Tired of Being Tired — The Upper Airway Resistance Syndrome

Note: This is an edited transcription of a podcast recording 

Today, we are going to spend the next 30 minutes talking about upper airway resistance syndrome, or UARS. It’s a relatively new description of a condition that’s related to obstructive sleep apnea but as you’ll hear in this podcast, has enormous ramifications in regards to so many health conditions that we see, not only in our field, but in almost every other field in general. I have to say, however, that this is a condition that is not yet accepted by the medical community as it is a relatively new diagnosis and much of what I will talk about is based on my own experiences in my practice. If you think you may have this condition, please see your doctor first and get a complete medical evaluation before considering this diagnosis. In my practice, I am amazed at how consistently I see the same pattern over and over again and I am excited to share this new information with you. 

Upper airway resistance syndrome was first described by researchers at Stanford University in 1993. They described a group of young women and men who complained of chronic fatigue and excessive daytime sleepiness. They all also underwent a formal sleep study and all were found not to meet the official criteria for obstructive sleep apnea. However, by treating them as if they had obstructive sleep apnea, most improved significantly. To understand how upper airway resistance syndrome is unique or different from sleep apnea, you have to first understand what obstructive sleep apnea is.   

Obstructive sleep apnea is a well-known sleep related breathing disorder characterized by repetitive breathing cessations during sleep, due to total collapses of the tissues of the throat.  This can happen anywhere from a few times every hour to over 100 times every hour. By definition then, apnea is defined as a total cessation of breathing for 10 seconds or more. And hypopnea is restricted breathing with greater than 30% chest wall movement decrease and blood oxygen drop of more than 4% for 10 seconds or more. A pretty complicated definition! The total combinations of apneas and hypopneas for the entire night divided by the total number of hours one sleeps gives us the apnea/hypopnea index or the AHI. This is the most commonly used measure to diagnose sleep apnea. Untreated, sleep apnea can lead to hypertension, diabetes, obesity, depression, lack of sexual desire, heart disease, heart attack or even stroke.   

Unlike sleep apnea where you have obstruction, apnea, then arousal, UARS patients typically have mostly obstructions and then arousals. As mentioned previously, all UARS patients have some form of fatigue, almost all state that they are “light sleepers,” and almost invariably, they don’t like to sleep on their backs. In some cases, they actually can’t. Some people attribute their poor quality sleep to insomnia, stress or working too much. Due to repetitive arousals at night, especially during the deeper levels of sleep, one is unable to get the required deep, restorative sleep that one needs to feel refreshed in the morning. In most cases, the anatomic reason for this collapse is the tongue. There are many reasons for the tongue to cause obstruction including being too large or being overweight. But once it occurs, the only thing you can do is to wake up.   

In deeper levels of sleep, especially during REM sleep, the normal protective layers of muscle tone that keeps your airway open during inspiration diminishes. So, if your airway is normal to begin with and you take a deep breath in, a vacuum-like pressure is set up and the back of your tongue can fall back completely. In many cases, whenever I examined this narrowed airway with the patient lying flat on his or her back, all I see is a 1-2mm slit between the back of the tongue and the throat.   

When awake, you’re fine, but once you start to fall asleep, the tongue falls back and you wake up, either fully or subconsciously. This is why so many people can’t fall asleep on their backs and therefore, have unconsciously trained themselves to roll over to their side or their stomach where the tongue collapse is less likely, although it can still happen. This can happen 10, 20 or 30 times every hour preventing you from sustaining deep sleep. You may realize that you are waking up sometimes, but the vast majority of arousals are subconscious. If this happens for a few nights in a row and you return to your normal sleep habits, you’re fine. But if it occurs continuously for months or years, then certain events can happen. 

Due to repetitive arousals, your body goes into almost a chronic state of low-grade stress. Think of what would happen if somebody poked you with their finger every few minutes while you tried to sleep for 6 months straight. Think about how you would feel the next morning. Think about how you would feel after months or years of inefficient sleep. You would feel tired, groggy with no motivation to do anything, have focus or concentration problems, or, you could feel depressed.   

Physiologically, these multiple arousals also affect what is called the autonomic nervous system, or the AMS. The AMS is the internal nervous system that regulates your internal body functions such as digestion, breathing, heart rate, blood pressure, etc. It’s divided into two parts: the sympathetic and the parasympathetic parts. When you’re frightened or running away from a bull, your heart rate and blood pressure goes up, your vision and hearing are very sensitive, and all your blood flow and energy are mobilized around a fight. These functions are activated by the sympathetic nervous system. In contrast, after a good meal, your digestive organs kick in and begin to break down your food and you feel sleepy. This is your parasympathetic nervous system working.   

Your autonomic nervous system is in a constant state of relative balance between the two, depending on what you’re doing. Imagine if you’re stressed because you keep waking up at night for years. Your sympathetic nervous system becomes overly activated and stays active even when awake. A number of events can occur. Your hands or feet can become cold or numb, in general, activated by cold temperatures or stress. Some people have to wear mittens or socks all year round. This condition is called Raynaud’s phenomenon. There are many theories as to why people why so many people have this condition but there is no definitive cure. Since you’re under stress, your body thinks that it is under attack and it shunts blood from your peripheries to the more central muscles and to the heart, so that you can run or fight more effectively.  This might actually validate the saying “cold hands, warm heart.”   

Similarly, since you don’t need to digest food when you’re fighting, blood gets shunted away from your entire gastrointestinal system to the heart muscles, leading to chronic diarrhea, constipation, indigestion, acid reflux or bloating. Remember the last time you were stressed?  How well were you able to eat, or digest food if you had just eaten? We already know that stress can aggravate acid production in the stomach. In addition to chronic gastrointestinal problems, many people with UARS also have LPRD, or laryngopharyngeal (throat and voice box) reflux.  It’s somewhat different than GERD, or gastroesophageal reflux disease. In most cases, you won’t feel any heartburn or the classic symptoms associated with GERD.   

The common complaints of LPRD include one or many of the following:  chronic throat clearing, postnasal drip, hoarseness, cough, throat or ear pain, lump in the throat, difficulty swallowing, tightness or pain with swallowing. You don’t have to feel any heartburn, either. Studies have shown that once acid reaches the throat, it can also go into the lungs, causing or aggravating asthma or bronchitis and even into the nose and ears causing more aggravating nasal congestion, sinus or ear infections.   

Pepsin, one of the stomach’s digestive enzymes and even H. pylori, a bacteria that can cause stomach infections have been found in the lungs, ears and the nasal cavity in people with infections. Any degree of swelling or irritation blocking the very narrow ear or sinus openings can cause pressure build-up or infections.   

Another study showed that in about 23% of people with UARS have low-blood pressure, sometimes dangerously low. In addition, these people frequently are dizzy or lightheaded, aggravated by standing up too soon. This is called orthostatic intolerance.  Even if the blood pressure is normal, one may still be prone to episodes of dizziness or lightheadedness.   

Recurring periods of stress may confuse your autonomic nervous system, so it doesn’t respond to the changes in blood flow and head position appropriately or quickly enough. People can also have chronic or recurrent sinus pain or pressure or infections, which can be debilitating.  Frequently, patients are  seen multiple times for recurrent sinus infections, given antibiotics (which only help temporarily), and in many cases, migraines can also masquerade as a sinus headache without the classic symptoms. 

Your nose is also regulated by the two opposing parts of the autonomic nervous system.  Studies have shown that there is an imbalance between the two parts of the ANS in the nose in people with acid reflux or sleep apnea. Thus, many people with either sleep apnea or UARS have chronic runny or stuffy noses with postnasal drip and are prone to sinus headaches or infections.  This process, in addition to the acid exposure described earlier is a very good reason for chronic nasal or sinus problems.   

Classic migraine and tension headaches are also frequent in UARS along with TMJ (temporo-mandibular joint) problems, due to grinding and clenching of the teeth. Sometimes these sinus headaches and pressure problems responded to decongestants and sometimes, anti-migraine medications. One doesn’t have to have the classic, typical migraine headache to have one. A recent study showed that in most cases of self-diagnosed sinus headaches, they were actually migraines.  Regardless of what comes first, the chicken or the egg, one probably aggravates the other, leading to a vicious circle.  TMJ can also give you ear pain, headaches along the side of your head, and it can also wear down your teeth.   

UARS is also associated with depression, anxiety or attention deficit problems. For obvious reasons, sleep deprivation, especially deep sleep deprivation with multiple arousals, can lead to many of these conditions. In addition, if you don’t sleep deeply, it’s been shown that your body produces increased levels of cortisol. And as we all know, cortisol is what makes you gain weight and eat more. It also lowers your immune system’s ability to fight infections and aggravate insulin resistance, leading to diabetes.   

Almost invariably, people with UARS prefer not to sleep on their backs. Many people state that if they try, they choke or wake up as they fall asleep. Over the years, they have trained themselves to sleep on their side or their stomach. Even then, they obstruct and wake up to a certain degree.  Many people also state that they have crazy or vivid dreams or sometimes no dreams at all. This is because when you wake up while you’re dreaming in REM sleep; you’ve remembered your dreams vividly. By definition, all dreams are wild and vivid. Only because you tend to wake up more frequently when you are dreaming, do you remember your dreams more vividly. Some people wake up as they begin to enter the dreaming stage, so they never dream at all.   

Family history is also very important. This is one way that I gauge what the patient might look like in 20-40 years. And in many cases, patients with UARS or sleep apnea have one or more parents that snore severely with one or many of the cardiovascular consequences such as obesity, diabetes, high blood pressure or heart disease. If one parent is noted to have had a heart attack or stroke in their 40’s or 50’s, I take the patient’s condition more seriously.   

The natural course of UARS is highly variable with some patients remaining unchanged for years or decades, where others are slowly progressing into sleep apnea. Some older, overweight women in their 50’s or 60’s with sleep apnea tell me that when they were in their 20’s, they were very thin and had cold hands, low blood pressure, chronic diarrhea, and dizziness, and now they don’t have any of these conditions except that now they have high blood pressure, snoring and severe fatigue.   

What seems to aggravated UARS symptoms most however, is a relative change in their lives.  So a relative weight gain, even 5 or 10 pounds, can aggravate the symptoms which go away once the weight has stabilized and as the body adjust and accommodates to the new weight. A bad cold or infection can also aggravate these symptoms, since it causes swelling, which narrows the upper airway. Pregnancy is another situation where this occurs. 

UARS people who are already living on the edge tend to have more prolonged or severe colds as airway swelling causes more narrowing and anatomic collapse, which further aggravates throat acid reflux, which causes more swelling, perpetuating the vicious cycle. At a certain point, the body can’t adjust and the vicious cycle is self-perpetuating. Poor sleep can also aggravate weight gain for reasons described before, previously. Weight gain narrows the throat even more, causing more obstruction and arousals.  Stress is also a big factor, whether it is emotional, psychological or physical. Whether the stress is internal or external, the body behaves the same way. 

On a personal note, my wife has many features of UARS. She has cold hands and low blood pressure. But after each of her two pregnancies, her UARS symptoms were greatly exaggerated.  After our first son, she had severe postpartum depression for almost a year. Only after she lost her entire pregnancy weight did she feel back to normal. After our second son was born, for four months she was severely lightheaded and dizzy, to the point of not being able to function properly. She saw a number of doctors and even had to go to the Emergency Room because one doctor thought she was having a stroke. The only objective finding was that her low blood pressure, which was low to begin with, was even lower. Only after she lost her entire pregnancy weight, did this condition go away. Sure enough, when I looked at her airway lying down, she had the typical narrowed airway behind the tongue.  Furthermore, her father has known moderate sleep apnea with diabetes. 

So how does one diagnose UARS?  The first step is to undergo a complete ear, nose and throat evaluation. In most cases, the exam is normal. Sometimes what we’ll see is a deviated septum or nasal congestion due to allergies but more commonly what you’ll see is when we look in the mouth, the back of the throat is very narrow and you’ll have a very large tongue that sits very high up, covering up the uvula, the little thing that hangs down in the middle of your throat.   

The next step is to undergo an endoscopic evaluation, meaning that a small, tiny camera is placed through your nose and your airway is visualized. Normally, when you look at the airway, you can see the vocal cords behind your voice box but in people with UARS, the tongue fits further back, so most of the voice box is covered up. Especially if the person lies down, the tongue falls back even more, leaving a 1-2mm slit. When you are awake, you can breathe through this slit.  But as you fall asleep, the muscles relax as you get deeper into sleep. Then, when you reach deeper levels of sleep, or REM sleep (when you’re dreaming), the muscles have to relax completely and that’s when you start to obstruct. Then, once you obstruct, you stop breathing and you get aroused, going to light sleep and the cycle happens over and over again.   

One of the ways that this is treated is using a dental device that pulls the lower jaw forward, which is similar to what you use for snorers and mild sleep apnea patients. So I have the patients thrust their jaw forward and by putting the jaw forward, it also pulls the tongue forward and you can see a vast improvement in the caliber of the airway.   

Based on an extensive series of questionnaires, your physical examination, your past family history and the endoscopic evaluation, you can determine whether or not you need a sleep study. So if you undergo a sleep study and you are found to have sleep apnea, then it is treated like normal sleep apnea. That is a topic for another podcast in itself. But if you don’t officially meet the criteria for sleep apnea—meaning that your apnea/hypopnea index is less than 5 but you do have evidence of multiple arousals, then we can say that you may have UARS.   

You may be wondering, I just gave you a good explanation for UARS, but what can you DO about it?  In general, UARS is treated like sleep apnea. In general, the options are nasal breathing optimization, dental appliances, CPAP, or surgery, as a last resort.  Nasal optimization means if you have any degree of nasal congestion or obstruction, that’s dealt with, whether medically or surgically.  So, for most people, allergies are a very common reason that can be treated properly with medications or avoidance measures or even allergy shots. If you have a deviated septum, then that can be dealt with surgically if the medical options don’t work.  Dental appliances are also useful in people with sleep apnea and snoring in the same way it can be used for UARS patients, as well.  The mechanism is essentially the same: as the tongue starts to fall back—if it only falls back partially, then you create a vacuum effect upstream and the palate starts to collapse and then you get snoring. But in UARS patients, the tongue falls back completely, causing obstruction and more arousals. Some of the problems with a dental device include jaw pain, ear pain, and bite problems due to the nature of this device. 

CPAP, or Continuous Positive Airway Pressure, is actually the gold standard treatment for sleep apnea. In the original article that described UARS, CPAP was used successfully in many of these patients. The way CPAP works is that a small mask is placed tightly over your nose and a small amount of positive air pressure is gently blown in through your nose, stenting your airway open while you are sleeping at night. If you have tried and failed these conservative options, then there are surgical options as well.   

Before we finish this evening’s discussion, let me just bring up an interesting case example which will illustrate my point. I had a patient, a young woman in her 30s, who came to see me with recurrent throat infections and was also found to be extremely tired and had depression, on anti-depressants. She also had severe cold hands and feet, low blood pressure with frequent lightheadedness and dizziness, recurrent sinus infections, migraines and chronic diarrhea. She was severely distraught because her overall health had deteriorated to the point where she couldn’t function normally at her job. A sleep study showed that she had mild sleep apnea, at 14 events every hour. She tried CPAP but couldn’t tolerate the mask. Then, she also refused a dental device because she had TMJ. Finally, after a long discussion we decided to perform sleep apnea surgery with her palate and tongue. 

We did a conservative procedure on her palate, called a uvulopalatal flap, as well as a tongue-based procedure. Six months later on a follow-up sleep study; her apnea/hypopnea index had dropped to .2, which is basically cured. But, more surprisingly, she noted that her cold hands and feet were gone, her diarrhea was much better and even her sinus headaches and migraines were better. On her last doctor’s exam, she noted also that her blood pressure had normalized and she wasn’t lightheaded or dizzy anymore. She was completely off her anti-depressants and reported a “life-changing experience.”   

This woman had classic UARS but because she also met the criteria for sleep apnea, was able to undergo definitive treatment. My guess is that, untreated for many years, she would have gained more weight eventually. Many of her UARS symptoms would have disappeared as the onset of sleep apnea signs and symptoms began to appear.   

One interesting study many years ago looked at UARS and its possible association with the somatic syndromes and these include a wide-ranging list of medical conditions like chronic fatigue syndrome, fibromyalgia, hypothyroidism, irritable bowel syndrome and more. Obviously, not all patients with the above conditions have UARS but based on this paradigm, I think it’s safe to say that a significant number of people with these conditions actually have UARS instead. People with these somatic syndromes all have in common some form of chronic fatigue, as well as an inability to sleep well. Obviously, more study is needed in this area.   

As you can see, UARS can potentially explain many symptoms. Typically, these patients see multiple doctors for various complaints without ever finding complete relief. In the end, some even lose faith in Western or allopathic medicine and look elsewhere in alternative or complimentary forms of treatment. UARS is a treatable condition. The first step is a thorough evaluation by someone who knows what to look for. 

If you want more information about UARS, 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. 

That’s it for tonight’s podcast.  For more information, please visit doctorstevenpark.com. You can sign up for my email updates and newsletters as well at this address. 

Until next time, good night! 

Please note: I reserve the right to delete comments that are offensive or off-topic.

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33 thoughts on “Tired of Being Tired — The Upper Airway Resistance Syndrome

  1. My mom says I moan and sound like I have slit of phlegm and my loud snoring is non stop. She is worried for me. I’m 47 and always tired. I would hate to wear a cpap mask but I’m so tired of my snoring. It’s embarrassing and when I talk I grunt sometimes because of the thick phlegm. I’m not congested. What do I do??

  2. I’m wondering if I have UARS. I’ve never been able to sleep on my back, and a few weeks ago I developed a new problem–even when sleeping on my side I can’t fall asleep. The moment I fall asleep I experience a loud snore which immediately wakes me up. This happens over and over for hours until I’m so exhausted (around 3 a.m. or so) that I fall asleep for a few hours. The only way I can avoid this is to try to sleep sitting up with my head tilted slightly forward. In any case, I’m making plans for a sleep study soon, but I’d never heard another doctor describe the symptoms of UARS and wanted to enquire.

  3. Mr. Hancock,

    If you’re found to have obstructive sleep apnea on your sleep test, then UARS is excluded. However, UARS can be treated like OSA, even if you don’t have it. Good luck!

  4. I have been diagnosed with UARS in 2007.

    Could you recomend a good UARS specialist around Washington, DC (MD or Northern Virgiunia)?


  5. Dr Park,

    Why do you say that if OSA is found in a sleep study, then UARS is excluded?

    I have an AHI of 5, but an AI of 70. The reason is a small airway caused by recessed jaws.

    UARS and OSA could happen together, right? I was proposed MMA surgery by several surgeons.

  6. Paul,

    In general, you can have BOTH OSA and UARS. This is why your AHI can go down dramatically with CPAP or surgery and still have lots of micro-obstructions and arousals (which by definition is UARS).

  7. Thanks for your answer.

    Is MMA surgery a good solution for UARS and low OSA when the lower airway is small because of recessed jaws?

  8. MMA is always a good option for UARS if you can’t tolerate or benefit from CPAP. However, you’ll need a sleep apnea diagnosis for any surgery to be covered by insurance. The only way to tell if you’re a good candidate for any type of surgery is an in-office examination.

  9. Thank you for your answer.

    I cannot tolerate CPAP. Would you consider 70 arousals per hour a severe case, even though AHI is low?

  10. Dear doc,
    I am going thru severe insomnia and what feels like hell. I have been to sleep study and told AHI is 20. I try to sleep but can’t induce sleep because of apnea event before inducement takes hold. If I do sleep it’s 3 hrs or less now. COPD has set in, but I feel part the problem is palate/ epiglottis/ and loose voice box. And ENT said there’s nothing he can do for me. My lung doc/ sleep disorder said I should see a shrink for my anxiety/ stress/ frustration with nothing they can do. I live in Florida and seem nothing can be done for me.

  11. The only sleep doctor I know in Texas is Dr. Simmons at houstonsleep.net. He does esophageal manometry for UARS. Good luck.

  12. Hello,

    A few years ago I asked if it was possible that the inflammatory cytokine, TnF-alpha, could cause inflammation in the airways and lead to UARS. The response, which I appreciated, was that if that was the case then NSAIDs would show some effect on the disorder. I pointed out that those are COX-1 and COX-2 inhibitors and would not affect TnF-alpha. I’d like to follow up by posting a study on OSHAS: https://www.spandidos-publications.com/10.3892/etm.2018.7110

    I don’t think this conflicts with most of what has been written on Sleep Breathing Disorders, but perhaps all of those correlated symptoms are associated with causing, or being affected by this inflammation. The study argues that TnF-alpha may constrict airways. Interestingly, TnF-alpha has been shown to be elevated in fatigued patients, and induced sleep when administered–maybe when in the ENT office, a patient’s TnF-alpha levels are low enough to not cause an issue, and it’s only when they are sleeping that the levels become problematic.

    Please note too the latest studies showing that inflammation in GERD may actually cause acid production, rather than the other way around. Considering your stomach, gut, and upper airways are all just one big tube, perhaps it’s the same inflammation that causes airway problems. Comments welcome!

  13. What are your thoughts on using a Maxillary Skeletal Expander (MSE or Won Moon appliance) for curing my UARS? I am very skinny, I don’t snore, but I have a narrow upper palate, difficulty breathing through the nose, deviated septum, nasal valve collapse, and enlarged turbinates.

    The maxilla (upper jaw) comprises much of the inside of the nose; by splitting the midpalatel suture and widening the upper jaw, the inside of the nose becomes bigger. Thus, the inside of the nose becomes less obstructed. Skeletal expansion of the maxilla using MSE (or SARPE) should, in theory, allow one to go from having a narrow nasal airway to a significantly enlarged nasal airway.

    One last thing is that I wonder if my deviated septum is even worth fixing. I have no idea how badly deviated it is.

  14. Greg,

    From what you’re describing, any kind of palatal expansion makes sense, whether orthodontic or surgical, or both. In theory, this should open up the nasal cavity. However, if your nose is still stuffy after expansion, then perhaps consider nasal surgery. Good luck.

  15. Could UARS explain elevated heart rate during sleep? My HR during sleep is typically 10-20+ bpm above my average resting HR. My Gp doesn’t want to see me because it’s still within normal range. I think It’s odd -HR should go down, not up, during sleep.

  16. If I first get deviated septum surgery and then later fix my narrow jaw/crooked teeth with orthodontics/mewing, would my septum become deviated again?

    My deviated septum could be caused by my narrow jaw and I wonder if it would become deviated again if I do septum surgery before fixing narrow jaw.

  17. I have some of the symptoms of UARS (never able to sleep on my back, low blood pressure, and most recently some signs of LPR – I started having sore throat once or twice a month and linked it to my menstrual cycle). I also have deviated septum. What puzzles me is that you mentioned I think in podcast (if I remember correctly) that progesterone keeps some muscles (I don’t remember their name) tight, but I know that in pregnancy progesterone is responsible for slowing down bowel and, as I recall, making muscles more relaxed. Can you explain more the relationship between progesterone and muscles? Another question is: Could removal of the tonsils help people with UARS?

  18. Hey Dr. Park, I am currently on the search for a diagnosis of possible UARS. Do you know anyone in FL that specializes in UARS?
    My local sleep doctor says my sleep is very “fragmented” and sent me on my way.

  19. Mr. Walker,

    Sorry to hear. Your best bet is to find an ENT that’s willing to perform a DISE (drug induced sleep endosopcy) to see objectively what may be causing your interrupted sleep. Here’s a link to my article on this subject. Good luck.

  20. I have a 15 yr old (thin) who I suspect has had UARS for many years and last few years has progressed to daily headaches, cold hands feet, acrocyanosis and severe dizziness. I am looking into a Vivos DNA appliance to help with her jaw issues which may be contributing to this. Do you know if The DNA appliance has been helpful with UARS?

    Thank you in advance.

  21. Joanne,

    The Vivos/DNA is one of many good appliances that can help widen the upper airway for obstructive sleep apnea and upper airway resistance syndrome. The key is to find a practitioner that gets consistently good results. Good luck!

  22. I saw a post about recommending Vivos/DNA appliance. Would caution recommending such appliance. It does not do what it claims. I personally wen through treatment and all I sustained was minimal bone loss, tooth restorations, and increased sensitivity. The appliance does not archived true skeletal expansion, but expands at the teeth which does not help increase Nasal Aperture volume. Dr. Kasey Li is truly the pioneer of Maxillary/NasaoMaxillary Expansion with the EASE technique.

  23. John,

    Sorry to hear about your negative experience with the DNA. Both opposing options (surgically assisted rapid palatal expansion (SARPE) vs. non-surgical functional appliances) have their pros and cons. I’ve seen many successes on both sides as well as a few less than optimal/negative results in both camps as well. Dr. Li’s EASE procedure is a variation of the SARPE technique using an endoscope to make the hard palate cut through the nose. There’s no doubt that you can get much more aggressive expansion using any of the SARPE methods, including widening the nasal aperture. But many people who are candidates are resistant to the “surgical” portion of these procedures. Until there are prospective comparative studies between these two options, you can’t say that one is better than the other. My feeling is that overall, the SARPE options work somewhat better, but both options are very operator dependent. I can argue that a functional dentist that’s good at using an appliance can get better results than for a SARPE procedure done poorly.

    With all dental appliances and palatal widening surgical procedures, you’ll see various degrees of successes and failures. It’s never black or white. Also, both options don’t address any jaw retrusion, with minimal to no movement of both the maxilla and mandible forward. Only the maxillo-mandibular advancement procedure can do this to a significant degree. I have to add that certain functional dentists will disagree with me on this. This is an ongoing debate.

    Additionally, most people undergoing any of these procedures can’t depend on that one step to solve all their health problems. Most will need multiple additional steps including dietary and lifestyle changes, and perhaps even further surgery.

    Fulll disclaimer: Both my wife and I had excellent results using a non-surgical appliance (two different competing models). But it was only a small portion of the overall holistic plan to improve our health.

    If you’re planning to undergo the EASE procedure with Dr. Li, best of luck. And please give my regards to Dr. Li as well.

  24. There are many cons to the non-surgical appliances so are claimed to “Expand the Airway”. We currently have no imaging showing expansion at the Midpalatal Suture/Nasal floor. However there are adequate images showing expanded arches however that does not justify true “skeletal expansion” without a AP CBCT. This means all that is occurring is Dentoalveolar expansion which only improves tongue space and broadens the smile. This also puts the teeth at a higher risk for bone loss and periodontal damage if pushed too far. The problems with SARPE included the Hyrax tooth borne expander that is still used and not assessing whether posterior nasal aperture expansion was achieved. Large Diastemas do not prove that successful expansion that most may believe becuase it does prove that mostly anterior expansion occurred without PMD (Pterygomaxillary Joint Dysfunction). Also, expansion only occurs below the Lefort 1 cut and nothing superior to that. When looking EASE, there is no Lefort 1 so you achieve full nasal aperture expansion (anterior to posterior) and minimal dental movement which is a plus when pursuing ortho and for those with adequate occlusion. Will give him your regards of course! Would highly recommend you take time to watch his recent lectures on Youtube. (I have no affiliation with Dr. Li or any other Institution). Take Care

  25. Dr. Park–
    Thank you for creating this website. I have diagnosed OSA and I use CPAP to treat it. However, I rarely sleep through the night and it is not to get up to pee. I believe I may have UARS as well. I wake up tired. I can make it to the 5 hour mark, but then it is all a matter of luck if I can get back to sleep. I am tired very day, but I do not have the frontal headache that I used to get before CPAP. I am working and I am a college professor. I need to be clear and efficient and some days I am foggy. My sleep doctor and NP praise me about how well I am doing and that appraisal is based solely on the fact that I use my CPAP every night and have 1.5 events total. If I am doing so well, why am I waking up, not able to get back to sleep, and feel foggy and tired all day? They tell me that “human beings have two sleeps” and not to worry about it. I worry about it because it is not normal and they are not hearing me. Do you know a competent sleep doctor in Philadelphia? Many thanks.

  26. JM,

    Thanks for sharing. What you’re describing is very common. You can have excellent CPAP “adherence” numbers but still feel terrible or even worse. I wrote about one possible explanation why in my YouTube video on why some people gain weight on CPAP. The CPAP machine prevents the true apneas and hypopneas (episodes > 10 seconds) but doesn’t prevent episodes less than 10 seconds. Unfortunately, I don’t know any conventional sleep medicine doctors in your area that truly understands UARS. Your best bet is to work with your sleep doctor to find an alternative to CPAP. There are lots of other good options. Good luck!