Does your spouse or bed partner keep you up at night with snoring and sleep apnea San Antonio?
Snoring and sleep apnea can be diagnosed and treated with sleep endoscopy and surgery targeting the site of airway obstruction.
Snoring and Sleep Apnea Surgery helps to correct nasal and airway obstruction. Causes of obstruction include nasal deviations or narrowing, soft palate redundancy, a large tongue, or a small airway.
WHAT IS OBSTRUCTIVE SLEEP APNEA?
Snoring and sleep apnea are part of a spectrum of syndromes called sleep disordered breathing. This syndrome is comprised of snoring, upper airway resistance syndrome (UARS), and obstructive sleep apnea (OSA). OSA is a syndrome not a disease and the specific etiology is unknown. However, it is largely secondary to anatomic upper airway narrowing during sleep and a yet unidentified central nervous system (CNS) component. Obstructive sleep apnea syndrome consists of periods of apneas (cessation of airflow at the nose or mouth for > 10 seconds) and hypopneas (reduced respiration with desaturation terminated by arousal). In general, OSA can be defined by the number of apneas and hypopneas per hour or apnea-hypopnea index (AHI). Mild OSA is defined as an AHI > 5 and < 15 but with symptoms of sleepiness. Moderate OSA is an AHI > 15, < 30 and severe OSA is an AHI > 30. The prevalence of OSA was reported in an epidemiologic study to be 24% in males and 9% in females by attended polysomogram. Most patients fail to be diagnosed; in fact, 93% of females and 82% of males with moderate to severe OSA have not been identified.
The profound effects of SDB upon the cardiovascular, respiratory systems and neuro-cognitive function have been documented. The Sleep Heart Health Study and the Wisconsin Sleep Cohort have demonstrated a strong association between SDB and hypertension. Other risk factors associated with SDB include heart failure, stroke, motor vehicle accidents, excessive daytime sleepiness, depression and obesity.
HOW DO WE EVALUATE PATIENTS?
A complete history should be taken from the patient. It can be broken into behavioral quality of life issues and physiologic derangement. Patients with OSA suffer from quality of life issues including nighttime complaints of snoring, unusual movement, insomnia, hypersomnia, and sexual dysfunction. In addition, daytime dysfunction including sleepiness, morning headache, learning and memory problems, and depression are common.
Patients with OSA most often complain of excessive daytime sleepiness (EDS). The patients may experience serious social, economic, and emotional problems from
the EDS associated with this syndrome. The uncontrollable desire to sleep may predispose the patients to safety sensitive occupational or automobile accidents.
IS SNORING AN INDICATION OF A SERIOUS PROBLEM?
Almost all patients or their bed partners give a chronic history of heavy, loud snoring. The snoring is produced from the passage of air through the oropharynx causing vibrations of the soft palate. Typically the snoring is interrupted by periodic apneic episodes that may last 30 to 90 seconds. A loud snort followed by a hyperventilation usually signals an end to the apneic episode.
WHAT ARE MORNING HEADACHES AN INDICATION OF?
Morning headaches and nausea result from unexpelled carbon dioxide (hypercarbia) which develops obstructive episodes during snoring and sleep apnea.
DID YOU KNOW THAT YOU CAN DEVELOP HIGH BLOOD PRESSURE AND CARDIAC PROBLEMS FROM SLEEP APNEA?
Pathophysiologic abnormalities include systemic hypertension that is a common finding in OSA and may be related to abnormal sympathetic tone during sleep. In more severe cases, pulmonary hypertension, polycythemia, and cor pulmonale may develop and become life threatening.
Sinus dysrhythmia is commonly associated with the apneic episodes. Bradycardia may be directly proportional to the severity of oxygen desaturation. The development of severe and life-threatening medical complications from the apneic events clearly depends on the frequency, duration, and degree of hypoxemia and associated hypertensive response.
These procedures require a sleep study for evaluation and an evaluation of the airway in clinic.
A contemporary two-phase surgical approach for OSAS treatment has been developed to limit over operating and to decrease risks of surgery. It is important to note that if this phased protocol is used the patient and referring physician must understand that both phases may be necessary. The protocol was not intended to be a single phase protocol. A polysomnogram is necessary after phase one (3-6 months). If the patient is controlled no further treatment is needed. If incompletely treated then phase two is appropriate.
The first phase is the most conservative approach and addresses palatal and tongue base obstruction without movement of the jaw or teeth. Learn more at Sleep Surgery at Texas Center for Facial Plastic and Laser Surgery. It should be emphasized that improved surgical success is dependent upon optimizing the soft-tissue or primarily phase I protocol prior to beginning phase II.
Patients who have had incomplete response or failed to respond to phase I intervention may be considered for a phase II operation or maxillomandibular advancement (MMA). The MMA advances the midface and provides more room for the tongue. Additionally, the saggital split osteotomy of the mandible places additional tension on the tongue-hyoid complex.
Combined advancement of the maxilla and mandible is the most recent and efficacious surgical procedure for the treatment of obstructive sleep apnea. The surgical technique includes a standard Le Fort I osteotomy in combination with a mandibular sagittal split osteotomy. A concomitant Genioglossus advancement as previously described, is an adjunct and recommended to improve tongue advancement. MMA surgery may result in some facial change, which is most often favorable. However, the patient must be made aware of the possibility of any unfavorable aesthetic outcomes that may occur from this surgical procedure.
Nasal Reconstruction or Functional Rhinoplasty
Palate surgery (UPPP or uvulopalatal flap)
Genioglossus advancement (GTA)
Tongue base radiofrequency
Re-Evaluate at 4 to 6 Months
For incomplete treatment of phase one
Maxillomandibular Advancement (MMA) or
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.