Choosing Surgery

Choosing Surgery to Treat Sleep Apnea

Snoring had become a normal part of your sleep. It never bothered you much, but it drove other people in your house crazy. What did bother you was feeling tired all the time. You also began to get bad headaches in the morning. To make matters worse, your bed partner told you that you stop breathing and move around a lot in your sleep. You began to think that something really might be wrong. After putting it off for years, you finally decided to talk to your doctor. Your doctor was also concerned and referred you to a sleep center.

At the center, a sleep specialist went over your complete medical history and recorded all of your sleep complaints. You went back a second time and did an overnight sleep study. The doctor called it a polysomnogram. The study showed that your bed partner was right. You do stop breathing during sleep due to a blockage of your airway. These pauses in breathing happen to you over 100 times each night. The doctor said that you have obstructive sleep apnea. In a way you are relieved. It is a comfort to know what has been causing you to feel so tired all the time. At the same time, you may be a little scared. This all sounds a lot more serious than you expected. You're also faced with one big question: What do you do now?

Consider non-surgical options first

Your sleep specialist will present a number of options to you. At the top of the list may be a need for you to lose weight. Excess weight builds fat deposits around your throat. This can narrow the size of your airway. As you fall into deep sleep, your muscles relax. The tissue in the back of your throat collapses and blocks the airway. As a result, you are unable to breathe normally.

Your sleep doctor may also tell you to try changing your sleeping position. Sleep related breathing problems are most common when you sleep on your back. Gravity can cause your tongue to fall back and block your airway. You can try using a sleep positioning device. This will help you stay off your back and sleep on your side instead.

You should also limit the use of alcohol and some medications at night. They can slow your breathing and relax your muscles even more. This will only make your sleep apnea worse. Allergies and other sinus problems can block the flow of air in your nose. This can make it hard for you to breathe. Topical nasal sprays and oral medications may help treat these problems. Using them may open your airway back up.

All of these tips are helpful. But you and your doctor may decide that they are not enough. Your sleep apnea may be too severe for these tips to solve your problem. In this case, other options will need to be explored. One such option is to visit a dentist. A dentist can fit you with an oral appliance to wear when you sleep. This is very much like a sports mouth guard. It helps move your jaw and tongue forward, away from the back of your throat. This may help keep your airway open while you sleep. It would also allow you to sleep in any position you like.

The most common option for sleep apnea is to use positive airway pressure (PAP). A small, quiet machine sits next to your bed. It blows a steady stream of air into a mask that you wear over your nose. This stream of air keeps your airway open and keeps you from snoring. While there are three types of PAP, the most common one uses a level of air pressure that is continuous (CPAP). The level of pressure that you need is determined during a CPAP study. The unit is small enough to take with you when you travel. It needs to be used whenever you go to sleep. It is a very effective treatment for many people with sleep apnea.

The surgical option

An oral appliance or PAP may not work for some people with sleep apnea. Often, the sleep apnea may be due to a structural problem in your face, nose, jaw, or throat. You may find that surgery is the best option for you. It may also be done along with the use of other treatments. Your sleep specialist can refer you to an ear, nose and throat doctor (ENT). These doctors are also called otolaryngologists. They are head and neck surgeons. The ENT will evaluate you for possible surgical treatment. A small scope may be inserted through the nose to find the area of closure or narrowing. This spot is often in the nose, in the throat, or at the base of the tongue. Narrowing can also occur in more than one place. An MRI, CT scan or x-ray may also be used to evaluate you. Finding the point of obstruction is very important. This will determine what kind of surgery you may need.

Your surgeon will discuss the exam results with you. Together you will decide on the best option. It may be a quick procedure that can be done in the doctor's office. Other options may require you to go to a hospital. You may even need to stay in the hospital overnight. This depends on the type of surgery performed. In some cases, you may be monitored in the intensive care unit. This is to assure that your airway stays open after the surgery. They need to make sure that you are able to breathe well on your own.

The most common surgical treatments for obstructive sleep apnea focus on one of the three following areas:

Nose

A number of options exist to help open up the breathing passage in your nose. One procedure is called radiofrequency ablation. It is done in your doctor's office. This uses microwaves to scar the tissue inside your nose. This shrinks the tissue down. As a result, it opens up your nose for airflow. A chemical solution can also be injected in the nose. This too will scar and shrink the tissue. This chemical is called a sclerosing solution. It keeps the tissue from expanding and contracting so much.

A bent septum may be the cause of your breathing problem. The septum is the bony divider between the two nostrils. If it is bent, it may keep air from flowing freely through the nostrils. It can be reshaped so that it is in the middle of the nose. This surgery is called a septoplasty. It is done on an outpatient basis. Another process is called turbinate reduction. It reduces or removes large turbinates and polyps that block your nose. Turbinates are curved bones along the wall of the nasal passage. Polyps are growths of tissue that stick out from the mucous lining of the nose. Opening the nasal passage helps you to have normal airflow. This is a benefit both when you are asleep and awake. It can also help improve how well CPAP therapy works.

Throat

Large tonsils may play a role in blocking your throat. The tonsils are a pair of small masses of tissue located on each side of the wall between your mouth and throat. Simply removing them may help cure your breathing problems. This is a very common way to treat obstructive sleep apnea in children. At times it is also used for adults. Another problem area may be the soft palate and uvula. The uvula is a long mass of tissue that hangs down from the palate in the back of the throat. A floppy uvula and palate can vibrate when you breathe. This can lead to loud snoring. Removing or reducing this tissue can help limit snoring. This may not have any effect on sleep apnea.

Other common procedures can be used either for snoring or for sleep apnea. As in the nose, radiofrequency ablation can also be used on the throat. Microwaves scar and shrink the tissue of the palate and uvula. This can also be done by injecting sclerosing solutions. Small implants may also be used to stiffen the palate. These options can be taken care of in the office. Another surgery that can be done in the office uses a laser. It is called a laser assisted uvulopalatoplasty (LAUP). Part or all of the uvula and some tissues of the soft palate are removed using a laser. This stiffens the tissue of the palate that remains. It can be mildly effective for treating sleep apnea.

An uvulopalatopharyngoplasty is performed at a hospital. It trims down the size of the soft palate. The tonsils and uvula may also be removed. This reduces sleep apnea when the area around the palate is the source of the problem.

Tongue

Your problem may lie at the area deep in your throat at the base of your tongue. Again, radiofrequency ablation may be used. Microwaves shrink the tissues at the back of the tongue. This brings them off the back of the throat. As a result, the airway is opened. This often requires several treatments over a period of time. After each treatment, a few weeks are needed for the scars on the tongue to heal.

Other surgeries take place in a hospital. The most common of these is an option called a genioglossis muscle advancement procedure with hyoid myotomy. It shortens the muscles that attach your lower jaw to your tongue. This pulls your tongue forward from the back of your throat. Your hyoid bone is also moved forward. This is a u-shaped bone at the base of the tongue in the back of the neck. It supports the tongue muscles.

Another option is to remove extra tissue from the base of the tongue. This can be done with a laser.

Combined Procedures

Some people will benefit from more than one type of surgical procedure. For example, nasal surgery may be done along with palate or tongue surgery. In this case, the septum might be straightened first. The uvula and soft palate might then be trimmed. The tonsils may also be removed. In addition, the tongue might be moved forward. All of this still may not solve the problem.

Then another step can be taken through surgery. This procedure is called maxillomandibular advancement. You will need to stay in a hospital to have this done. It pulls both your upper jaw (maxilla) and your lower jaw (mandible) forward. This pulls your tongue, palate, and lower jaw off the back of your throat. The entire airway is opened. Small stainless steel plates hold the upper and lower jawbones in their new positions. As a result, your jaws may be wired shut for several weeks. This combination of surgeries may be an effective treatment for obstructive sleep apnea.

Other Surgical Therapies

There are also a couple of other surgeries to consider for treating sleep apnea. One is weight loss surgery. This is also called bariatric surgery. This may help if you are morbidly obese. This means that you are about 100-125 pounds or more over your ideal body weight. Losing a large amount of excess weight can help open up your airway. Talk to your doctor first to see if this might be a good choice for you.

Another surgery is a permanent tracheotomy. A small opening is made in the windpipe in the lower part of the neck. A special type of tube is inserted to keep the hole open at night. You breathe through this hole as you sleep. This bypasses the entire upper airway. Your breathing is not obstructed. The small opening and tube can be capped or closed when you are awake. This allows daytime breathing and speech to be normal. This method can be 100% effective in treating obstructive sleep apnea. But this is also the most drastic option. It is only considered as a last resort.

Conclusion

It is crucial that you talk openly with your doctor and sleep specialist about these procedures. Make sure that you understand the risks and benefits of each surgery. Do not make a hasty decision before you know what all of your options are. Realize that almost no surgery comes with a 100% guarantee. For each surgery there is a chance that it will not work. Even if it does work at first, it may still be less effective over time. But for some people, surgery is the best option to treat obstructive sleep apnea. It may be done alone, or along with another treatment. This can greatly reduce the symptoms of sleep apnea. Just make sure that surgery is the best option for you.

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