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More Sleep Apnea Bites the Dust

I had a crazy day today with a packed schedule full of patients, but the one thing that made it worthwhile for me was the feedback I got from three different patients about either how well they were sleeping, or how their lives were changed as a result of sleep apnea treatment.

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.

Sleep Apnea Surgery: Paralysis by By Analysis

One of the great advances of the internet is the boom in information available for health related topics. There's a ton of great information about sleep apnea out there, but unfortunately, much of it is the same old, recycled information that's not always accurate. I make it my job to know what patients are reading, and believe me, I try to read everything. 

There are a lot of benefits and problems associated with having all this information, but one thing that stands out is the paralysis that can occur when someone is considering surgery. Let's say that you tried everything possible with CPAP and oral appliances and wish to consider surgery. The first barrier that you'll encounter is all the negative opinions about the uvulopalatopharyngoplasty procedure, one of the more common procedures that's offered for sleep apnea. Much of the comments by patients that underwent this procedures are not very supportive of this procedure, in direct contrast to the studies that I read about in my journals. Granted, the overall success rate is about 40% at best long term, and there is a small risk for complications. 

One of the most commonly mentioned of the complications is something called velopharyngeal incompetence, where due to too much soft palate being removed, air or food can leak into the nose when you talk or swallow. It's like having a cleft palate. This was a common complication in the early 80's when this procedure was first developed, but these days, it's rare. Even when it happens, it's usually temporary. But because a small minority of people who suffer from this complication continue to voice their opinions against the uvulopalatopharyngoplasty procedure, it seems like this complication happens all the time. 

For some reason, physicians and the lay public are overly fixated on the soft palate as the source of all snoring and sleep apnea. We've known for years that sleep apnea involves multiple levels, including the nose, soft palate and tongue areas. If you definitively address all the appropriate areas with surgery, your success rates can go up to about 80% (for soft tissue procedures only). If you add bony framework surgery (maxillo-mandibular advancement), then success can go up to 95%. 

Once you get past the possible complications of sleep apnea and the fact that you'll probably need to address multiple levels of your airway, the next hurdle to overcome is: Which combination of procedures do you need?

There are multiple types of procedures for each area of the throat. Even with the same operation, all surgeons, by definition, will do it differently. Given all the different options available along with different recommendations by different surgeons, how are you to choose? 

Some people get more opinions, with even more confusion. Others just put off the decision altogether. Some just end up biting the bullet and pick a surgeon that they trust and go with it.

Are you someone that's considering surgery and can't make a decision? What's preventing you from making a choice?

Ask Dr. Park: An Insider’s Guide To Sleep Apnea Surgery

Secrets To Sleep Apnea Surgery…

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.
  

Click here to purchase MP3 recording.

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.

 

To listen to an interview with Stanford University surgeon Dr. Kasey Li, click here.

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.
 

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