Sleep Medicine / Sleep Surgery : Sleep Disorder Treatments

Sleep Disorder Treatments

CPAP

CPAP is the first line of treatment for patients diagnosed with OSA. This therapy is thought to act by stenting the airway open through the delivery of positive pressure that keeps it open, which allows the patient to continue breathing normally without any interruptions. The positive effects of CPAP are undisputable as it has been shown to normalize sleep architecture, decrease daytime sleepiness, elevate mood, reduce accidents, and decrease hypertension and cardiovascular events.

Turbinate Reduction

Turbinates are small projections from the lateral nasal wall that cleanse and humidify the air that passes through the nose before it enters the lungs. They are made of a bony structure surrounded by a vascularized mucousal membrane that can become swollen and inflamed secondary to allergies, irritation, or infection. This can lead to nasal obstruction by increasing the amount of mucus produced and by compromising the space available for airflow through the nasal valve. Medical treatment with topical nasal corticosteroids, antihistamines, and allergic desensitization is usually the first-line therapy. When this fails, surgical reduction can be considered.

Turbinate Reduction is a procedure that can be performed in the office setting or in the operating room usually when it is done in combination with other procedures. There are different techniques that can be used for this. When done in the office, or when the main cause of turbinate enlargement of engorgement of the mucosa, volumetric reduction can be achieved by inserting a needle-like instruments that ablates or creates a submucosa tissue injury.

Septoplasty / Septorhinoplasty

The septum is a structure made of bone and cartilage in the central portion of the nose that separates one nasal cavity from the other and is the main structure for support of the nose. Nasal septum deviation can occur secondary to trauma, which is frequently associated with fracture of the nose. More commonly it is congenital and not appreciated by patients who have become accustomed to unilateral nasal obstruction. In some cases, the deviated nasal septum is associated with inferior turbinate hypertrophy, twisted nose deformity, and/or nasal valve collapse. All these need to be addressed if the goal is to reestablish normal nasal function and breathing.

Nasal surgery is usually performed as an outpatient surgical procedure without overnight admission, and is typically performed under general anesthesia. During septoplasty, the deviated portions of the septum (bony and/or cartilaginous) are removed in order to straighten the septum in the midline position as much as possible. This procedure is done through a small incision in the inside part of the nose that is not visible. When necessary, septoplasty is done in combination with inferior turbinate reduction in order to maximize airway space.

When the deviated nasal septum involves the most anterior portion of the septum, or is associated with a twisted nose deformity or nasal valve collapse, septoplasty must be carried out together with a rhinoplasty. These nasal deformities cannot be managed successfully by septoplasty alone and require an external approach in order to fix them. This is usually accomplished through an external incision made on the collumela that in the majority of the cases is barely noticeable after the healing process has completed. In most cases, patient’s own septal cartilage is used to correct these nasal deformities. However, there are cases where the septal cartilage is scarce or severely disrupted from previous trauma, and it is necessary to use donor rib cartilage to fix the problem. Risks associated with nasal surgery are: infection, septal hematoma, septal perforations, nasal collapse, recurrence of nasal obstruction, and bleeding.

Palate Surgery

Studies have shown that the area behind the soft palate is the narrowest portion of the upper airway and that the majority of the patients with OSA present with obstruction at this level. Hypertrophy of the tonsils and/or soft tissue redundancy of the soft palate is typically found in OSA patients with obstruction at the level of the palate. Palate surgery is one of the classic procedures that have been done with the goal of treating OSA. Initially, palate surgery or uvulopalatopharyngoplasty (UPPP) as it has come to being known, involved removal of the tonsils and ablation of part of the soft palate in order to open up the space in this area. Inconsistent outcomes and complications resulting from such an aggressive approach, led to a modification of this procedure where know the only resection that is done is that of the tonsils, and the rest of the procedure involves repositioning of the palate muscles in order to increase the cross-sectional area and increase the tension of the soft palate and surrounding structures. More recently, palate surgery has evolved to also address narrowness caused by transverse maxillary deficiency. Nowadays, we are able to correct this problem in adult patients through a combination of surgery and distraction osteogenesis involving orthodontic treatment to expand the hard palate.

The indications for palate surgery have also evolved as well, since now it is also offered with the goal of reducing CPAP pressures so that patients’ feel more comfortable and improve their adherence with this therapy. As with any patient, it extremely important to carefully select patients for this procedure and to set real expectations. UPPP almost universally corrects, or at least significantly improves, snoring since this is a problem that originates from the palate in almost 85% of the cases. When done with the goal of curing OSA, it has been shown that outcomes improve when done in non-obese patients with tonsillar enlargement, adequate palatal width, and minimal obstruction at the level of the tongue base. Continuous nasal breathing that allows patients to keep their mouths closed during sleep, also is known to improve outcomes of palate surgery.

Hypopharyngeal Surgery

The hypopharynx is well recognized as one of the predominant sites of airway obstruction in patients with Obstructive Sleep Apnea. Contributors to obstruction at this level may include collapse of the epiglottis, lingual tonsil hypertrophy, and/or tongue base obstruction secondary to retroposition of the jaw, tongue enlargement, or loss of upper airway tonicity during sleep. The majority of OSA patients present with obstruction at multiple levels of the airway, and structures found in the hypopharynx are oftentimes involved in this process. This is why outcomes of surgery for the treatment of OSA improve when multi-level surgery is performed. Again, careful evaluation of OSA patient to identify the degree and cause of hypopharyngeal obstruction is extremely important before selecting the treatment that will be offered to increase the retrolingual space. Several approaches are available to address hypopharyngeal obstruction including upper airway stimulation, ablation of lingual tonsils causing airway obstruction, and bony advancement when there is retroposition of the jaw that leads to a posteriorly displaced tongue.

Skeletal Surgery

Some OSA patients present with specific anatomical features or patterns of airway collapse that will likely respond better to skeletal surgery for the treatment of their OSA. Non-CPAP compliant patients with facial skeletal deficiencies and/or complete collapse of the the lateral walls of the pharynx, typically require maxillomandibular advancement surgery (MMA) to completely address their problem. MMA involves the forward advancement of the maxillary and mandibular skeletal complex, which in addition to increasing the cross-sectional area of the entire airway, also increases the stability of the lateral pharyngeal wall, the velum, and the tongue base. This may explain why MMA results in a higher success rate than the other surgical treatments that were previously described.