Sleep Apnoea

Whilst simple snoring is socially disruptive, obstructive sleep apnoea (OSA) has serious medical ramifications, including hypertension, heart disease and cerebro-vascular disease.


Current Recommendations from Havas ENT Clinics

Snoring and mild OSA +/- tongue base ptosis ⇒ oral appliances.

Mild to moderate OSA⇒ nCPAP or oral appliances.

Moderate to severe OSA⇒ nCPAP.


Sleep Apnoea Treatments

Prior to 1981, the treatment for OSA was tracheotomy. In 1981, two other treatment options became available. Colin Sullivan reported on the application of nasal continuous positive airway pressure (nCPAP) producing results similar to that of tracheotomy. Coincidentally, in that year Fujita et al introduced uvulopharyngopalatoplasty (UPPP) as a new surgical modality for the treatment of snoring and mild OSA.

This operation was subsequently modified by Kamami in 1994, and further recently modified by the introduction of laser-assisted UPPP.

Subsequent surgical options include advancement of the maxilla and the mandible, somnoplasty (which is the application of radiofrequency energy to the soft palate and/or the base of the tongue) and a variety of tongue-base suspension procedures, either by way of soft tissue to bone anchor (like the Repose System) or by formal genial tubercle advancement procedures.

Uvulopharyngopalatoplasty (UPPP)

UPPP is an operation designed primarily to shorten the palate/uvula and widen the oropharyngeal isthmus. It involves trimming the soft palate and uvula often associated with removing the tonsils if they are still present.

It is done under general anaesthetic and the cutting implement used is often a carbon dioxide laser as this has been shown to marginally reduce the pain associated with this procedure.

Similar results have been reported for conventional surgical techniques as compared to laser-assisted techniques.

Advantages of UPPP:

  • controlled resection of uvula and soft palate;
  • ability to widen oropharyngeal isthmus.

Disadvantages of UPPP:

  • requires hospital admission;
  • usually requires a general anaesthetic;
  • an extremely painful procedure with significant discomfort lasting for 5 to 7 days.

UPPP Results:

Short-term results are good for simple snoring, in the order of 80 per cent. Five year follow-up results drop below 50% in most studies.

The operation takes one hour of operating time and is usually associated with two days of hospitalisation, essentially for pain control. During the two days of hospitalization, patients are given what is called Patient Controlled Analgesia (PCA) to facilitate pain control and to get them eating and drinking as quickly and as efficiently as possible.

Most of the UPPP performed by A/Prof Havas are at St Luke's Hospital, Potts Point, which has particular expertise in all surgeries related to snoring and sleep apnoea.


Somnoplasty

Somnoplasty involves the application of radiofrequency energy to the soft palate and/or to the base of the tongue.

Advantages of Somnoplasty:

  • it can be performed under local anaesthesia;
  • hospitalization is not required;
  • It is much less painful than UPPP.

Disadvantages of Somnoplasty:

  • The disposable needle used to deliver the energy is expensive, in the order of $500.00;
  • The potential long-term downside of this procedure is loss of intrinsic palatal muscle due to scarring, with potential functional deficit and/or thinning of the palate.

Somnoplasty Results:

The results of radiofrequency ablation are comparable to that of UPPP, but somewhat less predictable. The scarring required to achieve an optimal result takes 12 to 14 weeks. Long-term results of somnoplasty are starting to emerge and are similar to conventional or laser-assisted UPPP.


Tongue Base Suspension with Soft Tissue to Bone Anchor

There is a commercially available Repose System, which involves putting a screw on the inside of the jaw and then a suture through the base of the tongue, bringing the base of the tongue forward and tying it to the screw.

The procedure is usually performed under anaesthesia in an operating room setting. The anaesthesia can be neurolept and local or general anaesthetic.

Advantages:

  • effective for snoring due to tongue-base ptosis and for mild to moderate OSA.

Disadvantages:

  • the soft tissue sling is uncomfortable and patients have complained of mild dysarthria and occasionally dysphagia with the sling in place.

Results:

Results in terms of reducing snoring are comparable to UPPP, however the procedure has been associated with significant patient intolerance.


Genial Tubercle Advancement

This is a relatively new operation and involves formally advancing the genial tubercle and the attached genioglossus muscle, pulling the tongue base forward.

Advantages:

  • effective and controlled procedure for snoring due to tongue-base ptosis and for mild to moderate OSA.

Disadvantages:

  • requires major surgical intervention involving orthognathic surgery under general anaesthesia.
  • the perioperative pain and discomfort is moderate.

Results:

Short-term results are good; not only for snoring but also for mild to moderate OSA.

At this stage there are no long-term results.


Formal Mandibular and Maxillary Advancement

This involves major surgery for severe cases of OSA in those patients who are not capable or willing to comply with nCPAP.

It often requires a tracheotomy and a period of time in intensive care and is not to be recommended lightly.


Oral Appliances

The majority of oral appliances work to achieve anterior mandibular positioning, opening the posterior airway by advancing the mandible on the maxilla and repositioning the tongue and the soft palate in a more forward position.

Advantages:

  • oral appliances have been shown to be effective, not only for snoring but for mild to moderate OSA.

Disadvantages:

  • the appliances are initially not well tolerated;
  • the appliance is moderately expensive ($700.00);
  • potential problems with temporomandibular joint and/or tooth pain.

Results:

There are no long-term compliance studies with oral appliance, but compliance at around 70% has been reported at the three and a half year mark.

Four randomised control studies and 3 crossover studies have shown that oral appliance therapy is comparable to nCPAP in the management of mild to moderate OSA.

In 3 crossover trials performed comparing oral appliances to nCPAP the majority of patient’s preferred oral appliances.

Diagnosis of the Obstructive Sleep Apnoea

Diagnosis of the obstructive segment can be done acoustically or directly.

  • Acoustic analysis is based on the fact that the soft palate vibrates at a certain fundamental frequency and airway constriction caused by tongue-base ptosis causes sound at a different fundamental frequency. By acoustically analysing the fundamental frequencies in snoring a proportion of turbulence can be attributed to either, or both, of these two sites.

  • Direct visual diagnosis of the obstructive segment is usually done using flexible fibreoptic rhinolaryngoscopy with the patient seated and/or prone. The patient is asked to breathe deeply with mouth open and mouth closed and the narrowest part of the airway is documented. Some institutions use sleep nasendoscopy in an attempt to mimic profound muscle relaxation associated with rapid eye movement sleep, to accurately diagnose the collapsing segment, but no literature exists supporting this affording any benefit over awake, prone nasendoscopy.