What is Sleep Apnea?
Whether you have a snore you can't ignore, or have been told that you stop breathing at night, you may be suffering from obstructive sleep apnea syndrome (OSAS).
Snoring is no laughing matter!! Although snorers are a target of bad jokes and middle of the night elbows, loud snoring can be a sign that there is a breathing problem during sleep.
Snoring is caused by vibration of narrow air passages during sleep. For many, loud disruptive snoring is more of a social problem that may strain a relationship. But for others, blockage of the airway may cause sleep apnea, a potentially life threatening disease.
There are three main types of sleep apnea: obstructive (the most common), neurologic (where the brain tells the body not to breathe) and mixed (a combination of both).
For patients with sleep apnea, deprivation of oxygen during sleep results in poor sleep patterns, daytime tiredness, poor memory, irritability and strain on the heart and lungs.
Here are the facts:
- 50% of patients with high blood pressure and heart disease have OSAS
- 77% male and 64% female stroke patients have OSAS
- OSAS my be responsible for 30,000 cardiovascular deaths per year
- OSAS patients are 7 times more likely to be involved in motor vehicle accidents
The severity of sleep apnea is determined by how many times the patient stops breathing per hour (the Apnea Hypopnea Index). An apnea is when you stop breathing for 10 seconds or longer, and a hypopnea is a less severe version of an apnea, with different definitions, but in general, greater than 50% reduction in airflow and more than a 4% drop in your oxygen levels. Anything above 5 (apneas or hypopneas per hour) is considered clinically significant, with an AHI of 5 to 15 being considered mild, 15 to 30 is moderate, and anything above 40 is considered severe. This information is determined by undergoing a sleep study (Polysomnogram). Most studies are performed in a hospital or other outpatient settings. Home based sleep studies are available, which give Dr. Sultan basic information regarding your sleep patterns.
In addition to the AHI, your airway anatomy must be critically evaluated.
The upper airway begins at the tip of the nose and extends to the vocal cords. The most common areas of blockage are at the level of the:
- Nasopharynx- nasal septum, valves, turbinates, adenoids
- Oropharynx- soft palate/uvula, tonsils
- Hypopharynx- tongue, hyoid bone/neck
- Jaw structure- upper/lower jaw/chin
Although most patients with "common variety snoring" have one main area of blockage, sleep apneic patients often have multiple levels of obstruction. As the severity of the apnea increases, the magnitude and number of blockages increase.
Not treating all levels of blockage may result in incomplete or ineffective results. Dr. Sultan prides himself on evaluating the entire spectrum of the upper airway in order to customize the best treatment for your sleep disorder.
SO ... WHAT HAVE YOU TRIED?
Snoring is an age-old problem, and in the eternal pursuit of a better night's sleep, people have devised countless "cures for snoring".
An internet search of "snoring cures" will return literally thousands of pages containing various solutions and natural remedies, such as:
- increasing room humidity
- losing weight
- reducing alcohol intake
- special pillows
- throat rinses or sprays
- Breathe-RightÂ® nasal strips
- chin straps
- dairy-free diet
- electric shock devices
- herbal remedies
- sewing a tennis ball onto the back of your pajamas to encourage side sleeping
- Oral appliances (there are over 100 types)
WHAT IS YOUR SNORE SCORE?
Snoring can be a harmless annoyance or an indication of a more serious sleep disorder. The Epworth Sleepiness Scale can help you to determine if you may need further evaluation for a sleep condition.
How likely are you to doze off in the following scenarios:
- Watching TV
- Sitting inactive in a public place
- Lying down to rest in the afternoon
- Sitting and talking to someone
- Sitting quietly after lunch without alcohol
- In a car stopped in traffic
Use the following scale to rate each situation:
0 = no chance
1 = slight chance
2 = moderate chance
3 = high chance
Now add your score:
1-6 Congratulations, you are getting enough sleep
7-8 Your score is average
>9 Seek the advice of a sleep specialist without delay!
Treatment Options for Sleep Apnea and Snoring
Fortunately, many treatment options are available to provide effective relief of symptoms, and to reduce the severity of disease.
In order to diagnose your condition and present you with the best treatment options available, Dr. Sultan will meet with you to perform an initial evaluation. At this appointment, Dr. Sultan will speak with you about your medical history, investigate your snoring history & sleeping habits, provide you with a 3-Dimensional airway analysis and perform a fiber optic exam of your breathing passages.
Following your exam and a review of your records, Dr. Sultan will present you with a summary of his findings, and make recommendations for your treatment. Please note that in some cases Dr. Sultan may require additional studies - such as a sleep study, or polysomnogram - in order to make a thorough and complete diagnosis. Sleep studies take place in either a sleep lab or in your own home with a take-home sleep study kit. Dr. Sultan will recommend the best option for you, depending on your case.
It is extremely important that you bring your sleeping partner to this appointment with you, as they are the ones who witness your sleeping patterns & habits. Also, please bring any X-rays, CT scans, MRI films, Sleep Studies (if applicable), and previous surgical reports. You may request to have the facility that performed these tests forward the films/ studies and results to our office. If there is not enough time, please pick them up and bring them with you to your initial consult. Most modern imaging facilities provide their data on a CD for review.
Once all tests have been completed, Dr. Sultan will discuss your treatment options with you. He will include any alternative treatments, appliances or devices that may help you, as well as more permanent surgical options- including a discussion of all the benefits, risks, and potential complications.
For your convenience and to reduce your waiting time, we have made our health history form available to you online which you can fill out prior to coming to your appointment. Please click health history online to fill this form out now.
Consider the main portion of the upper airway as a long, floppy tube with a consistent diameter and circumference. The tongue, a large mass of muscle, is attached to the back of the chin portion of the lower jaw (mandible). As we lie down to sleep, our mandible falls backward, due to loss of muscle tone, with the bulk of the tongue following along. Unfortunately, evolution has resulted a decrease in overall jaw size. Sleep disorder patients may have excessive soft tissue encircling their airway. Overall, these conditions may result in a collapse of the upper airway, resulting a hypopnea or apnea. So it makes sense that any treatment that results in an opening of the airway will effectively treat sleep disordered breathing!
Oral Appliances function by bringing the tongue off the back of the throat during sleep. There are many types on the market (over 50 at last count!) The most common type of appliance repositions the lower jaw forward, bringing the tongue with it. Each appliance is custom made by a dentist trained in the technique. Some appliances function by holding the jaw in a set position throughout the night, while others allow the jaw some mobility. Still others function by moving the tongue only.
Here is the good and bad of oral appliance therapy:
- Advances the lower jaw, opening the airway
- Is diagnostic and therapeutic
- Is successful if tolerated
- Useful for both snoring and some forms of sleep apnea
- Minimal jaw movement throughout sleep
- Potential TMJ problems
- Potential for causing permanent changes in tooth and jaw position, requiring additional treatment
- Less effective as severity of apnea increases
- Percent of non-compliance (40% in the literature)
Continuous Positive Airway Pressure (CPAP) has always and continues to be the gold standard for the treatment of sleep disordered breathing. CPAP functions by allowing the patient to breath oxygenated air under pressure during sleep. This effectively eliminates passive collapse of the upper airway, eliminating the symptoms of sleep apnea.
The device can only be prescribed by a sleep medicine physician. The exact settings are adjusted over time after an initial night in a sleep lab until all symptoms are minimized. The positive results of CPAP are only good as long as the patient uses the device continuously.
Here is the good and bad of CPAP:
- Very effective in a compliant patient
- Is not effective with nasal congestion. Can cause nasal driness, sore throat
- Tolerance of mask a problem
- Travel dilemmas
- Percent of non-compliance
- 70% average after 2 years of use
- 46% actual compliance for regular use (4 hours per night on 70% days)
- 6% actual compliance for adequate use (7 hours use for > 70% days)
WHEN IS SURGERY CONSIDERED?
The goals for the treatment of sleep disordered breathing are based on the expectations of each patient's quality of life. It would be great if every doctor can promise 100% success in each treatment provided. Unfortunately, this is not the case.
Treatment success is therefore relative, and base on each patient's symptoms and response to treatment. If a patient with a loud "roar of a snore" is reduced to a low hum, that may be considered a successful outcome. If a 50% or greater reduction in a patient's Apnea Hypopea Index can be achieved, the same is true. However, if a patient cannot tolerate the treatment (non-compliance), not even the most successful results can be maintained.
Therefore, surgery for the treatment of Sleep Disorder Breathing is indicated for those patients:
- who cannot/will not tolerate the use of non-surgical modalities (appliance, CPAP)
- as an adjunct to improve the outcome of non-surgical therapy
- failure of complaint patients to achieve relief of symptoms with non-surgical therapy alone
YOUR SURGICAL OPTIONS
As you have read, snoring and obstructive sleep apnea are caused by blockages in the airway. Thankfully, there are a number of surgical procedures available that can help remove these blockages permanently.
To obtain the proper result, each area of blockage must be identified and treated individually. Based on the severity of the disease, a combination of procedures may be recommended. Based on the results of therapy, additional procedures may be indicated. A follow-up sleep study is normally performed a few months after surgery to effectively gauge reduction in symptoms.
Therefore, treatments concentrate on either reducing, stiffening, repositioning, or removing both the soft and hard tissue that is blocking the airway.
Below are some of the most common procedures recommended in our practice:
COBLATION (Radiofrequency Volumetric Reduction)
The Coblation Procedure uses temperature controlled radio frequency to reduce and tighten the tissues of the nose, palate/uvula, tongue and tonsils. The treated area is heated and slowly absorbed by the body over a 3-8 week period. It is relatively painless and is an effective treatment for snoring, nasal obstruction, and mild sleep apnea.
Snoring is due to the vibration of the soft tissues in the airway. Although most people are familiar with the effects of a large, floppy soft palate, other tissues may be involved. They include nasal turbinates in the nasal airway, the tongue base and tonsils. The uvula (a floppy muscle attached to the base of the soft palate) may also be a culprit.
RadioFrequency (RF) is a technique used to shrink, or reduce the size and bulk of these tissues. This process also results in a stiffening of these tissues, preventing them from vibration as air passes through.
CoblationÂ® is an advanced technology that combines gentle radiofrequency energy with a natural salt solution that quickly and safely reduces tissue size and bulk. Traditional procedures may cause excessive bleeding or use high levels of heat that may cause damage surrounding healthy tissue. Coblation does not cause heating or burning, which leaves the healthy tissue surrounding the target tissue unaffected.
Some patients may be familiar with Somnoplasty, which also uses radiofrequency energy to volumetrically reduce soft tissue size. We have found the Coblation technique to offer superior results with less complications.
Coblation technology is based on a controlled, non-heat driven process that uses radiofrequency (RF) energy to excite the electrolytes in a conductive medium, such as saline solution, in order to create a precisely focused plasma. Energized particles, or ions, in the plasma have sufficient energy to break, or dissociate, molecular bonds within soft tissue at relatively low temperatures (typically 40Â°C to 70Â°C). This enables Coblation devices to volumetrically remove target tissue with minimal damage to surrounding tissue. Coblation devices are also used for tissue shrinkage and homeostasis.
Coblation is a cool technology!
Because the RF current does not pass directly through tissue during the Coblation process, tissue heating is minimal. Most of the heat is consumed in the plasma layer, or in other words, by the ionization process. These ions then bombard tissue in their path, causing molecular bonds to simply break apart and tissue to dissolve.
Coblation for Nasal Airway Obstruction
Nasal airway obstruction can be uncomfortable and annoying. Blocked nasal passages force you to breathe through your mouth, making simple, everyday activities such as eating, speaking, and sleeping more difficult. Sometimes the cause of nasal airway obstruction is enlarged turbinates. Turbinates are small, bony structures located in the nasal passages that are covered with mucous membranes.
Nasal turbinates facilitate the conduction, filtration, heating, and humidification of the air we breathe. Allergies or environmental irritants (such as smoke or household chemicals) are the most common cause of irritation, inflammation, and enlargement of turbinates, resulting in blocked nasal passages. Additional causes of turbinate enlargement include anatomical causes (such as a deviated septum) and hormonal changes (such as those that occur during pregnancy). Turbinate size can also fluctuate throughout the day, especially depending on head position (i.e. standing up versus lying down).
Treatment Options for Nasal Airway Obstruction
Traditional medical therapy, including allergen/irritant avoidance and/or use of nasal medications, may be sufficient to address turbinate enlargement. In some cases, however, turbinate enlargement is unresponsive to medical management.
Coblation is an advanced technology that quickly removes and shrinks soft tissue inside the turbinates using gentle radiofrequency energy and natural saline to alleviate nasal obstruction in patients. Coblation is not a heat-driven process. As a result, surrounding healthy tissue is preserved. This quick outpatient procedure takes less than 10 minutes. Patients typically return home shortly after the procedure, and can experience a 50% reduction in nasal airway obstruction within one week.
The Pillar Procedure focuses on inserting three tiny woven implants in the soft palate. Over time, the implants, together with the body's natural fibrotic response, add structural support to and stiffen the soft palate. This support and stiffening of the soft palatal tissue results in a reduction of lose tissue vibration (which causes snoring) and helps prevent palatal tissue collapse (which can obstruct the upper airway and cause obstructive sleep apnea (OSA). Over time, the implants stiffen the palatal tissue, resulting in a tighter, shorter palate which allows more airflow through the airway. This procedure is performed in the office under local anesthesia.
THE EVOLUTION PALATAL SURGERY IS IT EFFECTIVE?
Palatal Surgery involves the repositioning, and in some cases, removal of loose, floppy tissue at the back and top of the mouth. Since most snoring involves a palatal component, surgery is very helpful.
The traditional approach to surgically treating excessive palatal tissue is the uvulopalatopharyngoplasty (UPPP). Historically it is reserved for patients with obstructive apnea. A portion of the soft palate, along with the tonsils and uvula are removed in order to open the airway. The procedure is done under general anesthesia in the hospital and commonly requires a prolonged recovery. Because the palatal musculature altered and the palate shortened, the procedure has an increased risk of difficulties in swallowing and fluids going through the nose while drinking (nasal reflux). It has been described as a painful procedure. Unfortunately, the success rates in the literature do not exceed 50% when performed alone. In hopes of reducing postoperative complications, the carbon dioxide laser was used to perform a modification of the UPPP (Laser Assisted Uvulo Palatoplasty). The LAUP was performed for treatment of both apnea and snoring. The postoperative pain and variable results led to the development of more refined, less invasive palatal procedures, which in many cases yield equivalent or better results than the UPPP.
A modification of the UPPP is the Uvulo Palatal Flap (UPF). This technique involves the repositioning of the lower portion of the soft palate without altering or removing the palatal muscles. The result is less postoperative pain, greatly reduced risk of nasal reflux and a speedier recovery.
Another variation, which can be combined with the UPF is utilizing non-dissolving sutures to suspend the lateral portions of the soft palate. This "palaal facelift" is effective with altering the palatal opening to a more square configuration without removal of palatal musculature.
Coblation/RF technology can be used independently to shrink the palate for those patients who snore and have mild apnea. The procedure is performed under a local anesthetic in the office. Postoperative discomfort is minimal and results are seen within 3-6 weeks.
Coblation can also assist in the UPF to reduce pain and bleeding. A recently developed variation involved removal/repositioning of tissue can be performed (Coblation Assisted Uvulo Palatoplasty) with very promising results.
TONGUE BASE REPOSITIONING
THE KEY TO TREATING OBSTRUCTION
The base of tongue is a large, floppy tissue that poses a major bottleneck in air passing through the vocal cords into the lungs. Untreated, it can perpetuate sleep apnea. If unaddressed during surgical treatment planning, it can significantly reduce the success of surgical outcome.
Like the palate, there are many different ways to treat the tongue by either reducing, repositioning, or eliminating tissue.
The tongue suspension muscles (genioglossus) attach to the back portion of the bony chin. By pulling forward that portion of the bone where those muscles attach, the bulk of the tongue would follow. This is the basis for performing the genioglossue/tongue base procedure. Either a small window, or even the entire chin section can be brought forward to achieve tongue advancement.
As we lay down to sleep, our lower jaw, and tongue base fall back, collapsing on the posterior airway space. An elegant procedure has been developed for suspending the muscles of the tongue while sleeping, preventing this airway collapse.
TONGUE BASE SUSPENSION (Repose®) (Airvance®)
Tongue base repositioning is performed through a small incision beneath the chin. The procedure involves the use of a small titanium screw with attached permanent sutures, which are implanted into the back part of the bony chin, where the tongue muscles are attached. The objective of the Repose procedure is to stabilize the base of tongue, not forward advancement associated with conventional chin surgery. The procedure minimizes the potential for prolapse and obstruction of the base of tongue when the patient is supine (lying flat) and asleep.
THE REPOSE® HYOID SUSPENSION
The hyoid bone is the only bone in the human body not attached to another bone. It is, however, attached to a number of muscle groups in your neck, which contribute to airway collapse. By suspending this free floating bone, when done in combination with tongue base suspension, increases the success of reconfiguring the airway. It is performed in a similar method to the Repose Tongue Base Suspension, through the same incision.
JAW REPOSITIONING SURGERY
Out of all the surgical procedures available for treating obstructive sleep apnea, advancement of the jaw structure provides the best overall outcomes. Once considered the "last resort", jaw repositioning was only considered when "less invasive procedures" were ineffective in sufficiently improving symptoms. Currently, there is sufficient evidence to support these techniques early on in treatment sequencing, or as a primary, "stand alone" procedure.
WHY DOES IT WORK?
Morphologically, we see patients with obstructive apnea fall into two basic categories; those with excessive soft tissue blocking the airway, or a deficiency or setback in the jaw structure. These bony deficiencies present as an "underbite", or a flat facial profile. These patients may have previously undergone orthodontic therapy, many with the removal of teeth, in order to correct the bite, but overlooking the functional deficit causing airway obstruction.
As the tongue musculature attaches to the back part of the lower jaw, advancing that bone will also advance, and suspend the tongue. This is the premise behind the use of an oral appliance. In fact, an oral appliance can be used as a diagnostic tool in planning for jaw repositioning surgery. Similarly, advancing the upper jaw will open the restriction of the soft palate musculature off the back of the throat.
HOW IS IT PERFORMED?
These procedures are performed by surgeons skilled in both orthognathic and sleep apnea surgery. The planning and mechanics of the procedure are unique, in order to maximize airway opening as well as facial esthetics. Depending on the jaw and bite relationship, surgery may be done in coordination with orthodontics. Surgery can be performed only in one jaw, or by bringing both jaws together as a unit. Planning of the surgery is enhanced by state of the art computer guided planning. By using titanium plates and screws, the jaws are not wired shut following surgery. Patients undergoing jaw advancement surgery routinely experience immediate, long lasting relief, and manyt times cure from obstructive sleep apnea!
TREATMENT SEQUENCING / IT ALL TOGETHER
Depending on the severity apnea and the sites of airway blockages, some patients may not require surgery, but others might; while other patients may require a combination of both medical and surgical management. Furthermore, some patients may require more than one surgical treatment in order to achieve the best results.
For those patients who snore without evidence of sleep apnea:
- Blockage is typically in one anatomical area, usually the palate or nasal areas
- Non-surgical management may effective (oral appliance)
- Lesser invasive surgical options that REDUCE OR REPOSITION TISSUE may be effective
- Palatoplasty/Palatal Flap
- If surgical procedures are ineffective, patients should consider a sleep study to rule out obstructive sleep apnea
For patients diagnosed with MILD OBSTRUCTIVE APNEA:
- Blockage may be at more than one site (nasal/palatal or palatal/tongue)
- Non-surgical methods should be considered first (CPAP, oral appliance)
- Surgery should be directed towards each site of obstruction to REDUCE OR REPOSITION TISSUE:
- PALATE – Palatoplasty with Coblation
- NASAL – Coblation Turbinate reduction, nasal valve repair, septoplasty
- TONGUE – Suspension and/or advancement
- JAW DEFICENCY – consider Jaw repositioning
- Follow up sleep study is recommended 3-6 months following treatment
- Consider jaw advancement surgery if the above recommendations fail to achieve success in relieving symptoms
For those patients with MODERATE TO SEVERE APNEA:
- Blockage is at two or more levels
- CPAP should be considered at evaluated.
- Oral appliance therapy can be considered as diagnostic for success of jaw repositioning surgery, or to decrease the need for CPAP
- Surgery is directed towards each level of obstruction to REDUCE, REPOSITION, OR REMOVE TISSUE
- PALATE– palatoplasty
- NASAL– turbinate reduction/removal
- TONSILLAR– reduction/removal
- TONGUE– suspension/advancement/reduction
- HYOID– suspension (with tongue suspension)
- MAXILLOMANDIBULAR ADVANCEMENT can be considered as a first line procedure or performed if multilevel airway techniques fail to achieve success
- Surgery is directed towards each level of obstruction to REDUCE, REPOSITION, OR REMOVE TISSUE
- Snoring is a condition caused by a partial blocakage of the airway
- Although not all snorers have apnea, all patients with sleep apnea snore
- Sleep apnea is a serious disease and should be respected for its impact on overall health
- Obstructive sleep apnea is a disease caused by airway obstruction at multiple locations
- Failure to address and treat each level of obstruction may result in a poor surgical outcome
If you're one of the many people who can't stop snoring, Dr. Sultan, your snoring & sleep apnea surgeon can help! Remember, the overall goal of surgical treatment is to help you and your partner have a future full of restful nights – without you ever having to be inconvenienced by or depend on CPAP or appliances again.
You can be sure that Dr. Sultan will always keep your comfort, convenience, and what is most cost-effective for you in mind when planning your treatment.
Maxillomandibular Advancement Procedure Video