Obstructive Sleep Apnea (OSA)

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OSA & Snoring Topics

• Snoring

• Obstructive Sleep Apnea

• Nasal Obstruction

• Tonsillectomy & Adenoidectomy

If you are already familiar with obstructive sleep apnea (OSA), skip down to treatment.

Obstructive Sleep Apnea (OSA) is a serious medical condition where one's own throat and nasal tissues collapse to the point where air movement is very nearly or completely obstructed (ie, your own body is choking you). OSA not only prevents you from having a good night's rest and ability to stay awake during the daytime, but it also increases the risk of heart attack, stroke, hypertension, and even death. OSA affects patients of all different ages from infants to adults.

OSA may be suspected in a person if you have one or more of the following symptoms (Watch Video):

Severe snoring (there are procedures to address this specifically)
Feeling tired during the daytime
Morning headaches
Restless sleep
Waking up repeatedly throughout the night
Loved ones note that you literally stop breathing repeatedly throughout the night
Sore throat in the mornings

In order to determine whether you have OSA or not, a sleep study is required (video of a sleep study shown below).

Once a sleep study documents that you have OSA, treatment is mandated given the various serious medical conditions it can cause adversely affecting your overall health.

In children, the treatment for OSA is always removal of the tonsils & adenoids first (standard of care).

In adults, the treatment protocol is a bit more complicated. Treatment for OSA in adults is geared towards keeping the airway open by:

Forcing air into you via face mask (ie, CPAP or BiPAP machines). This treatment is considered the gold-standard.
Making the airway larger preventing collapse via surgery (see the list of surgeries below)
Oral appliance obtained through your dentist (medical grade) or over-the-counter (which forces your tongue and jaw forward preventing collapse)
Losing weight is also very helpful as fat deposits occur in the throat which does narrow and increase the risk of collapse.
Making sure you are not hypothyroid

The key thing to remember regarding surgical options for OSA is that multiple surgical procedures may be required to thoroughly address obstruction at different levels of the airway (nose, oral cavity, and tongue/throat). Why? The best analogy to use is a pipe through which water flows. Imagine this pipe has 3 clogs in it. Improving water flow will not occur until ALL THREE clogs are removed. The three clogs in a human contributing to OSA include nasal factors, oral cavity factors, and tongue collapse against the back of the throat. Each individual may have one or all 3 contributing to the OSA and it is up to the ENT to determine where the clogs are and discuss the chances of improvement if not cure with various surgical procedures. In the properly selected patient, significant improvement if not OSA cure will occur (ie, not all patients are candidates for surgical treatment).

Airway Level	Surgery to Correct	Over-The-Counter Products That May Help
Nasal Level	Adenoidectomy for adenoid hypertrophy Septoplasty for deviated septum Turbinate Reduction for turbinate hypertrophy	Breathe Rite Strips Nasal Decongestants Nasal Valve Expanders
Oral Cavity Level	Tonsillectomy for tonsillar hypertrophy Uvulopalatopharygnoplasty (UPPP) for uvulo-palatal hypertrophy and retro-lingual collapse Mandibular-maxillary advancement	Sleeping on your side
Tongue Level	Base of tongue reduction Lingual Tonsillectomy Thyro-Hyoid Advancement (THA) Repose Procedure (Genio-glossal advancement) (GA) Genio-hyoid advancement (GHA) Mandibular-maxillary advancement (MMA)	OTC Oral Appliances Medical Grade Oral Appliances
ALL Levels	Trach

Indeed, in a recent study, the most common airway obstruction (ignoring nasal level) was mixed involving the soft palate and tongue base (43.5%), followed by soft palate alone (34%), and tongue base alone (22.5%). Reference (Arch Otolaryngol Head Neck Surg. 2009;135[2]:168-172). Of note, our office performs all the listed procedures EXCEPT for GA, GHA, and MMA.

For more information, Dr. Kasey Li in Palo Alto, CA has a good website going over various sleep apnea surgical options.

Financial Considerations

ONLY in adults, in order for insurance to pay for any type of OSA surgical procedure(s) involving the oral cavity and tongue/throat level, a strict protocol must be followed. These steps have been set by some (but not all) health insurance plans. The steps to follow are as follows.

Sleep Study (required by all)
CPAP Use for at least 3 months (required by all)
Letter from pulmonologist documenting (required by some):
- Failure of CPAP use and reasonable intervention to try and allow for CPAP tolerance
Use of an oral appliance/dental device tried and failed if applicable (required by some)
Letter from your primary care doctor documenting the following (required by some):
- Documentation of height and weight over time.
- Documentation to support that weight loss has been tried and failed if applicable.

IF everything above has been accomplished and AHI score is >10, only than are surgical options considered. Most insurances require at least the sleep study and 3 months of CPAP trial. An increasing number are now requiring the other steps to also be obtained.

The only surgical procedures that can be performed without going through these steps are surgeries to address nasal obstruction (nasal level).

If snoring and/or obstructive sleep apnea is affecting your quality of life, please contact our office for an appointment.

Commonwealth Sleep Center (Gainesville, VA), Nova Sleep Center (Warrenton, VA), 1st Class Sleep Center (Gainesville, VA), and Fauquier Health Sleep Center (Warrenton, VA) performs sleep studies in our area. The video below was done at the Commonwealth Sleep Center in Gainesville, VA. If you are unable to view video, click here.