CPAP FAILURE: Recent article discusses surgical options.

A recent article (abstract below) discusses surgical options for treating sleep apnea in patients who do not tolerate CPAP. The author states " Uvulopalatopharyngoplasty is still the standard procedure for many patients with moderate OSA" This statement is untrue and dangerous. Numerous studies have shown minimal reduction in apnea from UP3 surgery, high morbidity and most patients still need CPAP or oral appliances.

AVOID UVULOPALTOPHARYNGEALPLASTY AS A FIRST LINE TREATMENT OF APNEA!

Patients who undergo UP3 surgery first are more likely to have problems with velo-insufficiency related MaxilloMandibular Advancement surgery which according to the author "is as effective as CPAP in severe OSA"

The author also stated "Tonsillectomy and maxillomandibular advancement may be offered as a first-line treatment in certain patients."

Again probably poor advice in most adults. The exception may be the patient with a severely recessive maxilla and mandible. In general, Maxillomandibular advancement should usually be preceded by oral appliance therapy to find an effective position of the jaw to eliminate apnea before doing surgery.

Tonsilectomy is a first line treatment for pediatric apnea but new studies show it should usually be done in conjunction with maxillary expansion.

The author never mentioned oral appliance therapy, but many physicians arre still taking the ostrich approach to oral appliances. Pretend it doesn't exist and it will go away.

Curr Opin Pulm Med. 2010 Sep 14. [Epub ahead of print]

Surgical treatment of obstructive sleep apnea: standard and emerging techniques.
Maurer JT.

Department of Otorhinolaryngology, Sleep Disorders Center, University Medicine Mannheim, Medical Faculty Mannheim of the Ruprecht-Karls-University Heidelberg, Mannheim, Germany.

Abstract
PURPOSE OF REVIEW: Patients with obstructive sleep apnea (OSA), as well as their physicians, seek alternative therapies to continuous positive airway pressure (CPAP) due to problems with CPAP adherence. A large variety of surgical options exist, and each intervention must be individually evaluated. The author performed a literature search concerning surgery for sleep apnea until May 2010. The studies were evaluated according to evidence-based medicine criteria.

RECENT FINDINGS: An increasing number of controlled and even randomized controlled trials are available. Minimally invasive surgery remains under debate due to the very limited efficacy versus very low morbidity. Uvulopalatopharyngoplasty is still the standard procedure for many patients with moderate OSA, whereas maxillomandibular advancement is as effective as CPAP in severe OSA. Multilevel surgery is reserved to secondary treatment after CPAP failure. Tonsillectomy and maxillomandibular advancement may be offered as a first-line treatment in certain patients. There is increasing evidence that upper airway surgery has a positive impact on arterial hypertension, markers of cardiovascular disease, insomnia, daytime symptoms, quality of life, and CPAP adherence.

SUMMARY: Patients who are nonadherent to CPAP must be thoroughly evaluated before choosing any of the available surgical options. Upper airway surgery may improve disease markers of OSA, if appropriately chosen and properly indicated and performed.

PMID: 20842037 [PubMed - as supplied by publisher]

Sleep Apenea Surgery: Soft Palate Surgery is rarely, if ever a first line treatment for sleep apnea.

There are only two first line treatments for Sleep Apnea, CPAP and Oral Appliances. CPAP is extremely effective but the majority of patients abandon CPAP use due to comfort issues. Oral Appliances are a first line treatment for mild to moderate sleep apnea and an alternative to CPAP for the 60% of patients who abandon CPAP and those who use CPAP but just want to experience a more comfortable alternative to CPAP.

Note: For the morbidly obese CPAP is still the best treatment, for younger thinner and healthier patients oral appliances are effective and easy to fit into busy lifestyles.

Surgery, especiall soft palate surgery used to be considered a first line of treatment for sleep apnea but dismal results and high morbidity have relegated soft palate surery to a secondary proceedure, at best.

There were several types of soft palate surgery but the grandfather of all was the UP3, UPPP surgery or Uvulopalatopharyngoplasty. This surgery was excruciatingly painful, had a high morbidity and was usually unsuccessful in treating sleep apnea. According to Wikipedia the risks of UP3 surgery include:

"One of the risks is that by cutting the tissues, excess scar tissue can "tighten" the airway and make it even smaller than it was before UPPP. Some individuals who have undergone UPPP experienced a worsening of their breathing following UPPP.
Others have spoken of severe acid reflux.
After surgery, complications may include these:
Sleepiness and sleep apnea related to post-surgery medication
Swelling, infection and bleeding
A sore throat and/or difficulty swallowing
Drainage of secretions into the nose and a nasal quality to the voice. English language speech does not seem to be affected by this surgery.
Narrowing of the airway in the nose and throat (hence constricting breathing) snoring and even iatrogenically caused sleep apnea.
Patients who have had the uvula removed will become unable to correctly speak French or any other language that has a uvular 'r' phoneme."

All surgeries to the soft palate carry risk and are painful. The LAUP procedure or Laser Assisted Uvuloplasty was less painful than up3 but still very painful. There was less chance of scarrig that dangerously narrowed the airway as seen with UP3.

Somnoplasty of the soft palate was less painful but equally ineffective in treating sleep apnea. Somnoplasty is a procedure to consider in patients with soft palate snoring and no sleep apnea. Other surgical alternatives are snoreplasty and pillars which again are useful for snoring but minimally helpful for treating sleep apnea.

Tracheotomy is the grandfather of surgeries and allows patients to breathe thru their throats. It is very successful but most patients do not want a long term tracheotomy.

The majority of sleep apnea is caused by the base of the tongue obstructing the airway or pressing on the epiglottis that blocks the airway.

There are several procedures that can be done to either advance the tongue or make it smaller. Somnoplasty on the base of the tongue is probably the preferred surgery for most patients contemplating reducing tongue size.

MaxilloMandibular Advancement is probably the most successful sleep apnea surgery but is extensive surgery carring definite risks. I strongly recommentd that patients undergoing this rocedure avoid ENT's and Plastic Surgeons and utilize Oral Surgeons with extensive experience in this type of surgery. The dental background of Oral surgeons make themthe first choice. They frequently do these surgeries for orthodontic purposes and understand stomatognathic function.

PATIENTS CONTEMPLATING MAXILLOMANDIBULAR ADVANCEMENT SHOULD ALMOST ALWAYS GO THRU A TRIAL OF AN ORAL APPLIANCE TO DETERMINE THE BEST POSITION FOR THE JAWS AFTER THIS RADICAL SURGERY. THIS WILL PREVENT NEEDLESS SECONDARY SURGERIES.

Nasal surgery is frequently helpful but rarely is a cure for apnea when done alone. Correction of deviated septums and turbinate reduction offer greater comfort for most patients with obstructed breathing due to anatomical or allergic problems.

Nasal surgery is usually and ENT procedure but is frequently one by oral surgeons as well.

Pediatric patients with sleep apnea are usually candidates for removal of tonsils and adenoids. While effective at opening the pharyngeal airway newer research suggests that orthodontic widening of the hard palate should be done either before or after T&A procedures. Widening prior to surgery may reduce post-operative complications.

Sleep apnea is probably responsible for at least 80% of the cases ADD and ADHD in children. The earlier the airway obstructions are addressed the healthier it is for future development.

UPPP Failure and limited success at Cleveland Clinic. Is it time to Abandon UP3 surgery as pPrimary Apnea Treatment

An article "UTILITY OF UPPP IN OSA: THE CLEVELAND CLINIC EXPERIENCE by Lee-Iannotti JK, Bae CJ, Kominsky A, Alsheikhtaha Z reviews the results of UPPP (UP3) surgery on 28 patients who met study criteria from 250 charts reviewed.

These 28 patients unerwent Uvulopalatopharyngealplasty, with or without tonsilectomy and/or septoplasty. ONLY 2 PATIENTS (6.6%) WERE "CURED" HAVING AN AHI OF LESS THAN "5". THE STUDY STATES THAT THERE WAS A 43 % SUCCESS RATE. HOWEVER SUCCESS WAS DEFINED AS 50% REDUCTION AND AHI OF LESS THATN 20. THESE PATIENTS STILL HAD MILD TO MODERATE SLEEP APNEA!

THE STUDY REPORTED " Overall, there was a decrease in the overall AHI in all the patients undergoing surgery (mean AHI ± SD, 45.6 ± 29.2 pre-UPPP vs. 30.4 ± 26.1 post-UPPP, P = 0.019*.) Thirteen patients (43%) achieved a 50% or greater reduction
in the AHI and/or an AHI of 20 or less.

The study showed no reduction in CPAP pressures: " Of the patients requiring CPAP therapy post-UPPP, there was
no significant decrease in pressure requirements (mean CPAP pressure
± SD, 9.4 ± 0.5 pre-operatively vs. 9.1 ± 0.7 post-operatively, P = 0.35.)"

The authors concluded that: "UPPP achieved surgical success in 43% of our patients. Younger patients (< 40 years) with lower Friedman scores (≤ 2) seemed to have greater surgical success rates. BMI, neck circumference, tonsil-
lar size, severity of OSA and presence of retrognathia did not seem to be predictors of outcome.

EXCEPT FOR YOUNGER AGES AND LOWER TONGUE POSITION THERE WERE NO PREDICTORS OF POSITIVE SUCCESS. BASED ON THIS STUDY THE USE OF UPPP SURGERY IN ADULTS OVER 18 IS QUESTIONABLE AT BEST.

BOTH CPAP AND ORAL APPLIANCES ARE MUCH MORE SUCCESSFUL EVEN WHEN POOR CPAP COMPLIANCE IS CONSIDERED.

COMPARED TO SURGERY ORAL APPLIANCES ARE DEFINITIVELY A BETTER TREATMENT CHOICE. CPAP IS A SUPERIOR CHOICE IF IT IS USED ALL NIGHT ON A REGULAR BASIS.

ONE ADVANTAGE TO SURGERY IS THAT PATIENT COMPLIANCE IS A NON-ISSUE.

New surgery to treat obstructive sleep apnea.

There is a new surgery designed to treat sleep apnea. Permanent sutures are placed to secure the tongu to the jaw preventing it from blocking the airway. The is a logic to this procedure and it may require more than 1 surgical procedure. There is no long term data. In general surgery has been ineffective for treating apnea unless major surgical prcedures are done. Soft palate surgery carried high risk of morbidity and poor results. Tongue reduction was more successful,especially base of the tongue reduction. A recent article showed similar rsults with base of tongue reduction and somnoplasty on the base of the tongue. The somnoplasty proceedure had lower risk and morbidity.

CPAP remains the "Gold Standard" for treatment of obstructive sleep apnea but the majority of patients do not tolerate CPAP or BiPAP. Oral appliances are the only other therapy considerd a first line treatment of mild to moderate sleep apnea. Oral Appliances are considered an alternative treatment for severe sleep apnea when patients do not tolerate CPAP. Even when sleep apnea is severe the majority of patients do not tolerate CPAP.

Bimaxillary advancement is the most successful surgical proceedure but is a major orthopedic procedure with significant risks of morbidity. The surgery works in a similar method to oral appliances. Prior to surgery a trial oral appliance can help determine the best position to place the jaws to prevent additional future surgeries.

Suturing the tongue to the jaw is a novel approach to treating sleep apnea. Hopefully it will be more successful and less painful that soft palate surgery has proven to be.