the number has dropped into the single digits.
In my practice, I have a modification of the Stanford approach where I place a suture behind the jaw and I sling that around the back of the tongue, thus suspending the tongue so it doesn’t fall back at night and this is a lesser invasive procedure. They’ve done studies with this procedure showing equivalent results with much less potential for complications as well.
Now, another technique that is commonly used is called the radiofrequency tongue base reduction or volumetric tissue reduction. Basically, these are techniques where a needle is placed in the back of the tongue and radiofrequency energy or any other type of thermal or electromagnetic energy is delivered to cause a small controlled burn. With time, as it heals, the scar tightens and contracts the back of the tongue. The downside to this procedure is it has to be repeated 4 or 5 times for optimal success. In my experience, it does work, but many patients elect not to go through with the entire series of procedures.
A newer option is to use a Coblator instrument (which melts tissues at low temperatures) through a tiny tunnel through the top of the tongue and melt away a certain portion on the base of the tongue, without cutting through the mucous membranes. This way, it doesn’t hurt as much and it’s a one-step procedure. This is called a SMILE procedure and was described by Dr. Eric Mair.
Now all of this may sound somewhat aggressive, but it’s all relative, depending on how you look at it. At Stanford, of the people who failed the first stage of operations – about 20-25% of patients – where these operations didn’t work, what they offered them was something called a maxillomandibular advancement. This is where the oral surgeons literally pull the bony upper and lower jaw forward – and by doing that, it opens up the airway significantly. These patients have well over 90-95% success rate.
As I’ve mentioned before, the last resort is a tracheotomy, where a small hole is created below the voice box and a tube is placed to bypass the upper airway entirely. This procedure is performed rarely, in only life-threatening situations.
So, in summary, there are a number of different options for surgery when it comes to sleep apnea. Due to a number of different anatomic factors, you have to tailor the surgery to what’s appropriate for each patient’s anatomy, to what the patients needs, and what the patient wants and desires. With my patients, again, I insist that they try the more conservative options first (such as CPAP and dental devices). Then when they come to me, wanting to know about surgery, I have a very long and thorough discussion about all of the different options, what I recommend, and what the alternatives are along with what the possible complications are. As with any surgery, there are certain risks and a good surgeon should be able to handle any kind of complication that arises. Obviously, if you don’t know how to handle the complications, you should not be doing the operation.
I just want to make a few comments about snoring. A lot of patients come to me for snoring issues and once they find out that they don’t have sleep apnea, then we need to address the snoring. And, typically the techniques are very similar. Many patients will have tongue collapse and if you do something to pull the tongue forward, especially with these dental devices, that will help to alleviate the snoring. We also have many techniques that are done in the office to help to stiffen the soft palate, since that is where the majority of the snoring sounds are coming from. The major options include: palatal implants (which are thin, polyester woven braids that are implanted into the soft palate). As it heals, it scars, contracts and tightens the soft palate.
Other options include, again, radiofrequency energy, where a little needle is inserted into the muscles and a slight burn is caused. There is even a scarring agent that’s used for varicose veins that used for snoring called injection snoreplasty. It’s a shot that’s given into the mucous membrane to cause a small ulcer, and again, as it heals, it scars and tightens the palate. And, lastly, the laser can be used to trim the free, soft edges of the soft palate. This hurts a lot and is not used as much anymore. With the exception of the implant procedure, many of these options require 2-3 steps.
In my experience, not too many people are good candidates for these procedures, especially if they have tongue collapse and in most cases, there is a good likelihood that as their sleep apnea worsens, that the snoring may come back. I offer these patients snoring procedures very sparingly and only when I’m confident that it is truly the right procedure for them. Again, if they have any degree of nasal congestion, I address this first.
I also have an interest in looking at alternative or complimentary methods of treating snoring or sleep apnea. There was an interesting article that was published recently that used acupuncture to treat sleep apnea where the apnea/hypopnea index dropped on average by 50%. Quite surprising! So, I’m looking into whether I can replicate that in my practice. There are even tongue exercises that have been prescribed to help for snoring. There are also reports of playing a didgeridoo, which is an Australian Aborigine wind instrument. If you’ve been reading my newsletters, you’ll see what that’s all about or you can go to our website, which describes these options in more detail.
If you want more information about all these options, as well as a more complete picture of why we have so much of these problems and what we can do about it, go to sleepinterrupted.com to take a look at my newly released book, which describes everything in much more detail.
So, that’s it for this podcast episode. If you have any comments or questions, I’d love to hear from you!
Until next time…Goodbye!