Snoring and Sleep Apnea Treatment
- 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. Also see:
- Overview of Snoring and Sleep Apnea Procedures
- Sleep Apnea - Comprehensive
Evaluation
- Snorers without
Significant Sleep Apnea |
