Obstructive Sleep Apnea Treatment
There are several options available for the comprehensive treatment of OSA, and CENTA is uniquely able to assist in determining which option is best for you or your loved one. Our goal is to treat the disorder comprehensively and generally starts in the adult case with non-operative therapy. Surgery is kept in reserve for failure or intolerance of non-surgical therapy.
CPAP
The mainstay of OSA treatment is continuous positive airway pressure (CPAP). This involves the use of a stream of air in the throat to stent the airway open, no matter where the obstruction is coming from. This low air pressure, usually in the range of 6 to 20 cm of water pressure, is produced by a very quiet bedside air compressor which is about the size of a large clock radio. It is delivered through respiratory tubing to one of a number of different masks which fit over the nostrils, entire nose, or nose and mouth.
CPAP machines come in a number of different versions, with some that can vary the air pressure throughout the night and some that can drop the pressure on exhalation. In addition, there are multiple different sizes and shapes of CPAP masks, with the goal being to optimize compliance. We have a variety of masks and machines in the office for demonstration purposes. We work with a variety of CPAP vendors in the area and can download pressure and usage information from properly equipped machines in our office.
Your CENTA physician can help the vendor select the proper equipment for you, and can follow you throughout your CPAP treatment course. Close follow up is important, since studies indicate that up to half or more of people prescribed CPAP do not use it regularly and effectively. Unused CPAP is no better than no therapy at all, and an unused CPAP unit is no more than a very expensive paperweight on your nightstand.
ORAL APPLIANCE THERAPY (OAT)
There are a couple dozen FDA-approved oral appliances available for OSA treatment. Though there are differences between them, they all do essentially the same thing—pull the lower jaw, or mandible, forward during sleep. This then pulls the tongue forward and can help stabilize the palate. Like CPAP, OAT is effective only if the appliance is worn, so it is imperative that the correct appliance is fitted to the proper candidate. Most effective for mild to moderate OSA, OAT might be an option for you, and your CENTA physician can discuss this option with you.
SURGERY
The Internet is full of websites which discuss one form of surgery for OSA, referred to as uvulopalatopharyngoplasty, or UPPP. Many of these sites suggest that UPPP is the only form of OSA surgical therapy, which is incorrect. As such, there is not only a great deal of information available on this subject, but also much misinformation.
It is important for a patient who is interested in surgery for OSA to be thoroughly evaluated by a surgeon who knows the upper airway anatomy well, how it behaves during sleep, and who is well versed in the wide variety of procedures available for this complex disorder. Unlike CPAP, it is important to localize the site (or sites) of obstruction of the throat when surgery is contemplated. This is important because more than one part of the throat might be contributing to the problem, and because there are a number of different procedures which have been developed to treat these different areas. Consequently, proper OSA surgical treatment often involves a comprehensive treatment plan which might involve more than one procedure to more than one area of the airway. Unfortunately, most non-surgical sleep physicians are not familiar with the vast majority of these procedures, and most ENT surgeons have not been exposed to them during their training.
How the proper surgical procedures are selected
The pre-surgical evaluation starts with a thorough ENT examination. It generally then involves an awake office endoscopic evaluation with a flexible fiberoptic scope. This scoping is also sometimes repeated in an operating room under heavy sedation, in order to gain information on what the airway does in simulated sleep. At times, radiologic tests such as CT scans or lateral cephalometric X-Rays are helpful in outlining the anatomy for the surgeon. Once the abnormal anatomy is identified, your CENTA physician can discuss the relative risks, benefits and anticipated course of the surgical procedures which could best treat this anatomy. As no two people have exactly the same anatomy, there is no one plan that is right for everyone.
Areas of the airway treated surgically:
There are multiple areas of the airway which can be involved with OSA. Surgical treatment might be necessary to treat one or more of the following areas:
- The soft palate can be treated by one of the various versions of the UPPP procedure, often in combination with a tonsillectomy. Our practice performs about a half dozen different variations of UPPP, depending upon the particular anatomy involved. Most work by addressing the soft tissues of the palate, but one, the transpalatal pharyngoplasty, also involves work on the hard palate, and is designed to pull the soft palate forward away from the back of the throat.
- The side walls of the throat are treated at the tonsil level (the oropharynx) to tighten the walls or remove bulk. This can often be performed in conjunction with the UPPP procedure, particularly via the UPPP variations called the lateral pharyngoplasty and the sphincteroplasty.
- The base of the tongue causes blockage either due to too much tissue, because the tongue base sits back too far in the throat, or because it relaxes too much during sleep. There are procedures which can separately accomplish treatment for each of these. Tongue base advancement or suspension can be accomplished by the Repose procedure or genioglossus advancement. Alternatively, the tongue base can be surgically reduced in size by one of several minimally invasive transoral (through the mouth) approaches, and one of our physicians, Dr. Tod Huntley, is actively involved with using the da Vinci® robotic surgical system for such surgery.
- The epiglottis and hyoid bone. The epiglottis is the flipper which falls over the voicebox during swallowing to prevent aspiration. It is attached by a ligament to the hyoid bone, which is a horseshoe-shaped bone lying immediately above the Adam's apple. The epiglottis can sometimes contribute to airway obstruction in OSA and can either be surgically reduced in size or moved forward by moving the hyoid bone forward (hyoid advancement).
- The maxillofacial skeleton, or the upper and lower jaws, may need to be addressed. Maxillofacial surgery, sometimes referred to as maxillomandibular advancement (MMA), is surgery designed to enlarge the mouth and throat by lengthening the upper jaw (the maxilla) and the lower jaw (the mandible) surgically. This is the most aggressive surgery for OSA and can be extremely effective in the right setting. Its role is usually as a "clean-up hitter" after soft tissue surgery, but sometimes it has a role as initial therapy, particularly in cases with obvious growth or development problems with the jaws.
- Tracheostomy. This is the single most effective procedure for OSA but, for obvious reasons, is not done as frequently as other surgeries. It involves the creation of a breathing hole in the windpipe, or trachea, below the vocal cords. By definition, since this hole is below the levels of obstruction with OSA, the tracheostomy treats OSA by bypassing the obstruction rather than by correcting it. A trach can be performed as a stand-alone procedure or in conjunction with other the procedures listed above, depending upon the situation.
- Nasal surgery. Perhaps the most frequent surgery we do for OSA, nasal surgery generally can't correct the problem by itself, but is a very helpful adjunct with other procedures. Yet often it is the only surgery performed, as a way to improve CPAP tolerance. Commonly performed procedures include straightening the nasal septum (septoplasty), reducing the size of the inferior turbinates, or enlarging or tightening the internal nasal valves.
- Tonsillectomy and Adenoidectomy (T&A). This is by far the most common treatment for pediatric OSA and is usually all that is needed in such cases. A T&A is usually not sufficient for adults with OSA, however.
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