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Surgery for obstructive sleep apnea
I am an ENT surgeon practicing in So. CA for almost 20 yrs and have an interest the medical/surgical treatment of snoring and sleep apnea. When I was in my residency training program at Univ CA-Irvine in the late 70's, sleep apnea was only beginning to be widely recognized. There was no CPAP treatment at that time. Our only effective treatment then was tracheotomy which today is probably the still the gold standard to which other treatments must be measured. Most people will not accept this option of therapy. CPAP came along in the early 80's and gave OSA patients an effective and non-surgical treatment. Since then, CPAP in various forms has become the therapy of 1st choice. Now I hope not to insult any CPAP users that might read this, but most people do not their CPAP machines for the long term. Studies using microchips in the CPAP machines have shown a less than 50% compliance rate in CPAP usage. Many patients that I see will just stop using their machines after about 6-12 mos. Consequently, they are not being treated for a chronic disease and are at risk for serious medical problems. Surgery for sleep apnea has also had an interesting evolution. As I said before, tracheotomy was our 1st and only treatment 20 yrs ago. Uvulopalatopharyngoplasty(UPPP) was originated in Japan and came to be the procedure of choice in the early 80's.At that time, it was felt that most of the obstruction found in OSA pts was at the level of the soft palate. In about the mid-80's, it became apparent that the UPPP procedure alone was effective in less than 50% of the time in regard to eliminating OSA. Consequently, people still needed to use CPAP and the procedure by itself became questionable. The basic problem is that OSA is caused by obstruction at the level of the soft palate/tonsils AND the base of the tongue. Blockage in the nose contributes to a much lesser degree. These facts are still not recognized by many MDs and ENTs alike. So when I see people in this forum talking about getting just a UPPP to try cure their OSA, it takes me back 15 yrs to a time we thought we could cure OSA with only the UPPP. Unfortunately, many of these folks may end up being disappointed. The Stanford Univ. Sleep Surgical group(Drs. Robt. Riley and Nelson Powell) recognized this problem and developed new operative procedures to address obstruction at the base of tongue. At this time, they will recommend a UPPP and the genioglossus advancement procedure as their Phase 1 surgery. They are able to CURE OSA in 75% of their pts who have RDI's less than 60. Their follow-up sleep studies show RDI's now in the 5-15 range, levels that now are no longer a medical risk. The people who do not respond are usually overwgt,ie BMI greater than 33. The non-responders, or those with very high RDIs may either elect to continue CPAP or go on to Phase 2 surgery consisting of a maxillary and mandibular (upper and lower jaw) advancement. This a big operation but it is curative in 95% of their pts. I have seen postings from some people in this forum who have had some of these procedures done. Nasal obstruction is usually not a major contributor to OSA. Obstruction in the nose may require higher CPAP pressures to be used and will contribute to night-time mouth-breathing. Once the nasal obstruction is improved, CPAP pressures might be able to be lowered and breathing in general becomes less labored. An important point that must be mentioned here is that it is risky to perform nasal surgery at the same time as a UPPP,or a Phase 1 operation. The post-op swelling could precipitate a serious airway obstruction. So when I see postings from people in this forum discussing their upcoming UPPP-septoplasty, it makes me very nervous. Most of us who do OSA surgery will do these seperately to protect the airway. I also get the feeling that these folks think that their OSA will be cured but again in most cases, the OSA problem will persist because the base of tongue obstruction is not being addressed. Somnoplasty(radiofrequency thermal ablation) of the tongue base has been recently FDA-approved for treatment of tongue base obstruction.Ther is no published data in regard to its efficacy as yet. Stay tuned. The above information can be verified in the 12-98 issue of OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA. I hope this discussion is of help to those of you considering OSA surgery.
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