Why UARS is Harder to To Treat Than Sleep Apnea

Almost routinely, I see patients who repeatedly stop breathing at night but don’t have any significant apneas on sleep studies. Jennifer was told by her husband that she choked multiple times at night with frequent arousals. But her apnea hypopnea index (AHI) on her in-lab sleep study was 1.0, well below the 5.0 threshold needed for an obstructive sleep apnea diagnosis. She underwent every possible test, including an MRI to rule out a brain tumor, but everything came back normal.
Eventually, drug induced sleep endoscopy (DISE) revealed severe tongue base and soft palate obstruction. Essentially, people with upper airway resistance syndrome (UARS) obstruct often but wake up to light sleep too quickly, less than the 10 seconds that are needed to be scored as an apnea or hypopnea.
Here are 5 reasons why UARS is harder to treat than obstructive sleep apnea:
1. If your AHI is less than 5, you’re told by sleep doctors that you don’t have sleep apnea. Your severe fatigue and various other conditions are often blamed on hormonal (pre-menstrual, menopause), neurologic (multiple sclerosis), infectious (Lyme, mononucleosis), rheumatologic (chronic fatigue, fibromyalgia), food/environmental allergies, mold sensitivities, or nutritional/vitamin deficiencies. As a result, treatment for a sleep-breathing problems is not even considered. 
2. If you’ve already been diagnosed with one of the above conditions in #1, then it’s very unlikely that you or your doctor will consider an alternative explanation, especially if you’ve already invested so much time, energy and resources.
3. If your doctor wants to treat you for UARS with continuous positive airway pressure (CPAP) or a dental appliance (that pulls your tongue forward), insurance won’t usually cover it, since your AHI is less than 5.
4. Most people with upper airway resistance syndrome also have various degrees of nasal congestion. Having a small mouth with dental crowding also leads to narrow nasal passageways, making it more likely that you’ll have a deviated nasal septum, enlarged or over-reactive turbinates, or flimsy nostrils. Having a stuffy nose will prevent you from being able to use CPAP or dental appliances. 
5. UARS is a structural problem caused by smaller-than-normal jaw structures, leading to narrowed air-passageways that lead to severe breathing problems at night. All the truly effective solutions involve using gadgets, devices or surgery. With few exceptions that can lead to temporary relief, you can’t treat it with a pill. 
The most common manifestations of UARS are severe chronic fatigue and exhaustion (not sleepiness), anxiety/depression, headaches, nasal congestion, TMJ problems, cold hands/feet, low blood pressure, diarrhea/constipation/bloating, frequent nighttime urination, and hypothyroidism. The typical exam findings include a high arched hard palate, narrow dental arches, crooked teeth, bite problems, head forward posture, and a relatively large tongue (due to a small mouth). 
If you fit some or all of the features described above, you may have upper airway resistance syndrome. For a more detailed description of UARS, you can read an article by clicking here. Please note that you can have UARS and various other conditions. But not being able to breathe and sleep properly can significantly aggravate any other condition that you already have. In addition, you can have obstructive sleep apnea and UARS overlap to various degrees.
Unfortunately, many mainstream sleep physicians will be resistant to acknowledging that UARS exists. If you do your research, you should be able to find a sleep physician that will be willing to treat your UARS even if you don’t have sleep apnea. Other specialists such as otolaryngologists and dentists may be more receptive to UARS, but even then, they are in the minority. A good place to start looking is to listen to some of my past expert interviews, particularly the episodes with Doctors Guilleminault, Krakow, Gold, Lawler, Palmer, Silkman, Belfor and Singh.

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21 thoughts on “Why UARS is Harder to To Treat Than Sleep Apnea

  1. Thank you for continuing to increase awareness of the very real disorder of UARS! It is one which I have… Can you please state the name(s) of the oral device you would advise for moving the tongue forward? Please feel free to describe your opinion of it and tips with it….

    I currently use a bipap that helps but doesn’t fix the disorder; I realize this is a multi-pronged approach and many daily issues (such as stuffy nose) can impact. I also tried a dental device from a specialized local dentist that move the jaw forward with limited success (and worsened neck pain- problems).

    Thanks for your time!

  2. I have just been diagnosed with severe REM-only OSA and have been surfing the Internet to find out more about it. There is a question as to whether or not it should even be treated, I have been working with a psychiatrist but finally had a sleep study with a neurologist who recommended online CBT and a dental appliance.

    However, I just came to your website and had my Eureka moment. I suffer unbelievably from insomnia, sometimes for nights in a row. I can’t fall asleep because as soon as I lie down I can’t breathe. When I get up and walk around the problem abates. I am excited to read more on your website, but the fact that someone recognizes what is going on is so exciting. Thanks so much,

  3. Db,

    The brand name of the tongue retaining device is the AveoTSD. It’s not something that everyone can use comfortably with good results, but I do have some patients that swear by it. Good luck!

  4. Matthew,

    Unfortunately, x-rays and CTs in dental offices are usually done sitting upright. The anatomy is very different when you’re lying flat on your back. Even then, since you’re awake with muscle tone, your airway will be more open than when you’re in deep sleep, when your muscles are most relaxed.

    As time passes, I’m relying less and less on imaging studies and more on the history and physical examination.

  5. Speaking of taking a patient’s history, did you catch this in today’s news.

    Weaker breaths in kids linked to early pesticide exposure

    Taking a deep breath might be a bit harder for children exposed early in life to a widely used class of pesticides in agriculture, according to a new paper by researchers at the University of California, Berkeley.

    A new study has linked the levels of organophosphate pesticide metabolites in the urine of 279 children living in California’s Salinas Valley with decreased lung function. Each tenfold increase in concentrations of organophosphate metabolites was associated with a 159-milliliter decrease in lung function, or about 8 percent less air, on average, when blowing out a candle. The magnitude of this decrease is similar to a child’s secondhand smoke exposure from his or her mother.

    The findings, to be published Thursday, Dec. 3, in the journal Thorax, are the first to link chronic, low-level exposures to organophosphate pesticides—chemicals that target the nervous system—to lung health for children.


  6. Dr Park: hello again. Thank you as always for continuing to increase awareness and treat UARS. I have 3 questions related to your above info.
    ?QUESTION 1: Is there a tongue stabilizing device that keeps the tongue forward while allowing someone to breath from their mouth (if the nose stuffs up at night terribly), but a device that does not move the jaw?

    Here is my background info for the above questions: Although I am doing everything possible to unstuff nose daily-weekly (your recommendations, plus allergy shots, meds, clean sheets in hot water weekly, all items in dust mite proof, etc), I sometimes can’t breath through nose at night, or if side sleeping, I can’t breath through one side (I can’t tolerate a nasal mask with bipap or CPAP bec of this). With the AMD I tried, I had terrible neck pain & associated migraines with an Advanced Mandibukar Device even at low levels (cannot tolerate). In looking at a 2013 article reviewer you have one your site, I see that the Zyppah product combines both a AMD (moves jaw) and tongue stabilizer. I’m thinking that this device could be used & not set to move the jaw, but only stabilize the tongue…. But I’m hoping that there is something easier (& ideally cheaper, though I will pay -do anything to get refreshed sleep!).

    For your info: I use a bi pap, and my fatigue is debilitating daily so that I would like to try and use the tongue device and bi-pap if needed. I notice my tongue blocking my airway- waking me up- in the morning; so wondering about this….

    Thank you for above giving the name of Aveo TSD. I see that there is another similar model that is slightly cheaper & 1-size fits all (“Good. Morning Snore Solution”).
    QUESTION 2: Do you recommend one over the other in your patients?

    QUESTION 3: Lastly, what doctor specialist conducts the DEIS procedure you describe, who can determine if the tongue or throat is collapsing? I’m seeking -if possible- to better determine what is structurally preventing me from getting refreshed sleep. Is it an ENT, sleep doc, or a combined specialist only such as yourself, that conducts the DEIS?

    Thank you for all you do to maintain this site and provide the terrific UARS -OSA info you do!

  7. What type of doctor (specialist) conducts the DEIS procedure you describe? For example, it sounds as if this procedure will help identify (in drug-induced sleep state) if the tongue, soft pallet, or throat airway is collapsing. Is it an ENT, sleep doc, or a combined specialist only such as yourself, that conducts the DEIS? To me, this procedure sounds ideal to better view what is obstructing, and thus, determine what options may best treat the issue. I’m seeking -if possible- to better determine what is structurally preventing me from getting refreshed sleep. I have spent many years trying to improve my sleep quality and am currently unable to work due to the longterm and severe exhaustion and related symptoms.
    Thank you for all you do to maintain this site and provide the terrific UARS -OSA info you do!

  8. DB,

    As far as I know, only otolaryngologists are doing drug induced sleep endoscopy (DISE) for sleep apnea. Sleep medicine certification is not needed.

    It’s gaining more popularity, but you’ll still have to look around to find someone who does it.

    Good luck,


  9. I am in my late 60s and live in the Chicago area. I have Complex Sleep Apneas – both Central and Obstructive – and wear a custom oral appliance for a somewhat retrognathic and somewhat small lower jaw.

    I use a ResMed S9 VPAP Adapt at night and have to use it all night, every night. The only mask I can tolerate and get a good seal with is Swift Mirage II nasal pillows.

    This system gives me AHI = 0 if I use it all night, every night. Sleep studies showed that without the machine my oxygen levels could drop as low as the 70s!
    So I can’t go without the machine.

    I have had problems with dryness of eyes, mouth, and somewhat of the nose for many years and these have recently gotten worse. Standard blood tests for SJogren’s and – years ago – a salivary gland lip biopsy were negative, though I was told I could still have Sjogren’s. I have other diagnosed autoimmune disorders – Fibromyalgia, Celiac Disease, Secondary Hyperparathyroidism (thyroid function is normal), etc. .

    Last September (2015) I began having nosebleeds, but in the right nostril only. I was diagnosed with a deviated septum. I went to three different otolaryngologists over time. The first two tried chemical cauterization an electro-cauterization, respectively, but the nosebleeds recurred. Doctor#1 had me use Ayr nasal spray and gel. Doctor #2 had me use Bacitracin and then later switch to Vaseline. The nosebleeds recurred. We have a whole house furnace humidifier, and a cool mist room vaporizer in the bedroom.

    Specialist #3, a University of Chicago Otorhinolaryngologis, examined me recently and said I have a deviated septum causing the dryness in the right nostril (left has dryness but not as severe), which has caused a thin nasal lining that gets splits, causing the nosebleeds. He said Septoplasty would improve my breathing, and also might help the dryness and nosebleed issues (though it may not solve the nosebleed problem).

    He also said that I can’t have a septoplasty because I would have to stop usning my sleep apnea equipment for up to 4 weeks. I can’t even go without it for one night. He also said septoplasty has a 5% rate of complications.

    Is there a way to have septoplasty when I have to use the sleep apnea machine every night? Nasal pillows are a problem after surgery, I assume, and an oral mask wouldn’t work because the nostrils would have to be plugged or packed for up to 4 weeks to use the oral mask.

    At one point he suggested an oxygen tent or a face tent, which my sleep neurologist (not at U of Chicago) ruled out because it won’t necessarily correct the sleep apneas and Medicare won’t pay for it anyway.

    There is a total face mask (FitLife – which I haven’ tried) that goes around the outside of the face. I don’t know if I could get a good air seal or tolerate the materials (have sensitivities) or pressure points. I would have to buy one and try it. There is also an Amara View (Respironics) hybrid mask.

    Should septoplasty be done in a person with complex sleep apneas who has to use a sleep apnea machine every night?

    Meanwhile, I did some research online and am trying out other nasal lubricants that have been effective for preventing nosebleeds in other people, I have read the user reviews on these products and a few products are on their way here.

    Feedback greatly appreciated. Thank you for the help!

  10. Deena,

    Re: #1: It’s probably not a good idea to use tongue stabilizing devices if your nose is stuffy. The same principle apples to CPAP or mandibular advancement devices. The stuffer the nose, the less likely you’ll benefit or tolerate these devices.

    #2: Sorry, but I don’t have any experiences comparing one with the other. There are unlikely to be any objective studies as well. Ultimately, it’s a matter of trial and error.

    #3: Typically, it’s an ENT surgeon, like myself. Whether or not he or she is sleep certified makes no difference.

    Good luck,


  11. Dr. Park, I love your site! Thank you! Fascinating, well written & organized, and so important to those of us affected by sleep disordered breathing.

    For anyone considering the AveoTSD, I second Dr. Parks’ recommendation. I love my AveoTSD. I ordered it online without my sleep doctor, who said there wasn’t enough evidence for it’s type of device – I was just at my wits end trying to treat my OSA after failing CPAP and trying out a couple ineffective, very expensive dental devices, one of which was the kind that moved my jaw forward.

    At first, the AveoTSD was uncomfortable. It felt like it was cutting my mouth. Also it leaves a rash above or below your mouth, depending on how you wear it, and the suction deforms your tongue temporarily so that in the morning you may talk a little funny, but that effect goes away fairly quickly.

    Despite those shortcomings, I stuck with it, and barely notice it in now – in fact, when I use it it’s a comfy cue to sleep, like pulling a warm blanket up to my chin or putting on an eye mask. I swear it has saved my life (literally – I was terrified of getting in *another* car accident because of dozing at the wheel while trying to live life in an area without viable public transport). I don’t yawn constantly; don’t fall asleep during the day; can participate in activities after 4PM; don’t nap at lunch or before driving. It’s been revolutionary for me. Last year I had another sleep study with it in and I didn’t have an AHI high enough to qualify for OSA, anymore.

    Other ‘bonuses’: It’s relatively cheap; easy to clean; seems to be a fairly safe material to soak in saliva enzymes and keep close to your mucus membranes/the entry to your digestive tract for several hours whereas idk what I was breathing with my CPAP; doesn’t require a lease or maintenance visits or multiple fittings with expensive medical pros; and I’ve been using the same one for a couple of years; it’s a simple, durable piece of molded silicone. It’s also really helped with jaw pain, clicking and headaches from teeth grinding. The grinding may be getting transferred to my tongue, but it doesn’t really hurt it. If you’re on the fence, and nothing else has worked out, I say try it – of course, on your own recognizance.

    If it works, consider getting an extra to have on hand in case supply chains break down during the zombie apocalypse, or to keep in your purse, car or workplace in case you can’t get home, or your dog chews it up, etc. The advantage of its low cost, portability and the fact it doesn’t require electricity (I live in a place where wind storms knock out roads and power lines) is so huge if you can’t sleep well without help!

    Dr. Park, I do wonder if I have UARS. Have you seen someone with OSA “tune down” to UARS with successful OSA treatment, particularly if the treatment is the AveoTSD? I don’t need to sleep during the day anymore, but I do tend to be fatigued and have most of the other symptoms you discuss on your page about UARS. I didn’t think it had to do with sleep disordered breathing anymore, but maybe it does…I don’t know how to approach this with my sleep doc. Should I go to an ENT instead?

    Thanks again,

  12. I have a lot of the symptoms. After having turbinate surgery and a corrected deviated setpum, I still struggle to get enough sleep. I would do just about anything to get my hands on an Alaxolito nasal stent stent. The ENT who did my surgery noted that my sinuses etc. are small relative to my body.

  13. Hi!

    I’m a 24 y.o. male from Hungary. And after being diagnosed with hypothyroidism (Hashimoto’s thyreoditis) in January 2016 and treated with T4 (also tried T3) but my sleep did not improve (wake up after once almost every night usually after 4 hours, frequent urination, fall back asleep easily but sleep a total of 8h, even if fragmented) I suspected something was still off and had a sleep study done, which (Thank God) was done by a doctor who acknowledged UARS and diagnosed me in December 2016. I am a medical student too but have never heard of the condition up until then. I am extremely tired every day, can’t concentrate get easily irritated by pretty much everybody and is all around killing my chances of successfully integrating into socity as a responsible adult. At first I tried MAD of the brand TheraSnore of size M, but still woke up about the same time as without it. Then i used an old CPAP which I could not tolerate. I had a deviated septum which was corrected in June 2016, but CPAP therapy is straight up suffocating for me. I am amazed how accurately you described my symptoms, you can assume that i have almost all of which you mentioned above. A month ago (February) I tried the best available CPAP in my country with A-Flex, in hopes that it would be easier to breathe out, but during sleep I removed it without waking up and it was again suffocating. It felt like trying to breathe against stong air current (like without a helmet on a motorcycle). So I am almost certain that CPAP is not an option for me. I also had my MAD redone, again a TheraSnore but of a size L. But again I woke up and a TMJ pain developed over time. My teeth are crowded and somewhat disorderly. Also i have a mild overbite with a relatively large tongue.

    Well, I tried to give a brief overview of my condition hoping that you might have a suggestion for as I am at the point of absolute hopelessness. I delayed finishing uni because I’m so tired I could not do my exams and write my thesis, and I am completely terrified when I think about how I’m going to get a work and sustain myself (not to mention wife, kids etc.). Should I try another MAD/MAS device? BPAP? These are not covered by the insurance in my country and I don’t really think would help anyway. Honestly, I am at the point where I would be grateful if I got a disability pension and linger the rest of my life, but seeing as not even the doctors acknowledge the condition it would be even harder to get the government to acknowledge it. And by disability I am not joking, this seriously affects me in doing any difficult mental task. People just smugly think this is some kind of insomnia and I should get over it and grow up.

    Your help is appreciated, thank you in advance:


  14. Hello,

    After 20+ years of sleep issues and wrong diagnoses (almost all of what you listed above), I have been diagnosed with UARS. The prescribed therapy is an Automatic CPAP machine (APAP). However, I have been struggling to be able to use it effectively as I have fairly severe nasal congestion at night, that seems to be exacerbated by the constant air from the machine. I see that you list this commonality among most people who have UARS (#4 above). I have to say that reading this was a relief as the sleep specialist who identified my sleep disorder through an overnight sleep study, doesn’t seem to understand the congestion issue. His suggestions consist of using a nasal decongestant spray and then other actions to “get used to it”. (for the record, I have been trying to use the machine for over 4 months and am using 2 different nasal decongestants, which only minimally help.) All this being said, I am currently working with an ENT to, hopefully, properly address my allergies to reduce the nasal congestion. Unfortunately, while relieved that my issue is not unique, I am also worried that the smaller nasal passage, over active turbinates, and small jaw you mention (which I have all of) will render CPAP therapy ineffective/nonviable as a treatment even if I get my allergies fully under control. So, what do I do?? I cannot continue to have such poor quality sleep and feel so horrible because of it, both mentally and physically. I eat well, am a non-smoker, do not drink excessively, am not overweight, exercise regularly, and practice good sleep hygiene. I have a diagnoses and a treatment/therapy, but given the attributes that restrict the use of the therapy, I am feeling hopeless. ANY suggestions would be so appreciated. PLEASE help me sleep!!

  15. Ms. Zaniewski,

    Sorry to hear about your many year struggles. UARS can be challenging to treat, especially since it’s mainly due to craniofacial underdevelopment. There’s no simple fix. There’s only so much you can try with CPAP. Sometimes, a mandibular advancement device can help, but not always. There are also dental appliance options to enlarge the jaws, but this results in inconsistent results, as it’s usually not aggressive enough. Most people in your situation are good candidates for jaw surgery but rarely consider this option. I’m assuming that you’ve optimzied your diet and lifestyle factors, including aggressive toxin elimination. Some women find help with a comprehensive hormone rebalancing program, for which you need to see a holistic doctor that uses bio-identical hormones.
    Without examining you in person, I can’t make any formal recommendations, but consider some of the options I just listed. Good luck.

  16. Just as the article was really getting good, it ended. It perfectly describes my frustration over 2.5 years. I’ve seen 3 sleep therapists and 3 otolaryngologists. I left all 6 offices with the words “I can’t help you” repeating over and over in my mind. CPAP, BiPAP, oral appliance, numerous sleep studies and positional sleep therapy…but I’m still only getting partial relief. I’m miserable, tense, depressed and ornery, despite my best efforts.

    In my last sleep study I scored an AHI of 2.5 but an RDI of 17. Afterwards I felt better than usual – but still fatigued – so I know my RDI is typically worse.

    I know the problem is my soft palate, which is long thin and “floppy” according to 2 ENT doctors. I also feel it disturbing my sleep, since I wake up frequently through the night. It’s been suggested that it needs to be stiffened, but doctors aren’t willing to do a UPPP or modified UPPP. The pilar procedure, injection snoreplasty and sonoplasty make the palate more rigid but they aren’t being suggested.

    Thank you so much for the article. Any advice would be greatly appreciated.

  17. Mr. Kirkham,

    Sorry to hear about your frustrations. Yes, it can be challenging working with ENTs when you officially don’t have OSA. You can try looking for ENT that specialize in office snoring procedures.

    Did you ever try myofunctional therapy? It’s been found to lower OSA/UARS by 50%.

    Good luck,


  18. Dr. Park,

    In a website post about UARS, you say that “many people with UARS also have LPRD, or laryngopharyngeal (throat and voice box) reflux” – is this solely due to the activation of the stress response while sleeping, or is there something anatomical that contributes to both UARS and laryngopharyngeal reflux, such as a retrusive or narrow jaws?

    Have you seen an improvement in this type of reflux with patient who are treated for UARS?

    Thank you!

  19. James,

    Yes, you’re right in that having narrowed jaw anatomy narrows the airway, leading to obstructive breathing, which leads to reflux. This is the main thesis of my book, Sleep, Interrupted.