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Sleep Surgeon Question 51

Question 51 - The myth about sleep endoscopy.

From: L. E.

Hello Dr. Li:

I am a 49-year-old female. 5’6’’ tall and weigh 170 lbs. Use to weigh 140 but I have not exercised in about 4 years due to my severe sleep apnea. 74 apneas an hour when I sleep on my side and 96 an hour when I sleep on my back. On the 24th of this month an ENT is going to repair my deviated septum, trim or cut some turbinate’s and do a sleep endoscopy. Later he wants to do a UP3, remove my tonsils (they are small; atrophy?) A hyoid suspension and radio frequency on the back of my tongue.

Then the Maxillofacial Surgeon wants to do an upper palate expansion. Then braces to fix my bite and then a MMA/GA.

The ENT has said that my uvula is large but I did not ask him if I have an abundance of soft tissue; but I will. I am hoping for some relief from the soft tissue surgery. At least a little until I can have the MMA/GA.

Is an upper palate expansion a common procedure for someone my age? Is it painful since my bones have already fused? Will this help to increase my airway?

I live in the Houston, TX area. I will be at Methodist Hospital in Houston. My Maxillofacial is the dept. chair at Methodist. He recommended the ENT. Do you think they qualify?

Thank you so very much for your help.

L. E.

Response Provided by Dr. Kasey Li
Feb. 03, 2009

Obstructive sleep apnea syndrome is a complex problem with multiple risk factors. It is impossible to provide you with proper recommendations as I have not examined you. However, from the descriptions, I suspect that your major risk factors are small jaws, weight as well as being peri/post menopause. I am quite sure that you always had sleep apnea but like many women, the apnea worsened significantly in the perimenopausal/postmenopausal period. Although it is possible, soft tissue excess is not common in women and I suspect that you really do not have much "excess tissues". Looking at the severity of your sleep apnea, I will tell you that all of the surgery that your ENT is recommending will unlikely to improve you much. Your best chance is MMA, as you already know.

Many patients undergo presurgical orthodontia because their surgeons tell them that they have to do it and I suspect that it is your case as well. Clearly, it is the best thing to do in an ideal world. However, patients with severe sleep apnea do not have 12 months to wait. They are suffering greatly RIGHT NOW. It is possible to manage the jaw/bite in patients without orthodontia, or have orthodontia after surgery-when their sleep apnea is much improved.

Finally, more and more patients are asking me about SLEEP ENDOSCOPY. The only true sleep endoscopy is performed when the patient is asleep naturally and the airway is monitored with simultaneous sleep study to correlate airway obstruction during sleep. The airway obstructs differently during different sleep stages. As I mentioned above, sleep apnea is a complex process...

The sleep endoscopy that is being promoted today by many surgeons is simply an exam under artificial sleep-done in the operating room using a drug call Propofol. It does not represent sleep. The ratioinale is to try to find the site of obstruction, whether it is palate, tongue or palate/tongue. The issue is this-WHAT ARE YOU GOING TO DO WITH THE INFORMATION? It is simply an academic exercise that puts patients through a process unnecessarily. Take your case for example, your surgeon finds that only your palate obstructs (which is impossible). Is he only going to recommend UPPP/tonsillectomy? Here is the bottom line. SLEEP ENDOSCOPY DOES NOT CHANGE THE TREATMENT PLAN! Therefore, why are you going through this process if the information that is gathered will not influence the treatment plan?

I know I have probably given you more questions than answers. Again, since I have not examined you, I can not be sure that my assumptions about you is true. This is the best that I can do under the circumstance. If you have questions, please speak with your surgeons about it.

Best of luck,

KKL