January 7, 2013
Maxillo-mandibular advancement (MMA) surgery has been around a long time for obstructive sleep apnea. It has a good track record with high success rates raging from 80-95%. Here’s a study showing that that the success rate was 100%. In Dr. Prinsell’s 50 patients, the apnea hypopnea index (AHI) dropped from 59 to 5, and the apnea index (AI) dropped from 35 to 1. Success was defined as the AHI < 15, AI < 5, and the low oxygen saturation > 80%, and the AHI and AI dropping more than 60%.
MMA surgery is one of the bread and butter procedures for most oral surgeons. However, different surgeons have different success rates for obstructive sleep apnea. If you’re considering this procedure, ask about results specifically for obstructive sleep apnea.
One thing to note is that just because the AHI dropped significantly doesn’t mean that you’ll always feel dramatically better, or that the results will last for a long time. These are issues that need to be addressed, like with any surgical procedure for obstructive sleep apnea.
July 24, 2012
Sorry, but this program has been canceled. Please look for more upcoming Expert Interviews and Ask Dr. Park programs.
May 11, 2012
I was recently interviewed by the staff at Sleep-Apnea-Guide.com, which is a great resource for people with obstructive sleep apnea. It was a very in-depth interview where we talked about my work and various other issues important issues. You can read the full transcript here.
Some of the questions I get asked include:
- How did you become interested in sleep apnea surgery?
- As a busy surgeon, how do you have time to do run your website and do your programs?
- How do you decide who can benefit from surgery?
- Why do modern humans have more sleep apnea?
- How do I find the right surgeon to treat sleep apnea?
- Any advice for people who are considering surgery for sleep apnea?
April 4, 2012
In this Ask Dr. Park Teleseminar, I answer the following questions:
- I’ve had my CPAP machine for 5 years. Should I undergo another sleep study to see if anything has changed?
- Does palatal expansion work for people over 60?
- What do you think about Provent therapy?
- Is it possible to have a dental device lose its’ effectiveness without any weight gain?
- What’s your vision in the multidisciplinary approach to OSA treatment and comorbididies?
- Will restorative breathing correct OSA cases previously recommended for surgery?
- Can sleeping on your side be OK for sleep apnea?
- A recent Chinese study reported OSA in 27% of 5 to 12 year olds. In view of the obesity epidemic here in the US, is the incidence here in the US at least as high, if not higher?
- Should a person’s stuffy nose be addressed before OSA therapy?
- Does CPAP create “dependence,” so that surgical options later on may not work as well due to a weakened diaphragm or other muscles for breathing?
- Your opinion on the new implants (Pillar and hypoglossal nerve stimulation)
- Does sleeping on a 45 degree incline help with obstructive sleep apnea?
- What can be done to reduce the number of “getups” each night?
- What percentage of OSA is due to tongue collapse (vs. soft palate)?
And much, much more.
Click here to purchase the 60 minute MP3 recording.
February 2, 2012
– How to find the right surgeon
– The most common misconception about sleep apnea surgery
– Uvulopalatopharyngoplasty: What you must know
– What is surgical success?
– Pros and cons of surgery
– Information about tongue base procedures: genioglossus advancement, hyoid suspension, Repose suture suspension, Coblation tongue reduction, Robotic surgery, hypoglossal nerve stimulation, maxillo-mandibular advancement, tracheotomy.
– And much more….
Click here to order the MP3 recording ($17)
* Please note different day of the week*
September 2, 2011
List of questions answered will be updated shortly.
April 23, 2011
At SleepGuide.com, I responded to a post that referenced Dr. Kasey Li’s answer to a question about sleep apnea surgery. There are a number of important points that summarizes things you should consider if you’re ever going to consider sleep apnea surgery. Here’s the link to the discussion.
What’s your opinion on this debate?
February 10, 2011
As a resident during otolaryngology training, I rotated in the medical center’s craniofacial clinic, seeing various disorders that lead to underdeveloped or malformed facial or skull structures. These syndromic children clearly had severely asymmetric faces or underformed jaws. In many cases they had breathing problems requiring surgery.
One of the more common conditions you’ll see in such a clinic is Pierre Robin sequence, where due to improper maturation of the lower jaw, the lower chin is recessed severely. You’ll see milder variations of this all the time, but if severe enough, these people can’t breathe, especially at night.
Treating Only The Extremes
One of the problems with modern medicine is that we name and treat only the extreme end of a continuum, or only when significant problems result. Having a slightly recessed chin may be thought of a the person’s normal facial feature, and his or her ability to breathe is never even considered.
The entire basis for my sleep-breathing paradigm is that all modern humans have constricted facial structures, not due to a congenital or genetic problem, but due to our eating and lifestyle habits. Genetically, we’re all programmed to have relatively wide jaws, with room for all your wisdom teeth. Now, that rarely ever happens. This is why obstructive sleep apnea can be described as a mild craniofacial condition that can significantly affect your upper breathing passageways.
Small Jaws, Small Airway
It seems that almost everyone these days will need braces to fix crooked teeth or narrow dental arches. Dental crowding by definition means that your upper and lower jaws are underdeveloped. This creates less total volume inside your mouth, leading to overcrowding of your tongue. Your tongue can then fall back easier when on your back, and when in deep sleep, due to muscle relaxation, you’ll stop breathing more often at night.
Even your nose can be affected by this problem. Since your nasal sidewalls follow your upper molars, the side to side distance in your nose will be more narrow, and as the roof of your mouth (nasal floor) gets pushed up, it’ll also cause your septum to buckle.
If you add additional inflammation and swelling in your nose (due to colds, allergies or nonallergic rhinitis), your nose will become stuffier faster, and even worse, your nostrils will cave in easier.
Having underdeveloped upper jaws prevents proper cheekbone fullness, giving your mid-face a sinked-in look. This type of facial appearance is so common these days that it’s almost accepted as normal. I remember reading in the New York Times a few years back where they reported that women’s preferences for male actors has changed from the classic square-faced, angular facial features, to softer, more feminine, rounded faces.
Despite having some good first line options such as CPAP or oral appliances, these approaches don’t really address the root cause. If your child’s jaw was severely underdeveloped and your choice was either lifetime CPAP or jaw enlargement, which would you choose? What if, rather than cutting the jaws and pulling it forward, you can apply distraction plates that can be pulled slowly, little by little, to normalize the jaws and improve the airway significantly? What about advanced dental appliances that can expand your upper and lower jaws in three dimensions, making more room for your tongue? With current technology, we can modify your jaws significantly. But for adults with obstructive sleep apnea, any kind of surgical or dental modification of the jaws is only considered as a last resort.
I describe obstructive sleep apnea as the end extreme of a continuum of sleep-breathing disorders. Similarly, if you look at obstructive sleep apnea as being a craniofacial problem, everyone will have various degrees of jaw underdevelopment. If you have impacted molars, or had to have your wisdom teeth taken out, then your breathing passageways are compromised.
Not only are your jaws more narrow, but the soft tissues that line your breathing passageways will be much more likely to become inflamed and cause even further obstruction. Frequent obstructions can cause a vacuum effect in your throat which literally suctions up your normal stomach juices into your throat, promoting more inflammation and swelling. These juices (which include acid, bile, digestive enzymes and bacteria) can then also reach your nose, sinuses, ears and even your lungs, causing additional inflammation and swelling. If your nose is stuffy, then a vacuum effect is created downstream in your throat and the tongue can fall back much easier, whenever you’re in deep sleep (due to muscle relaxation).
Our Airways Are Like Plumbing
In the medical community, craniofacial problems are generally treated surgically. Even with plumbing, if you only open up one area of multiple clogged areas, the pipes will still be clogged (like doing a UPPP). Sometimes you can put in drano to soften the clogging and open up the passageways (like allergy medications), but after years of buildup and accumulation, you have to physically open up all the blocked areas. You can also use a plunger to force the water down the drain (like CPAP), but you know that sooner or later, it’ll get clogged again. The older the pipes, the worse it becomes (old age).
CPAP and oral appliances are both important and necessary tools to treat the vast majority of people with sleep apnea, but we also need to open our minds to the idea that we shouldn’t have to sleep with gadgets or devices for the rest of our lives.
A Modern, Western Dilemma
It’s commonly known that our brains are getting bigger over time. As modern human’s mid and lower faces get smaller and smaller, I predict that in a few hundred to a few thousand years, everyone will be tethered to a hose while sleeping, like in the science fiction movies. Maybe vocal speech and communication will not be needed anymore, and we’ll be able to communicate with mental telepathy. We’ll all begin to look like that alien in the old Star Trek episode with the huge brain and a tiny face.
Sadly, it’s already started. If you look at the younger generations, you’ll see how narrow their dental arches are, along with flat cheekbones and narrow nasal widths. Recently, I happened to see an Amish chorus singing songs in the Grand Central subway station. I was amazed how most had very prominent cheekbones, well-formed jaws, and good looking smiles. It’s not surprising that cultures that eat organically and off the land will have more fully developed jaws.
So the next time you’re sitting in an auditorium and a public place with lots of people, think about that classic first day of college speech by the dean or president:
“Look to your left…and look to your right. At the end of this year, one of the two that you see will not be here with you.”
Similarly, every other person sitting next to you will most likely have smallish jaws, and have an undiagnosed sleep-breathing problem. From a craniofacial standpoint, they won’t be able to sleep well due to narrowed breathing passageways. If you end up befriending or marrying one of these people, now you’ll understand what makes them tick, or sick.
January 31, 2011
This month, I’ll be answering the top 10 questions I get asked about obstructive sleep apnea. Of course, I’ll also leave plenty of time for me to answer your other questions at the end of the program.
1. What’s the difference between snoring and apnea, and where is each coming from?
2. What’s the best CPAP – mask combination?
3. Is snoring itself harmful or do you need to have sleep apnea to have adverse health effects?
4. How effective are mouthpieces for sleep apnea?
5. How can the source of airway blockages be determined?
6. What’s the best operative solution after UPPP fails and what is it’s success rate?
7. Does sleep apnea cause permanent brain damage?
8. Can CPAP convert OSA into UARS?
9. Do you have any suggestions for what to do for patients who just cannot sleep in a sleep lab?
10. What’s the best sleep apnea treatment?
Please click here to purchase the 60 minute MP3 recording for $17.
Click here to purchase the PDF transcript for $7.
January 10, 2011
One of the more heated debates in sleep medicine is the role of surgery for obstructive sleep apnea. There are some sleep doctors that say that there’s no role for surgery at all, except for nasal issues. Then there are physicians who argue that some improvement is better than not using CPAP at all.
Here’s a study that compared non-optimal use of optimal therapy (CPAP) with optimal effect (100%) of non-optimal therapy (surgery). What they found was that the more severe the AHI, the higher percentage of the total sleep time CPAP must be used to significantly reduce the AHI. For example, patients with moderate OSA who use CPAP for 4 hours per night with an effective AHI from 0 to 5 will reduce the average AHI by 33 to 48%.
Medicare’s new guidelines regarding CPAP compliance for coverage requires that you use the CPAP machine at least 4 hours per night for at least 70% of the time over a 30 day period. So if you normally sleep 8 hours, you’ll have to use your CPAP machine at least 35% of your total sleep time (40% if you sleep 7 hours per night) to meet Medicare Guidelines. This doesn’t take into consideration what your average AHI is during the time that you’re using your CPAP.
Since reported non-compliance rates range from 29 to 83%, it’s safe to estimate that about 50% won’t be considered compliant.
The study authors argue that rather than calculating the average AHI only during the time it’s being used, you should also include in the calculation all the sleep times where the patient is not using CPAP. During this time, there’s no improvement at all, so your total average AHI will be significantly lower.
With surgery, however, even if you have mild residual disease, and since your final AHI will remain constant, it will remain at that level during 100% of your sleep times. So the average AHI for the total sleep time can be as good, if not better than CPAP that’s not being used 50% of the time.
This may explain an old VA study that showed that patients who underwent UPPP only had higher survival rates than people placed on CPAP after a few years, but not by much.
While I agree with the basic premise of their paper, there are a few caveats. Many people use their CPAP machines religiously 100% of the time, with an excellent average AHI (less than 5). Clearly, these people should continue with CPAP, and surgery is not an option. However, there are some people who are perfectly happy with CPAP, but wish to be able to come off of it entirely.
Compliance studies are an average measure of large groups of people, and this data can’t be extrapolated to individual situations. As I’ve stated before, there’s a lot more that sleep physicians, ENTs, and DME vendors can do to increase effective CPAP use. But there will alway be some people who try everything with CPAP and just give up. So if this person has an AHI of 59, isn’t an AHI of 11 after suboptimal surgery (which is considered mild sleep apnea) better than staying at 59?
Once surgeons go beyond the soft palate and begin to address the entire upper airway from the nose to the tongue, soft tissue surgical success rates will improve. If you think of obstructive sleep apnea as a craniofacial problem, then it explains why the skeletal framework options (including dental appliances, orthodontic appliances that expand the jaws, and jaw surgery) also work well to significantly lessen the severity of obstructive sleep apnea.
I admit I’m a bit biased being a surgeon, but it’s important to look the practical and real-life aspects of CPAP treatment, and not just the superficial numbers. What are your thoughts on this issue?