TREATMENT OPTIONS

Treatment options for Obstructive Sleep Apnea syndrome include:

Medical Treatment

· CPAP (continuous positive airway pressure oxygen) is the gold standard and the most common therapy for obstructive sleep apnea (different types of CPAP machines are discussed in the following section). Studies show that CPAP use leads to a decrease in the number of cardiovascular events and cardiac arrhythmias, improvement in neurocognitive and heart function, lower blood pressure, and a decrease in snoring, night awakenings, daytime sleepiness and MVA accidents.

· Medications may be used to reduce nasal congestion, treat congestive heart failure, or increase ventilatory drive

· Modafinil has been shown to improve residual daytime sleepiness in patients who are regular users of CPAP therapy

· Oxygen therapy: in some cases (such as congestive heart failure or persistent hypoventilation) low flow oxygen therapy may be added to CPAP to increase oxygen saturation values and reduce the number of apneic episodes

Oral Appliance Therapy

· See OAT section

Combination CPAP-Oral Appliance Therapy

· See Taking Control: Combination Therapy and Adjunctive Treatments

Surgical Treatment

A number of surgical procedures are available to address the different anatomical problems responsible for the constriction of the upper airway:

· Adenotonsillectomy is very commonly used in children with adenoidal and/or tonsillar hypertrophy suffering from mild to moderate obstructive apnea. This procedure is often sufficient to significantly improve symptoms, resulting in better cognitive performance, emotional stability and quality of life. Sometimes this procedure is planned in conjunction with orthodontic palatal arch expansion, where an orthodontic evaluation has determined that the airway is constricted by abnormally narrow arches

· Nasal Surgery (turbinectomy or septal reconstruction) may assist patients with severe nasal obstruction due to enlarged turbinates or a deviated septum, by improving nasal breathing and increasing CPAP tolerance

· Uvulopalatopharyngoplasty (UPPP), the first surgical procedure that was developed to reshape the pharyngeal airway, is indicated in patients with excessive soft palatal tissues and may be combined with removal of enlarged tonsils or adenoids.

· Laser-assisted Uvulopalatoplasty is a modified version of UPPP that involves scarring cuts to tighten the soft palate and sequential trimming of the uvula over several appointments.

· Lingual tonsillectomy / base of tongue resection may be used for patients with an enlarged tongue or posterior displacement of the tongue base as a result of retrognathia

· Genioglossal advancement repositions the base of the tongue forward

· Maxillomandibular advancement, which advances the mandible and hyoid bone along with the base of the tongue and the pharyngeal muscles, has success rates between 94-100%. It is typically used as the primary surgery in non-obese patients with moderate to severe apnea and maxillo-mandibular jaw deficiencies, often in combination with a second, orthodontic phase to correct changes in bite and tooth alignment. In patients who are obese, the rate of success is far lower when MMA is employed as a sole procedure. MMA requires an overnight hospital stay.

· Radiofrequency Volumetric Tissue Reduction ("Somnoplasty') is a conservative surgical approach used to reduce soft palatal volume in patients who snore. Subjective outcomes are comparable to CPAP therapy.

· Bariatric surgery, such as gastric bypass, may be indicated for morbidly obese patients with sleep apnea and has been shown to reduce the AHI by up to 75%. Cervicofacial liposuction is another weight reduction surgery that removes excessive fatty tissues below the chin and anterior neck to reduce the weight against the underlying soft tissue and thus minimize airway collapse during sleep.

· Tracheostomy creates an opening in the larynx, bypassing the entire upper airway. It is reserved as a treatment of last resort for severe sleep apnea.

Orthodontic Treatment

Children with obstructive sleep apnea and adenotonsillar hypertrophy have a high rate of malocclusion (especially cross bites and anterior open bites) as a result of chronic mouthbreathing. Rapid maxillary expansion, which widens the nasal airway and reduces tongue crowding, has been shown to significantly reduce and sometimes fully normalize the AHI in cases where it was used as a sole therapy (no T/A needed) as well as when used as part of combination therapy (Adenotonsillectomy plus Rapid Palatal Expansion)

Alternative Approaches and Devices for CPAP-intolerant patients

Provent is a small prescription nasal device using a micro-valve design which partly closes when exhaling, so that the expiratory positive airway pressure generated (EPAP) helps maintain the airway open. Provent is appropriate for all apnea severities, however those with severe breathing or heart disorders, very low blood pressure, acute upper respiratory conditions or perforated ear drums are advised not to use it.

http://www.proventtherapy.com/about-provent.php

Inspire Upper Airway Stimulation (UAS) This FDA-approved therapy consists of an implanted system that detects and interprets breathing patterns, then delivers a stimulus to activate specific upper airway muscles involved in opening the airway. Hypoglossal nerve stimulation is contraindicated in patients with complete concentric collapse of the airway, patients who will require magnetic resonance imaging (MRI) or in whom central + mixed apneas represent over 25% of the total apnea-hypopnea index.

https://www.inspiresleep.com/

Additional Sources: Roy, Sree. " 9 Alternative Therapies for Obstructive Sleep Apnea" Sleep Review, September 18, 2014

Behavioral Interventions

In addition to the treatments listed above, these conservative approaches may help to various degrees:

· weight loss: a 10% reduction in body weight can produce a 26% drop in AHI.

· positional therapy - using electronic or home-made devices that encourage sleeping on the side, which reduces the posterior repositioning of the tongue). See http://www.advancedbrainmonitoring.com/night-shift/

· avoiding alcohol and sedative medications before sleep

· avoiding large meals for 2-3 hours before bedtime (as pressure on the diaphragm can worsen breathing and cause gastroesophageal reflux, which further irritates the upper airway)

· elevating the head of the bed

· treating colds and allergies promptly to reduce nasal resistance and encourage nasal breathing

· smoking cessation

Articles

Taking Control: Combination Therapy and Adjunctive Treatments

Liana Groza, DDS