Sleep Apnea

Sleep Apnea

Sleep apnea is a sleep disorder. It occurs when a person's breathing is interrupted because the upper airway becomes repeatedly blocked during sleep, thus reducing or completely stopping airflow.  The amount of oxygen to the brain and the rest of the body is reduced.

There are two types of sleep apnea: Obstructive sleep apnea (OSA): This is the more common form; it is caused by an obstruction of the airway not allowing the airflow to freely pass to the lungs. Central sleep apnea (CSA): In this for the brain does not send signals for the breathing sequence, due to conditions affecting the respiratory center.

Risk factors for obstructive sleep apnea include male gender, obesity, age over forty, retrognathia (a small lower jaw), a large tongue or tonsils, a large short neck, a deviated septum, gastroesophageal reflux disease, sinus problems, hypothyroidism, polycystic ovary syndrome, heart or kidney failure, smoking, alcohol consumption, lack of physical exercise, unhealthy eating patterns, and family history.

The patient may show signs of reduced or absent breathing (apnea events); Loud snoring as well as gasping for air may be reported from the spouse.

Symptoms include fatigue, headaches, daytime sleepiness, lack of concentration, a decrease in attention, dry mouth, depression, anxiety, insomnia, academic underachievement or poor professional performance.

If OSA is left untreated, it can lead to high blood pressure, stroke, heart attack, diabetes, asthma, chronic kidney disease, behavioral and cognitive disorders, dementia, eye disorders or pregnancy complications.

A sleep apnea test called a polysomnogram (sleep study) is indicated for patients with symptoms of sleep apnea. This test may be done at a sleep disorder center or even at home. The sleep study records specific physical activities while the patient sleeps. It detects apnea events (time of reduced or absent breathing), it monitors the breathing muscle activity, the heart and brain activity, as well as the oxygen levels in the blood during sleep.

All the recordings are then analyzed by a  sleep specialist to evaluate whether or not the patient has sleep apnea, as well as the severity of the disease. The findings may indicate mild sleep apnea: 5 to 14 apnea events in an hour, moderate sleep apnea: 15 to 29 apnea events in an hour, or severe sleep apnea: 30 or more apnea events in an hour.

The diagnostic workup for sleep apnea also includes a physical examination and history taking, lateral cephalometric x-rays and blood tests.

Treatment of sleep apnea may be conservative or invasive according to the severity of the disease and the relative response to the treatment modality used.

The first line of treatment may be just to quit smoking, to reduce alcohol consumption and to adopt healthier life habits including moderate physical activity and favorable eating choices, to lose weight and to develop healthy sleeping habits.

A CPAP is the most commonly used treatment modality for sleep apnea. It is usually prescribed by a pulmonologist, and it helps the patient by applying positive airway pressure to compensate during the times of reduced breathing. Mandibular repositioning mouthpieces (a device that holds the jaw in a forward position that prevents it from blocking the airway) and the tongue retaining devices (a mouthpiece that holds the tongue in a forward position), may also be helpful in certain cases.

Surgical treatment for sleep apnea is indicated for patients with mild and severe sleep apnea who are not compliant with the use of the CPAP or other devices, and to whom the conservative treatment has failed. UvuloPalatoPharyngo-Plasty (UPPP), correction of the deviated septum, turbinate reduction are some of the surgical procedures that are implemented towards treatment.

In our clinic, we perform three other types of surgical treatment.

1. The anterior mandibular osteotomy. The procedure is done under general anesthesia or sedation. The patient is usually discharged the same day. A horizontal cut is made at the anterior part of the lower jaw, below the lower front teeth, and the chin is moved forward. As the attachments of the genioglossus muscles are located at the lingual side of the chin, the forward repositioning of the chin will also pull the genioglossus muscles forward. The genioglossus muscles are the main dilators of the pharyngeal airway. Relaxation of the genioglossus, especially during sleep, is implicated in obstructive sleep apnea, so by pulling them forward, we aim to increase the space of the air passage at this level and to prevent the tongue from sinking backward.

2. The genioglossus advancement. This procedure follows the same principle as previously described, but it is reserved for those patients that facial aesthetics will not allow for advancement of the chin, as it would result in a very prominent chin point. During this surgery, we advance only the area of the genioglossus insertion without moving the whole chin forward.

3. The maxillomandibular advancement. According to the current literature, this surgical procedure for the treatment of OSA has an overall successful outcome ranging from 85-100%. It is an extended surgical intervention during which both the upper and lower jaws are moved forward, as a unit. By advancing the maxillomandibular unit, we can achieve a total widening of the airway and dramatically improve the quality of the patient's life. To consider a patient as a candidate for this procedure, we must have a documented obstruction at the base of the tongue level, a sleep study that shows more than 50 obstructive episodes per hour, a saturation level of less than 85%, and a history of failure of other conservative or surgical treatment modalities. The procedure takes 4-6 hours to be completed and requires hospitalization of 3-4 days. In severe cases, it can be combined accordingly with some of the other types of surgical procedures described above.

The Surgical Robot has been very recently implemented for the treatment of OSA. The superior visualization and ergonomics of Trans Oral Robotic Surgery (TORS) are ideal for the treatment of OSA by removing excess tissue at the base of the tongue level. However, not all patients are suitable candidates for TORS. As we constantly follow the recent advances in Maxillofacial-Head and Neck Surgery, we are already certified in Robotic Surgery, and we are currently evaluating its use in the treatment of obstructive sleep apnea.