Snoring/Obstructive Sleep Apnea
- Snore when you sleep?
- Wake suddenly during the night perspiring, choking, or gasping for air?
- Wake in the morning with headaches or a sore throat?
- Fight falling asleep during the day, at work, or while driving?
- Feel irritable, have memory loss, or a lack of concentration?
- Suffer with obesity, gastric reflux, or high blood pressure?
Obstructive sleep apnea (OSA) is a condition caused by a decrease in upper airway size and patency during sleep, which leads to multiple physiologic changes such as a decrease in oxygen saturation and increased arousals in sleep. This resulting sleep fragmentation and repetitive lack of oxygen have a variety of adverse consequences, including daytime sleepiness (fighting falling asleep during the day), reduced quality of life, and organ system dysfunction. Patients are also at an increased risk of heart disease and motor vehicle accidents (MVA).
It is estimated that 26% of adults are at high risk of OSA1. The prevalence of OSA increases with age, and men have a higher prevalence of OSA than women by almost a three-fold increase. Risk factors for OSA include obesity, anatomical abnormalities, heredity, and nasal congestion.
Snoring and daytime sleepiness are the most common manifestations of OSA. A simple questionnaire, the Epworth Sleepiness Scare (ESS) is a rapid screen that reveals the significant subjective sleepiness of the patient. Additional symptoms and signs include restless sleep, periods of silence terminated by loud snoring, moodiness, morning headaches, decreased libido and impotence, poor concentration, fatigue, and awakening with a sensation of chocking, gasping, or smothering. OSA may be associated with a decreased heart rate during sleep, and there is increasing evidence that severe OSA might be a cause of heart disease and heart attacks. Many patients present with a medical history of high blood pressure, heart disease, stroke, kidney disease, diabetes, and gastric reflux. Surprisingly, studies have shown a resolution of cardiopulmonary complications with treatment of obstructive sleep apnea2.
The first-line diagnostic study when OSA is suspected is an overnight sleep study, also called a polysomnogram. This sleep study is performed at a sleep clinic credentialed by the American Academy of Sleep Medicine. During this overnight stay, you will be taken to a room, which resembles a hotel room. After changing into your night clothing, a technician will attach monitors to various parts of your body. These wires will connect to a computer and are lightweight and hardly noticeable. They will record various respiratory variables and positioning of your body during the night.
If you do not wish to sleep overnight in a sleep clinic, an alternative option is to take an at-home sleep apnea test. This test involves wearing a small, FDA-approved device that will monitor changes in peripheral arterial tone and activity, as well as blood oxygen saturation levels. It also identifies sleep apnea events just like the equipment used in traditional sleep studies performed in sleep clinics. This device is an excellent alternative for patients who are not willing to spend a night away from home in a sleep lab. This test is done in the comfort of your own bedroom, an environment that best reflects the pattern of your sleep habits.
Based on these results, if you are diagnosed with obstructive sleep apnea, you will first be presented with non-surgical treatment options, such as losing weight, exercise, good sleep hygiene, or each night sleeping with a continuous positive airway pressure machine with mask (CPAP) or sleeping with an oral appliance. These treatment options can be very effective with compliant patients. However, if patients do not follow the prescription of these non-surgical treatments for the rest of their lives, they will not achieve optimum health, and their health can become severely compromised. Surgical options can be considered for ineffective non-surgical treatment.
Sleep apnea surgery is aimed at enlarging and decreasing the collapsibility of your airway. These procedures include the following:
The Pillar Procedure is one of the most effective snoring treatments available. During this procedure, tiny woven inserts are placed inside the soft palate to reduce the vibration that causes snoring. It also stiffens the palate and prevents it from obstructing the airway. This is completed in a single office visit using local anesthetic, and clinical studies have shown a reduction in snoring in about 80% of patients. These inserts are not visible, and do not interfere with swallowing or speech. Most patients resume normal diet and activities the same day.
To treat obstructive sleep apnea, the Tongue Suspension helps prevent the tongue from falling back and blocking the airway while the patient is asleep. The objective of this procedure is to advance and stabilize the tongue muscle to help prevent it from falling back and occluding the airway when the patient is supine and asleep. A suture is looped through the tongue to form a hammock that suspends it.
To treat obstructive sleep apnea, the Hyoid Suspension procedure suspends the hyoid bone to help maintain an open airway while the patient is asleep. The goal of this procedure is to open the airway. This is accomplished by advancing and suspending the hyoid bone and associated musculature.
Nasal obstruction is a common finding in patients with OSA. This can be due to turbinate tissue overgrowth, deviated septum or collapse/narrowing of the nasal valve. Nasal surgery can be very successful in improving nasal breathing, however, in patients with moderate to severe obstructive sleep apnea, nasal surgery alone usually does not achieve significant improvement.
Radiofrequency is used in sleep apnea surgery to reduce the volume of soft tissue of the nasal turbinates, soft palate, or tongue. Radiofrequency is very precise in targeting tissue and so heat dissipation to the surrounding tissues is limited, therefore minimizing excessive tissue injury and complications. This is often done as an outpatient procedure in the office. During the healing process of one to three weeks, scar tissue forms, causing tissue to shrink, thereby increasing the airway space.
This procedure prevents the tongue from collapsing toward the back of the throat during sleep. The genioglossus is the primary muscle of the tongue and is attached to the front of the lower jaw. Part of the chin is moved forward and the attached tongue is repositioned forward opening up the airway.
This surgery is can be done in combination with a hyoid bone suspension procedure, as this combined approach increases the overall success of the treatment of obstructive sleep apnea3
Patients with obstructive sleep apnea often have narrowed jaws, resulting in the displacement of the tongue toward the back of the throat, creating airway obstruction. For these patients, the upper and lower jaws are widened to improve the airway space, using bone cuts in the jaws. An orthodontic device is then placed on the jaws to expand the jaws into proper position. Orthodontic treatment is required and done in conjunction with this procedure to move the teeth into proper position and close any spaces created when expanding the jaws.
This surgery involves moving the upper and lower jaws forward, thereby opening up the entire airway (Fig. 1-2). This procedure is performed on patients with moderate to severe obstructive sleep apnea as the only treatment, or when other procedures have failed. It is also sometimes combined with a chin advancement to maximize the enlargement of the airway space. Maxillomandibular advancement has been shown to significantly increase airway dimensions in both lateral and anterioposterior directions4. Maxillomandibular advancement surgery has been show to have a success rate as high as 90% in the treatment of obstructive sleep apnea5.