Treatment Options for Obstructive Sleep Apnea
In the video below Christopher Yang, M.D., otolaryngologist and head and neck surgeon at Swedish Medical Center, talks about the diagnosis of and treatment options for obstructive sleep apnea and CPAP users.
Treatment of OSA requires close work between sleep medicine physicians, sleep surgeons and sleep dentists in developing optimal care plan. There is no one size fits all therapy and each patient requires individualized evaluation and treatment plan.
Treatment strategy should include avoidance of alcohol or other sedative medications, weight loss and positional therapy. However, these methods alone will not relieve sleep apnea for most and further treatment is required.
CPAP is the first line treatment of majority of patients with OSA. CPAP is short for Continuous Positive Airway Pressure where pressurized air is administered using a nasal or face mask to deliver positive pressure to overcome airway obstruction. The pressure of the air is adjusted in order to maintain adequate pressure to overcome airway obstruction. When used, it is highly effective and when used properly will completely eliminate OSA.
Many patients discover immensely satisfactory sleep and energy for the first time. Some patients however find CPAP cumbersome, difficult to use, or incompatible with their lifestyle. Close evaluation and support is needed to maximize tolerance and troubleshoot potential problems that interfere with optimal tolerance. This requires evaluation by medical and surgical providers to identify and treat potential barriers such as nasal obstruction.
Despite best efforts, some patients will not be able to tolerate CPAP and will opt for airway surgery.
Oral Appliance Therapy
Oral appliance therapy involves use of a oral device to hold the lower jaw and or the tongue in the forward position to prevent collapse. There are many different types of appliances from inexpensive boil and bite types to more customized appliances. Overall, these devices are typically more effective when the level of collapse is limited to the lower part of the throat. Excessive salivation can be a problem. Patients with TMJ problems may have trouble with the device and dental movement and orthodontic problems may result from prolonged use.
The structures of the human upper airway is complex and is responsible for handling numerous functions including breathing, eating, communications, taste, and sensations. More often than not, airway collapse occurs at multiple levels in the throat and may require multiple procedures to effectively treat OSA. As such, airway surgery requires delicate balance between needs of the airway while maximizing preservation of other functions. Close and detailed examination of upper airway features is paramount in evaluating levels of obstruction.
Nasal obstruction leads to interference of nasal breathing both day and night. It can also be a contributing factor in OSA. Treatment can also improve ability of some patients to better tolerate CPAP therapy. The most common procedures include septoplasty, turbinate reduction, sinus surgery and nasal valve surgery.
Pilllar Implant and Somnoplasty
For patients with mild sleep apnea, pillar procedure and somnoplasty may offer minimally invasive treatment option. The procedure is performed under local anesthesia and is similar to techniques employed in treatment of snoring as previously described.
UPPP - Uvulopalatopharyngoplasty
UPPP has been the traditional surgery for OSA. The procedure involves both tissue removal and tissue repositioning to enlarge specific part of the airway. When tonsils are still present, they are usually removed at the same time. Over many years, thousands of patients have been treated with this technique with some improving and others not. We are now better able to assess which patients are better suited for this technique based on anatomic features. Some patients will be determined poor candidates for this procedure and others may be a good candidate. The procedure is done in the hospital under general anesthesia and most patients are able to go home the following day.
The tongue is a common site of airway obstruction in the lower part of the throat called the hypopharynx. Excessive bulk or relaxation of the tongue can result in obstruction in the hypopharyngeal region.
In this technique, radiofrequency energy is delivered using a radiofrequency probe to the base of tongue region to create a controlled lesion which then becomes absorbed over time resulting in tightening of tissue and reduction in size of the treated area. The treatments can be performed in the operating room or under local anesthesia. Most patients should expect need for several treatment sessions.
Lingual tonsils are much like tonsils we can see on the sides of our throat in our mouth. However, lingual tonsils are located on the back of the tongue. In some patients, excessive enlargement of the lingual tonsils can contribute to obstructive sleep apnea. The procedure is performed in the operating room under general anesthesia.
In some patients the tongue is excessively enlarged that it results in airway obstruction during sleep. In these cases, it may be beneficial to remove a portion of the back of the tongue using this technique. This procedure is performed under general anesthesia in the operating room. After mapping out the major vessels of the tongue, the central and posterior portions of the tongue is partially removed.
The largest muscle of the tongue, the genioglossus is anchored to the front, inner aspect of the lower jaw. The procedure involves capturing this area of attachment and advancing it forward. By advancing this anchor forward, the space behind the tongue is enlarged. The procedure is performed under general anesthesia and involves an incision in the inner aspect of the lower lip. A rectangular piece of the lower jaw is cut capturing the anchor point of the genioglossus muscle. This segment is then pulled forward and secured to the lower jaw.
Investigational and Research
Obstructive sleep apnea surgery is a constantly evolving field. Our division is involved in evaluation of latest cutting edge therapies and research to deliver highest quality care to our patients.
Our division is involved in investigation of new novel therapies including hypoglossal nerve stimulator and transoral robotics surgery.