What is obstructive sleep apnea (OSA)?

In some people, the relaxation of the throat muscles and tongue, which naturally occurs during sleep, ends up partially blocking the airway. This blockage can cause breathing to be labored and noisy, and to possibly stop completely. These obstructions in breathing are called obstructive sleep apnea. They can affect the quality of your sleep and cause you to not feel well-rested.

How is OSA diagnosed?

Although anyone can have OSA, it is more common in obese men over 40 years old. The three factors which are most suggestive of OSA are: loud snoring disruptive to others, labored and obstructive breathing witnessed by others, and excessive daytime sleepiness.

While a patient's physical features and sleeping pattern raise the possibility of OSA, a formal sleep study in a lab or hospital is required to confirm the presence and severity of OSA.

What does the sleep study measure?

The sleep study records how often you experience significant obstruction to your breathing. The RDI (respiratory disturbance index) is the average number of obstructions you have each hour. One grading scale rates a RDI of 0-5 as normal, 5-20 as mild OSA, 21-40 as moderate and over 40 as severe. Other sleep recordings are also important in determining your OSA severity including how low the oxygen level drops in your blood during the obstructions and if any irregular heartbeats occur. Interestingly, some patients with mild OSA can have significant excessive daytime sleepiness while others with severe OSA can feel fine during the day.

Why does OSA require treatment?

One common problem associated with OSA is heroic snoring which is extremely disruptive to bed partners and others. Admittedly, this snoring is more of a social problem than a medical problem.

Because OSA disrupts the quality of your sleep, another potential problem is excessive daytime sleepiness. For example, you may feel tired every morning, experience frequent fatigue, have difficulty concentrating or even doze off at inappropriate times.

The third reason OSA warrants treatment is its potential contribution to high blood pressure and other cardiovascular problems. While studies have well established that OSA is one of many risk factors for high blood pressure, we still cannot quantify how much risk it is for any one person.

What things can I do on my own to help treat my OSA?

The most important one is weight loss. While you do not have to be overweight to have OSA, obesity is a major determining factor in the development of OSA in most cases. Although long term weight loss is difficult to achieve, doing so is extremely likely to improve your OSA. In fact, studies suggest that a 10% weight loss is associated a 25% decrease in OSA severity.

Other conservative measures include

  • avoidance of alcohol and other sedatives at night
  • sleeping on your side by placing a large, wedge-shaped pillow behind you or even wearing a stuffed backpack to bed
  • using a cervical pillow which keeps your neck in a neutral position, instead of a regular pillow which flexes your neck and possibly contributes to airway obstruction.

What is CPAP?

CPAP stands for continuous positive airway pressure. This treatment involves wearing a plastic mask over your nose while you sleep. A small air blower sends a stream of air through your nose to help keep your throat from collapsing shut and causing apnea.

How effective is CPAP?

CPAP is clearly the most effective treatment option for obstructive sleep apnea, especially for moderate to severe OSA. At the proper pressure setting, it should completely resolve your OSA. In addition, the risks associated with CPAP are minimal. Because of its effectiveness, many insurance companies require a trial of CPAP before covering any surgical procedures for OSA.

Unfortunately, many patients simply cannot tolerate having a mask on their face throughout the night. Other patients may tolerate the mask but cannot imagine using it the rest of their life. Overall, a patient’s willingness to wear the mask is the major issue regarding CPAP use.

Are there other devices that help with OSA besides CPAP?

Oral devices are custom fitted mouth pieces that are worn at night time and removed during the day. When in place, they project your chin forward which opens a portion of your throat allowing better air flow. Although they are better tolerated than CPAP, the oral devices are not as effective and are usually only used to treat snoring or mild OSA.

Oral devices are obtained from an oral surgeon or dentist who adjusts it specifically to fit your mouth. They range in price from a few hundred dollars to a couple thousand dollars. Getting insurance companies to cover the expense of oral devices is extremely difficult and requires OSA documented by a sleep study.

What surgeries can be done to treat OSA?

Several different surgeries are available and new ones are often developed.

What is the best treatment option for OSA?

Good question, but no good answer. There is no single best treatment for OSA. Instead, the treatment should be decided on a case-by-case basis taking into account the severity of your OSA, your own physical features and your personal preferences. Fortunately, lifestyle changes (ex. weight loss), CPAP (continuous positive airway pressure), oral devices and surgery offer multiple treatment options from which you can choose.

What are the surgical options of treating obstructive sleep apnea (OSA)?

Numerous surgeries are available in the treatment of OSA and new ones are often being developed. So many different surgeries exist because not one consistently cures OSA with minimal pain and side effects. OSA procedures include:

  • nasal surgery
  • soft palate and tonsil surgery
  • base of tongue surgery
  • jaw surgery
  • tracheotomy

Since I have difficulty breathing through my nose at night, will alleviating my nasal obstruction help my OSA?

Unlikely. While nasal surgery improves nasal breathing in over 85% of cases, that improvement in nasal breathing only helps OSA in 20% of cases. OSA is usually due to obstruction in the throat and not in the nose.

One way to determine if better nasal breathing may improve your OSA is to use both nasal Breathe Right strips and a non-prescription decongestant nasal spray for a few nights. If your snoring and sleep quality improve with these measures, then more definitive treatment with nasal surgery or medications may be warranted.

If your nasal obstruction is bothersome to you, then nasal surgery is certainly a worthwhile consideration. There is an excellent chance that you will be pleased with the improvement in your nasal breathing and there is a small chance that it may also help your sleep issues. On the other hand, if you are currently satisfied with your nasal breathing, then you should consider other more effective surgeries for OSA.

What is meant by soft palate surgery and tonsillectomy?

The roof of the front part of your mouth is hard and bony (i.e. hard palate) while the part in the back of the mouth is soft and fleshy (i.e. soft palate). The dangling punching bag structure in the back of the mouth (i.e. the uvula) is one portion of the soft palate. Trimming away the uvula and other portions of the soft palate is a common surgery for treating OSA. This surgery, uvulopalatopharyngoplasty (i.e. UPPP), also involves removal of the tonsils if they are still present.

While UPPP is performed in a hospital operating room, there are other soft palate procedures,
such as Injection Snoreplasty, which are performed in the office. These office-based procedures, however, are used only with patients who have isolated snoring, while the UPPP is indicated for snoring patients who also have OSA. In other words, if your sleep study shows that you have moderate or severe OSA, then surgical procedures performed in the office are generally inappropriate.

How effective is UPPP?

Of those patients that we feel may potentially benefit from UPPP, only 40% will experience
satisfactory improvement in the severity of their apnea as determined by a postoperative sleep study. Interestingly, a much higher percentage of patients will get improvement in both their snoring and their excessive daytime sleepiness. We do not know why more patients receive improvement in their symptoms as compared to an objective improvement in their sleep study results. We are continually looking for more effective screening methods to determine which patients will benefit from UPPP.

What are the risks of UPPP?

Risks of the procedure include:

- intraoperative or delayed bleeding
- liquids going up into the back of the nose when swallowing
- altered sensation in the back of the mouth
- rare problems such as taste disturbance, tongue numbness or voice quality change
- anesthetic problems or difficulty breathing soon after the surgery
- difficulty managing postop pain

Fortunately, despite this intimidating list of risks, almost all patients recover uneventfully.
In fact, the biggest drawback with UPPP is not the likelihood of a complication but instead is the possibility of going through a painful surgery without improvement in your OSA.

What is meant by surgeries addressing the base of tongue?

The tongue is a much larger muscle than it appears just looking inside the mouth. The back of
the tongue (i.e. base of tongue) is especially large and can block off the lower part of the throat resulting in OSA. While the oral device is a non-surgical method of trying to prevent your tongue from obstructing your airway, different surgeries are designed to accomplish the same thing.

In regards to effectiveness, no single tongue surgery has been shown to be superior to
another. In addition, since these procedures are usually performed in conjunction with UPPP, only limited data exists as to the effectiveness of any one of these procedures by itself. As a generalization, while UPPP alone has a success rate of 40%, combining UPPP with base of tongue surgeries increases the success rate to 60-70%.

What are the specific surgeries that address the base of tongue?

HYOID SUSPENSION: A portion of your tongue attaches to a bone in your neck called the hyoid. Pulling the hyoid forward should also pull a portion of your tongue forward and open your throat. This surgery requires making an incision in your neck skin and then suturing your hyoid bone to your thyroid cartilage (i.e. your Adam's apple). While hyoid suspension does require a neck incision, there is less pain with this procedure as compared to UPPP. The main risks of this procedure are temporary or permanent swallowing difficulties, postoperative wound infection and injury to the tongue nerves.
GENIOGLOSSUS ADVANCEMENT: One of your tongue muscles, the genioglossus, attaches to the inner surface of your chin. This tongue muscle can be pulled forward by making cuts into your chin bone and advancing your chin farther out. The risks of this procedure include tooth damage, numbness, and infection.
Instead of trying to pull your tongue forward, another option is to try to reduce the actual size of your tongue. A probe placed in the center of your tongue delivers a precise amount of radiofrequency energy. The result is that the tongue tissue at that site becomes vaporized, scarred, and reduced in size.

The procedure can be performed in the operating room in conjunction with other OSA surgeries or perhaps even in the office.

Radiofrequency reduction of the base of the tongue is one of the newer OSA procedures, so studies are still ongoing as to the exact amount of treatment required and the expected success rate. At this time, we believe a few sessions treating a few sites in the tongue each time will be required to receive any benefit. In addition to a moderate degree of postoperative pain, risks include infection (i.e. abscess formation) and injury to the nerves in the tongue.

What is the jaw surgery done for OSA?

Maxillomandibular advancement (MMA) refers to making cuts in some of your facial bones
and your jaw bone so that the roof of your mouth (i.e. maxilla) and jaw bone (i.e. mandible) can be advanced forward. Other than tracheotomy, MMA is the single most effective for OSA. As such, some physicians recommend it as the initial surgery for anyone with moderate or severe OSA. On the other hand, MMA is the most involved surgery with the greater risks. Therefore, some physicians, such as the internationally known experts from Stanford University, recommend performing MMA only after UPPP and base of tongue surgeries. Consultation with an oral surgeon who performs MMA is recommended if you wish to consider this procedure.

What is meant by tracheotomy?

Tracheotomy refers to making a hole through the front of the neck and into your trachea (i.e.
windpipe). The hole is kept open with a plastic tube. During the day, the tube is plugged so that you can breathe through your mouth and talk like normal. During the night, the tube is opened so that you breathe through the hole going into the trachea.

Since collapsing of the throat can no longer obstruct your airflow, tracheotomy is the single most
effective procedure for obstructive sleep apnea. Unfortunately, there are cosmetic issues and other hassles associated with having a plastic tube in the front of your neck. As such, tracheotomy is usually reserved for severe life-threatening OSA.

What is the best surgical treatment for OSA?

No single best surgery exists for OSA. Instead, the surgery or surgeries recommended are
decided on an individual basis taking into consideration the severity of your OSA, the sites of obstruction, and your personal preferences.

How is the severity of OSA determined?

A sleep study done in a lab or hospital records how often you experience significant obstruction to your breathing. The RDI (respiratory disturbance index) is the average number of obstructions you have each hour. One grading scale rates a RDI of 0-5 as normal, 5-20 as mild OSA, 21-40 as moderate and over 40 as severe. Other sleep recordings are also important in determining your OSA severity including how low the oxygen level drops in your blood during the obstructions and if any irregular heartbeats occur. Interestingly, some patients with mild OSA can have significant excessive daytime sleepiness while others with severe OSA can feel fine during the day.

How is the site of obstruction determined?

Three methods of evaluation may be used. A thorough head and neck exam assesses findings such as the size of your tonsils, the length of your soft palate and the adequacy of your nasal airway. A fiberoptic scope advanced into your throat may reveal whether your obstruction occurs behind your palate, your base of tongue or both. An x-ray of your throat is another means of trying to locate your site of throat obstruction. Even with the use of all three evaluation methods, we are still only making a clinical judgment as to where your throat obstruction is and, therefore, which surgery or surgeries to recommend.

What non-surgical options exist for treating OSA?

Lifestyle changes (ex. weight loss), CPAP and oral devices are treatments not involving surgery. These options are discussed in the handout "OSA - Treatment Considerations".

Are their general recommendations regarding the treatment of OSA?

All patients are advised weight loss along with avoidance of alcohol and other sedatives. Nasal surgery is a consideration primarily if you have a deviated septum and associated bothersome nasal obstruction. If you have mild OSA and desire to avoid surgery, an oral device is a reasonable consideration. If you have moderate or severe obstructive sleep apnea, then a trial of CPAP is always appropriate. If you do not tolerate or desire CPAP or an oral device, then surgery often includes UPPP. The need to combine UPPP with a base of tongue surgery, such as hyoid suspension or Somnus reduction, is based on your physical features and the severity of your OSA. Maxillomandibular advancement or tracheotomy are considerations for patients with severe OSA who do not tolerate CPAP, who have not been cured with UPPP and related procedures or who desire a single more effective surgery.

Obstructive sleep apnea is a true medical problem that can significantly impact your quality of life. While there is not a medication or simple office procedure that cures the problem, numerous treatment options exist which may improve your situation. We look forward to working with you in trying to determine which option or options are most appropriate for you.

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