By Christopher Clark, MD
As Seen In Birmingham Medical News
Obstructive Sleep Apnea (OSA) is a common problem affecting nearly one-third of the adult population. The long-term health effects of untreated OSA are beginning to become established and are frightening: increased risk of cardiovascular disease, stroke, dementia, pulmonary hypertension.
The etiology of OSA is multifactorial and related to the interplay of anatomic obstruction as well as physiologic relaxation of the upper airway during sleep. The primary goal of treatment for OSA is to relieve anatomic obstruction of the upper airway. This has most commonly and most effectively been achieved by the use of continuous positive airway pressure (CPAP) therapy. There are, however, many difficulties with tolerance of CPAP which may be easily overcome after identifying and treating areas of often overlooked anatomic obstruction.
Otolaryngology (ENT) as a medical and surgical subspecialty has the unique opportunity to directly identify and treat upper airway obstruction as it may relate to nasal, nasopharyngeal, oropharyngeal, oral, or supraglottic anatomy. Specific sites of obstruction that may be identified with in-office flexible laryngoscopy include:
• Nasal obstruction resulting from: External/Internal valve collapse, nasal septal deviation, turbinate hypertrophy, chronic rhinosinusitis/nasal polyps, or adenoid hypertrophy
• Oropharyngeal obstruction, resulting from tonsillar hypertrophy, long/hypotonic soft palate, or retropulsion/collapse of the base of tongue
• Supraglottic obstruction resulting from lingual tonsillar hypertrophy, epiglottic cysts, etc
• Laryngeal or tracheal obstruction from upper airway stenosis
The widespread adoption of Drug Induced Sleep Endoscopy has allowed further qualification and quantification of upper airway obstruction and assists with identifying potential procedures that would most effectively improve CPAP tolerance. This simple, approximately 15 minute long procedure is performed in the operating room with the assistance of Anesthesiologists.
Titration of sedative medication which usually consist of propofol, midazolam and/or dexmedetomidine is administered until the physiological effects of sleep become manifest, namely the demonstration of upper airway obstruction. A flexible laryngoscope is then inserted into the nasal cavities and observation is undertaken at each potential level of obstruction. Any sites of obstruction would be appropriately documented and addressed either during the same anesthetic event, or catalogued and submitted for discussion with the patient to be addressed at another encounter.
Potential surgical treatment options for upper airway obstruction may include:
• Nasal: Nasal Valve Collapse Repair (Functional Rhinoplasty), Septoplasty, Turbinate Submucous Resection, Sinus Surgery for removal of polyps
• Oropharyngeal: Tonsillectomy, Uvulopalatopharyngoplasty (UPPP), Expansion Pharyngoplasty, Base of Tongue Suspension, Lingual Tonsillar Coblation, Hyoid Suspension
• Supraglottic/Glottic: Microsuspension laryngoscopy with removal of any obstructive lesions or masses. Upper airway stenosis is most commonly treated with endoscopic airway dilation.
Perhaps the most promising and unique procedure to treat OSA that is directly performed by ENT doctors involves the principle of hypoglossal nerve stimulation during sleep. Stimulation of the hypoglossal nerve provides tone to the intrinsic tongue musculature and prevents upper airway collapse in the first place.
INSPIRE is the only FDA-approved implantable device for the treatment of moderate to severe OSA. A small power source and sensor is placed during a short, outpatient surgery, and therapy may be initiated without the requirement of CPAP masks or hoses. Recent studies have demonstrated a 79 percent reduction in AHI (Apnea/Hypopnea Index), and five-year study data has maintained that reduction.
There are many variables in the treatment of OSA, including many sites of easily treatable obstruction. Simple ENT procedures may improve CPAP tolerance, or as in the case of Hypoglossal Nerve Stimulation, may free patients from CPAP masks and hoses entirely.
All patients evaluated in sleep clinics would benefit greatly from ENT evaluation as part of their multidisciplinary (Sleep Medicine, ENT, Dentistry/OMFS, Diet & Weight Management) workup for OSA treatment.