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Ask Dr. Park: Any Question About Surgery for Sleep Apnea

In this Ask Dr. Park teleseminar, I answer your questions about surgical options for obstructive sleep apnea.

 

List of questions answered will be updated shortly. 

 

 

 

Click here to purchase MP3 recording ($17).

Sleep Apnea and Scarring

In the medical world, the word scarring has negative implications. Other similar words include growth, tumor, and lump, all of which are words used to describe certain anatomic features without any prognostic value. Whenever a doctor uses words "scar tissue," it evokes an image of a complication or adverse effect. However, with sleep apnea and snoring procedures, scarring is usually a good thing. 

Many of the procedures that are performed in the upper airway rely on fibrosis and scarring, not only to shrink the soft tissues, but also to tighten floppy structures and prevent either vibrations or obstruction. For example, many of the various soft palatal snoring procedures are dependent on significant scarring for good results. Whether it's using one of the minimally invasive procedures without any cutting (injection snoreplasty, radiofreqeuncy stiffening, or the Pillar implants), or the ones that involve cutting or tissue vaporizing (laser procedures and the UPPP), the appropriate level of scarring in the right place will determine whether or not the procedure is successful. Of course, sometimes, you'll have scarring in the wrong places, which can be complication.

 

In the nose, many of the turbinate procedures involve irritating, burning, or destroying the blood vessels and soft tissues underneath the mucous membranes. With time, scarring occurs inside the turbinates, with tightening and shrinkage, leading to better nasal breathing.

 

The challenge with many of the more "minimally invasive" snoring and sleep apnea procedures is that you'll tend to get minimal results. Most will work very well initially, but in my experience, there's a significant degree of recurrence years later. One of the main reasons for this is that these minimally invasive procedures usually only address one area. Obstructive sleep apnea, by definition, means that you have some degree of narrowing in multiple levels of your entire upper airway, from the tip of your nose to your voice box. Stiffening your soft palate when you have nasal congestion or tongue base collapse is not going to treat the problem definitively. In carefully selected patients, these minimal procedures can be useful, but many will need more aggressive, multi-level procedures later on.

 

Did you undergo one of the soft palatal stiffening procedures? Did it work for you? Please describe your experiences below in the comments box.

The LAUP Procedure for Snoring and Sleep Apnea

Snoreplasty Procedure Rediscovered to Cure Snoring

It seems like snoring and sleep apnea treatments are rediscovered and proclaimed by the media as a new "cure," when in fact, it’s been described years before. A British doctor reports that by injecting a scarring agent into the soft palate, snoring is eliminated. The material he used was sodium tetradecyl sulfate, which is the same material that’s been used for varicose veins for 50 years.

This procedure was originally described by Dr. Eric Mair in 2001. He reported a 92% initial success rate, which dropped to 75% at 19 months on average. Most people will need 2 to 3 injections for optimal results. I performed this procedure quite a lot with good results until other, more sophisticated options became available.

It literally takes less than 5 minutes to perform in the office. Topical anesthesia is used in the mouth and a very tiny needle is used to create a bleb underneath the mucous membrane of the central soft palate. After a few weeks of healing, scarring and tightening occurs, which stiffens the palate, lessening snoring vibrations. It can take a few weeks and up to 2-3 months before results are seen. Repeat injections are given as necessary.

There will be some mild throat discomfort, but most people don’t need to take any pain medications. However, a prescription pain medication is usually given.

One important point to remember is that all this does is to stiffen the soft palate. It’s not designed to treat any underlying obstructive sleep apnea. Typically, it’s much less expensive than the more high-tech, sophisticated procedures such as Pillar implants or laser procedures. Because snoring treatments are considered "cosmetic," they’re usually not covered by insurance carriers. 

It seems like medicine has a way of forgetting about simpler, more cost effective methods of treatment.

 

Have you undergone any in-office snoring treatments? If so, how long did it last? Please enter your response below in the comments box.

 

 

 

 

 

Usual and Unusual Ways to Stop Snoring

What I’ll describe in below is a comprehensive list of all the standard medical, surgical, and over-the-counter options that you’ll hear and read about. If you see one that I’ve left out, please let me know and I’ll give you my opinion. Remember, many of these devices (with a few exceptions) only cover up the snoring, without treating the real cause. If you try a variety of these options to find no relief, it’s time to see your medical doctor or a sleep specialist for a formal evaluation and treatment. Not doing so can cost you more than your sleep. It can cause you to lose your life.

Medical Options For Snoring

Note: Many of the procedures below, although effective for snoring, are never 100 successful. Success rates range from 70% to 95%. There is also a small chance of relapse even if initially successful.

Continuous Positive Airway Pressure (CPAP): This option may be overkill, and you’ll need to pay for it out of pocket if you don’t officially have obstructive sleep apnea. But it does work, if you can get used to it.

Dental devices: There are multiple options with this type of treatment, with the formal mandibular advancement devices that are made by dentists. These devices pulls your tongue forward by pulling your lower jaw forward. There are many different models that all have various features that make it more likely to work depending on your anatomy. Different dentists have different preferences as well. A less expensive way to "test" whether or not these devices may work is to try one of the many over-the-counter (or over-the-internet) boil-and-bite models. These devices are softened in hot boiling water and the set as you softly clench down while simultaneously pushing your jaw forward.

Laser Assisted Uvulo-Palatplasty (LAUP): A laser is used to trim the free edge of the soft palate. It’s somewhat painful, and usually must be performed 2-3 times. It can be performed in the doctor’s office, and is relatively expensive.

Injection Snoreplasty: Any type of scarring agent (sodium tetradecyl sulfate, ethanol, etc.) can be injected just underneath the mucous membrane of the soft palate. Must be performed 2-3 times for maximum effectiveness, is less painful in general, and is the least expensive.

Pillar Procedure: Three thin woven braided polyester rods are inserted inside the muscle layer of the soft palate. It’s usually performed under local anesthesia and is one of the least painful. Typically, only one treatment is needed, and is most expensive.

Uvulopalatopharyngplasty (UPPP): Usually used for obstructive sleep apnea, but very effective for snoring. In general, it’s only about 40% successful for obstructive sleep apnea.

Some Unusual Ways to Stop Snoring

Note: All the options listed below, although not proven to help snorers on a consistent basis, have been reported to work at least some times in some people. Most of the reports are anecdotal, with no objective supportive data. One major problem is that if it works, it may only delay diagnosing and treating any underlying obstructive sleep apnea.

Tennis balls: For some people, staying off your back can make a big difference. The problem is staying on your back. The most common recommendation is to sew a sock filled with a tennis ball to the back of your pajamas. This method has mixed results, and in general, although it sounds great, doesn’t work that well. It just only annoys the snorer or they just sleep on top of it.

Sleep position devices: There are a number of gadgets and devices that prevents you from rolling onto your back. They range from triangular wedges to shirts filled with foam rods to prevent sleeping on your back. The only way to know whether or not they work is to  try it. For some people, it can make a huge difference, even if you have obstructive sleep apnea. For many others, you may have a mixed response, or no response at all.

Side sleep position pillows: This one positions your arm above your head and somehow forces you to sleep on your side. Again, I’ve heard mixed responses from my patients. If you can sleep with your arm above your head for hours without it becoming numb, then this may work for you.

"Contour" pillows: This pillow works better if you prefer to sleep on your back. The lower end of this pillow is a bit higher than the middle part that the top of your head touches. This forces your head to be cocked back a bit, lifting up your chin somewhat, thereby opening up your airway somewhat. This the the same maneuver that you’re taught to do during CPR to open up the airway before you give mouth-to-mouth. Notice that after you fluff up your pillow you go to bed, the pillow height diminishes slowly, and by the end of the night, your chin is closer to your head, which closes your airway. Another option is to either roll up a towel into a "log" or get one of the Asian husk-filled pillows that are shaped like a roll. You’ll have to experiment to find the right height.

Diet and weight loss: This will help to various degrees for most people who are overweight, but what if you’re already thin? Also, since poor sleep leads to weight gain hormonally and metabolically, it can be very difficult to lose weight no natter how much you diet or exercise. For some, losing 10-15 pounds may help a great deal with your snoring, but chances are, it’ll return sooner or later as you get older.

Nasal dilator clips: Whether external (Breathe-Rite) or internal (Nozovent, Nasal Cones, or Breathewitheez), these work sometimes by pulling your soft flimsy nostrils apart, preventing nostril collapse when you inhale. During sleep, especially when your muscles relax, any degree of nasal congestion can aggravate higher vacuum pressures that can aggravate tongue collapse. Despite being touted to cure snoring, it only works about 10% of the time. Here’s one simple test to see if you should invest any money on these products: take both you index fingers and gently press on your skin, right next to your nostrils. Press gently and pull your cheeks apart on each side towards the outer corners of the eyes. This is called the Cottle maneuver.

Wind instruments: Playing any type of wind instrument (flute, clarinet, trumpet, etc.) can in theory promote throat and tongue muscle tone. Reports of success are anecdotal.

Playing the Didgeridoo: Various studies have suggested that playing this ancient Aborigine wind instrument can help relieve snoring. The mechanism in how it works is similar to any wind instrument.

Singing: The mechanical act of singing promotes profound throat muscle tone and control. Similar to all the wind instruments, prolonged periods of singing promotes relaxation, since exhalation is activated by your parasympathetic nervous system.

Tongue Exercises: Has been found to be helpful for some people, but needs continuous exercises.

Throat sprays: Various mixtures of herbs and natural ingredients are promoted for snoring, but a recent objective study showed that they were not helpful.

Acupuncture: No consistent evidence, but helps with stress and fatigue.

Bedpartner’s elbow: Works to wake you up to stop snoring, but never curative. This is called the "bruised rib syndrome".

Electronic devices that wake you up when you snore: More expensive than a bedpartner elbowing you in the ribs.

Ear plugs for the bedpartner: May help the bedpartner sleep, but not very effective for the very low-frequency snoring vibrations.

Sleeping in another room: Usually alleviates the problem, but bad for relationships, and not very helpful for "heroic" snorers where the sounds vibrate the bedroom walls 2-3 rooms down.
 

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