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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?

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?

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.

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.