Options for Sleep Apnea and Snoring

From the 15th Annual Advances in Diagnosis and Treatment of Sleep Apnea and Snoring, presented February 13-15, 2009, by the University of Pennsylvania School of Medicine, the Penn Sleep Centers of the University of Pennsylvania
Health System, and the University of California, San Francisco, School of Medicine

Educational Objectives

The goal of this program is to improve management of sleep-disordered breathing. After hearing and assimilating this pro­gram, the clinician will be better able to:  

1.   Describe surgical outcomes for genioglossus advancement (GA), hyoid advancement (HA), and uvulopalatopharyn­goplasty (UPPP) for treating obstructive sleep apnea (OSA).

2.   Discuss outcomes and limitations of maxillomandibular advancement (MMA) surgery.

3.   Assess factors that create turbulent air flow and sound production in order to evaluate and treat snoring.

4.   List advantages and disadvantages of surgical procedures  for alleviating snoring and OSA.

5.   Explain behavioral, dietary, and pharmacologic methods for weight loss in patients with OSA.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of in­terest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Foster has received re­search funding from Orexigen Therapeutics, is a consultant for Amylin Pharmaceuticals, Arena Pharmaceuticals, and GI Dy­namics, and is on the science advisory boards of Nutrisystem and ConAgra Foods. Drs. Li and Kezirian and the planning committee reported nothing to disclose.

Acknowledgments

Drs. Li, Kezirian, and Foster were recorded at the 15th Annual Advances in Diagnosis and Treatment of Sleep Apnea and Snoring, sponsored by the University of Pennsylvania School of Medicine, the Penn Sleep Centers of the University of Pennsylvania Health System, and the University of California, San Francisco, School of Medicine, and held February 13-15, 2009, in Orlando, FL. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Hypopharyngeal Surgery and Maxillomandibular Advancement

Kasey K. Li, MD, Adjunct Associate Clinical Professor of Sleep Medicine, Department of Psychiatry, Stanford University School of Medicine, Stanford, CA

Defining surgical success: aimed at reducing severity of obstructive sleep apnea (OSA); continuous positive airway pres­sure (CPAP) responder (>70% of days with ³4 hr per day)  —»50% reduction; surgical responders  —  ³50% reduction and respiratory disturbance index (RDI; lower than 15 or 20 events/hr postoperatively); rationale for surgery  —  support tongue; x-rays  —  obtain before all procedures

Genioglossus advancement (GA):  avoid roots of mandibular teeth; make 4-wall parallel cut to isolate attachment of  genioglossus muscle, turn rectangular fragment (60° or 90°, depending on bone overlap), remove excess, and insert screw to stabilize; before surgery  —  palpate for muscle insertion; avoid tooth root injury; minimize risk for fracture (eg, avoid surgery in patients with short mandibles); fixation  —  use lag screw technique; closure  —two-layer; reapproximate mentalis muscle

Complications: injuries to teeth; failure to incorporate muscle; muscle avulsion occurs by pulling fragment too forcefully; loss of fixation; mental nerve injury; mandibular fracture; edema  of floor of mouth —  happens often (manage hyperten­sion); facial changes  —  unlikely

Hyoid advancement (HA): make straight 4- to 5-cm horizontal incision above hyoid bone; Bovie dissection  —  straight downward to hyoid bone; isolate hyoid bone, dissecting some muscle to allow advancement; secure to thyroid notch; monitor hemostasis; avoid superior laryngeal nerve injury; limited myotomy to manipulate and mobilize hyoid bone; fixation  —  4-0 braided polyester sutures for stability; closure  —  use surgical drain to avoid seroma

Complications: hyoid bone fracture  —  especially in women; loss of fixation  —  “click” can occur with improper stabiliza­tion; dysphagia  —  more likely in older patients

Tongue base suspension (eg, Repose system): incision  —extraoral more secure than intraoral; dissection  —  blunt; place screw into mandible, loop suture through tongue, and tighten to secure it to screw; dressing  —  pressure dressing impor­tant; drain not needed; complications  —  injury to mandibular teeth (from placement of screws), hematoma, tongue excur­sion problems, and loss of fixation

Surgical outcomes: Journal of Oral and Maxillofacial Surgery [JOMS] 1999  —  uvulopalatopharyngoplasty (UPPP) and GA; »70% success (RDI to <20); 2 infections from GA and 1 incidence of postoperative bleeding from UPPP; Otolaryngology  –  Head  and Neck Surgery [OHNS] 1993  —  UPPP, GA, and HA; 61% success rate (mild OSA); overweight group; objective result not likely to­day; American Journal of Respiratory and Critical Care Medicine [AJRCCM] 2000  —  UPPP, GA, HA; 22.7%; severe OSA; mid­dle-aged group; improvement limited; lingual hematoma and GA fragments resorbed (ie, not much muscle captured); Singapore Medical Journal 2001  —  »10 of 13 patients with significant improvement (RDI reduced from 50 to 15); wound infection, dehis­cence, and paresthesia of lower teeth; Archives of Otolaryngology Head and Neck Surgery [AOHNS] 2002  —  35% success (ex­pected); RDI 60 to 45 and lowest oxygenation saturation (LSAT) improved; patients with mild OSA improved more than those with severe OSA; AOHNS 2005  —  obese patients (body mass index [BMI] >32); 5 of 29 with successful objective results (based on polysomnography [PSG]); low success rate probably due to high BMI

Tongue base suspension (Repose): OHNS 2000  —  16 patients; RDI reduced from 35 to 17; complications included infection and hematoma; Laryngoscope 2006  —  55 patients (UPPP/tongue base) with mean RDI 52; 78% achieved success at 3 yr; Journal of Laryngology and Otolaryngology 2002  —  19 patients (palatopharyngoplasty[PPP]/tongue base); 8 of 12 successful, based on postoperative PSG; BMI »31; complications included transient velopharyngeal inade­quacy and limited anterior excursion of tongue

Limitations of GA, HA, and tongue base suspension: do not affect lateral wall; difficult to predict patient outcome; suc­cess inversely related to OSA severity and BMI

Temperature-controlled radiofrequency (TCRF) tongue base reduction: OHNS 2002  —  18 patients (failed previous surgery); initial RDI reduction; by 2-yr follow-up, recurrence of hypopnea; apnea-hypopnea index (AHI) unchanged; OHNS 2001  —  multicenter trial; »50 patients; sequential TCRF treatment; improvement in RDI and LSAT; few complica­tions (eg, abscesses, edema); Acta Oto-laryngologica (Germany) 2002  —  aggressive, shorter treatment periods; 10 of 18 showed improvement, RDI (30s to 20s) and LSAT improved; palate, tonsils, and tongue (Laryngoscope 2003)  —   »15 pa­tients; improvement in Epworth Sleepiness Score (ESS), snoring scale, and RDI (in 5 of 15, RDI <20); palate and tongue (Laryngoscope 2004)  —  22 patients; improved AHI (by 50%), quality of life (QOL), daytime somnolence, and reaction time; no improvement in LSAT; excluding severe group  —  compared to 11  (CPAP) patients; CPAP improved AHI, QOL, and daytime somnolence, but no change in reaction time; limitations of procedure  —  similar to those for UPPP, GA, and HA

Maxillomandibular advancement (MMA) surgery: moving upper and lower jaw forward causes large opening in airway; some patients continue to have OSA; maximize advancement  —  few millimeters not sufficient; JOMS 2001  —  »60% suc­cess; improved LSAT and RDI; Chest 1999 (Atlanta)  —  100% success; reduction in weight and OSA severity; 2-wk re­covery (4-6 wk more likely); AJRCCM 2000 (France)  —  75% success rate; weight loss and improved RDI; Stanford study  —  500 patients (300 reviewed retrospectively; 200 postoperatively); 88% success rate; RDI reduction >50%; im­proved LSAT and QOL; 89% success in 306 patients, based on postoperative polysomnography; complications  —transient paresthesia of lower teeth and lip; 10% to 15% permanent paresthesia (more likely in older patients); facial changes  —  inevitable; malocclusion  —possible; »5% need postoperative orthodontia; infection  —possible but unlikely; hospital stay  —  2 to 3 days; blood loss  —  300 to 400 mL; surgery time  —  3 to 4 hr

Long-term outcomes: 40 patients with severe OSA  —  90% success rate after 4 to 5 yr; German study  —  at 2 yr, 12 of 15 patients improved

Conclusions: encourage patients to use CPAP before deciding on surgery; however, CPAP not only workable treatment; re­liable surgical options  —  MMA, tonsillectomy (for large tonsils), and pharyngoplasty; severe OSA  —  with exception of MMA, no surgery; combine surgery with oral appliance; nasal surgery  —  promotes CPAP comfort

What Are the Best Treatment Options for Snoring?

Eric J. Kezirian, MD, Assistant Professor, Department of Otolaryngology  –  Head and Neck Surgery, University of California, San Francisco, School of Medicine

Overview of snoring: goal of history and physical examination (PE)  —  determine factors that create turbulent air flow and sound production (not synonymous); treatment  —  behavioral (eg, weight loss, avoidance of supine position and alcohol or sedatives); CPAP  —  not recommended for primary snoring without OSA; anatomy  —  medical, nonsurgical, surgical, and oral appliances; treatment and outcomes  —  differ between snoring and OSA; effective treatment  —  directed at sound production and site of air­way narrowing (eg, nose, palate, hypopharynx)

Treatment of Snoring

Palate radiofrequency (RF) therapy: used to treat turbinates, palate, tonsils, and tongue; various methods of RF energy delivery (eg, monopolar, bipolar); premise  —  deliver thermal energy to create tissue injury which turns into fibrosis; advantage  —  minimally invasive; titratable (feedback on outcomes); outcomes  —  primarily subjective (objective out­comes equivocal); technologies differ, with little direct comparison; effectiveness similar to that of other stiffening pro­cedures; patient selection critical

Complications: uncommon in literature review; major  —significant airway compromise; infection requiring drainage (1 of 669 patients); moderate (»1% of all patients)  —hemorrhage, palatal fistula, nerve paresis or paralysis

Laser-assisted uvulopalatoplasty (LAUP): serial reshaping and removal of tissue from soft palate and oropharynx; British method  —  involves ablation of mucosa of anterior soft palate; uses various lasers or cautery-assisted method; LAUP technique  —  patient with normal or slightly thickened uvula and normal palate; trenches occur with removal of portion of uvula; can revise trenches if needed (adding British central lesion); studies  —  describe selection criteria or specific tech­nique (eg, timing of sessions); find LAUP less painful than PPP but more painful than palate RF treatment

Outcomes: snoring  —  bed partner ratings usually improve, but objective data limited (decrease of »3.8 dB); other outcomes  —  improvements in QOL (including in partner) and Epworth sleepiness score

Cautery-assisted palatal stiffening: removal of mucosa and submucosa from oral surface of soft palate; defining contour of uvular muscle; resecting some tissue, and allowing healing process; outcomes  —  92% resolution of snoring (subjec­tive); improvement but not complete resolution of OSA; Pang and Terris modified version  —  additional removal of strip of mucosa and submucosal tissue from oral surfaces of soft palate to create favorable vector; outcomes  —  6 of 8 patients experienced improved snoring (subjective) over 90-day period

Injection snoreplasty (IS): technique using sodium tetradecyl sulfate (eg, Sotradecol); selected patients with mild sleep ap­nea and AHI <10 or primary snoring; evaluation  —  have patient reproduce snoring sound while awake (determine whether patients can produce palatal flutter); outcome  —subjective improvement; follow-up  —  50% of IS-treated patients could not reproduce palatal-flutter snoring; remaining 50% had increase in palatal flutter frequency, suggesting changes in palatal stiffness; some relapse; 50% ethanol technique  —  may be used in place of sodium tetradecyl sulfate; results not as impressive (ie, 15% reduction in number of palatal snores)

Pillar procedure: 3 polyethylene implants inserted into soft palate musculature at junction of hard and soft palate; host response turns into fibrosis, which decreases airway compromise and snoring; for primary snoring and mild to moder­ate OSA; efficacy  —  improved bed partner’s assessment and patient’s ESS score; objective measurements  —  no benefit seen across multiple measures (eg, snoring index, primary vibration frequency, maximum relative loudness); pillar as single modality  —  some benefit for patients with primary snoring or mild OSA; not helpful for moderate OSA; patient selection  —critical for snoring; palate  —  primary factor in sound production and creating turbulent airflow; select pa­tients with  — modified Mallampati position 1 or 2; BMI  £32; absent or relatively small tonsils; short or normal-length palate

Tongue RF: devices not cleared for primary snoring; speaker has performed in few patients; can be used (not preferred) if tongue is primary factor; treatment of tongue base and ventral tongue with TCRF; multiple lesions and treatment sessions at target energy level; no studies for primary snoring

Mandibular advancement devices: can significantly improve snoring; target hypopharyngeal and palatal airway; range in sophistication for OSA and primary snoring; multiple studies show objective improvement in snoring (eg, number of snores, intensity); most studies have not addressed patient selection; treatment potentially expensive

How to Achieve Weight Loss in Patients
with Sleep Apnea

Gary D. Foster, PhD, Professor of Medicine and Public Health, and Director, Center for Obesity Research and Educa­tion, Temple University School of Medicine, Philadelphia, PA

Behavioral and Dietary Treatments

Behavioral overview: pavlovian link  —  multitasking while eating leads patient to pair eating with activities, places (eg, go­ing to ballpark), thoughts, and emotions; activities then trigger and reinforce eating; therapy  —  aimed at breaking link and uncoupling behaviors; Diabetes Prevention Program (NEJM 2002)  —  3000 patients with impaired glucose tolerance fol­lowed 4 yr; given placebo, metformin, or lifestyle intervention; lifestyle changes decreased weight by »4% (»4 kg) at 4 yr and lowered risk for type 2 diabetes by »60%

Behavioral treatment: focus on antecedents (eg, how behaviors occur, triggers such as routine); record food intake  —  single most ef­fective change; changes behavior by increasing consciousness; 80% lose weight; predicts weight loss at 1 mo to 2 yr; identify spe­cific goals  —  how to eat less (eg, popcorn instead of potato chips); follow up at next treatment visit (reinforce concepts)

Low-carbohydrate (low-carb) diet: low-carb  &am