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Ask Dr. Park Your Question About Sleep Apnea Surgery

Please join me as I host another Ask Dr. Park teletraining program on "What You MUST Know About Sleep Apnea Surgery." 

Topic:  "What You MUST Know About Sleep Apnea Surgery" 
Date:    Tuesday,  February 9th, 2010 
Time:   8PM Eastern 

I get inundated with questions about surgery all the time, and I thought it was time I spoke my mind about this controversial subject and often misunderstood topic. To ask me your question and to register for this event, please go to the link below: 

http://doctorstevenpark.com/ask-dr-park 

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.

Sleep Apnea Surgery: Sham or Science?

As a surgeon, it’s difficult for me to say that most surgical procedures that are performed for sleep apnea don’t work. But like everything else in life, it’s never black or white—there are always various shades of gray.

 

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.

Maxillomandibular Advancement for Obstructive Sleep Apnea: Is It Right For You?

With all the surgical options for obstructive sleep apnea, maxillomandibular advancement (or the MMA) is not mentioned too often as a first line treatment option. Historically, it’s thought to be a big procedure with lots of potential complications, and a long recovery. 

 

The MMA involves cutting the upper and lower jaws and pushing it forward 1 cm or more and fixing it in place using plates and screws. It’s typically reserved for patients that can’t tolerate CPAP, or who’ve failed other soft tissue procedures. 

 

A recent paper published in Otolaryngology – Head & Neck Surgery reported on the complications of 59 patients that underwent this procedure. They reported an 80% success rate with no serious complications. Minor complications included 6 cases of fixation plate infection requiring removal, 2 cases of minor bleeding and one case of vein inflammation. Ninety-four percent reported numbness of the lip area immediately after the procedure, and after 18 months, 52% still complained of numbness. 

 

Despite these complications, the vast majority (94%) were happy with the overall results and would recommend the procedure to family and friends. Many patients were also happy that although their facial appearance changed (usually for the better), they also looked younger, which is due to the facial stretching effect of the procedure.

 

Overall, success rates for the MMA are reported to be from 80% up to 97%. This is much better than multi-level soft tissue surgeries which are no better than 80%. In this particular study, the average distance the jaws were moved was .7 cm, which is much less than what’s typically achieved (over 1 cm). Also, many of the patients that "failed" had large tonsils and bulky soft palate tissues, in addition to being more overweight.

 

Perhaps one way of increasing the overall chances of success if to address any soft tissue areas of obstruction first, and of the 20 or so percent that don’t respond, offer them the MMA procedure. It’s also important to move the jaws the maximum distance possible, but that’s not as easy as it sounds. 

 

Granted this procedure is not for everyone, but once you begin to look at surgical options, you should at least know about what’s involved the the MMA.

UPPP Revisited for Obstructive Sleep Apnea

The uvulopalatopharyngoplasty (UPPP) procedure is probably one of the most controversial issues in sleep medicine for sleep apnea treatment. Despite study after study showing limited success rates, surgeons continue performing this procedure. Some in the sleep community are adamant that with such low success rates, it should not be performed anymore. But then there are studies that come out once in a while that show there’s some benefit to this procedure. With all the conflicting information and confusion, who are you to believe?

 

A recent paper published in the Mayo Clinic Proceedings concluded that there’s still a role for the UPPP in some sleep apnea patients. While not "curative" in all patients, a significant number of people had improvements not only in their sleep apnea scores, but also in quality of life measures. (Take a look at my response to Sleep Apnea Ed’s blog here.)

 

With the UPPP, the overall "success" rate is found to be around 40% in numerous studies. You could say that it doesn’t work most of the time (60%), or that it worked 40% of the time. Is there a way to predict who’ll respond and who won’t? A common screening system developed by Dr. Friedman showed that if you have very large tonsils and a relatively low-sitting tongue, and you’re not very overweight, then you’ll have about an 80% chance of surgical "success." Unfortunately, not too many people fit into this category.

 

ENT surgeons tend to overly focus on the soft palate, mainly because that’s where the snoring is coming from, and it’s the traditional operation that we do for snoring and sleep apnea. Now we know that the soft palate is only a small part of the condition that causes sleep apnea. Once you address the entire upper airway (from the tip of the nose to the voice box), then surgical success rates can go as high as 80%. If you make the jaws much larger (the maxilla-mandibular advancement, or the MMA), success rates are well above 90%. The thinner you are, the better these procedures will work.

 

One study that I recall showed that even the 40% success rate was better in the long term than CPAP. Patients were recruited from a VA hospital with newly diagnosed sleep apnea and two groups were followed: CPAP users and UPPP patients. What why found a few years later was that you had a higher chance of being alive if you underwent a UPPP than if you were assigned to the CPAP group. Even though the overall success rate for UPPP is only 40%, these 40% stayed "successful", at least for the first few years. CPAP users, on the other hand, probably began to drop off in using their CPAP machines, at after a few years, compliance was poor. Based on research that shows that your overall risk of dying from cardiovascular disease in much higher if your have untreated sleep apnea, these results make sense.

 

Of course there’s still a lot more we as physicians can do for sleep apnea patients before they even consider surgery (counseling for CPAP, oral appliances, etc.), but once they run out of all other options, it’s important to know the facts and see the big picture. With good patient selection, intensive counseling, and setting realistic long-term goals, surgery can be a good option for some people. Usually, a UPPP alone is never the answer.

 

How many of you have undergone a UPPP operation and it didn’t help? How much counseling, follow-up and support did you receive with CPAP or oral appliances? Was multi-level surgery offered besides just a UPPP? Please enter your response in the text area below.

Ask Dr. Park – A Live Teleconference

Join me on the next "Ask Dr. Park" call.  We’ll talk about lots of things, but the focus of this teleseminar will be sleep apnea. Everything about the quality of your sleep will be discussed: from tips on improving your sleep quality to a discussion on the best treatments for OSA. And, you get to set the actual agenda! I would like to hear from YOU about what your biggest questions and topic areas of concern are. The aim is to arm you with lots of information about sleep apnea that you want to know. This is a rare treat for any of you or your loved ones who suffer from sleep apnea.

This event will be held live on 5/12 at 8PM Eastern. You’ll be able to either call in using your telephone line, or listen in on your computer’s browser. You can ask your question during registration or during the call. 

Click here to register and receive the call-in information.

 

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.
 

Surgery for Snoring and Sleep Apnea

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! 

Copyright © 2008 Doctor Steven Y. Park, MD | New York, NY | Integrative Solutions for Obstructive Sleep Apnea, Upper Airway Resistance Syndrome, and Snoring · Design by Fervent