What is Obstructive Sleep Apnea (OSA)?

Obstructive sleep apnea is a sleep breathing disorder characterized by repetitive collapse of the airway leading to awakening during sleep. A sleep study records the repetitive airway collapse (apnea/hypopnea index or AHI) and decreased oxygen content in the blood.

In children, OSA is diagnosed with an AHI >1. OSA is associated with attention deficit hyperactivity disorder (ADHD), irritability, and poor concentration and performance in school.

In adults, the sleep study is scored as follows: normal AHI 0-5, mild AHI 5-15, moderate AHI 15-30, severe AHI >30. OSA may lead to symptoms such as excessive daytime sleepiness and fatigue, other health issues such as heart disease, diabetes, and stroke, and increased risk for car accidents.

Who are the members of sleep team?

The collaborate approach to treat sleep apnea is imperative to optimize successful outcomes. The sleep team consists of sleep medicine (specialist who diagnose and medically treat OSA), dental providers such as orthodontist, pediatric dentist, general dentist (specialists who can modify growth patterns in children and who make the mandibular advancement device (MAD)), and surgeons such as oral and maxillofacial surgeons, ENT, and plastic surgeons (specialist who alter the upper airway).

How is OSA Diagnosed?

A complete medical and sleep history is initially reviewed. Patient questionnaires such as Epworth sleepiness scale are also scored to further screen for OSA. If OSA is suspected, the patient is referred to sleep medicine for diagnosis by a polysomnography (PSG) or home test. If the patient is diagnosed with obstructive sleep apnea, sleep medicine provider will then initiate the various medical treatment options.

What is the first-line treatment of OSA?

In children, tonsillectomy and adenoidectomy are often first-line treatment options. These procedures open up the airway behind the nose and palate. Lingual frenectomy procedures may be indicated if tongue restriction is found which can lead to improper development of the upper and lower jaws. Positive airway pressure (PAP) and MAD are not usually utilized as it may affect the growth of the upper and lower jaw; the use of PAP or MAD depends on a case-by-case basis.

In adults, the first-line option for treating OSA is behavioral modification, such as weight loss and adjusting sleep position, and use of PAP therapy. PAP therapy is the gold-standard for OSA treatment when used regularly. However, some patients can't tolerate PAP therapy due to due to issues of claustrophobia, obstruction in nasal or pharyngeal airway, feeling uncomfortable from the mask and hose, and high positive pressure. Patients who have failed PAP treatment are then considered for alternative treatment options.

What are the general additional treatment options for OSA?

Adult patients who are unable to tolerate PAP therapy are then considered for mandibular advancement devices (MADs) or sleep surgical options. The selection of the various choices from MAD and sleep surgery depends on many factors discussed below.

What is a MAD?

MAD is a dental appliance that fits onto the upper and lower teeth and advances the lower jaw forward. It prevents airway collapse behind the tongue and alleviates snoring. Risk factors associated with MAD include development of temporomandibular joint disorder and shifting of teeth.

What additional tests are needed to select surgical options for OSA patients?

Sleep surgical options are tailored to the patient specific airway anatomy in order to optimize surgical success. A thorough history including types of symptoms can point towards the anatomic area of obstruction. For example, chronic mouth breathing and dry mouth can indicate nasal obstruction; recurrent tonsillitis and uvular swelling can suggest palatal or oropharyngeal source of obstruction. A complete physical examination entails examination of the head, face, and neck including looking inside the nose and mouth. Measurements and various grading scales are assessed by examining the structures such as nasal turbinates, nasal septum, uvula, tonsils, dentition, tongue, and upper and lower jaw relationships.

2-D and 3-D radiographs may be taken to examine the area and volume of the airway and pinpoint the obstruction from the nose down to the throat. A scope may also be placed when the patient is awake or asleep in the operating room (drug induced sleep endoscopy (DISE)) to further characterize the airway and determine the levels of obstruction.

The patient history, sleep study results, physical examination, radiographs, and endoscopic evaluation all are incorporated in determining the ideal surgical option for the patient on a case-by-case basis.

What are the different types of sleep surgeries?

The sleep surgeries can target either selective or global structures. The various procedures are listed below. Please consult with one of are surgeons for further details regarding these procedures.

Nasal procedures

  1. Turbinate reduction
  2. Septoplasty
  3. Nasal valve surgery
  4. Rhinoplasty
  5. Endoscopic procedures

Pharyngeal procedures

  1. Uvulopalatopharyngoplasty
  2. Lateral expansion pharyngoplasty
  3. Tonsillectomy
  4. Adenoidectomy
  5. Uvular flap

Tongue Procedures

  1. Lingual tonsillectomy
  2. Genioglossus advancement
  3. Hyoid suspension
  4. Tongue reduction
  5. Epiglottidectomy/epiglottopexy

Global Skeletal and Nerve Stimulator Procedures

  1. Maxillomandibular advancement
  2. Tracheotomy
  3. Upper airway stimulation

What is the postoperative course and management following sleep surgery?

Each type of sleep surgical procedure has particular postoperative instructions that will be discussed at the time of pre-operative evaluation. Most patients will stay at least one night post-operatively in the hospital. Our surgical team works closely with the hospitalist and ICU team at the California Pacific Medical Center in San Francisco to provide the highest level of care. Around 2-3 months post-operatively, patients will undergo a repeat sleep study with sleep medicine to determine the status of OSA. The surgical team closely follows the patient through the post-operative course to ensure optimal success.

How is sleep surgery success determined?

Society guidelines define surgical success as reduction of AHI by 50% or reduction of AHI below 20. Although the goal of sleep surgery is for complete elimination of OSA, this may not be achieved due to multiple factors causing the OSA. Detailed discussions of the surgeries are conducted with each patient to ensure realistic expectations for overall goals. Patients who achieve an AHI less than 15 and are asymptomatic may not need further treatment; this is again reviewed on a case-by-case basis in conjunction with sleep medicine. Patients are informed that they may still require additional surgical options or use of PAP or MAD after the initial treatment if they are found to have residual sleep apnea and are still symptomatic. Furthermore, some patients undergo surgeries with the plan to continue with PAP therapy; by alleviating certain obstructive sights, the PAP pressures can be decreased leading to higher compliance.

How do I get started?

If you suspect sleep apnea problems, please call our office for an appointment. Every OSA patient is unique and proper diagnostic workup is very important. If you need surgery, our surgeons work out of California Pacific Medical Center in San Francisco, with new and modern instruments and equipment.