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