Sleep Apnea Basics
If you want a basic, cursory overview about obstructive sleep apnea, I recommend to go to commercial sites like WebMD or the Mayo Clinic. If you want to learn something totally unique as well as practical advice about sleep apnea, then listed below are a number of articles that I strongly recommend you read in order. The first three articles go into great detail about obstructive sleep apnea, upper airway resistance syndrome and surgical options for obstructive sleep apnea.
Some of the symptoms of sleep apnea include: snoring, depression or irritability, poor concentration, memory or focus problems, morning headaches, poor job performance, attention deficit disorder, and obesity. A recent study came out describing the number of car accidents in one year. It’s estimated that about 800,000 car accidents occur every year due to sleep apnea and of these, there are about 1,400 fatalities. In addition, it’s estimated that of all the commercial truck drivers in America, about 28% of them had this condition, and of this group, about one third of them have moderate to severe sleep apnea.
There are a number of medical conditions associated with sleep apnea, as well. It’s found that people with sleep apnea have up to a 50% incidence of high blood pressure and people with high blood pressure have about a 50% incidence of sleep apnea. Now the studies show that if you have had a heart attack, you are 23 times more likely to have sleep apnea and the reverse showed that if you have sleep apnea, you are about 1 ½ times as likely to have heart disease.
Another study looked at 200,000 charts retrospectively and found that patients on medicines for depression or high blood pressure were 18 times more likely to be eventually diagnosed with sleep apnea. So what they concluded was that many patients are being treated for the symptoms or complications of sleep apnea rather than the underlying cause itself.
I mentioned previously that attention deficit disorder was associated with sleep apnea. In an interesting study that came out in the Journal of Pediatrics, researchers recruited 78 children who were about to undergo a tonsillectomy for various reasons including recurrent infections or sleep apnea and compared them against 22 other children undergoing other types of surgical procedures. All these children underwent formal sleep studies and a battery of psychological tests including that for attention deficit disorder and found that 22 children, or 28% of the tonsillectomy group, were found to have ADHD by official psychiatric criteria. The control group only had 7% that were found to have sleep apnea. After surgery, one year later, 11 children or 50% of the children who originally had ADHD, no longer had by official criteria. Furthermore, after the surgery, the incidence of sleep apnea in the tonsillectomy group was equivalent to that in the control group.
I could go on and on about snoring and sleep apnea being associated with increased risk of children having memory, attention or cognitive skill problems, asthma, chronic cough, etc. but I’ll stop here. One more comment about adults and sleep apnea and ADHD: there was one study that looked at three adult patients with attention deficit disorder and sleep apnea and all three of these patients were on Ritalin. Two of these patients, after treatment for sleep apnea, were weaned off the Ritalin and the third selected weight loss and conservative regimen. This goes to show that sleep apnea and ADHD can co-exist in adults, as well.
Other medical conditions include heart disease, stroke, diabetes, erectile dysfunction and obesity, seizures, migraines, and even preeclampsia, which is a condition where pregnant women get high blood pressure at dangerous levels. All of these conditions have been associated with sleep apnea and to various degrees, respond to treatment.
So how do you diagnose sleep apnea? To diagnose sleep apnea, you have to undergo a formal sleep study, which is an overnight test where you go into a facility and they hook you up to all these monitors all over your body and they analyze all the different parameters like breathing, respirations, heart rate, brain waves, etc. while you sleep. This way they can calculate how many times you stop breathing every hour and how long for every episode. To officially get the diagnosis of obstructive sleep apnea, your apnea/hypopnea index, or the number of times you stop breathing totally or partially for greater than 10 seconds for each episode, has to be greater than 15 events every hour. Now, if you’re symptomatic – if you’re very sleepy or if you have any of the medical complications of sleep apnea such as depression, diabetes, high blood pressure, etc.—then your number can be down to 5.
One of the problems with these criteria for sleep apnea is that if you stop breathing for 9 seconds at a time and you stop breathing 50 times every hour, then officially you won’t have the diagnosis of sleep apnea and then you get into the realm of upper airway resistance syndrome, which I discussed in another article. If you snore only and don’t have any significant apnea or you’re otherwise asymptomatic, then you can elect to undergo snoring treatment, which I’ll talk about in a separate article. If you snore and have significant apneas, then treating the apneas will also treat the snoring, in general.
There are a number of conservative measures that are recommended to treat snoring and sleep apnea including weight loss, positional therapy, sleeping with the mouth closed as well as a number of different snoring treatments but there’s only so much one can do with this. First of all, it’s hard to lose weight because you’re so tired and it’s hard to exercise. In terms of trying to sleep on your side or on your back, you only have so much control over that when you’re sleeping. One note about snoring treatments: over-the-counter snoring treatments have been found to work sometimes but a recent controlled study which looked at three popular snore aids, including a nasodilator strip, an oral lubricant and a pillow. All were found objectively not to have any significant benefit. However, I have many patients who swear by these over-the-counter snore aids, but in my experience, it only works sometimes for some people but in general it doesn’t work most of the time.
If you’re found to have obstructive sleep apnea, the best way to treat this condition is via what’s called a Continuous Positive Airway Pressure machine, or CPAP. This is a small device that acts as an air pump which blows some positive gentle air pressure through your nose and it stents your airway open so you don’t stop breathing at night. When used effectively, it works. You wake up feeling much more refreshed, have much more energy and all the medical problems start to get better. One of the problems with CPAP, however, is that people just don’t like to use it, but with good counseling and proper follow-up from clinic staff and the equipment people that administer the device, many people can do well with this device.
However, there are certain people who just can’t use CPAP for other reasons despite trying different kinds of masks, headgear and devices. These people end up going to different devices, one of which is a mandibular advancement device, which are oral appliances that dentists make. They make an impression of your teeth and the bottom part, the mandible, the jaw bone slowly is pushed forward. The way this works is that it pulls the tongue forward, which is one of the reasons for sleep apnea, amongst many other reasons. Again, when applied properly and when patients use it, this device does work especially for snoring and for mild to moderate sleep apnea. But compliance is also a problem due to jaw pain, dry mouth, ear pain, headaches, and bite problems.
The last major option is surgery and this is a huge topic in itself and I will discuss this in detail in another article, but just to summarize, when considering doing surgery, people have to have failed trying CPAP, or at least consider the mandibular advancement device and reject it. One has to be really motivated. Secondly, there has to be some type of anatomic reason for the collapse so when I do the examination and do the endoscopy to look inside the airway passages, I have to see is some sort of obvious collapse to address it via surgical measures.
The first and most obvious area of obstruction is actually the nose. If your nose is stuffy for whatever reason—allergies, polyps, deviated septum, or anything else—that’s the first thing that I address, whether medically or surgically. This is because if you don’t breathe well through your nose, then everything else downstream is more prone to collapse. So once the nose is taken care of and if you still have sleep apnea, then you can try going back to the CPAP. Many people with stuffy noses can’t tolerate CPAP that well, but once that problem is corrected, a certain number of people can start using the CPAP more effectively. If you go further downstream, the other two major areas are at the palatal level and the tongue level. In our field (ear, nose, throat, head & neck surgery) we’ve been focusing too much on the palate because that’s typically where the snoring sounds are coming from, but that’s not the only area. If you don’t address the tongue, as well as the palate, then your success rates aren’t going to be that great. (Note: This is an edited transcription of a podcast recording.)
Upper airway resistance syndrome was first described by researchers at Stanford University in 1993. They described a group of young women and men who complained of chronic fatigue and excessive daytime sleepiness. They all also underwent a formal sleep study and all were found not to meet the official criteria for obstructive sleep apnea. However, by treating them as if they had obstructive sleep apnea, most improved significantly. To understand how upper airway resistance syndrome is unique or different from sleep apnea, you have to first understand what obstructive sleep apnea is.
Obstructive sleep apnea is a well-known sleep related breathing disorder characterized by repetitive breathing cessations during sleep, due to total collapses of the tissues of the throat. This can happen anywhere from a few times every hour to over 100 times every hour. By definition then, apnea is defined as a total cessation of breathing for 10 seconds or more. And hypopnea is restricted breathing with greater than 30% chest wall movement decrease and blood oxygen drop of more than 4% for 10 seconds or more. A pretty complicated definition! The total combinations of apneas and hypopneas for the entire night divided by the total number of hours one sleeps gives us the apnea/hypopnea index or the AHI. This is the most commonly used measure to diagnose sleep apnea. Untreated, sleep apnea can lead to hypertension, diabetes, obesity, depression, lack of sexual desire, heart disease, heart attack or even stroke.
Unlike sleep apnea where you have obstruction, apnea, then arousal, UARS patients typically have mostly obstructions and then arousals. As mentioned previously, all UARS patients have some form of fatigue, almost all state that they are “light sleepers,” and almost invariably, they don’t like to sleep on their backs. In some cases, they actually can’t. Some people attribute their poor quality sleep to insomnia, stress or working too much. Due to repetitive arousals at night, especially during the deeper levels of sleep, one is unable to get the required deep, restorative sleep that one needs to feel refreshed in the morning. In most cases, the anatomic reason for this collapse is the tongue. There are many reasons for the tongue to cause obstruction including being too large or being overweight. But once it occurs, the only thing you can do is to wake up.
In deeper levels of sleep, especially during REM sleep, the normal protective layers of muscle tone that keeps your airway open during inspiration diminishes. So, if your airway is normal to begin with and you take a deep breath in, a vacuum-like pressure is set up and the back of your tongue can fall back completely. In many cases, whenever I examined this narrowed airway with the patient lying flat on his or her back, all I see is a 1-2mm slit between the back of the tongue and the throat.
When awake, you’re fine, but once you start to fall asleep, the tongue falls back and you wake up, either fully or subconsciously. This is why so many people can’t fall asleep on their backs and therefore, have unconsciously trained themselves to roll over to their side or their stomach where the tongue collapse is less likely, although it can still happen. This can happen 10, 20 or 30 times every hour preventing you from sustaining deep sleep. You may realize that you are waking up sometimes, but the vast majority of arousals are subconscious. If this happens for a few nights in a row and you return to your normal sleep habits, you’re fine. But if it occurs continuously for months or years, then certain events can happen.
Due to repetitive arousals, your body goes into almost a chronic state of low-grade stress. Think of what would happen if somebody poked you with their finger every few minutes while you tried to sleep for 6 months straight. Think about how you would feel the next morning. Think about how you would feel after months or years of inefficient sleep. You would feel tired, groggy with no motivation to do anything, have focus or concentration problems, or, you could feel depressed.
Physiologically, these multiple arousals also affect what is called the autonomic nervous system, or the AMS. The AMS is the internal nervous system that regulates your internal body functions such as digestion, breathing, heart rate, blood pressure, etc. It’s divided into two parts: the sympathetic and the parasympathetic parts. When you’re frightened or running away from a bull, your heart rate and blood pressure goes up, your vision and hearing are very sensitive, and all your blood flow and energy are mobilized around a fight. These functions are activated by the sympathetic nervous system. In contrast, after a good meal, your digestive organs kick in and begin to break down your food and you feel sleepy. This is your parasympathetic nervous system working.
Your autonomic nervous system is in a constant state of relative balance between the two, depending on what you’re doing. Imagine if you’re stressed because you keep waking up at night for years. Your sympathetic nervous system becomes overly activated and stays active even when awake. A number of events can occur. Your hands or feet can become cold or numb, in general, activated by cold temperatures or stress. Some people have to wear mittens or socks all year round. This condition is called Raynaud’s phenomenon. There are many theories as to why people why so many people have this condition but there is no definitive cure. Since you’re under stress, your body thinks that it is under attack and it shunts blood from your peripheries to the more central muscles and to the heart, so that you can run or fight more effectively. This might actually validate the saying “cold hands, warm heart.”
Similarly, since you don’t need to digest food when you’re fighting, blood gets shunted away from your entire gastrointestinal system to the heart muscles, leading to chronic diarrhea, constipation, indigestion, acid reflux or bloating. Remember the last time you were stressed? How well were you able to eat, or digest food if you had just eaten? We already know that stress can aggravate acid production in the stomach. In addition to chronic gastrointestinal problems, many people with UARS also have LPRD, or laryngopharyngeal (throat and voice box) reflux. It’s somewhat different than GERD, or gastroesophageal reflux disease. In most cases, you won’t feel any heartburn or the classic symptoms associated with GERD.
The common complaints of LPRD include one or many of the following: chronic throat clearing, postnasal drip, hoarseness, cough, throat or ear pain, lump in the throat, difficulty swallowing, tightness or pain with swallowing. You don’t have to feel any heartburn, either. Studies have shown that once acid reaches the throat, it can also go into the lungs, causing or aggravating asthma or bronchitis and even into the nose and ears causing more aggravating nasal congestion, sinus or ear infections.
Pepsin, one of the stomach’s digestive enzymes and even H. pylori, a bacteria that can cause stomach infections have been found in the lungs, ears and the nasal cavity in people with infections. Any degree of swelling or irritation blocking the very narrow ear or sinus openings can cause pressure build-up or infections.
Another study showed that in about 23% of people with UARS have low-blood pressure, sometimes dangerously low. In addition, these people frequently are dizzy or lightheaded, aggravated by standing up too soon. This is called orthostatic intolerance. Even if the blood pressure is normal, one may still be prone to episodes of dizziness or lightheadedness.
Recurring periods of stress may confuse your autonomic nervous system, so it doesn’t respond to the changes in blood flow and head position appropriately or quickly enough. People can also have chronic or recurrent sinus pain or pressure or infections, which can be debilitating. Frequently, patients are seen multiple times for recurrent sinus infections, given antibiotics (which only help temporarily), and in many cases, migraines can also masquerade as a sinus headache without the classic symptoms.
Your nose is also regulated by the two opposing parts of the autonomic nervous system. Studies have shown that there is an imbalance between the two parts of the ANS in the nose in people with acid reflux or sleep apnea. Thus, many people with either sleep apnea or UARS have chronic runny or stuffy noses with postnasal drip and are prone to sinus headaches or infections. This process, in addition to the acid exposure described earlier is a very good reason for chronic nasal or sinus problems.
Classic migraine and tension headaches are also frequent in UARS along with TMJ (temporo-mandibular joint) problems, due to grinding and clenching of the teeth. Sometimes these sinus headaches and pressure problems responded to decongestants and sometimes, anti-migraine medications. One doesn’t have to have the classic, typical migraine headache to have one. A recent study showed that in most cases of self-diagnosed sinus headaches, they were actually migraines. Regardless of what comes first, the chicken or the egg, one probably aggravates the other, leading to a vicious circle. TMJ can also give you ear pain, headaches along the side of your head, and it can also wear down your teeth.
UARS is also associated with depression, anxiety or attention deficit problems. For obvious reasons, sleep deprivation, especially deep sleep deprivation with multiple arousals, can lead to many of these conditions. In addition, if you don’t sleep deeply, it’s been shown that your body produces increased levels of cortisol. And as we all know, cortisol is what makes you gain weight and eat more. It also lowers your immune system’s ability to fight infections and aggravate insulin resistance, leading to diabetes.
Almost invariably, people with UARS prefer not to sleep on their backs. Many people state that if they try, they choke or wake up as they fall asleep. Over the years, they have trained themselves to sleep on their side or their stomach. Even then, they obstruct and wake up to a certain degree. Many people also state that they have crazy or vivid dreams or sometimes no dreams at all. This is because when you wake up while you’re dreaming in REM sleep; you’ve remembered your dreams vividly. By definition, all dreams are wild and vivid. Only because you tend to wake up more frequently when you are dreaming, do you remember your dreams more vividly. Some people wake up as they begin to enter the dreaming stage, so they never dream at all.
Family history is also very important. This is one way that I gauge what the patient might look like in 20-40 years. And in many cases, patients with UARS or sleep apnea have one or more parents that snore severely with one or many of the cardiovascular consequences such as obesity, diabetes, high blood pressure or heart disease. If one parent is noted to have had a heart attack or stroke in their 40’s or 50’s, I take the patient’s condition more seriously.
The natural course of UARS is highly variable with some patients remaining unchanged for years or decades, where others are slowly progressing into sleep apnea. Some older, overweight women in their 50’s or 60’s with sleep apnea tell me that when they were in their 20’s, they were very thin and had cold hands, low blood pressure, chronic diarrhea, and dizziness, and now they don’t have any of these conditions except that now they have high blood pressure, snoring and severe fatigue.
What seems to aggravated UARS symptoms most however, is a relative change in their lives. So a relative weight gain, even 5 or 10 pounds, can aggravate the symptoms which go away once the weight has stabilized and as the body adjust and accommodates to the new weight. A bad cold or infection can also aggravate these symptoms, since it causes swelling, which narrows the upper airway. Pregnancy is another situation where this occurs.
UARS people who are already living on the edge tend to have more prolonged or severe colds as airway swelling causes more narrowing and anatomic collapse, which further aggravates throat acid reflux, which causes more swelling, perpetuating the vicious cycle. At a certain point, the body can’t adjust and the vicious cycle is self-perpetuating. Poor sleep can also aggravate weight gain for reasons described before, previously. Weight gain narrows the throat even more, causing more obstruction and arousals. Stress is also a big factor, whether it is emotional, psychological or physical. Whether the stress is internal or external, the body behaves the same way.
On a personal note, my wife has many features of UARS. She has cold hands and low blood pressure. But after each of her two pregnancies, her UARS symptoms were greatly exaggerated. After our first son, she had severe postpartum depression for almost a year. Only after she lost her entire pregnancy weight did she feel back to normal. After our second son was born, for four months she was severely lightheaded and dizzy, to the point of not being able to function properly. She saw a number of doctors and even had to go to the Emergency Room because one doctor thought she was having a stroke. The only objective finding was that her low blood pressure, which was low to begin with, was even lower. Only after she lost her entire pregnancy weight, did this condition go away. Sure enough, when I looked at her airway lying down, she had the typical narrowed airway behind the tongue. Furthermore, her father has known moderate sleep apnea with diabetes.
So how does one diagnose UARS? The first step is to undergo a complete ear, nose and throat evaluation. In most cases, the exam is normal. Sometimes what we’ll see is a deviated septum or nasal congestion due to allergies but more commonly what you’ll see is when we look in the mouth, the back of the throat is very narrow and you’ll have a very large tongue that sits very high up, covering up the uvula, the little thing that hangs down in the middle of your throat.
The next step is to undergo an endoscopic evaluation, meaning that a small, tiny camera is placed through your nose and your airway is visualized. Normally, when you look at the airway, you can see the vocal cords behind your voice box but in people with UARS, the tongue fits further back, so most of the voice box is covered up. Especially if the person lies down, the tongue falls back even more, leaving a 1-2mm slit. When you are awake, you can breathe through this slit. But as you fall asleep, the muscles relax as you get deeper into sleep. Then, when you reach deeper levels of sleep, or REM sleep (when you’re dreaming), the muscles have to relax completely and that’s when you start to obstruct. Then, once you obstruct, you stop breathing and you get aroused, going to light sleep and the cycle happens over and over again.
One of the ways that this is treated is using a dental device that pulls the lower jaw forward, which is similar to what you use for snorers and mild sleep apnea patients. So I have the patients thrust their jaw forward and by putting the jaw forward, it also pulls the tongue forward and you can see a vast improvement in the caliber of the airway.
Based on an extensive series of questionnaires, your physical examination, your past family history and the endoscopic evaluation, you can determine whether or not you need a sleep study. So if you undergo a sleep study and you are found to have sleep apnea, then it is treated like normal sleep apnea. That is a topic for another podcast in itself. But if you don’t officially meet the criteria for sleep apnea—meaning that your apnea/hypopnea index is less than 5 but you do have evidence of multiple arousals, then we can say that you may have UARS.
You may be wondering, I just gave you a good explanation for UARS, but what can you DO about it? In general, UARS is treated like sleep apnea. In general, the options are nasal breathing optimization, dental appliances, CPAP, or surgery, as a last resort. Nasal optimization means if you have any degree of nasal congestion or obstruction, that’s dealt with, whether medically or surgically. So, for most people, allergies are a very common reason that can be treated properly with medications or avoidance measures or even allergy shots. If you have a deviated septum, then that can be dealt with surgically if the medical options don’t work. Dental appliances are also useful in people with sleep apnea and snoring in the same way it can be used for UARS patients, as well. The mechanism is essentially the same: as the tongue starts to fall back—if it only falls back partially, then you create a vacuum effect upstream and the palate starts to collapse and then you get snoring. But in UARS patients, the tongue falls back completely, causing obstruction and more arousals. Some of the problems with a dental device include jaw pain, ear pain, and bite problems due to the nature of this device.
CPAP, or Continuous Positive Airway Pressure, is actually the gold standard treatment for sleep apnea. In the original article that described UARS, CPAP was used successfully in many of these patients. The way CPAP works is that a small mask is placed tightly over your nose and a small amount of positive air pressure is gently blown in through your nose, stenting your airway open while you are sleeping at night. If you have tried and failed these conservative options, then there are surgical options as well.
Before we finish this evening’s discussion, let me just bring up an interesting case example which will illustrate my point. I had a patient, a young woman in her 30s, who came to see me with recurrent throat infections and was also found to be extremely tired and had depression, on anti-depressants. She also had severe cold hands and feet, low blood pressure with frequent lightheadedness and dizziness, recurrent sinus infections, migraines and chronic diarrhea. She was severely distraught because her overall health had deteriorated to the point where she couldn’t function normally at her job. A sleep study showed that she had mild sleep apnea, at 14 events every hour.
Thanks for joining me today. I’m Dr. Steven Park and I’m an otolaryngologist, or an ear, nose & throat physician and surgeon, interested in sleep-related breathing disorders. Today’s topic will be: Surgical Treatment of Snoring and Obstructive Sleep Apnea. Before we get to the “meat” of the matter, a brief review is in order.
Obstructive sleep apnea is a condition where one stops breathing repeatedly through the night due to obstruction in the throat area. So if untreated, it is associated with high blood pressure, depression, obesity, heart disease, as well as many other medical conditions. This diagnosis is based on a formal overnight sleep study, where one has to stop breathing at least 10 seconds per each episode. If this occurs more than 5-15 times every hour, you are told you have sleep apnea.
Upper airway resistance syndrome, on the other hand, is a condition where you don’t officially meet the criteria but are still tired and groggy with many other caveats. For a more thorough discussion of upper airway resistance syndrome and obstructive sleep apnea, please refer to the other articles in this series.
If you are found to have obstructive sleep apnea, there are a number of treatment options available. First of all, you need to consider conservative options including weight loss, sleep positions and just good diet and lifestyle habits. Weight loss, however, is easier said than done because most people are very tired and unmotivated to exercise. So it’s a very difficult proposition. Furthermore, you don’t have to be overweight to have sleep apnea. It’s been found that even young, thin women who don’t snore can have obstructive sleep apnea.
There are three major categories of treatment options. We’ll start with dental devices, which are oral devices or oral appliances. These are appliances that dentists make these by making a mold of your teeth where the bottom part of this device slides out gradually thereby pulling on the lower jaw and your tongue. Tongue collapse is the cause of many cases of people with sleep apnea. These devices do work for most people and they have been shown to be effective in people with mild to moderate sleep apnea. However, you need to choose these patients carefully because not everyone who has sleep apnea has tongue collapse. As discussed in my previous article, there are different anatomic reasons which can aggravate, if not cause sleep apnea including the nose, the palate and the tongue. So patients who are candidates for oral appliances have to be selected very carefully based on history and a very thorough physical examination.
Some of the problems with dental devices are: excessive salivation, dry mouth, TMJ pain or jaw discomfort and sometimes it can even cause bite changes, so it is very important to be evaluated and followed by a dentist who specializes in these devices.
The next treatment option that is available is CPAP, or Continuous Positive Airway Pressure and this is typically the first line treatment that’s offered to people with significant sleep apnea. Basically, it’s a mask that fits tightly over your nose and a machine at the bedside blows some gentle air pressure through your nose via the mask to sort of stent your airway open while you’re sleeping at night. The exact pressure setting has to be calibrated in the laboratory where you had the sleep study done, and for the most part, people tolerate this very well and get significant improvement in their quality of sleep.
The issues of compliance and efficacy with CPAP are a huge topic in itself and maybe we’ll discuss that another time. Unfortunately, for many people, no matter how hard they try to use the CPAP machine and after multiple, ongoing trials of different masks, headgear and tubing and different pressure settings, some people just can’t tolerate using the CPAP at home every night. So for these few people who have tried everything, surgical management is the only other option available to them.
Now, looking at the whole range of surgical options, you need to look at the entire anatomy from the tip of the nose all the way to the tongue base and the voice box. As I’ve said before, sleep apnea is usually due to a combination of nasal congestion, palatal collapse or tongue collapse and any combination of the above— you can have one, two or three different levels. More commonly, patients will have tongue collapse along with some mild palatal collapse. Some people can have palatal level of obstruction, especially if they have large tonsils. So, we need to look at the entire pathway and then decide what to do.
Starting from the nose, if they have any degree of nasal obstruction, we need to address this area. So, if they have allergies, we treat that first; if they have a deviated septum and if allergy treatment doesn’t work, then we can offer a septoplasty. There is also surgery to reduce the turbinates, which are these wing-like structures on the side of the nose that swell when you have a cold or allergy and there’s one other condition called nasal valve collapse that is frequently undiagnosed. This is a condition where the sidewall nostrils of your nose tend to collapse due to just natural weakening or due to previous surgery. Now these are the people that benefit very well from Breathe-Rite strips, or those nasal dilator strips. It obviously doesn’t work for everyone.
The next level to address is if you have very big tonsils or if you have a very redundant palate. This is getting into the area of an operation called uvulopalatopharyngoplasty, or UPPP. Going further down the airway, if you have any degree of tongue collapse, then that needs to be addressed, as well. So, there are options available for each of these three different levels.
One more comment on a historical note: before CPAP was available in the early 80’s, as well as the UPPP operation in the early 80’s, the only other option that was available for sleep apnea was a tracheotomy, which is where a surgeon places a breathing tube below the voice box. Basically, you’re bypassing the voice box in order to allow you to breathe at night. Obviously, this was a cure in 100% of the cases but not very socially acceptable for obvious reasons.
The key to success in sleep apnea surgery is in choosing the right type of patients to offer this surgery to. If you are severely overweight, these operations will not work as well. If you have any other major medical problems, such as heart disease, then you’re at a higher risk for complications. So there are many other issues that need to be addressed before you decide whether or not you even want to consider surgery. In my practice, I usually insist on trying one of the other conservative non-surgical options first but for the few who can’t tolerate these other treatment options and want something more definitive, then I have a long discussion with these patients face to face, after a thorough re-evaluation of their upper airway anatomy. Once the decision is made to look at surgical options, then we have a discussion about which areas need to be addressed.
As I mentioned before, one of the first options that was made available for sleep apnea patients is called a UPPP or a uvulopalatopharyngoplasty. When it was first offered in the 80s, surgeons were pretty successful in terms of results but with time, what we found was that the success rate kept dropping and dropping and eventually, it leveled off at about 40%. So this is the most widely quoted statistic for the success rate of uvulopalatopharyngoplasty surgery and as a result, it’s gotten quite a bad reputation within certain fields. But if you look at the flip-side of the coin, in 40% patients did respond whereas in 60% they didn’t. Now, with further research we realize that one of the most common reasons for failure was that the surgeons did not address tongue base collapse. So, now, if you address both levels, both the tongue and the palate, the success rates can be as high as 75%-80%.
A few years ago, there was a paper by Dr. Friedman in Chicago, who looked at patients undergoing the UPPP procedure and what he found was that certain patients with certain anatomic features responded to this operation alone better than others. The bottom line is that if you have very large tonsils and you can see most of your palate by looking inside your mouth—in other words, if the top of the tongue sits very low in the mouth and you can see pretty much the entire edge of your soft palate along with large tonsils—then you have about an 80% success rate. There are some other details and other factors associated with the staging criteria but if you don’t meet these criteria, then you have a pretty poor prognosis. So, if you came to me with sleep apnea and you were found to have large tonsils and I can see the free edge of your soft palate, then you would be a good candidate for the UPPP alone. However, there’s still the possibility – about 20%, that despite undergoing this operation, you may still have persistent sleep apnea. If this happens, it usually means that the palatal operation was not either aggressive enough or there was underlying tongue collapse that was not properly addressed.
These days there are a number of different varieties of UPPP procedures; some more invasive and some less invasive and some designed to be less painful. The bottom line is you need to do this operation properly and not be so concerned about what kind of instruments you use and what kind of techniques that you use. As long as you do the basic operation properly, that is the most important part.
One of the variations that I do quite frequently is called a uvulopalatal flap, where there is no muscle cut whatsoever. Instead, I remove a portion of the mucous membrane in the soft palate and then I flap, or flip the uvula and the soft palate up onto the upper part of the soft palate thereby kind of tightening the soft palate as it heals. I’ve also been using a new cutting tool, called a Coblator, which I use routinely for tonsillectomies but I’ve also applied for the palatal operation and there seems to be significantly less pain with this cutting tool, as well. One other note about the laser procedure for sleep apnea—the laser procedure for sleep apnea was originally brought forth 10-20 years ago as a lesser invasive form of surgery for sleep apnea, especially since it could be done in the office. There have been many, many studies published looking at the results and they’ve all been mixed, so the pendulum has been swinging away from offering the laser procedure for sleep apnea, especially since there have been some cases where the sleep apnea got worse following palatal surgery. Needless to say, in these patients where the sleep apnea got worse, they probably had underlying tongue collapse as well. For many people, they will have tongue and voice box collapse as well, and you need to address both if you want success. There are a number of different ways of addressing this.
The one protocol that I began to follow, many years ago, was that from Stanford and what they do is something called a genioglossus advancement, along with a mandibular osteotomy. It’s just a fancy word meaning that they cut out a small, rectangular piece of bone in the lower jaw in the front, which attaches to the lower front part of the tongue, so if you pull on that bone, it pulls the tongue forward, thus opening up the airway space in the back. Along with this, they pull down what’s called the hyoid bone, which is a c-shaped bone on top of your voice box, which attaches to your tongue and your voice box. By pulling that down onto your voice box, it acts as an adjunctive procedure to open up your airway space. So the combination of the hyoid procedure, the genioglossus advancement and the palatal operation are where they get the 75% success rate for people who have mild to moderate sleep apnea. And over the years, there have been various modifications of this—in general the success rate is 75-80%.
One thing to note, and I mentioned this in a previous podcast, is what the definition of success is. As surgeons, our definition of success is when the apnea-hypopnea index (the number of times you stop breathing every hour) drops by 50% and the final number has to be less than 20. So if you start off with 50, you need to be under 20 to be called a success. Obviously, that still has its shortcomings because you still have mild sleep apnea but it’s better than not treating it at all. Many patients feel significantly better. In many cases, the number has dropped into the single digits.
In my practice, I have a modification of the Stanford approach where I place a suture behind the jaw and I sling that around the back of the tongue, thus suspending the tongue so it doesn’t fall back at night and this is a lesser invasive procedure. They’ve done studies with this procedure showing equivalent results with much less potential for complications as well.
Now, another technique that is commonly used is called the radiofrequency tongue base reduction or volumetric tissue reduction. Basically, these are techniques where a needle is placed in the back of the tongue and radiofrequency energy or any other type of thermal or electromagnetic energy is delivered to cause a small controlled burn. With time, as it heals, the scar tightens and contracts the back of the tongue. The downside to this procedure is it has to be repeated 4 or 5 times for optimal success. In my experience, it does work, but many patients elect not to go through with the entire series of procedures.
A newer option is to use a Coblator instrument (which melts tissues at low temperatures) through a tiny tunnel through the top of the tongue and melt away a certain portion on the base of the tongue, without cutting through the mucous membranes. This way, it doesn’t hurt as much and it’s a one-step procedure. This is called a SMILE procedure and was described by Dr. Eric Mair.
Now all of this may sound somewhat aggressive, but it’s all relative, depending on how you look at it. At Stanford, of the people who failed the first stage of operations – about 20-25% of patients – where these operations didn’t work, what they offered them was something called a maxillomandibular advancement. This is where the oral surgeons literally pull the bony upper and lower jaw forward – and by doing that, it opens up the airway significantly. These patients have well over 90-95% success rate.
As I’ve mentioned before, the last resort is a tracheotomy, where a small hole is created below the voice box and a tube is placed to bypass the upper airway entirely. This procedure is performed rarely, in only life-threatening situations.
So, in summary, there are a number of different options for surgery when it comes to sleep apnea. Due to a number of different anatomic factors, you have to tailor the surgery to what’s appropriate for each patient’s anatomy, to what the patients needs, and what the patient wants and desires. With my patients, again, I insist that they try the more conservative options first (such as CPAP and dental devices). Then when they come to me, wanting to know about surgery, I have a very long and thorough discussion about all of the different options, what I recommend, and what the alternatives are along with what the possible complications are. As with any surgery, there are certain risks and a good surgeon should be able to handle any kind of complication that arises. Obviously, if you don’t know how to handle the complications, you should not be doing the operation.
I just want to make a few comments about snoring. A lot of patients come to me for snoring issues and once they find out that they don’t have sleep apnea, then we need to address the snoring. And, typically the techniques are very similar. Many patients will have tongue collapse and if you do something to pull the tongue forward, especially with these dental devices, that will help to alleviate the snoring. We also have many techniques that are done in the office to help to stiffen the soft palate, since that is where the majority of the snoring sounds are coming from. The major options include: palatal implants (which are thin, polyester woven braids that are implanted into the soft palate). As it heals, it scars, contracts and tightens the soft palate.
Other options include, again, radiofrequency energy, where a little needle is inserted into the muscles and a slight burn is caused. There is even a scarring agent that’s used for varicose veins that used for snoring called injection snoreplasty. It’s a shot that’s given into the mucous membrane to cause a small ulcer, and again, as it heals, it scars and tightens the palate. And, lastly, the laser can be used to trim the free, soft edges of the soft palate. This hurts a lot and is not used as much anymore. With the exception of the implant procedure, many of these options require 2-3 steps.
In my experience, not too many people are good candidates for these procedures, especially if they have tongue collapse and in most cases, there is a good likelihood that as their sleep apnea worsens, that the snoring may come back. I offer these patients snoring procedures very sparingly and only when I’m confident that it is truly the right procedure for them. Again, if they have any degree of nasal congestion, I address this first.
I also have an interest in looking at alternative or complimentary methods of treating snoring or sleep apnea. There was an interesting article that was published recently that used acupuncture to treat sleep apnea where the apnea/hypopnea index dropped on average by 50%. Quite surprising! So, I’m looking into whether I can replicate that in my practice. There are even tongue exercises that have been prescribed to help for snoring. There are also reports of playing a didgeridoo, which is an Australian Aborigine wind instrument. If you’ve been reading my newsletters, you’ll see what that’s all about or you can go to our website, which describes these options in more detail.
If you want more information about all these options, as well as a more complete picture of why we have so much of these problems and what we can do about it, go to sleepinterrupted.com to take a look at my newly released book, which describes everything in much more detail.
Tennis balls: For some people, staying off your back can make a big difference. The problem is staying on your back. The most common recommendation is to sew a sock filled with a tennis ball to the back of your
pajamas. This method has mixed results, and in general, although it sounds great, doesn’t work that well. It just only annoys the snorer or they just sleep on top of it.
Sleep position devices: There are a number of gadgets and devices that prevents you from rolling onto your back. They range from triangular wedges to shirts filled with foam rods to prevent sleeping on your back. The only way to know whether or not they work is to try it. For some people, it can make a huge difference, even if you have obstructive sleep apnea. For many others, you may have a mixed response, or no response at all.
Side sleep position pillows: This one positions your arm above your head and somehow forces you to sleep on your side. Again, I’ve heard mixed responses from my patients. If you can sleep with your arm above your head for hours without it becoming numb, then this may work for you.
“Contour” pillows: This pillow works better if you prefer to sleep on your back. The lower end of this pillow is a bit higher than the middle part that the top of your head touches. This forces your head to be cocked back a bit, lifting up your chin somewhat, thereby opening up your airway somewhat. This the the same maneuver that you’re taught to do during CPR to open up the airway before you give mouth-to-mouth. Notice that after you fluff up your pillow you go to bed, the pillow height diminishes slowly, and by the end of the night, your chin is closer to your head, which closes your airway. Another option is to either roll up a towel into a “log” or get one of the Asian husk-filled pillows that are shaped like a roll. You’ll have to experiment to find the right height.
Diet and weight loss: This will help to various degrees for most people who are overweight, but what if you’re already thin? Also, since poor sleep leads to weight gain hormonally and metabolically, it can be very difficult to lose weight no natter how much you diet or exercise. For some, losing 10-15 pounds may help a great deal with your snoring, but chances are, it’ll return sooner or later as you get older.
Nasal dilator clips: Whether external (Breathe-Rite) or internal (Nozovent, Nasal Cones, or Breathewitheez), these work sometimes by pulling your soft flimsy nostrils apart, preventing nostril collapse when you inhale. During sleep, especially when your muscles relax, any degree of nasal congestion can aggravate higher vacuum pressures that can aggravate tongue collapse. Despite being touted to cure snoring, it only works about 10% of the time. Here’s one simple test to see if you should invest any money on these products: take both you index fingers and gently press on your skin, right next to your nostrils. Press gently and pull your cheeks apart on each side towards the outer corners of the eyes. This is called the Cottle maneuver.
Wind instruments: Playing any type of wind instrument (flute, clarinet, trumpet, etc.) can in theory promote throat and tongue muscle tone. Reports of success are anecdotal.
Playing the Didgeridoo: Various studies have suggested that playing this ancient Aborigine wind instrument can help relieve snoring. The mechanism in how it works is similar to any wind instrument.
Singing: The mechanical act of singing promotes profound throat muscle tone and control. Similar to all the wind instruments, prolonged periods of singing promotes relaxation, since exhalation is activated by your parasympathetic nervous system.
Tongue Exercises: Has been found to be helpful for some people, but needs continuous exercises. Recent studies have confirmed some benefit.
Throat sprays: Various mixtures of herbs and natural ingredients are promoted for snoring, but a recent objective study showed that they were not helpful.
Acupuncture: No consistent evidence, but helps with stress and fatigue. One recent study showed a drop in the apnea severity by 50%. I do find it helpful in some of my patients as a complementary form of treatment in addition to standard options.
Bedpartner’s elbow: Works to wake you up to stop snoring, but never curative. This is called the “bruised rib syndrome”.
Electronic devices that wake you up when you snore: More expensive than a bedpartner elbowing you in the ribs.
Ear plugs for the bedpartner: May help the bedpartner sleep, but not very effective for the very low-frequency snoring vibrations.
Sleeping in another room: Usually alleviates the problem, but bad for relationships, and not very helpful for “heroic” snorers where the sounds vibrate the bedroom walls 2-3 rooms down.