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

List of questions answered will be updated shortly. 

What’s your opinion on this debate?

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.

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?

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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?

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?

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.

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?

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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