Obstructive Sleep Apnea Treatment
The first step in sleep apnea treatment resides in recognition of the symptoms and seeking appropriate consultation. Oral and Maxillofacial Surgeons offer consultation and treatment options.
In addition to a detailed history, Dr. Kent E. Moore will assess the anatomic relationships in the maxillofacial region. While current technology is limited in our ability to assess sites of airway obstruction (these techniques are typically utilized during the awake state), a combination of techniques are utilized to assess airway shape and reactivity. With a 3-D cone beam CT scan, Dr. Moore can assess the overall shape of the airway, the airway pattern type, as well as any craniofacial skeletal relationships that may be contributing to airway shape.
Dr. Moore has published a classification system for describing patterns of tongue-base narrowing, which can be helpful in applying specific surgical techniques. A supine nasopharyngeal exam is done with a flexible fiber-optic camera (this is a subjective exam), and an acoustic pharyngometer device can utilize sound-waves in order to make objective measurements of upper airway volume (enabling objective correlation to the subjective exam). To confirm the amount of cardiovascular compromise and decreased oxygenation levels, a sleep study is recommended to monitor individuals overnight.
The American Academy of Sleep Medicine (AASM) has recently published an exhaustive and detailed paper which reviews the use of Oral Appliances in the treatment of snoring and obstructive sleep apnea. Within the past several years, the medical literature surrounding the use of oral appliances has matured greatly, and there are now a significant number of Level I (ie: prospective, randomized-controlled, and placebo-controlled) trials which document the efficacy of oral appliances as a viable treatment option.
While not as effective as CPAP, the AASM has revised its recommendation for use of Oral Appliances in the treatment of Snoring and OSA, and as stated in its revised practice parameter paper oral appliances should be offered as first-line treatment for patients with mild-moderate OSA. Importantly, the AASM paper also makes note that the efficacy of oral appliances may be higher than that of soft palate surgery, which is currently one of the most common surgical procedures performed for this disorder. The AASM position paper (and accompanying literature review) now offers those millions of afflicted patients the option of another viable and efficacious non-surgical treatment modality for resolution of their sleep-related airway problem.
Initial treatment may also consist of using a nasal CPAP (Continuous Positive Airway Pressure) machine that delivers pressurized oxygen through a nasal mask to limit obstruction at night. This therapy can be a life-changing treatment for those patients who accommodate well to it; however, while this treatment is still considered the gold-standard among non-surgical therapies for this disorder, many patients with milder forms of this disorder cannot tolerate the pressures inherent with this therapy (or with an alternative form of airway pressure therapy, called Bi-PAP [Bi-level Positive Airway Pressure]), and other options must be sought.
Soft Tissue Upper Airway Surgery
One of the surgical options that deals with the upper soft tissue airway is a uvulopalatopharyngoplasty (UPPP), which is performed in the back of the soft palate and throat. A similar procedure is sometime done with the assistance of a laser and is called a Laser Assisted uvulopalatoplasty (LAUP). In other cases, a radio-frequency probe is utilized to tighten the soft palate. Radiofrequency energy can also be used to shrink swollen inferior turbinate tissues (contributing to nasal obstruction), as well as shrink enlarged tonsils (utilizing Coblation or Somnoplasty technology). These procedures are usually performed either under light intravenous sedation in the office, or under general anesthesia in a hospital setting (patients with significant OSA should have their airways monitored post-operatively in a hospitalized ICU setting).
Soft palate surgery is often inappropriately performed as a first-line treatment for obstructive sleep apnea and snoring. While often considered the mother of all sore throats, risks of soft palate surgery are multiple. Significant complications including: bleeding, infection, velopharyngeal incompetence (inability of the soft palate to close off the nose from the mouth), palatal stenosis (complete closure of the nose from the mouth), inability to cure OSA and snoring, and importantly death. While isolated success stories exist, unfortunately, the general public has for years succumbed to the notion that snoring = soft palate surgery, and has resultingly suffered greatly.
Sleep Apnea Surgery / Tongue-Base Surgeries
Surgical therapies that deal with tongue-base obstruction (which is where the basic anatomic problem with OSA lies) include: genioglossus advancement (whereby the genioglossus and geniohyoid muscle to the mandibular symphysis are advanced forward via a block cut through bone in the anterior mandible), tongue-suspension suture techniques (Repose) involving a nonresorbable suture technique that holds the upper tongue-base forward, Hyoid Suspension (performed generally using tissue grafts that pull the hyoid bone closer to the mandibular symphysis or thyroid cartilage), radiofrequency tongue base reduction, jaw-advancement (telegnathic) surgery, and tracheotomy. Except for jaw advancement and tracheostomy, the surgical literature surrounding the above listed options is poor (at best), as most of these options are used in combination with other listed surgical treatments, and treatment effect for any one procedure is difficult to determine.
In more severe cases, the bones of the upper and lower jaw may be repositioned forward in order to increase the size of the airway (Telegnathic Surgery). This procedure is currently considered within the medical and dental literature as the most effective surgical option in treating OSA (outside of tracheotomy), and is performed in the hospital under general anesthesia, and requires several days overnight stay in the hospital.
Caution is advised when considering surgical therapy for OSA; no guarantees for sleep apnea surgery are ever provided in establishing a cure.
OSA is a very serious condition that needs careful attention and treatment. Most major medical plans offer coverage for diagnosis and treatment.