Obstructive Sleep Apnea Surgery

Addressing Sleep Apnea with ENT Tulsa Specialist Dr. Cordray

Sleep apnea: this is potentially a serious sleep disorder that Ears, Nose, Throat of ENT Tulsa sees frequently. It causes breathing to repeatedly start and stop. There are several types of sleep apnea, however obstructive sleep apnea is the one that we are most concerned with and the one that Dr. Scott Cordray would like to deal with today.

Apnea is defined as not breathing for more than 10 seconds as we are sleeping throughout the night. We have stages that we go through classically defined as stage 1, 2, 3, 4 and REM sleep, (rapid eye movement sleep). It’s during the 4th stage and rapid eye movement sleep (which is considered the deepest type of sleep) is when the apnea usually will occur. Although you’re sleeping, you’re not getting the deeper forms of sleep very well. That’s because when apnea occurs, it will stop you from continuing in the deeper forms of sleep and bring you back to stage 2 or 3. At Ears, Nose, Throat of ENT Tulsa, we explain this challenge to our patients.

You should know that as we sleep, we go through what we refer to as a sleep cycle. The sleep cycle involves rotating through each stage of sleep from stage 1, stage2, stage 3, stage4 and REM sleep. The cycle continues through the night repeating every hour and a half or so. However, in these deeper forms of sleep, apnea will disrupt your sleep and prematurely and send you back to stage 2 leaving you with very little time in deeper stages of sleep. This is what results in fatigue and the other symptoms the following day. Of note, Ears, Nose, Throat of ENT Tulsa now uses a newer classification of the sleep cycle but the above older classification explains it better in Dr. Cordray’s judgement.

Now even though you’ve been in bed with your eyes closed and asleep, you feel like you have slept very little. The most common symptom is daytime sleepiness or tiredness.  Loud snoring is a key symptom that is usually associated with obstructive sleep apnea.

Other problems or symptoms that can come from sleep apnea are high blood pressure, difficulty concentrating during the day, headaches, and awakening with a dry mouth or sore throat (that’s primarily from the snore wear). Instead of having our nose warm, humidifying and filtering the air, our mouth is primarily doing that. Other symptoms include awakenings that are accompanied by gasping or choking. Obviously, if you have observed episodes of breathing where it starts and stops, that could indicate obstructive sleep apnea. If your child, another family member or friend has any of the symptoms above, it would be advisable to ask your doctor about the possibility of having a sleep study conducted to help confirm and diagnose obstructive sleep apnea.  Ears, Nose, Throat of ENT Tulsa can recommend specific clinics that conduct the sleep studies if requested.

What causes obstructive sleep apnea is when the muscles in the back of your throat relax too much thus collapsing while breathing. It also occurs when the tongue relaxes with your other muscles when you fall asleep. The tongue then lapses into the airway and causes obstruction producing periods of apnea. This risk correlates with excess body weight. The more overweight you are the more narrow the airway will be which causes more collapse that can occur to the breathing pathway. As Ears, Nose, Throat of ENT Tulsa has witnessed with many of its patients, you can be born with a narrowed airway as well. The neck circumference is a key parameter we use to predict the diagnosis of obstructive sleep apnea

High blood pressure, nasal congestion with a deviated nasal septum or turbinate hypertrophy, and really anything that closes down the nasal airways can make you susceptible to obstructive sleep apnea. Smoking, diabetes, a family history of sleep apnea and asthma are all can be associated as well. Why is it important? From our experience at Ears, Nose, Throat of ENT Tulsa, complications can occur from obstructive sleep apnea. Why should you treat it?

Daytime fatigue and sleepiness can obviously be very detrimental in work. For example, a truck driver or someone else that has to pay attention as part of their jobs would be at high risk for accidents. Obstructive sleep apnea can lead into hypertension and increase the risk of heart failure. Researchers that ENT Tulsa specialists rely upon have also found a connection between obstructive sleep apnea and certain eye conditions such as glaucoma.

The other risk that we typically don’t think about involves sleep-deprived partners. The loud snoring frequently will keep the partner awake and is maybe one of the most common reasons that I’ve seen someone in the office. It is common to have the sleep partner send the patient in for treatment.

A sleep study is helpful diagnose obstructive sleep apnea. There are sleep centers that will upon Ears, Nose, Throat of ENT Tulsa physician’s order, hook the patient up and monitor their blood pressure, their pulse oxygenation, and their heart rhythm along with many other factors. They will do this at night for at least 4 to 6 hours to get a good idea of how the patient sleeps and determine if they have obstructive sleep apnea. If they have apnea, we can further define it as mild, moderate or severe category. Of course, this will help determine what form of treatment is indicated.

The treatment can be as simple as a mouth guard that helps keep the oropharyngeal airway open by forcing the tongue down and forward instead of it lapsing back into the throat causing obstruction. Sometimes more treatment is needed and that’s where CPAP may be beneficial.

CPAP stands for Continuous Positive Airway Pressure; it’s the pressure from the machine that will keep the airway open all night. One of the issues related to failure is the requirement of wearing a mask attached to a small bedside machine. This is not tolerated by some. It can give a claustrophobic feeling. It also it difficult to keep on the face if one flops around when they sleep.  Other problems can be the pressure has to be so high that is uncomfortable upon exhalation. Many times we will suggest BiPAP. BiPAP will lower the pressure for exhalation, but have a very high pressure for inhalation to keep the airway open.

The most common way to keep your airway open and overcome obstructive sleep apnea is to use a PAP. This machine automatically adjusts the pressure to keep the airway open. When you first fall asleep, you don’t need as much pressure, however, in the deeper forms of sleep, you’ll need more pressure. So the machine gives you only the least amount of pressure to keep your airway open. In addition to that, it also can sense when you inhale and exhale.  Instead of giving the same pressure even when you’re exhaling, it will decrease and eliminate most of the pressure when you exhale, making it more comfortable with some ENT Tulsa patients.

No matter what we try medically, it still doesn’t work for some patients. This makes them a good candidate for surgery. This is Dr. Cordray’s expertise at Ears, Nose, Throat of ENT Tulsa.  The old surgery method removes the uvula and a small portion of the soft palate that helps open up the oral pharyngeal airway. Unfortunately, although in some patients it’s an excellent procedure, approximately 80 %, patients will fail after a year.

Therefore, in current times at Ears, Nose, Throat of ENT Tulsa, we now suggest a tongue base suspension suture and hyoid suspension. This is where I would make a small incision underneath the chin and attach a very tiny titanium screw to the back part of the Jawbone, the mandible, and then a suspension suture would be passed through the base of tongue and tied to this titanium screw. This effectively forms a sling for the base of the tongue, so that when the patient falls asleep, the tongue will stay in a forward position. Even though the tongue relaxes it will not lapse to the back of the throat causing obstruction.

We also, through the same incision, can put small titanium screws to the back of the mandible with sutures going around the hyoid bone. The hyoid bone is a small “U” shaped bone in the throat and if you pull this bone forward, it will pull structures like the epiglottis in the lower throat forward opening up the airway. The epiglottis is a flap of skin and cartilage that covers and protects the airway when we swallow food or water. This keeps it out of the airway going down into the stomach. This structure can cause obstruction of the airway and by pulling it forward it will open up the lower airway helping to eliminate obstructive sleep apnea.

Our experience at Ears, Nose, Throat of ENT Tulsa find that most patients that are operated on for obstructive sleep apnea need the back of the throat surgery (uvulopharyngopatatoplasty or UPPP), Tongue base suspension suture and the hyoid advance all at the same time.   If you think you are a candidate please call Tulsa ENT at 918.582.8217 for your appointment.