Obstructive Sleep Apnea

Introduction

Obstructive sleep apnea (OSA) is a serious health condition characterized by a repetitive stopping or slowing of breathing that can occur hundreds of times during the night. This often leads to poor quality sleep and excessive daytime sleepiness. Risks of untreated sleep apnea include high blood pressure, stroke, heart disease, and motor vehicle accidents. It is estimated that 1 in 5 Americans have at least mild OSA.

A variety of surgical and non-surgical options are available for the treatment of snoring and sleep apnea. Medical options include positive pressure (i.e. CPAP), oral appliances, and weight loss. Many of these treatment options depend on regular, long-term adherence to be effective. In patients having difficulty with other treatments, surgical procedures for the nose and throat can be a beneficial alternative. Surgical therapy can also be effective when used as an adjunct to improve tolerance and success with CPAP or an oral appliance.

Surgical Treatments

Nose

Increased nasal congestion has been shown to cause or contribute to snoring, disrupted sleep, and even sleep apnea. It is also a leading cause of failure of medical treatments for OSA, such as CPAP or an oral appliance. Nasal obstruction may result from many causes including allergies, polyps, deviated septum, enlarged adenoids, and enlarged turbinates.

Medical treatment options, such as a nasal steroid spray or allergy management, may be helpful for some patients. Structural problems, such as a deviated septum, often benefit from surgical treatment. One surgical option, known as radiofrequency turbinate reduction (RFTR), can be performed in the office under local anesthesia. RFTR uses radiofrequency to shrink swollen tissues in each side of the nose.

Upper throat (palate, tonsils, uvula)

In many patients with OSA, airway narrowing and collapse occurs in the area of the soft palate (back part of the roof of the mouth), tonsils, and uvula. The specific type and combination of procedures that are indicated depend on each individual’s unique anatomy and pattern of collapse. Therefore the procedure selection and surgical plan must be customized to each patient. In general, these procedures aim to enlarge and stabilize the airway in the upper portion of the throat.

The surgery is performed in an operating room under general anesthesia, either as an outpatient or with an overnight hospital stay. The recovery varies depending on the patient and the specific procedures performed. Many patients return to school/work in approximately one week and return to normal diet and activity at two weeks. Throat discomfort, particularly with swallowing, is common in the first two weeks and usually managed with medications for pain and inflammation. Risks include bleeding, swallowing problems, and anesthesia complications, although serious complications are uncommon.

The tonsils and adenoids may be the sole cause of snoring and sleep apnea in some patients, particularly children. In children, and in select adults, with OSA and enlarged tonsils/adenoids, a tonsillectomy and/or adenoidectomy alone can provide excellent resolution of snoring, sleep apnea, and associated symptoms.

Lower throat (back of tongue and upper part of voice box)

The lower part of the throat is also common area of airway collapse in patients with OSA. The tongue base may be larger than normal, especially in obese patients, contributing to blockage in this area. The tongue may also collapse backward during sleep as the muscles of the throat relax, particularly when some patients sleep on their back. The epiglottis, or upper part of the voice box, may also collapse and contribute to airway obstruction.

Multiple procedures are available to reduce the size of the tongue base or advance it forward out of the airway. Other procedures aim to advance and stabilize the hyoid bone which is connected to the tongue base and epiglottis. A more recent technology involves implantation of a pacemaker for the tongue (‘hypoglossal nerve stimulator’) which stimulates forward contraction of the tongue during sleep. As with palatal surgery, the most appropriate type of procedure varies from one individual to another and is primarily determined by each patient’s anatomy and pattern of obstruction.

The procedures are done under general anesthesia, often with overnight hospital observation. Recovery and risks vary depending on the procedure(s) performed, but are generally similar to procedures in the upper throat.

Skeletal procedures

For the most part, the above procedures involve surgical enlargement and stabilization inside the airway. For some patients, particularly those with developmental or structural changes of the jaw or other facial bones, surgical or orthodontic procedures on the bones of the face, jaw, or hard palate (roof of the mouth) may be beneficial.

Orthodontic procedures to widen the palate (palatal or maxillary expansion) may be useful treatment options in some pediatric patients. Maxillomandibular advancement surgery includes a number of procedures designed to move the upper jaw (maxilla) and/or lower jaw (mandible) forward, thus opening the upper and/or lower airway, respectively. Although full maxillomandibular advancement surgery can provide effective enlargement and stabilization of the airway, the potential benefits must be cautiously weighed against the potential increased risks of complications, longer recovery, and changes in the cosmetic appearance of the face.

What should I know before considering surgery?

Surgery is an effective and safe treatment option for many patients with snoring and sleep apnea, particularly those who are unable to use or tolerate CPAP. Proper patient and procedure selection is critical to successful surgical management of obstructive sleep apnea. Talk to one of our ENT doctors for a complete evaluation and to learn what treatment may be best for you.

Pediatric Sleep Disordered Breathing /Obstructive Sleep Apnea

Overview of Pediatric Sleep Disordered Breathing

Sleep-disordered breathing (SDB) is a general term for breathing difficulties occurring during sleep. SDB can range from frequent loud snoring to Obstructive Sleep Apnea (OSA) a condition involving repeated episodes of partial or complete blockage of the airway during sleep. When a child’s breathing is disrupted during sleep, the body perceives this as a choking phenomenon. The heart rate slows, blood pressure rises, the brain is aroused, and sleep is disrupted. Oxygen levels in the blood can also drop.

Approximately 10 percent of children snore regularly and about 2-4 % of the pediatric population has OSA. Recent studies indicate that mild SDB or snoring may cause many of the same problems as OSA in children.

Could my child have Obstructive Sleep Apnea?

The most obvious symptom of sleep disordered breathing is loud snoring that is present on most nights. The snoring can be interrupted by complete blockage of breathing with gasping and snorting noises and associated with awakenings from sleep. Due to a lack of good quality sleep, a child with sleep disordered breathing may be irritable, sleepy during the day, or have difficulty concentrating in school. Busy or hyperactive behavior may also be observed. Bed-wetting is also frequently seen in children with sleep apnea.

A common physical cause of airway narrowing contributing to SDB is enlarged tonsils and adenoids. Overweight children are at increased risk for SDB because fat deposits around the neck and throat can also narrow the airway. Children with abnormalities involving the lower jaw or tongue or neuromuscular deficits such or cerebral palsy have a higher risk of developing sleep disordered breathing.

Potential consequences of untreated pediatric sleep disordered breathing

Social: Loud snoring can become a significant social problem if a child shares a room with siblings, at sleep-overs, or summer camp.

Behavior and learning: Children with SDB may become moody, inattentive, and disruptive both at home and at school. Sleep disordered breathing can also be a contributing factor to attention deficit disorders in some children.

Enuresis: SDB can cause increased nighttime urine production, which may lead to bed-wetting.

Growth: Children with SDB may not produce enough growth hormone, resulting in abnormally slow growth and development.

Obesity: SBD may cause the body to have increased resistance to insulin or daytime fatigue with decreases in physical activity. These factors can contribute to obesity.

Cardiovascular: OSA can be associated with an increased risk of high blood pressure or other heart and lung problems.

How is sleep apnea diagnosed?

Sleep disordered breathing in children should be considered if frequent loud snoring, gasping, snorting, and thrashing in bed or unexplained bed-wetting is observed. Behavioral symptoms can include: changes in mood, misbehavior, and poor school performance. Not every child with academic or behavioral issues will have SDB, but if a child snores loudly on a regular basis and is experiencing mood, behavior, or school performance problems, sleep disordered breathing should be considered. If you notice that your child has any of those symptoms, have them examined by one of our ENT physicians. Sometimes physicians will make a diagnosis of sleep disordered breathing based on history and physical examination. In other cases, such as in children suspected of having severe OSA due to craniofacial syndromes, morbid obesity, or neuromuscular disorders or for children less than 3 years of age, additional testing such as a sleep test may be recommended.

The sleep study or polysomnogram (PSG) is an objective test for sleep disordered breathing. Wires are attached to the head and body to monitor brain waves, muscle tension, eye movement, breathing, and the level of oxygen in the blood. The test is not painful and is generally performed in a sleep laboratory or hospital. Sleep tests can occasionally produce inaccurate results, especially in children. Borderline or normal sleep test results may still result in a diagnosis of SDB based on parental observations and clinical evaluation.

Treatment for sleep disordered breathing

Enlarged tonsils and adenoids are a common cause for SDB. Surgical removal of the tonsils and adenoids (T&A) is generally considered the first line of treatment for pediatric sleep disordered breathing if the symptoms are significant and the tonsils and adenoids are enlarged. Of the over 500,000 pediatric T&A procedures performed in the U.S. each year, the majority are currently being done to treat sleep disordered breathing. Many children with sleep apnea show both short and long- term improvement in their sleep and behavior after T & A.

Not every child with snoring should undergo T&A as the procedure does have risks. Potential problems can include anesthesia or airway complications, bleeding, infection, and problems with speech and swallowing. If the SDB symptoms are mild or intermittent; academic performance and behavior is not an issue; the tonsils are small; or the child is near puberty (tonsils and adenoids often shrink at puberty), it may be recommended that a child with SDB be watched conservatively and treated surgically only if symptoms worsen.

Recent studies have shown that some children have persistent sleep disordered breathing after T & A. A post-operative PSG may be necessary after surgical intervention, especially in children with persistent symptoms or increased risk factors for persistent apnea after T & A such as obesity, craniofacial anomalies, or neuromuscular problems. Additional treatments such as weight loss, the use of Continuous Positive Airway Pressure (CPAP) or additional surgical procedures may sometimes be required.

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