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This month, I’ve invited Stanford University’s sleep surgeon, Dr. Robson Capasso to talk to us about his institution’s philosophy on sleep apnea surgery. Here’s a short list of questions that are answered on the program:

1. What’s the success rate for sleep apnea surgery?

2. Can you wait until someone is asleep to image the site of obstruction? 

3. What is the progress in getting UARS recognized as a real condition?  How is it diagnosed and managed at Stanford?

4. How do you decide whether to recommend surgery or an oral appliance in a CPAP intolerant patient?  

5. Can you explain the different techniques for performing the MMA, and how successful these are for reversing OSA?  Is it possible to achieve an AHI of zero after an MMA?

6. Do you recommend adult jaw development as an alternative to surgery?

7. Is sleep apnea surgery covered by insurance?

….and many more.

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Theses are only rough estimates, but if you take 100 people who are newly diagnosed with obstructive sleep apnea, only about 1/2 are willing to even try it. Of the people who give it a try, maybe about 1/2 end up using it regularly, and of those who use it regularly, perhaps 1/2 continue to use it for more than 1-2 years. Even if you’re using it regularly, not everyone feels any significant improvement in their symptoms.

As you can see, out of all the possible people who are candidates for CPAP, only a small fraction ever end up benefitting at all. It’s shocking how many CPAP machines sit in the closet after only a few weeks use. In controlled research studies, compliance can be quite high, even up to 60 or 80%, but in the real world, it’s probably more like 20-30% long-term.

Despite the grim statistics, CPAP is still the best option that we have. Millions of people benefit from its’ use significantly, and in many cases, it’s a life-saver. There’s also so much more that can be done to educate and support new CPAP users so that more people are able to use and benefit from it.

The frustrating thing is that there are alternative forms of treatment that can be just as good, if not better than CPAP. But in most cases, they’re simply dismissed as being not effective.

The first treatment option that’s available that should be considered the real “gold standard” is tracheotomy. This is where a hole is surgically made just below your voice box into your windpipe, essentially bypassing your entire upper airway. This has essentially a 100% cure for obstructive sleep apnea.

The two other major options for sleep apnea are oral appliances and surgery. The criticism by certain sleep doctors against these two options is that it never gets the AHI down to normal levels. But even a 50% drop in the severity of your breathing pauses is much better than not using your CPAP at all. This was borne out in one Veterans Administration study that showed that the UPPP procedure (with a historical 40% success rate) had a higher overall survival rate years later compared to people placed on CPAP. Surgical “success” is a controversial topic, and I’ve talked in detail about my logic for offering surgery at all.

It’s clear that there are certain camps that are strong proponents for each of the three major treatment options (CPAP, dental devices, and surgery). Each has it’s advantages and disadvantages. CPAP should always be considered first, but the two other treatments should at least be offered once you’ve exhausted all your CPAP options. Advanced orthodontics is another emerging treatment option but we’ll have to see results from more studies.

One interesting observation is that for people who are happy with their surgery, they forget about the fact that they have obstructive sleep apnea. They just go on with their their normal (and more productive) lives. They’re not reminded every night that they have sleep apnea, as what happens with oral appliances or CPAP. For others, CPAP is a normal part of life, like brushing your teeth before bedtime, and are not bothered at all. Notice how different people deal with their treatment options differently.

In my mind, it’s not about which option is better, but customizing your treatment plan based on a systematic process that starts with CPAP, and making sure to go on to other options if CPAP is not working. Unfortunately, too many people give up after trying only CPAP. Ultimately, there is no gold standard.

What’s your feeling on this admittedly controversial topic?

- What are my options if I can’t use CPAP?

- What if I’m using CPAP 100% of the time and my machine says I have no apneas, and I don’t feel any better?

- Is sleep apnea linked with fertility problems?

- What are the treatment options for central sleep apnea?

- Does sleep apnea get worse as you get older?

- Can losing weight cure sleep apnea?

- And many more questions.

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While rounding at the hospital early this morning to see my post op patient, she was doing remarkably well one day after her multiple soft palate and tongue procedures for obstructive sleep apnea. She was already swallowing liquids pretty well, and ready to go home. She also noted that despite the pain and the poor sleep environment of being in a hospital with all the noises and distractions, she felt more refreshed than normal when she woke up this morning.

Another patient that I hadn’t seen in 6 or 7 years came in for ear wax removal, and just happened to thank me for changing his life. I had no idea what he was talking about. He reminded me that I had sent him to a dentist for his sleep apnea and he has been successfully using his dental device all this time.

A third patient came in one month after routine nasal surgery and remarked that his breathing is not only normal, but he’s not snoring anymore, and his sleep is much more refreshing and he’s dreaming more.

These are some of the examples of patients that have found success with either CPAP, oral appliances, or with surgery. Some people find success after their first option, while others go through everything before finding a solution that works.

Admittedly, not everyone that I see has great results like that ones above, but the vast majority do, while the remainder have partial or limited success.

This is what keeps me going, knowing that I’m able to help people breathe better and sleep better, regardless of which option they choose. It’s truly a privilege for me to be able to help people in this way.

What’s your success story? Please share your story with me in the comments box below.

Are you confused by all the conflicting information about sleep apnea surgery? Does it work? Which procedure is right for you? Which surgeon do you choose? In this Ask Dr. Park Teleseminar Program you will learn about Sleep Apnea Surgery. Even if you’re not considering surgery the good think to learned what the other option are and the rational of offering a surgery.

Learn:

• Why consider Sleep Apnea Surgery?
  

• Are you a candidate Sleep Apnea Surgery?

• In-depth descriptions of different Sleep Apnea procedures.
  

• How to find the right Sleep Apnea surgeon.
  

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There are numerous types of surgical procedures for obstructive sleep apnea. The more useful ones involve modifying the breathing space behind the tongue. Clinical trials have now begun testing a new way of treating tongue collapse, using a nerve stimulator based on pacemaker technology. I'm honored to be part of an innovative, IRB approved, national multi-site study of this investigational device. Please take a look at this brochure for more information. 

Please contact me if you have any questions @ doctorpark@doctorstevenpark.com.

Many people (and surgeons) think of the upper airway as a simple tube that channels air into the lungs. What’s not appreciated enough is that this passageway from the tip of the nose to the vocal folds is highly dynamic, constantly changing, with multiple levels of partial to total obstruction. There are major areas of potential obstruction (nose, soft palate and tongue), but there are many other factors that can cause inflammation, swelling, or narrowing, in addition to these 3 major areas. These other factors can include weather changes, your emotions, what you just ate, sleep position, drugs and medications, and your weight.

But even if you consider the three major areas only, even then it’s not that well understood. Imagine a simple, long semi-collapsible tube connecting your nose to you windpipe. If there’s one area of obstruction, then opening up this area will help should help in most cases (for example, large tonsils). But let’s say that in addition to the tonsils, you also have nasal congestion due to a deviated nasal septum. Then by undergoing only a tonsillectomy, you may feel better initially, but over time, vacuum forces created in the throat by having a stuffy nose will aggravate soft palate and tongue collapse, leading to sleep apnea later in life. If you start with obstruction in the tongue area, soft palate and the nose, then opening up the soft palate obstruction only may work sometimes, but not all the time.

This is the reason for the 40% success rate of the uvulopalatopharyngoplasty procedure (UPPP). You can argue what the meaning of surgical success, but that’s for another discussion. So this leads to one of the most common questions that I get asked: Does the UPPP procedure work for sleep apnea? The answer is yes, but only in people who have obstruction purely in the soft palate area, especially if you have very large tonsils. This situation occurs only in about 40% of the time in adults. 

In young children, undergoing tonsillectomy only without soft palate surgery is found to "cure" sleep apnea in about 2/3 of patients. This makes sense, since tonsils tend to be relatively bigger in children. But what’s the reason for residual sleep apnea in the other 1/3 of children? The answer is for the same reasons as in adults: smaller jaws that lead to tongue collapse and nasal congestion. Even in the children who are considered initially "successful," a certain proportion will go on to slowly re-develop obstructive sleep apnea, due to their smaller jaw anatomy and predisposition for inflammation in the upper airways. The tongue becomes more of an issue later in adulthood as the voice box develops and descends down in the throat. 

So does sleep apnea surgery work? Like everything else in life, it depends. 

If you want more detailed information on the truth about sleep apnea surgery, sign up for my free report on the box to the right.

Did you ever undergo surgery for sleep apnea? Was it addressing one level or multiple levels? Please enter your response in the comments box below.

Sleep apnea, just like any other chronic medical condition, has many different forms of treatment. In addition to how you choose to take care of your problem, you also have to integrate many other various methods as well, including a sensible diet and exercise regimen. Unfortunately, there’s no pill to solve this anatomic problem. 

I’m assuming that you’ve tried all the conservative options like losing weight or improving your nasal breathing. Once you and your doctor have decided that you need to move on to one of the more definitive treatment options, you have three to choose from: CPAP, oral appliances, or surgery.

If you’ve done your research (I’m assuming you have since you’re reading my blog),  you’ll see vastly differing opinions on success rates and patient experiences. Some discussions are very heated. Unfortunately, as expected, the internet forums are filled disproportionately unsatisfied patients that have tried each of the three treatment options. You won’t see a website called, "ILoveCPAP.com", or "IHadSuccessfulSleepApneaSurgery.com". Most people who are happy with their results go on to live normal and productive lives. The ones that are still searching for better answers tend to fill the blogs and forums with their individual experiences. 

In the medical world, we’re no better. Our research studies are full of conflicting data that the press ends up distorting in their quest to bring you the latest in breaking news. Even though a news story tries to present two sides to the coin, it can’t do it in 800 words. There are books on sleep apnea with over 100,000 words that don’t ever make strong conclusions that one is better than the other. Because science can only prove association between one variable and another (and never cause and effect), we’re only getting an overly simplified picture of peoples’ medical conditions.

In medical studies, we always try to exclude other variables besides what we’re studying. If one person doesn’t exercise whereas another does, then we have to "adjust" for this fact, so that it doesn’t skew our data for CPAP’s effects on blood sugar levels. 

This brings me to sleep apnea treatment options. Yes, we have hundreds, if not thousands of studies supporting various aspects of sleep apnea treatment. They all report their answers in averages, essentially negating a single individual’s experiences. If you’re an outlier, then you’re considered "deviated." You should be average, but for some reason, you’re an aberration because the dental device didn’t work for you.

If you look at the big picture, all three treatment options (CPAP, oral appliances and surgery) all work to similar degrees. In carefully controlled research studies, "success rates" are as high as 80 to 90% in some cases for all three options. However, in the real world, true success is probably way less than 50%. I’ll even hazard a guess at 10 to 20% long term (20 to 30 years). 

So what does success mean? For the sleep physician, it’s lowering your sleep apnea number no sleep study down below 10, or some variation. But what it your number goes from 35 to7, but you don’t feel any better? What if you start at 7 and go down to 4? We doctors just shrug our shoulders in this situation.

For the patient, success means different things for different people. As examples, for people who choose CPAP, it’s waking up in the morning completely refreshed and having the energy to perform during the day without feeling very tired or fatigued. For others, it’s being able to go to a movie with a loved one and not fall sleep. For oral appliance users, it’s getting to the point of not having to use CPAP or undergo surgery. For surgery patients, it’s getting to the point where you don’t have to use a device of any kind. Different people have different wants and needs from treatment, as well as different expectations. 

But just like you would never prescribe a pill for high blood pressure without stressing other issues such as proper diet, weight loss, adequate exercise and stress reduction, you can’t prescribe sleep apnea treatment without addressing all the other issues as well. Sometimes, these "other issues" can help more than the treatment itself in the long run. Occasionally significant weight loss can even "cure" someone with mild sleep apnea. 

We can leave the debate over the specific pros and cons of different sleep apnea treatments for another time. For now, what I want to stress is that it’s important to stress your ultimate goals before treatment, and have an integrated plan of action along with your sleep doctor. With sleep apnea, there’s no magic bullet.

What was your ultimate goal when you started sleep apnea treatment? Please write your comments below.