OBSTRUCTIVE SLEEP APNEA

Oral Appliances:
If you suffer from obstructive sleep apnea or snore, the oral appliance can benefit you. For your bed partner, this means peace and quiet again and a better night’s sleep. For you, it will mean better quality sleep. As a result, you will be less likely to suffer from headaches and daytime sleepiness and your ability to concentrate will improve.
If you have tried CPAP, and found it uncomfortable, try the oral appliance! The difference in comfort and tolerance will astound you.

SomnoMed Applaince (Pictured Above)

The Moses Applaince (Pictured Above)

NON-SURGICAL TREATMENT OPTIONS:

Weight Loss:
The most common cause of OSA is obesity, so losing weight is important for those who are overweight regardless of OSA severity. For mild sleep apnea, this might be enough.

Continuous Positive Airway Pressure (CPAP):
Nasal Continuous Positive Airway Pressure, or CPAP treatment, requires the patient to wear a mask over the nose during sleep. The mask is connected by a hose to a small air pressure generator. When the mask is worn, the air pressure inside the throat is increased. The air pressure is adjusted so that it is just enough to prevent the throat from collapsing during sleep. The CPAP eliminates a person’s snoring, gasping, and choking during the night. The CPAP prevents airway closure while it is worn, but apnea episodes will return when CPAP is stopped or if it is used improperly. CPAP technology has improved considerably in the past five years. The devices are much quieter and there are numerous mask options that improve the fit and comfort.
Treatment with CPAP requires adjustment (or titration) of the amount of pressure needed to keep the airway open. Patients who have an ARES study no longer need to have a CPAP pressure setting determined in the laboratory. Multiple studies have shown that auto-adjusting CPAPs, which automatically deliver the correct pressure, are as effective as in-laboratory determined pressure. Alternatively, the CPAP pressure can be predicted using a formula and the pressure adjusted until the snoring subsides. CPAP units are obtained from Durable Medical Equipment providers with a prescription provided by your physician.

SURGICAL TREATMENT OPTIONS

If you are looking for a cure for sleep apnea, surgery may be your best option. Sleep apnea surgery is aimed at enlarging and decreasing the collapsibility of your airway. These procedures include the following:

Pillar Procedure
Nasal Surgery
Radiofrequency
Genioglossus Advancement
Hyoid Advancement
Maxillomandibular Expansion
Maxillomandibular Advancement

Pillar Procedure:

The Pillar Procedure is one of the most effective snoring treatments available.  During this procedure, tiny woven inserts are placed inside the soft palate to reduce the vibration that causes snoring.  It also stiffens the palate and prevents it from obstructing the airway.  This is completed in a single office visit using local anesthetic, and clinical studies have shown a reduction in snoring in about 80% of patients.  These inserts are not visible, and do not interfere with swallowing or speech.  Most patients resume normal diet and activities the same day.

Nasal Surgery:
Nasal obstruction is a common finding in patients with OSA. This can be due to turbinate tissue overgrowth, deviated septum or collapse/narrowing of the nasal valve. Nasal surgery can be very successful in improving nasal breathing, however, in patients with moderate to severe obstructive sleep apnea, nasal surgery alone usually does not achieve significant improvement.

Below are airway studies done on three patients Dr. Cohen recently treated. These are volumetric airway studies showing the three-dimensional airway changes in these patients. The color chart below the scans illustrates the surface area changes in the airway, before and after surgery: black and red are indicative of a very narrow airway with a very small surface area, while yellow, green and blue indicate a much larger volume, three-dimensionally.

Radiofrequency:
Radiofrequency is used in sleep apnea surgery to reduce the volume of soft tissue of the nasal turbinates, soft palate, or tongue. Radiofrequency is very precise in targeting tissue and so heat dissipation to the surrounding tissues is limited, therefore minimizing excessive tissue injury and complications. This is often done as an outpatient procedure in the office. During the healing process of one to three weeks, scar tissue forms, causing tissue to shrink, thereby increasing the airway space.

Genioglossus Advancement:
Genioglossus Advancement prevents upper airway blockage by preventing the tongue to collapse toward the back of the throat during sleep. The genioglossus is the primary muscle of the tongue and is attached to a small bony projection on the interior of the lower jaw. During this surgery, this small bone projection is moved forward and the tongue attachment is repositioned anteriorly so that it is less likely to collapse posteriorly and block the airway during sleep (Fig. 1-2).

In patients with an esthetically pleasing facial profile, this procedure is accomplished with minimal change to the patient’s appearance. This procedure is called an Anterior Mandibular Window Osteotomy.

In patients who present with a small or retruded chin, this procedure is accomplished by creating a more prominent and aesthically-pleasing chin.

Hyoid Advancement:
The hyoid bone is a small bone under your chin, which is advanced to treat tongue base obstruction by expanding the airway. This surgery is often done in combination with a Genioglossus Advancement, as it has been shown that this combined approach increases the overall success of the treatment of obstructive sleep apnea³.

Fig. 1: Before – Hyoid Suspension with Genioglossus Advancement via Anterior Mandibular Window Osteotomy

Fig. 2: After – Hyoid Suspension with Genioglossus Advancement via Anterior Mandibular Window Osteotomy

Airway Before and After Surgery

Airway Before and After Surgery

Airway Before and After Surgery

Maxillomandibular Expansion:
Patients with obstructive sleep apnea often have narrowed jaws, resulting in the displacement of the tongue toward the back of the throat, creating airway obstruction. For these patients, the upper and lower jaws are widened to improve the airway space, using bone cuts, which are made on the jaws. An orthodontic device is then placed on the jaws to expand the jaws into proper position. Orthodontic treatment is required and done in conjunction with this procedure to move the teeth into proper position and close any spaces created when expanding the jaws.

Maxillomandibular Advancement:
Maxillomandibular advancement is the most effective and reliable treatment for patients with severe obstructive sleep apnea. This surgery basically involves moving the upper and lower jaws forward, thereby enlarging the entire airway (Fig. 3-6). This procedure is performed on patients with moderate to severe obstructive sleep apnea as the only treatment, or when other procedures have failed. It is also sometimes combined with a chin advancement to maximize the enlargement of the airway space. Maxillomandibular advancement has been shown to significantly increase airway dimensions in both lateral and anterioposterior directions⁴. Maxillomandibular advancement surgery has been show to have a success rate as high as 90% in the treatment of obstructive sleep apnea⁵.

Fig. 3: Before – Maxillomandibular Advancement with Chin Advancement

Fig. 4: After – Maxillomandibular Advancement with Chin Advancement

Fig. 5: Before – Maxillomandibular Advancement with Chin Advancement

Fig. 6: After – Maxillomandibular Advancement with Chin Advancement

At Park Avenue Oral & Facial Surgery, P.C., we use a multidisciplinary approach to diagnose and treat patients with obstructive sleep apnea. Our team consists of sleep medicine specialists, oral & maxillofacial surgeons, pulmonologists, and otolaryngologists. The patient’s primary care physician is also instrumental in helping us to achieve a successful outcome. If you suspect you may have obstructive sleep apnea, or if you have been diagnosed with obstructive sleep apnea and would like to learn how to cure sleep apnea, please call our office at (212) 988-6725 to schedule a consultation with Dr. Cohen.

1. Punjabi, NM. The epidemiology of adult obstructive sleep apnea. Proc Am Thorac Soc 2008; 5:136.

2. Grimm, W, Hoffmann, J, Menz, V, et al. Electrophysiologic evaluation of sinus node function and atrioventricular conduction in patients with prolonged ventricular asystole during obstructive sleep apnea. Am J Cardio 1996; 77:1310.

3. Vilaseca I, Morello A, Montserrat JM, et al. Usefulness of uvulopalatopharygoplasty with genioglossus and hyoid advancement in the treatment of obstructive sleep apnea. Arch Otolaryngol Head Neck Surg 2002; 128:435-40.

4. Craig Fairburn, S, Waite, PD, Vilos, G, Harding, SM, Bernreuter, W, et al. J Oral Max Surg 2007; 65(1) 6-12.

5. Powel, NB, Riley, RW, Guilleminault, C, et al. Obstructive sleep apnea surgery: risk management and complications. Otolaryngol Head Neck Surg 1997; 117(6) 648-52.

How to cure Sleep Apnea?

Do you often ask yourself how to cure sleep apnea? Are you looking for the cure for sleep apnea? You might be if you:

• Snore when you sleep
• Wake suddenly during the night perspiring, choking, or gasping for air
• Wake in the morning with headaches or a sore throat
• Fight falling asleep during the day, at work, or while driving
• Feel irritable, have memory loss, or a lack of concentration
• Suffer with obesity, gastric reflux, or high blood pressure

Obstructive sleep apnea (OSA) is a condition caused by a decrease in upper airway size and patency during sleep, which leads to multiple physiologic changes such as a decrease in oxygen saturation and increased arousals in sleep. This resulting sleep fragmentation and repetitive lack of oxygen have a variety of adverse consequences, including daytime sleepiness (fighting falling asleep during the day), reduced quality of life, and organ system dysfunction. Patients are also at an increased risk of heart disease and motor vehicle accidents (MVA).

It is estimated that 26% of adults are at high risk of OSA¹. The prevalence of OSA increases with age, and men have a higher prevalence of OSA than women by almost a three-fold increase. Risk factors for OSA include obesity, anatomical abnormalities, heredity, and nasal congestion.

Snoring and daytime sleepiness are the most common manifestations of OSA. A simple questionnaire, the Epworth Sleepiness Scale (ESS) is a rapid screen that reveals the significant subjective sleepiness of the patient. Additional symptoms and signs include restless sleep, periods of silence terminated by loud snoring, moodiness, morning headaches, decreased libido and impotence, poor concentration, fatigue, and awakening with a sensation of chocking, gasping, or smothering. OSA may be associated with a decreased heart rate during sleep, and there is increasing evidence that severe OSA might be a cause of heart disease and heart attacks. Many patients present with a medical history of high blood pressure, heart disease, stroke, kidney disease, diabetes, and gastric reflux. Surprisingly, studies have shown a resolution of cardiopulmonary complications with treatment of obstructive sleep apnea².

The first-line diagnostic study when OSA is suspected is an overnight sleep study, also called a polysomnogram. This sleep study is performed at a sleep clinic credentialed by the American Academy of Sleep Medicine. During this overnight stay, you will be taken to a room, which resembles a hotel room. After changing into your night clothing, a technician will attach monitors to various parts of your body. These wires will connect to a computer and are lightweight and hardly noticeable. They will record various respiratory variables and positioning of your body during the night.

If you do not wish to sleep overnight in a sleep clinic, an alternative option is to take an at-home sleep apnea test.  This test involves wearing a small, FDA-approved device that will monitor changes in peripheral arterial tone and activity, as well as blood oxygen saturation levels.  It also identifies sleep apnea events just like the equipment used in traditional sleep studies performed in sleep clinics.  This device is an excellent alternative for patients who are not willing to spend a night away from home in a sleep lab.  This test is done in the comfort of your own bedroom, an environment that best reflects the pattern of your sleep habits.

Based on these results, if you are diagnosed with obstructive sleep apnea, you will first be presented with non-surgical treatment options, such as losing weight, exercise, good sleep hygiene, or each night sleeping with a continuous positive airway pressure machine with mask (CPAP) or sleeping with an oral appliance. These treatment options can be very effective with compliant patients. However, if patients do not follow the prescription of these non-surgical treatments for the rest of their lives, they will not achieve optimum health, and their health can become severely compromised. Patients for whom the non-surgical options are ineffective, or for patients who cannot tolerate using them will be then referred for a surgical consultation.