Sleep Apnea San Antonio | Sleep Surgery San Antonio
Sleep apnea surgery is a CPAP alternative for patients failing to tolerate CPAP. Obstructive sleep apnea (OSA) currently affects over 13 million people in the United States. San Antonio Otolaryngologist and Facial Plastic Surgeon Dr. Jose Barrera, MD cares for patients suffering from sleep apnea and snoring. Dr. Jose Barrera is fellowship trained in Sleep Surgery and Facial Plastic and Reconstructive Surgery from Stanford University and is triple board certified having received certifications from the American Board of Otolaryngology-Head and Neck Surgery, subspecialty certification in Sleep Medicine, and the American Board of Facial Plastic and Reconstructive Surgery.
Obstructive Sleep Apnea
OSA is a condition whereby the individual experiences a collapsed airway while asleep leading to arousals or awakenings, sleep fragmentation and sleep deprivation. This results in excessive daytime sleepiness.
OSA is a serious condition that can be associated with:
Obesity, Hypertension, Diabetes, Heart Attack, Arrhythmia, Stroke, Pulmonary Disease, Motor Vehicle Accident, Depression, and Decreased Survival.
Loud snoring is very often associated with OSA. A sleep study may be necessary to rule out OSA. Once OSA is ruled out, snoring can be treated with in-office procedures. Snoring is often caused by:
It is estimated that 45 percent of all adults snore occasionally, and 25 percent habitually snore. Snoring is more common in males and people who are overweight. Snoring is obstructed breathing. In addition to disturbed sleep patterns and sleep deprivation, other serious health problems may result. Treatment options include:
• Radio-frequency to the palate, tongue, or nasal turbinates
• Palate operation
• Pillar procedure
• Functional septorhinoplasty
Treatment Options for OSA
There are several treatment options for OSA including: Positional therapy, weight loss, oral appliances, continuous positive airway pressure (CPAP), and sleep apnea surgery to improve snoring and treat OSA (Drug Induced Sleep Endoscopy, DISE, can assist the surgeon in determining the site of airway obstruction). CPAP alternative treatments include sleep surgery or airway reconstruction and nasal reconstruction which includes septoplasty, turbinate reduction, and nasal valve stenosis repair or functional rhinoplasty.
Nasal obstruction can be treated with antihistamines, nasal steroids, saline irrigation, and external nasal dilators such as the Breathe Right® nasal strips.
When medical treatment alone isn’t successful, sleep apnea surgery can improve the nasal airway. The most common nasal procedures include: Correction of septal deviations (septoplasty), and turbinate reduction. Sometimes correction of nasal valve stenosis is necessary to achieve improvement in the internal, intervalve, or external valve area. Sinus surgery may be necessary and can be combined with other nasal surgery.
These procedures aim to increase the potency of the nose to improve breathing. It may also decrease snoring and increase tolerance to CPAP.
The nasal valve (external, intervalve, and internal components), have been described anatomically as the cross-sectional area of the nasal cavity with the greatest overall resistance to airflow. It acts as the dominant determinant for nasal inspiration. Functional rhinoplasty or nose job surgery may consist of septoplasty (alignment of the septal cartilage), turbinate reduction and outfracture surgery, and/or nasal valve repair to improve internal and external nasal valve incompentance. Dr. Jose Barrera, MD recenty published his work on quantifying changes in nasal tip support in JAMA Facial Plastic Surgery journal. You can review Dr. Barrera’s research publications here on several topics related to sleep surgery including rhinoplasty, tongue base radiofrequency, genioglossus advancement, Sleep MRI and diagnostics, and maxillomandibular advancement (MMA) surgery for obstructivev sleep apnea.
Functional rhinoplasty is indicated to relieve nasal valve obstruction. Cosmetic procedures can be combined with functional rhinoplasty.
Many children suffer from OSA and its associated co-morbidities such as obesity, ADHD, depression, high blood pressure, diabetes, and cardiovascular disease.
The mainstay of surgical therapy is adenotonsillectomy. There are surgical variations. We combine removing the tonsils and adenoids with a lateral pharyngoplasty, accepted as strengthening and rearranging the pharynx instead of excessive tissue removal.
A floppy, elongated or thick soft palate and uvula can be responsible for the noise heard when snoring or the obstruction occurring during OSA.
Palate surgery or uvulopalatopharyngoplasty includes different techniques that consist of removing and/or repositioning the redundant tissues in order to open the posterior airway space. Palate surgery is usually very effective for snoring and obstructive sleep apnea caused by a floppy soft palate. A uvulopalatopharyngoplasty, UPPP, uvulopalatal flap, UPF, and palatal advancement surgery are performed by Dr. Jose Barrera, MD depending on the site of airway obstruction, soft palate anatomy, and OSA severity.
Radiofrequency is a form of energy that is delivered to tissues to cause stiffening and reduction of their volume. Radiofrequency can be used to:
• Shrink the nasal turbinates
• Tighten the soft palate
• Shrink the tongue base
Radiofrequency is used for patients with simple snoring, nasal obstruction and/or as an ancillary procedure for OSA.
The genioglossus muscle is the primary muscle holding the tongue in position. It attaches to the internal aspect of the lower jaw.
Genioglossus muscle advancement or GTA (geniotubercle advancement) is designed to place the base of tongue on tension to open the posterior airway space.
A rectangular cut is made in the lower jaw and the bony-muscle attachment is moved forward, which tightens the base of tongue.
Holding the base of tongue in a more forward position improves snoring and sleep apnea. Learn more about Maxillofacial Surgery for OSA.
Obstruction in the area behind the tongue plays an important role in OSA. This region is known as the hypopharynx.
Better outcomes are achieved by surgically targeting this area. Surgical procedures can be designed to make the tongue firmer and less collapsible during sleep, or can be used to remove tongue tissue such as the lingual tonsils.
Midline partial glossectomy is an effective surgical modality for the treatment of select pediatric and adult patients with mild to severe obstructive sleep apnea with significant macroglossia (large tongue).
Midline partial glossectomy can either be performed as a stand-alone procedure or as part of multi-level pharyngeal surgery.
The hyoid is a U-shaped bone that lies just above the voicebox. The hyoid is attached to the voicebox and the tongue by muscular attachments.
Hyoid suspension brings the hyoid forward. Advancing the hyoid will generally allow opening of the posterior airway space.
This can be used as a primary treatment, but usually as an adjunctive procedure.
Maxillomandibular Advancement (MMA)
MMA is performed to widen the entire upper airway space and minimize pharyngeal wall collapse. MMA consists of mobilization of the maxilla and mandible, as a unit, to maintain the existing teeth occlusion. The upper and lower jaws will generally be advanced 10-14 mm. Of all the sleep apnea surgeries, MMA offers the highest success rate, over 90% success in improving the apnea hypopnea index and resolving excessive daytime sleepiness. Learn more at Maxillomandibular Advancement.