In general, patients with snoring / sleep apnea are classified into those with a "global" problem, i.e. obesity, and those with a "local" anatomical problem (those with huge tonsils, long thick palate, big tongue or a small jaw).
Patients with a "global" problem are advised:
- a strict trial of weight loss,
- exercise regime,
- nutritionist consultation (dietary advise),
- regular close follow up and
- a nasal mask continuous positive airway pressure (CPAP) trial.
Careful search for patients with huge tonsils, huge adenoids or a huge tongue is done, these can be corrected surgically.
Very obese patients with BMI > 40 are also advised to see a bariatric (laparoscopic gastric/stomach banding) surgeon for consultation. Occasionally, weight reduction medications are considered for patients who fail 6 months of life-style modification; and throughout this period, CPAP must be strictly adhered to.
Those patients with morbid obesity and/or severe diseases like congestive heart failure, and/or respiratory/lung failure may be offered a tracheostomy (surgery performed to create an artificial hole in the airway).
This is a non-invasive method of treatment, it entails using continuous positive airway pressure (forced air) by a mask worn by the patient on the nose or the face throughout the night. CPAP is a very effective modality of treatment for OSA. However, for most patients with OSA, it is not easy to where the mask throughout the entire night and for every night for the rest of his life. Hence, the issue of compliance is a major problem.
The CPAP machine and its mask would only be effective if the patient wears the mask, it would not work if it was kept in the closet. Moreover, many patients wake up with the mask on the floor, and hence, would not use it the entire night. The CPAP machine and mask is as effective as the duration that it is worn.
The current automatic PAP adjusts and delivers variable levels of CPAP at the initiation of each respiratory cycle by automatically responding to changes that are detected in the airflow resistance, pressure or intensity of snoring. Hence, the "intelligent" CPAP (automatic CPAP) can adjust the pressure required to open the patient's airway dynamically from breath to breath. With the availability of the airway pressure data from the auto-PAP, the doctor can obtain the patient's average night pressure, average night time usage and the average treatment AHI.
The main drawback to the use of nasal CPAP is compliance. Common reasons for poor compliance with nasal CPAP include:
- nasal problems – nasal stuffiness, irritation, discharge, pain
- mask problems – poor fit, air leak, dry eyes, skin breakdown
- equipment problems – noisy, cumbersome, high air pressure, pressure-related arousals
- concept problems – failure to understand medical benefit
Failure of CPAP
The CPAP machine is very effective provided the patient can tolerate it the entire night. Compliance is the main problem. Most people do NOT use the machine the entire night and every night of the week. Hence, the treatment effectiveness is based entirely on the patient's use.
Long term follow up and research done on over 20,000 patients (by Weaver et al), compared patients on the mask CPAP and those who underwent surgery. This study (done in Seattle, Washington) was published in the American Otolaryngology Journal in 2006, showed that patients who underwent surgery had a better survival advantage (patients who went for surgery lived longer) on average than patients who were using CPAP (this was due to the poor usage of their CPAP). From this study, it was implied that patients who underwent surgery lived longer than patients on the nasal CPAP mask.
Oral appliances (like dentures) are designed to bring the mandible (lower jaw) and base of tongue forward, either by stabilizing the lower jaw position during sleep or by attempting to pull the tongue forward, in an effort to increase the posterior airway space. Oral appliances are offered especially when the patient is a poor candidate for surgical intervention, or are unable to tolerate nasal CPAP.
- Mandibular (lower jaw) repositioning device – these are removable devices worn only at night. They are affixed to the upper and lower teeth and are gradually adjusted to advance the mandible.
- Tongue-retaining device (TRD) – these come in the form of a soft suction cup that is placed in the mouth, creating a negative pressure to hold the tongue in a forward position during sleep.
Surgery in Snoring / Sleep Apnea
The key to surgical success is patient selection (for a successful surgery, the doctor has to select the suitable patient).
Success rates of surgery depend on
- type of patient selected for surgery – including height and weight of patient, age of patient, tonsil size, palate length, tongue size and nasal pathology
- type of palate surgery performed – including Uvulopalatopharyngoplasty (UPPP), Pang's Expansion Sphincter Pharyngoplasty (ESP) (invented by the author), Z-PharyngoPlasty (ZPP),
- type of tongue surgery performed – Tongue Reduction Surgery (minimally invasive tongue suspension surgery) (introduced to Asia by the author).
- whether nose, palate and tongue surgery is performed together
- severity of Sleep Apnea (disease) as noted on the sleep test
|Mild OSA||5-14||86% - 95%|
|Moderate OSA||15-29||75% - 85%|
Patient selection is by far the most important factor. A number of clinical features are sought for in each patient.
1. Friedman clinical staging criteria – Dr Friedman described a clinical staging for sleep apnea in order to predict the success rate of palate surgery. He described three stages based on the tongue position, tonsil size and BMI.
Stage I: Friedman Tongue Position 1 & 2. Tonsil size 3 & 4. BMI <40
Stage II: Friedman Tongue Position 1,2, 3 & 4. Tonsil size 1,2, 3 & 4. BMI <40
Stage III: Friedman Tongue Position 3 & 4. Tonsil size 1 & 2. BMI (any)
Dr Friedman reported an overall success rate of 80.6% for stage I, 37.9% for stage II and 8.1% for stage III. Generally, palate surgery should be done for patients with palate obstruction, and can be combined with procedures that address other sites of obstruction. The key is to identify these patients who are in Friedman's stage I; they have a high 80.6% success rate.
2. Fujita levels of obstruction – Dr Fujita identified 2 main areas that can block a patient when he sleeps, namely, the palate or the tongue. This is demonstrated on naso-endoscopy with Muller's Maneuver (reversed Valsalva / breathing in deeply with the mouth closed and nose pinched). The patient is made to breathe in as deeply as possible with a closed mouth and nose. This would mimic an upper airway obstruction, hence, the most vulnerable and collapsible area would close up. Care is taken to observe whether this collapse is mainly the palate or the tongue.
Type I: soft palate obstruction
Type II: both soft palate and base of tongue obstruction
Type III: base of tongue obstruction
Based on these levels (palate and / or tongue) on clinical endoscopic examination, surgery is planned and recommended.
3. Severity of Sleep Apnea – this is based on the results of the sleep test. Most sleep specialists concur that patients with severe sleep apnea would have a higher likelihood of a tongue obstruction. Hence, tongue surgery may be needed as part of the surgical planning.
Type of Surgery Required
Nose surgery is important for a few reasons:
- the nose represents 50% of the airway (the other 50% is the mouth), hence, having a clear nasal passage is important
- a clear nose is important for a patient who is using the CPAP machine, helps usage and improves compliance
- nose surgery also helps reduce snoring and obstructive sleep apnea to a good extent (if done together with other procedures, like palate or tongue)
- nose surgery alone (performed alone) is at best 20% to 30% effective in treating obstructive sleep apnea (should be done with other procedures, like palate or tongue, if the patient has moderate or severe obstructive sleep apnea)
Type of nose surgery may be dependent on the comfort level of the ENT surgeon. In general, the radiofrequency of the inferior turbinates are easy, simple, painless, quick and has minimal side-effects. Other types of nose surgery:
- Nasal Turbinate Reduction - Laser, Radiofrequency, Micro-debrider, Coblation
- Nasal Turbinectomy – cutting of the turbinate
- Endoscopic Sinus Surgery – involves the use of endoscopes through the nose to correct anatomical deformities, reduce or remove nasal swellings and enlarge sinus openings (improving sinus drainage).
This new technique is minimally invasive surgery; it is safe, convenient and effective in treating sinus diseases.
Palate surgery is important for many reasons:
- 70% to 80% of most snoring arise from the palate
- Surgery to the palate will reduce snoring and obstructive sleep apnea effectively
- Correct type of surgery to the palate is important to prevent complications (stenosis of the palate)
- Reconstruction of the palate is now the lastest method of surgery to the palate
- The recently invented Pang's Expansion Sphincter Pharyngoplasty technique (invented by the author) has been shown to be 86.2% effective in patients with sleep apnea
Types of Palate Surgery – For Snoring and Mild Sleep Apnea
- Radiofrequency of the Palate
- Pillar Implant Palate Procedure
- Laser Palate Surgery
- Cautery Assisted Palate Surgery / Anterior Palatoplasty (invented by the author)
- Coblator Palate Surgery
Types of Palate Surgery – For Moderate and Severe Sleep Apnea
- Traditional UvuloPalatoPharyngoPlasty (UPPP) – for selected group of patients.
- Z-PharyngoPlasty (ZPP) – good for patients with narrow palate and absent tonsils
- Pang's Expansion Sphincter Pharyngoplasty (ESP) (invented by the author) – very useful technique, have shown to be 86% successful in a randomized controlled trial.
Tongue surgery is important for a few reasons:
- the tongue contributes significantly in sleep apnea during an obstruction
- the tongue needs to be treated if the patient wants a good result
- the tongue is the cause of airway obstruction in at least 60% to 70% of all patients with sleep apnea • not treating the tongue, will lead to FAILURE of surgery
Types of Tongue Surgery
- Tongue Reduction Surgery / Excision
- Minimally Invasive Tongue Suspension Suture (effective) (introduced by the author into Asia)
- Radiofrequency of Tongue Base
- Genioglossus Advancement Mandibulotomy
- Minimally Invasive Midline Submucosal Tongue Excision (SMILE technique)
Types of Sleep Apnea Patients
- 30% to 40% OF PATIENTS WITH SLEEP APNEA HAVE PALATE OBSTRUCTION AS THE MAIN CAUSE (WILL NEED PALATE SURGERY)
- 60% to 70% OF PATIENTS WITH SLEEP APNEA HAVE BOTH PALATE AND TONGUE OBSTRUCTION AS THE MAIN CAUSE (WILL NEED PALATE AND TONGUE SURGERY)
Patients with palate and tongue obstruction who only have palate surgery done alone, will not be cured of their sleep apnea (will not have good result).
Patients with palate and tongue obstruction will NEED both palate and tongue surgery done together for a good result.
THE TONGUE NEEDS TO BE TREATED AND OPERATED ON, IF IT IS LARGE OR OBSTRUCTING THE AIRWAY, IF NOT, SURGICAL FAILURE IS LIKELY.