Sleep Apnea Surgery

Tired of CPAP? Heavy snoring? Always tired? Can’t get good sleep? Below is useful information about the effective option for sleep apnea surgery in Denver, CO as a form of reconstructive surgery performed by leading oral/maxillofacial surgeon, Randolph C. Robinson, MD, DDS, FAACS:

Obstructive sleep apnea (OSA) affects 18 million people in the United States. It is estimated that 40 million have a chronic sleep disorder. OSA causes daytime sleepiness, difficulty concentrating, and depression.

Long-term, it can lead to heart disease, obesity, and endocrine (glandular) system disorders. Many relationships suffer from snoring and sleep apnea because they keep the patient’s partner awake.

Now there’s a permanent solution for obstructive sleep apnea. Contact our office to schedule a consultation to discuss your options for sleep apnea surgery at Robinson Cosmetic Surgery.

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About Obstructive Sleep Apnea

The diagnosis is based on polysomnography (PSG) or sleep study. It is performed at a sleep lab or sleep clinic at night. The test monitors the heart rate and rhythm (EKG), brain waves (EEG), breathing rate, chest movements, eye movements (EOG), nasal airflow, blood oxygen concentration, blood carbon dioxide concentration, and leg muscle moments (EMG).

There are home systems for diagnosing and monitoring the patient’s condition that are becoming more advanced. The advantage of a home system is that the patient is in his/her normal sleeping environment. The disadvantage is that there is not a technician or as many monitors to gather as many points of data. Many patients have trouble sleeping in the sleep lab or clinic which can make the test less valid.

The main feature of the PSG is that it can document the effort to take in air with the chest movement monitor, but shows that there is obstruction because no air movement is recorded at the same time. These obstruction episodes are broken down into two categories:

• hypopneas (under breathings)
• apneas (no breathings)

For standardization, hypopnea obstructions last less than 10 seconds and apnea obstructions last more than 10 seconds.

The apneas and hypopneas are recorded and then reported as the number of events (apneas and hypopneas) in an hour. This number is called the Apnea Hypopnea Index (AHI). The presence and level of OSA is classified based on the AHI:

• 5—15 events/hour = mild
• 15—30 events/hour = moderate
• > 30 events/hour = severe

There is a correlation to the level and severity of the OSA and the symptoms and systemic medical effects.

Patient Frustrations with CPAP and DSA

The most common treatment for OSA is the use of a device which provides continuous positive airway pressure (CPAP) in the back of the throat. The device uses a mask that fits over the nose and mouth and is attached to a machine which provides the pressure. The pressures in the airway keep it from collapsing and are titrated (quantified in increments) during the sleep study.

Most patients do better on CPAP protocols and have more energy during the day. The majority of patients, however, cannot wear their CPAP masks and continue to risk their lives because of the deleterious (harmful) effects of obstructive sleep apnea.

Another treatment is a Dental Sleep Appliance (DSA) which positions the lower jaw forward. It is most effective in decreasing snoring and there are a variety styles available. DSAs should be placed and monitored by dentists who have experience in sleep medicine. The patient should have a PSG done to make sure that the treatment for snoring is not ignoring a true OSA problem.

The Sleep Apnea Surgery Procedure

For individuals who aren’t receiving adequate relief from dental appliances or CPAP machines, sleep apnea surgery can be both a more effective and permanent solution. There are multiple operations used for treating sleep apnea.

These surgeries are grouped according to the anatomical areas of the airway they treat. Some operations address the:

1. nasal area
2. back of the throat and palate
3. base of the tongue

The nasal area surgeries include the septoplasty (straightening the nasal septum) and the turbinectomy (removal of turbinates). The septum divides the right and left nasal passages. It can be deviated, or off-center, so that it decreases the airflow through the nose. The turbinates are torpedo-shaped small bones on either side of the lateral nasal wall and are covered with erectile tissue. They will swell and shrink to control humidification, warming, filtration, and creation of turbulance/resistance during nasal breathing. There are three levels of right and left turbinates: inferior, middle, and superior.

The turbinates can become enlarged over time so that the flow of air is decreased in the nose. Nasal obstruction can lead to sinus infections because it can prevent the proper drainage of the sinuses. The combination of a septal deviation and turbinate enlargement (turbinate hypertrophy) requires treatment to straighten the septum and reduce the size of the turbinates.

The entire turbinate should not be removed since it can lead to ‘dry (or empty) nose syndrome’ causing dryness, inflammation, and pain of the nasal mucosa. The muscosa should also be protected; important for proper nasal function. Multiple sinus infections during a year can be caused by nasal obstructive problems apart from sleep apnea issues. Most of the time, opening the nasal passage is not effective in reducing the AHI but traditional protocols require it before moving down the airway.

Your Surgery Options

The two surgical options for addressing issues with the back of the throat include:

1. shortening the soft palate, which is called a uvulo-palato-pharyngo-plasty (UPPP)
2. a tonsillectomy and adenoidectomy (T&A)

The UPPP can be effective against snoring but it is not as effective for improving sleep apnea as initially thought. Both the UPPP and T&A are painful, although both are usually part of the typical so-called Stanford Protocol (or more of Genioglossus Advancement or Hyoid Suspension). The Second Phase of the operation involves maxillomandibular advancement.

The most common location of obstruction in the airway in cases of obstructive sleep apnea is the base of the tongue. This area is treated by:

1. chin button advancement
2. tongue reduction
3. hyoid bone suspension

The chin button advancement is performed by drilling a button of bone from the front of the chin and pulling it forward to pull the tongue muscles forward. The amount of the advancement is limited to the thickness of the chin bone.

The tongue reduction can be effective, but must be considerable enough and far enough back on the tongue to be effective. The hyoid bone advancement involves looping threads of suture around the bone below the jaw and above the trachea (airway). By pulling this bone forward toward the chin, the airway at the base of the tongue is advanced. The advancement is limited, however, and nothing is done to correct a true jaw deficiency which may be significantly contributing to the airway obstruction.

Maxillary-Mandibular Advancement (MMA)

Maxillary-Mandibular Advancement (MMA) is used to open all three levels of possible obstruction: the nose, the throat, and the base of the tongue. The maxilla is the upper jaw and the mandible is the lower jaw. Many studies show that the MMA is the most effective treatment for OSA and, in many cases, should be considered before the usual steps in the Stanford Protocol which treat the nose and the throat first.

How effective is MMA? Effective enough for professional athletes suffering from sleep apnea. Read our recent blog article about MMA and how it helped a Boston Red Sox return to pro form: MMA/BiMax Surgery for Sleep Apnea

A standardized lateral head x-ray (lateral cephalometric radiograph) and the clinical examination of the patient’s facial soft tissue determine if an MMA will be helpful and possible. Now a 3-D CT scan is used to obtain the actual volume of the airway and whether the facial tissues will allow for advancement of the facial bones to open the airway. MMA is described under the orthognathic surgery section of this website.

The surgery takes approximately three hours to perform and requires general anesthesia and an overnight stay in the hospital. Only about half of the OSA patients who are treated with MMA will require orthodontic therapy. The pre-surgical orthodontic treatment could be as long as 12-18 months. It is recommended when bite problems accompany the jaw deficiency issues and have not been treated effectively in the past.

Related Blog Article:

• MMA/BiMax Surgery Helps Pro Baseball Player with Sleep Apnea

Recovery

After MMA surgery the teeth are not wired together and titanium bone plates hold the bones in the new position until they heal. This process is similar to bone fracture healing and takes 6-8 weeks. Most patients are on a non-chew diet and wear small elastic bands to guide the bite during healing. Most patients will lose 10-15 pounds. Even when the patient regains the weight the AHI is still better. The most recent statistics show a 45% cure rate with an AHI below 5 and an 87% improvement of the AHI to below 10 (Sleep Medicine Reviews 2010).

The recovery from nasal surgery requires packs in the nose for approximately 4-5 days. The UUUP and T&A require warm salt water rinses and gargling to help the healing. The throat is tremendously sore and there is difficulty swallowing for a couple of weeks. Most patients will lose 10-20 pounds, like the MMA, which can help improve the AHI but after the weight is back on then, unlike the MMA, the OSA improvements reverse.

Complications

The complications of the surgery for the nasal area include:

• septal perforations
• bleeding
• dry nose syndrome
• nasal asymmetries
• need for revision surgery

The complications of the UPPP and the T&A include:

• bleeding
• hypernasal speech
• scarring

The complications for tongue reduction, chin button surgery, and hyoid bone suspension include:

• bleeding
• speech changes
• numbness of the lip or tongue
• fracture of the hyoid bone or jaw

The complications of the MMA surgery are rare, except for the permanent numbness of the lower lip which occurs about 15% of the time. All patients will have some transient numbness with the bilateral sagittal split osteotomy (BSSO) of the lower jaw. This numbness is due to the fact that the surgeon must split the bone around the nerve, and it usually gets stretched and traumatized to some degree. It can take up to two years before it regenerates and before it can be determined that the injury is permanent.

Other complications include:

• TMJ problems
• infection
• bleeding
• damage to teeth
• poor healing of the bones
• relapse
• facial paralysis
• breathing problems
• continued OSA
• drug reactions
• anesthetic reactions that can be serious or possibly fatal

Pre-Operative Instructions

1. Arrange for someone to drive you home after surgery and help you the first 24 hours.
2. Stop smoking for at least two weeks prior to and two weeks after surgery because smoking constricts blood vessels. Permanent smoking cessation is best.
3. Take 1,000 mg of vitamin C, in four divided doses, daily beginning the week before surgery.
4. Do not take any aspirin, ibuprofen, blood-thinning medications, or vitamin E two weeks before surgery, unless otherwise directed by your surgeon.
5. Do not eat or drink anything after midnight the night before surgery (or as your anesthesiologist directs). If you are prone to be nauseated, consult with your surgeon about medications you can take before surgery.
6. Call if you have any questions about the surgery.
7. Weight reduction, if necessary, should be done in a reasonable manner prior to any surgery.

Post-Operative Instructions

1. Eat a balanced diet following surgery. If you are experiencing nausea and vomiting, take only clear liquids. If nausea and vomiting persist, after taking prescribed anti-nausea medication, then call our office.
2. Do not lift anything heavier than ten pounds for two weeks. Keep activity simple although walks may begin three days after surgery. Do not overdo it. Do not begin vigorous work outs until after the fourth week following surgery, and if you have any questions about an activity, ask your doctor.
3. Take 1,000 mg of Vitamin C, in four 250 mg doses, daily for six weeks following surgery.
4. Call if:
   • Excessive pain is unrelieved with medication.
   • Temperature is greater than 101.0° F by mouth.
   • Swelling is asymmetric (uneven).
   • Nausea and vomiting persist.
   • Severe redness occurs.
5. Take medications as directed.

How to Schedule an Appointment for Sleep Apnea Surgery in Denver, CO

We see patients from Denver, Colorado, and other parts of the country. If you’d like more information about sleep apnea surgery, please contact the office of Denver sleep apnea surgeon, Randolph C. Robinson, MD,DDS, FAACS. In some cases, a physician’s referral may be required. Please contact your insurance provider for coverage details.