Snoring and Sleep Apnea Treatment
- Severe Snorers with Obstructive Sleep
Apnea
Patients with proven obstructive sleep apnea are considered
to have a "medically-significant" condition that is, therefore,
covered by medical insurance. Treatment for sleep apnea needs
to be individualized for the patient as there exist several
options. Optimal results are achieved through a cooperative
effort between a sleep medicine physician, a dentist
sub-specialized in treatment of apnea and a surgeon working
along with a well-informed patient.
CPAP - First Line of Treatment for Sleep Apnea
The first-line recommended medical treatment is
Continuous Positive Airway Pressure (CPAP), along with
various mask modifications that are available to increase
patient comfort and compliance with treatment. Nasal CPAP with
humidification is an excellent modality for patients with
moderate to severe sleep apnea as CPAP splays the airway in the
open position and thus overcomes the sites of obstruction.
However, a major shortcoming of CPAP is its poor tolerance by
many patients who remove the mask in the middle of the night
and thus remain in untreated for the remainder of the night.
It is not surprising that following an adequate trial of CPAP,
many patients with mild-to-moderate sleep apnea decide to trade
in the CPAP machine and look for alternative treatments.
Dental Appliances for Sleep Apnea and Snoring
In Dr. Zemplenyi's experience, jaw-advancing dental
appliances ameliorate sleep apnea and snoring, but again
some patients do not tolerate having a device in their mouth
the entire night. Over longer periods of time some patients
using dental appliances develop discomfort in the
temporo-mandibular joints as well as problems with their dental
occlusion. Nevertheless, both dental appliances and CPAP are
well acceptable for many patients and are worthwhile modalities
to try first. In addition, medications such as Modafinil to
treat the daytime sleepiness as well as several other sleeping
aid medications may improve sleep and quality of life in
patients with sleep apnea.
Surgery for Sleep Apnea
Eventually, many patients become interested in a surgical
solution. Surgery for obstructive sleep apnea plays a
significant role in two categories: 1. Surgery for relief of
nasal obstruction designed to facilitate the usage of CPAP and
dental appliances; and 2. Surgery designed to salvage patients
from usage of CPAP. Please also see our for Nasal Surgery page.
Misinformation about Sleep Apnea
Much misinformation exists about surgical solutions for
sleep apnea as the "success" of surgery is often being
misquoted as less than 50 percent. The problem with this
statistics is that it refers only to success of
uvulo-palato-pharyngoplasty (UVPP) when performed on patients
who have NOT been further stratified according to their weight,
height and especially pertinent anatomy. In fact, the success
of surgical treatment depends on the severity of sleep apnea
and the involved anatomy.
Successful Treatment of Sleep Apnea
Dr. Zemplenyi has achieved very satisfactory surgical
results for many patients using UVPP with or without a
tonsillectomy and along with current conservative
modifications such as a palatal flap as long as their
anatomy was favorable to treatment of excess tissue of the soft
palate and uvula (retro-palatal site of obstruction). However,
many patients obstruct at the level of the base of the
tongue (retro-lingual site of obstruction). For these
patients UVPP is predictably not a sufficient solution. Other
surgical procedures that address the base of the tongue include
a volumetric reduction of the soft tissues of the tongue using
radiofrequency or plasma coblation and procedures
designed to move the base of the tongue forward such as
genioglossus advancement and hyoid advancement.
Orthognathic Surgery
Currently Dr. Zemplenyi prefers ReposeTM
suture suspension system for advancement of these
tissues as it is less invasive and better tolerated than the
more traditional "keyhole" mandibular osteotomy. Patients who
have a small mandible (lower jaw) or have mal-positioned upper
and lower jaws benefit greatly from orthognathic surgery
designed to address these maladies. In fact, advancement of
both of the jaws (maxillary/mandibular advancement) performed
by an oral/maxillofacial dental surgeon provides an excellent
avenue for treatment of obstructive sleep apnea. However, Dr.
Zemplenyi finds that many patients reject having jaw cutting
procedures because of their invasive nature, long preparatory
treatment by an orthodontist and the high cost of these
procedures.
Will Insurance Cover Orthognathic Surgery?
With some exceptions, many insurance companies provide only
partial or no medical coverage for orthognathic procedures.
Tracheostomy, as a procedure that bypasses the entire
upper respiratory tract, is 100% curative for obstructive sleep
apnea, but it is nowadays reserved only for patients with a
very severe condition that are usually awaiting the results of
the other surgeries as above. As many patient with
obstructive sleep apnea are severely obese (body/mass index
greater than 40) Dr. Zemplenyi recommends a consideration of
bariatric surgery such as a gastric banding or bypass for
treatment in these situations.
Also see:
- Overview of Snoring and
Sleep Apnea Procedures
- Sleep Apnea -
Comprehensive Evaluation
- Snorers without
Significant Sleep Apnea
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