Surgical Options For Addressing OSA

Yesterday I had a sleep endoscopy performed to determine if I could qualify for the Upper Airway Stimulation (UAS) Therapy offered by Inspire Medical Systems, Inc. In addition to providing the qualification data, the procedure also provides information regarding whether the blockage of my breathing is primarily at the palate and/or tongue regions and to determine which specific structures seem to be playing a major role in my airway obstruction.

UAS Therapy represents a option for a subset of patients with moderate to severe Obstructive Sleep Apnea (OSA) who are unable to use CPAP. The UAS Therapy is a fully implanted system consisting of a small generator, a sensing lead & a stimulation lead. The single external component is a small handheld remote used to turn the system on before bed and off upon waking. Once activated, the system senses breathing patterns & delivers mild stimulation to key airway muscles, which keep the airway open during sleep. If successful, this therapy avoids the removal or permanent alteration of facial or airway anatomy.

One of the key qualifications to becoming a candidate for UAS Therapy involves a complete concentric collapse of the soft palate when the patient is in a sleep-like state. And that is what they were looking for during my sleep endoscopy yesterday. Unfortunately, during my procedure my surgeon observed a lateral wall collapse in addition to anteroposterior collapse of the soft palate, which disqualified me for UAS Therapy.

So, where does that leave me? Well, the next step is to consider additional surgical options which involve the alignment of the bones & tissue in the jaw, mouth & throat. The most common surgical options rearrange, reduce, or totally remove the tissue in the throat that is blocking your airway while you sleep. This tissue can be in the soft palate, which is at the back of the roof of your mouth; the uvula, your tonsils & adenoids, or your tongue. There are also surgeries that correct the alignment of the bones in the mouth, nose & face.

I'd like to hear from anyone who has had any of these types of surgeries & what their experience was like. Does anyone know what kind of success rates these types of surgeries usually yield? What are the risks involved when having these types of surgeries? I have an appointment with my ENT who performed my sleep endoscopy on May 24 and I'd love to have some data on hand when I speak to him about my options. Thanks in advance for any information anyone can provide me.

There has not been much discussion of in-depth surgical issues on this board since I have been here. It may be difficult to find others in the the same or similar position you are so I would listen carefully to what the ENT recommends and ask him if he minded you getting a second opinion. If the two doctors have radically different opinions on treatment options, based on what you can read and elicit through self-education, you may be able to wade through the information to be able to make the best decision possible. Take care going to other sleep apnea boards as there are some where everyone seems to grant themselves amateur medical degrees and this type advice is almost worse than none at all. Good luck and I hope this works out for you.

I am a dentist working in dental sleep medicine. Before considering surgery, it might make sense to consider an oral sleep apnea appliance. Now, I know that there is an old wives tale that oral appliances can not be used with severe sleep apnea, but in many cases that is just wrong. The TAP family of appliances is generally recognized as the most effective for severe sleep apnea. They will do a very good job for about 54% of the patients and at least a minimally acceptable job for about 70%, so there is a fairly good shot at it. I have actually done successful oral appliances for a fairly large number of severe sleep apnea patients. Dr. Luisi

Hi again GBerger, The online boil and bite appliances are meant only to treat snoring and (maybe) the lowest end OSA. Your condition is far too severe for them to give you meaningful relief. The fact that you got even a brief positive response is encouraging. I think that you might benefit from trying a MyTAP device from Airway Management. It is highly effective against severe OSA and relatively inexpensive. I am talking about somewhere between $400 to $650 dollars. It has to be fitted and managed by a dentist trained in dental sleep medicine. If you use the "Find-A-Dentist" feature on their website, www.tapintosleep.com, you should able to find a suitable dentist near you. The device is not particularly strong and would probably last only one year or at most two, but it is good enough so that you could find out if an oral sleep apnea appliance could work for you. Dr. Luisi

GBerger: It is important to understand the cause of your obstructive sleep apnea and why UAS is not indicated. Complete collapse of your palatal tissues and tongue obstruction are primarily caused by their position in the back of the throat causing blockage of your nasal and oral airway. Why does this occur is the primary question that is facing the medical and dental profession. The answer truly lies in the growth of our upper and lower jaws. If you look at the anthropologic research that studies ancient skulls, you will see that in past generations for the most part all of the human remains that the teeth are perfectly straight and the wisdom teeth are erupted. Additionally, they had very wide dental arches and wide palates. Why is this important? There jaws were significantly more developed anatomically than most humans today. There are many theories as the cause and effect of this epigenetic transformation, but the modernization of agriculture and softening of the diet especially in children from birth to 5 years old seems to play a role. Therefore, compared to ancient man, the upper and lower jaws are believed to be somewhere between 5-12mm underdeveloped in a forward growth direction in modern man and women. This causes a smaller oral and nasal cavity, thus putting the palate and tongue further back in the airway and causing the obstruction. All standard accepted treatments are geared at opening the airway, but unless you treat the underlying cause in most cases, all treatments are symptom relievers and not curing the underlying causes. Therefore, if your posterior pharyngeal airway space is significantly decreased and is causing the obstruction, then jaw advancement surgery may be indicated. We call this surgery CPAP Surgery, and has very proven and stable track record. The surgery involves a careful analysis of your airway, jaw position, dental health, and systemic health. The surgical results are immediate, and we are seeing very good results with our patients eliminating the need for CPAP machines and appliances.

Dr. Scotty Bolding Sleep Surgeon Integrativedentalspecialists.com

All I will say is that after more than 15 years of performing sleep studies and seeing the results of many surgical procedures, the best result I've seen is one patient who about a 50% reduction in the severity of their sleep apnoea (from staggeringly bad to just bad). In every other case it either did nothing or made it worse. Also there is the question of the long recovery and high rate of post-operative infection. Every doctor I know would never recommend it, and every patient I've met who had surgery told me it was hellish and they would never do it again. Make your own judgement, but I suggest you approach with care.

I am not a surgeon, just a technician who sees the results and deal with the patients afterward.

My sleep medicine physician, who is also a surgeon, has told me exactly what sleep tech has shared here (above) about surgical approaches to sleep apnea.