Severe Snorers with Obstructive Sleep Apnea
Patients with proven obstructive sleep apnea are considered to have a “medically-significant” condition that is, therefore, covered by medical insurance. Treatment for sleep apnea needs to be individualized for the patient as there exist several options. Optimal results are achieved through a cooperative effort between a sleep medicine physician, a dentist sub-specialized in treatment of apnea and a surgeon working along with a well-informed patient. The first-line recommended medical treatment is Continuous Positive Airway Pressure (CPAP), along with various mask modifications that are available to increase patient comfort and compliance with treatment. Nasal CPAP with humidification is an excellent modality for patients with moderate to severe sleep apnea as CPAP splays the airway in the open position and thus overcomes the sites of obstruction. However, a major shortcoming of CPAP is its poor tolerance by many patients who remove the mask in the middle of the night and thus remain in untreated for the remainder of the night. It is not surprising that following an adequate trial of CPAP, many patients with mild-to-moderate sleep apnea decide to trade in the CPAP machine and look for alternative treatments.
In Dr. Zemplenyi’s experience, jaw-advancing dental appliances ameliorate sleep apnea and snoring, but again some patients do not tolerate having a device in their mouth the entire night. Over longer periods of time some patients using dental appliances develop discomfort in the temporo-mandibular joints as well as problems with their dental occlusion. Nevertheless, both dental appliances and CPAP are well acceptable for many patients and are worthwhile modalities to try first. In addition, medications such as Modafinil to treat the daytime sleepiness as well as several other sleeping aid medications may improve sleep and quality of life in patients with sleep apnea.
Eventually, many patients become interested in a surgical solution. Surgery for obstructive sleep apnea plays a significant role in two categories: 1. Surgery for relief of nasal obstruction designed to facilitate the usage of CPAP and dental appliances; and 2. Surgery designed to salvage patients from usage of CPAP. Please also see our for Nasal Surgery page.
Much misinformation exists about surgical solutions for sleep apnea as the “success” of surgery is often being misquoted as less than 50 percent. The problem with this statistics is that it refers only to success of uvulo-palato-pharyngoplasty (UVPP) when performed on patients who have NOT been further stratified according to their weight, height and especially pertinent anatomy. In fact, the success of surgical treatment depends on the severity of sleep apnea and the involved anatomy.
Dr. Zemplenyi has achieved very satisfactory surgical results for many patients using UVPP with or without a tonsillectomy and along with current conservative modifications such as a palatal flap as long as their anatomy was favorable to treatment of excess tissue of the soft palate and uvula (retro-palatal site of obstruction). However, many patients obstruct at the level of the base of the tongue (retro-lingual site of obstruction). For these patients UVPP is predictably not a sufficient solution. Other surgical procedures that address the base of the tongue include a volumetric reduction of the soft tissues of the tongue using radiofrequency or plasma coblation and procedures designed to move the base of the tongue forward such as genioglossus advancement and hyoid advancement.
Currently Dr. Zemplenyi prefers ReposeTM suture suspension system for advancement of these tissues as it is less invasive and better tolerated than the more traditional “keyhole” mandibular osteotomy. Patients who have a small mandible (lower jaw) or have mal-positioned upper and lower jaws benefit greatly from orthognathic surgery designed to address these maladies. In fact, advancement of both of the jaws (maxillary/mandibular advancement) performed by an oral/maxillofacial dental surgeon provides an excellent avenue for treatment of obstructive sleep apnea. However, Dr. Zemplenyi finds that many patients reject having jaw cutting procedures because of their invasive nature, long preparatory treatment by an orthodontist and the high cost of these procedures.
With some exceptions, many insurance companies provide only partial or no medical coverage for orthognathic procedures. Tracheostomy, as a procedure that bypasses the entire upper respiratory tract, is 100% curative for obstructive sleep apnea, but it is nowadays reserved only for patients with a very severe condition that are usually awaiting the results of the other surgeries as above. As many patient with obstructive sleep apnea are severely obese (body/mass index greater than 40) Dr. Zemplenyi recommends a consideration of bariatric surgery such as a gastric banding or bypass for treatment in these situations.