The most common kind of sleep apnea is called Obstructive
Sleep Apnea Syndrome. Sleep apnea means "cessation of
breath." It is characterized by repetitive episodes of upper
airway obstruction that occur during sleep, usually associated
with a reduction in blood oxygen saturation. In other words, the
airway becomes obstructed at several possible sites. The upper
airway can be obstructed by excess tissue in the airway, large
tonsils, a large tongue and usually includes the airway muscles
relaxing and collapsing when asleep. Another site of obstruction
can be the nasal passages. Sometimes the structure of the jaw
and airway can be a factor in sleep apnea.
What are the symptoms?
• excessive daytime sleepiness
• Frequent episodes of obstructed breathing during sleep.
(The patient may be unaware of this symptom -- usually the bed
partner is extremely aware of this).
Associated features may include:
• loud snoring
• morning headaches
• un-refreshing sleep
• a dry mouth upon awakening
• chest retraction during sleep in young children (chest
pulls in)
• high blood pressure
• overweight
• irritability
• change in personality
• depression
• difficulty concentrating
• excessive perspiring during sleep
• heartburn
• reduced libido
• insomnia
• frequent nocturnal urination (nocturia)
• restless sleep
• nocturnal snorting, gasping, choking (may wake self up)
• rapid weight gain
• confusion upon awakening
How serious is sleep apnea?
It is a potentially life-threatening condition that requires immediate
medical attention. The risks of undiagnosed obstructive sleep
apnea include heart attacks, strokes, impotence, irregular heartbeat,
high blood pressure and heart disease. In addition, obstructive
sleep apnea causes daytime sleepiness that can result in accidents,
lost productivity and interpersonal relationship problems. The
severity of the symptoms may be mild, moderate or severe.
How does the doctor determine if I have Obstructive Sleep
Apnea?
A sleep test, called polysomnography is usually done to diagnose
sleep apnea. There are two kinds of polysomnograms. An overnight
polysomnography test involves monitoring brain waves, muscle tension,
eye movement, respiration, oxygen level in the blood and audio
monitoring. (for snoring, gasping, etc.) The second kind of polysomnography
test is a home monitoring test. A Sleep Technologist hooks you
up to all the electrodes and instructs you on how to record your
sleep with a computerized polysomnograph that you take home and
return in the morning. They are painless tests that are usually
covered by insurance.
How is Sleep Apnea treated?
Mild Sleep Apnea is usually treated by some behavioral changes.
Losing weight, sleeping on your side are often recommended. There
are oral mouth devices (that help keep the airway open) on the
market that may help to reduce snoring in three different ways.
Some devices (1) bring the jaw forward or (2) elevate the soft
palate or (3) retain the tongue (from falling back in the airway
and blocking breathing). Sleep Apnea is a progessive condition
(gets worse as you age) and should not be taken lightly.
Moderate to severe Sleep Apnea is usually treated with a C-PAP
(continous positive airway pressure). C-PAP is a machine that
blows air into your nose via a nose mask, keeping the airway open
and unobstructed. For more severe apnea, there is a Bi-level (Bi-PAP)
machine. The Bi-level machine is different in that it blows air
at two different pressures. When a person inhales, the pressure
is higher and in exhaling, the pressure is lower. Your sleep doctor
will "prescribe" your pressure and a home healthcare
company will set it up and provide training in its use and maintenance.
Some people have facial deformities that may cause the sleep apnea.
It simply may be that their jaw is smaller than it should be or
they could have a smaller opening at the back of the throat. Some
people have enlarged tonsils, a large tongue or some other tissues
partially blocking the airway. Fixing a deviated septum may help
to open the nasal passages. Removing the tonsils and adenoids
or polyps may help also. Children are much more likely to have
their tonsils and adenoids removed.
TRACHEOSTOMY
The only available treatment until the early 1980's was a tracheostomy.
A tracheostomy is a surgical procedure where a small hole is cut
in the neck and a tube with a valve is inserted into the hole.
During the day the valve is closed so the person can speak. At
night, the valve is opened, thus avoiding the obstructions. This
procedure is only used today as a last resort or to avoid respiratory
distress, or other serious medical complications (You would have
to be extremely sick to require this).
UVULOPALATOPHARYNGOPLASTY (UPPP)
What is available today in the way of surgery is the uvulo-palato-pharyngoplasty
(UPPP). What does this mean? The uvulo refers to the uvula, that
fleshy thing hanging in the back of your throat, palato refers
to the palate, and pharyngoplasty means plastic surgery of the
pharynx (the pharynx is the joint opening of the gullet and the
windpipe). The uvula is removed along with excess tissue. This
surgery is usually done for patients who can't tolerate nasal
CPAP. This surgery has mixed reviews, it helps in around 50% who
have the surgery and in others it does not help at all or it helps
only partially and the patient may still need to use the C-PAP
machine due to scar tissue.
MANDIBULAR MYOTOMY
A procedure called mandibular myotomy was crafted by Drs. Nelson
Powell and Robert W. Riley who are associated with the Stanford
University Sleep Disorders Center. This procedure, mandibular
myotomy ( mandibular = relating to the lower jaw bone, and myotomy
= surgical division of a muscle) with genioglossis (chin and tongue)
advancement, involves cutting a rectangular piece of bone in the
anterior (front part) portion of the mandible (jaw) to which the
tongue muscles are attached. At that point, the rectangular piece
is pulled outward, rotated 90 degrees and attached so it overrides
the defect produced by the osteotomy (cutting of bone), where
it is reattached. This pulls the tongue forward six to ten millimeters
and almost always eliminates the sleep-related obstruction.
These surgeries requires much research and consideration before
you undertake it. They should only be performed by surgeons with
considerable experience and documented training and skill in both
ENT surgery and maxillofacial surgery.
LASER ASSISTED UVULOPLASTY (LAUP)
There is also Laser Assisted Uvuloplasty (LAUP), is a surgical
procedure to remove the uvula and surrounding tissue to open the
airway behind the palate. This procedure has been used to relieve
snoring. It has been used somewhat successfully in treating sleep
apnea. Always make sure you have a doctor who has done the procedure
many times and is preferrably extremely knowledgeable about sleep
apnea. Ask lots of questions and do your homework!
RADIO FREQUENCY (RF) PROCEDURE OR SOMNOPLASTY
The newest surgical procedure for snoring and sleep apnea is called
somnoplasty. The U.S. Food and Drug Administration has approved
a treatment for snoring that uses radio waves to shrink tissue
in air passages and eliminate snoring. The procedure is called
radiofrequency volumetric tissue reduction of the palate.
A new treatment for sleep apnea, radiofrequency volumetric reduction
of the tongue has been approved by the FDA.
The radiofrequency treatment involves piercing the tongue, throat
or soft palate with a special needle (electrode) connected to
a radio frequency generator. The inner tissue is then heated to
158 to 176 degrees, in a procedure that takes approximately half
an hour. The inner tissues shrink, but the outer tissues, which
may contain such things as taste buds, are left intact. Several
treatments may be required.
Unfortunately, at this time the procedure is so new that insurance
companies are not covering it yet. It is still seen as an experimental
procedure.
If you are still interested in the procedure, call Stanford Facial
Reconstructive Surgery at (650) 328-0511.
NASAL OBSTRUCTION
Sometimes the nasal passages are a site of obstruction. It can
be from a deviated septum, large turbinates (nasal bones) or a
collapse of the nostril area, called the nasal valve. The Radiofrequency
procedure (see above) can effectively reduce the size of the turbinates.
Septoplasty surgery can fix a deviated septum and nasal valve
surgery will take care of nostril collapse.
source: Stanford University
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