Obstructive Sleep Apnea: Therapeutic Alternatives DAVID N. F. FAIRBANKS,

MD, AND DAVID W. FAIRBANKS,

For more than a century, physicians have observed the coexistence of such common complaints as snoring and excessive sleepiness, but it was not until the last quarter century that their pathological interrelationships were recognized.’ Only in the past decade have effective and acceptable treatments become available. DIAGNOSIS

Effective treatment is contingent on the establishment of a correct diagnosis and the identification of pathophysiologic conditions affecting the upper airway. Snoring and obstructive sleep apnea (OSA) are manifestations of airway incompetence in the collapsible part of the airway-that segment between the larynx and the nasopharynx where there exists no rigid support. A number of factors, acting singly or in concert, lead to the airway collapse. They can be categorized as in Table 1. The list of possible conditions is rather extensive, but a thorough upper-airway examination is a fairly routine process in an otolaryngologist’s office, Thyroid studies, cardiopulmonary and neurological assessments, and polysomnographic studies all provide valuable diagnostic information that dictates treatment. THERAPEUTIC Self-Help

OPTIONS

Remedies

Unfortunately, ical consultation

few patients who seek medfor snoring or OSA are cured

From the Department of Dtolaryngology-Head and Neck Surgery, George Washington University School of Medicine, Washington, DC; and the Department of Otolaryngology-Head and Neck Surgery, Vancouver General Hospital, Vancouver, Canada. Address reprint requests to David N. F. Fairbanks, MD, Ear, Nose, & Throat Medical Group of Washington DC, Three Washington Circle, Suite 305, Washington, DC 20037. Copyright 0 1992 by W.B. Saunders Company 0196-0709/92/l 305-0003$5.00/O American

Journal

of Otolaryngology,

MD

by self-help alone. On the initial patient encounter, typical snoring-apneic patients are given the informational brochure, “SnoringNot Funny, Not Hopeless,“’ and the suggestions listed therein are presented in Table 2. Weight loss in the obese-apneic patient is a highly desirable but highly elusive objective. The obese-sleep-deprived patient suffers an understandable aversion to vigorous exercise, and the slow rate of weight loss from dietary programs makes it difficult for the patient to maintain his or her motivation. Occasionally an OSA patient may lose enough weight to achieve symptomatic improvement, but conservative treatment for weight loss usually is not effective for morbidly obese patients.3 Weight loss following surgical gastroplasty4 in obese-hypoventilating patients has been accompanied by significant improvements in OSA. Any drug that produces a sedative or muscle-relaxing effect can trigger or aggravate snoring or OSA. Anecdotes of fatal or nearfatal apneic events have been reported after consumption of such drugs. Barbiturates, antihistamines, phenothiazine-type antiemetics, and various “sleeping pills” and “tranquilizers” should be avoided completely by OSA patients. Likewise, consumption of alcoholic beverages for 4 hours before bedtime should be avoided. Caffeine and nicotine are stimulants rather than sedatives, but 2 or 3 hours after consumption, a rebound-sedative phenomenon may occur that can be troublesome during sleep. Heavy meals shortly before bedtime also seem to have a sedative effect. Positional therapy (sleeping on the side or in the prone position) helps to keep the tongue from regressing into the oropharyngeal airway. It may suffice for simple snorers, but it is only adjunctive therapy for OSA patients. Marbles or metal-pronged devices fastened over the spine, or “snore-balls” (such as a tennis ball placed into a pocket sewn into the pajama’s back), can deter the snorer from

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TABLE 1. to OSA

Pathophysiological

Conditions

Contributing

Inadequate muscular tone in the upper airway Hypothyroidism Cerebral palsy and other degenerative neuromuscular disorders Central component of mixed sleep apnea Drug-induced hypotonia (sedatives, hypnotics, tranquilizers, antihistamines, antiemetics, alcohol, nocturnal withdrawal from stimulants) Postprandial relaxation Soft tissue encroachment upon the airways Tonsillar (palatine/lingual) hypertrophy Cyst (thyroglossal, mucus inclusion) Macroglossia (agromegaly) Hyporetrognathia Tumor Abscess Redundant mucosal folds Submucosal fat accumulation Excessive length of soft palate/uvula Shallow nasopharyngeal orifice Redundancy Obstructive nasal airway (aggravating inspiratory negative pressure in collapsible airway) Nasal, septal, or turbinate deformities Allergic or vasomotor rhinitis Rhinosinusitis Nasal or choanal polyp, neoplasm, cyst Adenoidal hvpertrophy

sleeping on his or her back. A Styrofoam-filled back pack worn to bed is another variation. Bed head elevation is recommended on the presumption that vascular congestion in the head and neck tissues (especially the nasal turbinates) can be reduced when they are positioned above the heart. This is especially TABLE 2. Self-help Remedies or Occasional Snorers

for Adults

Who Are Mild

Adopt an athletic life style and exercise daily to develop good muscle tone and lose weight Avoid tranquilizers, sleeping pills, and antihistamines before bedtime Avoid alcoholic beverages within 4 hours of retiring Avoid heavy meals within 3 hours of retiring Avoid getting overtired; establish regular sleeping patterns Sleep sideways rather than on the back; consider sewing a pocket on the pajama back to hold a tennis ball; this helps to avoid sleeping on the back Try wearing a whiplash collar, one that is wide enough to keep the chin high Tilt the entire bed with the head upward 4 in (place two bricks under the bedposts at the bed head) Allow the nonsnorer to get to sleep first

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helpful for patients with nasal congestion. But sleeping on extra pillows is not satisfactory since pillows may kink the neck and aggravate snoring. Blocks should be used to tilt the entire bed, head-up, 4 to 6 in. Pharmacotherapy The condition of the occasional hypothyroid patient can be improved with thyroidreplacement medications; otherwise, drug therapy is usually an exercise in frustration. Protriptylene (Vivactyl; Merck & Co., Inc., West Point, PA) is a mood-elevating agent that keeps the patient out of the deeper stages of sleep, especially the rapid-eye-movement (REM) stage, in which apneic episodes are longest and most prevalent5 It is administered in 5-, lo-, or 15-mg doses about an hour before bedtime, beginning with the 5-mg dose and increasing to larger doses as needed and as tolerated. Side effects include stimulation and sleeplessness with nightmares, urinary retention, interference with erections, and painful ejaculations. Male patients rarely consider such drug therapy to be satisfactory (for the long term]. Respiratory stimulants, such as theophylline, strychnine, and progesterone, have been investigated as treatments for OSA, but they have been abandoned because of their ineffectiveness and unacceptable side effects. Patients whose nasal congestion contributes to their apnea might benefit from intranasal corticosteroid sprays or from a decongestant like pseudoephedrine (unless they are hypertensive or have cardiovascular reasons to avoid it). Mechanical Therapy Continuous positive air pressure. A forceful stream of air delivered to the collapsible oropharyngeal airway acts as a pneumatic “splint” to keep the airway open. In the continuous positive airway (CPAP) system, this is delivered through a nasal mask strapped firmly to the face. Almost all OSA patients can benefit from this treatment, except, of course, those patients whose nasal airways are obstructed. CPAP has almost entirely replaced trache-

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ostomy as treatment for severe apneics who are poor surgical candidates and for surgical failure patients. It is also useful for patients who are awaiting surgery or who are unsatisfied with the uncertainty that is associated with surgery. It can also be useful in the postoperative period to maintain the airway. The short-term compliance or acceptance rate from CPAP in well-instructed patients is about 90%; long-term compliance (2 to 4 years] is reported in various series between 50% and 80°&6 Compliance is equated to success. Treatment failure is defined as either obstruction that cannot be relieved by any realistic pressure or the patient’s intolerance to the CPAP system. Nasal obstruction thwarts the system and sometimes requires correction before CPAP can be applied. Some patients complain about skin irritation from the tightly strapped-on face mask. Some complain of sore eyes from air leaks around the mask. Some complain of abdominal bloating from swallowed air. In the trial period, a common complaint is a sense of claustrophobia. Mucosal irritation is the most troublesome complaint in the long term, and it is sometimes refractory to all treatments (decongestants, antiinflammatory agents, etc). CPAP is a system that is somewhat cumbersome; the patient must put on the mask and turn on the pump to sleep every night (presumably] for the rest of his or her life. Nevertheless, it is a very low-risk treatment that can be immediately and demonstrably effective. Miscellaneous. Over 300 devices are registered by the US Patent and Trademark Office as “antisnore” remedies. The use of chin straps to close the mouth ignores the fact that many persons snore quite well with their mouths closed, and closing of the mouth in a nasally obstructed patient makes no sense at all. A whiplash-type collar worn to bed to keep the chin up (and presumably the tongue pulled forward) is a harmless idea, but one of unproven merit. Psychophysiological conditioning devices delivering noxious stimuli to snorers are also of unproven worth. Snoring and apnea are involuntary phenomena.

Custom-made orthodontic devices that position the mandible, and thus the tongue, forward are being popularized, but valid studies showing efficacy are fewe7 The occasional patient may benefit, and the devices can be offered as adjunctive therapy to patients who are not fully satisfied with their surgical results. The tongue-retaining device has been reported as helpful in mild to moderate positional (back only) sleep apnea patients with low nasal resistance.’ Patient discomfort is a drawback. Surgical Therapy Nasal surgery. Nasal airway impairment increases the negative pressure of inspiratory effort, which increases the collapsible tendency of the flaccid oropharyngeal airway. Numerous studies have documented the role of nasal obstruction in snoring and obstructive sleep apnea, but even well-executed nasal treatment (medical or surgical) is often disappointing as a solitary remedy for severe OSA. To assess the nasal component of airway compromise, a simple at-home nose-spray test is recommended. A long-acting topical nasal decongestant spray, such as oxymetazoline (Afrin), is sprayed into the nose one-half hour before bedtime every other night for 1 week, alternating with nights in which the spray is not used for “control” observations. Snoring is compared for spray nights versus nonspray nights. (This is a test only; the spray is not intended for use as a remedy for snoring or stuffy nose.) If nasal-spray decongestant brings dramatic relief of snoring and apnea, then it is predictable that correction (usually surgical) of the nasal airway problem will do the same. If the nose spray gives only partial relief of snoring, so will nasal treatments (which would then be supplemental to other therapy), and if no improvement is evident, then nasal surgery would likely prove disappointing as a cure for snoring and apnea. Almost half of snoring-apneic patients express some complaints about nasal congestion; similarly, about half are found to have some nasal septal or turbinate deformitieseg However, only about 1 in 10 seems to benefit from the nose-spray test or nasal treatments,

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and they are generally those with the most stuffy noses and with simple snoring or mild to moderate apnea at worst. In patients with over 100 apnea episodes per night, nasal obstruction is more likely a minor (even though important] contributor. The most frequent nasal problem encountered is nasal septal and turbinate deformity; we use nasal septoplasty with submucous resection of turbinates for our most predictably successful results. Other nasal conditions may be encountered (eg, sinusitis, nasal polyps, antrochoanal polyp, allergic rhinitis), and diagnosis-specific treatments are applied. Just as nasal obstruction aggravates obstructive sleep apnea, so does nasal packing. Nasal packing intensifies the surgical (postoperative) risk in apneic patients. Therefore, in moderate to severe apnea patients who need both nasal surgery and uvulopalatopharyngoplasty, the nasal surgery is most safely performed at a second stage, several weeks later, when soft-tissue swelling has receded and the apnea is (presumably) lessened in severity.

Uvulopalatopharyngoplasty Uvulopalatopharyngoplasty (UPPP), also referred to as palatopharyngoplasty (PPP), uvuloveloplasty (UVP), or uvulopalatoplasty (UPP), is an operation only a decade old to western physicians. Its objectives are to remove excessive/redundant soft tissue from the collapsible oropharyngeal airway, to tighten up the tissue that remains, and to expand the nasopharyngeal opening. The techniques described by Ikematsu,” Fairbanks,l’ and MoranI are specifFujita,” ically designed to avoid the complications of palatal incompetence and nasapharyngeal stenosis. Other complications in the preoperative and postoperative period must also be part of the surgeon’s awareness, particularly those related to airway maintenance in the presence of postoperative edema and sedating analgesics/anesthetics that are administered. Complications and avoidance strategies have been described.12-‘4 There is no simple answer to the question “does UPPP work?“, except “it depends on patient selection.” As a cure for snoring in young patients with simple snoring (or only mild apnea) and with

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the anatomical features that UPPP corrects, it is a highly effective operation (80-90s cures).13 If obviously enlarged tonsils (and/or adenoids) are present, their removal along with the UPPP increases the likelihood of success.15 However, if other anatomical features are present, such as a bulky tongue, a receding chin, nasal airway obstruction, or pronounced obesity, then UPPP (which addresses only part of the problem) is less successful as a single therapy. In very obese patients, the airway is highly collapsible in the hypopharynx, distal to the surgical site for UPPP. Furthermore, as the disease of obstructive sleep apnea progresses in its duration and severity, it becomes more of a neuromuscular problem than a space-occupying airway disorder. Therefore, severe obstructive sleep apnea is often only somewhat improved after UPPP, the surgery converting a severe case to a moderately severe or mild case. The daytime sleepiness may be improved, but the snoring persists. For these reasons, the success of UPPP for curing moderate to severe OSA has been variously stated as between 40% and 70%~~ As Koopman and Moran have said, “Until a methodology has been worked out which allows us to reverse the neuronal abnormality that occurs during sleep, resulting in relaxation of the hypopharyngeal muscles involved, there will be no specific treatment for obstructive sleep apnea.“13 Various authors have stressed inclusion of the Mueller maneuvei? and cephalometric as important adjuncts to the radiography17 physical examination for determination of the “site of lesion.” The information is helpful to the surgeon, as long as he or she remembers that the maneuver is an artificial event (rather than the naturally occurring one), and that cephalometry is a two-dimensional view of an anatomical area that collapses in three dimensions. Cine-CT scanning” during sleep identifies the site(s) of obstruction rather well, but its expense relegates the technique to research rather than clinical use.

Mandibulo-maxillary Advancement When Riley and Powell17 reviewed whose OSA had been unsuccessfully

patients treated

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with UPPP, they concluded that the base of the tongue was the cause of continued airway Cephalometric analysis is compromise. stressed in their preoperative evaluation. Two different surgical procedures have been devised to effect an advancement of the tongue base. The first is a mandibular-hyoid advancement; the second (performed in a second stage for failures from the first) is a combined maxillary and mandibular advancement. In the first-phase operation, the hyoid bone is advanced toward the anterior inferior margin of the mandible and suspended from there with fascial slings. This is facilitated by severance of the thyrohyoid attachments. Furthermore, that portion of the anterior mandible to which is attached the genioglossus muscle (the genial tubercle) is advanced (after osteotomy) and fixated in a position approximately 1 cm more anteriorly. These two maneuvers advance the tongue position. Riley and Powell report that two-thirds of their patients are relieved of obstructive sleep apnea with this operation, which may be combined with UPPP or may be performed on UPPP failures. In the second-phase operation, osteotomies are performed in both the mandible (behind the last molar) and the maxilla (a LeFort type I separation). Both structures are then advanced and fixated in a forward position, which effects significant tongue advancement, yet maintaining normal dental occlusion. The reported success rate for patients undergoing all three procedures (UPPP and both advancement operations) is 97%. Riley and Powell also report that more than half of their patients require surgery to the nose as well. The extensiveness of these combined procedures requires extremely careful attention to postoperative airway maintenance. Dr Powell reinstates CPAP immediately after operation.

vaporizes hypertrophied lingual tonsils. For surgical exposure, to avoid laser damage to the endotracheal tube, and to maintain a safe postoperative airway, a tracheostomy is required before tongue surgery. Fujita’s results have been promising.lg Tracheostomy The ultimately successful (albeit nonphysiological) solution to the collapsible upper airway is to bypass it altogether, which is what tracheostomy accomplishes. CPAP has almost entirely preempted tracheostomy as a treatment strategy, but an occasional severe apneic patient who fails all other remedies, and who is completely intolerant of CPAP, will require permanent tracheostomy. Mucosal and skin flaps can be incorporated into the stoma1 orifice to insure its permanency and to reduce the nuisances of stenosis and granulationtissue formation. A temporary tracheostomy may be required for the markedly obese patient with severe obstructive sleep apnea in whom the airway cannot be secured during the perioperative period for UPPP. It is prudent to be prepared for tracheostomy if endotracheal intubation would be difficult. However, awake intubation can avert that need, and for the postoperative period, CPAP can be reinstated or an endotracheal tube can be left in place overnight to maintain the airway. Patients may be selected for overnight endotracheal (postoperative) intubation for any or several of the indications: (1) anatomical features that would make reintubation impossible (eg, severe obesity macroglossia, hypognathia); (2) severe OSA; (3) prolonged apneic episodes with severe oxygen desaturations (60% or lower] or cardiac arrhythmias; (4) likelihood of significant postoperative edema or swelling; (5) need for so much analgesia that hazardous sedation would be unavoidable.

Tongue Surgery

REFERENCES

Various operations on the tongue have been proposed, but the most carefully studied procedure is Fujita’s laser vaporization of the mid-third of the tongue base. In some cases, he also resects part of a floppy epiglottis or

1, Simmons FB, Hill MW: Hypersomnia caused by upper airway obstructions: A new syndrome in otolaryngology. Ann Otol Rhino1 Laryngol 63:670-673. 1974 2. American Academy of Otolaryngology-Head and Neck Surgery: Snoring: Not funny-Not hopeless. Alexandria, VA

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3. Stunkard A: The current status of treatment for obesity in adults, in Stunkard A, Stellar E (eds): Eating and Its Disorders. New York, NY, Raven Press, 1984 4. Charuzi I, Fraser D, Peiser J, et al: Sleep apnea syndrome in the morbidly obese undergoing bariatric surgery. Gastroenterol Clin North Am 16:517, 1987 5. Robinson RW, Zwillich DW: The effects of drugs on breathing during sleep, in Kryger MJ, Roth T, Dement WC (edsl: Princinles and Practice of Sleeo Medicine. Philadelphia, PA,‘Saunders, 1989, p 501 A 6. Westbrook PR: Sleep disorders and upper airway obstruction in adults. Otolaryngol Clin North Am 23:727743,199o 7. Orr WC, Bonham PE, Othman J, et al: Utilization of an oral appliance in the treatment of obstructive sleep apnea. Sleep Res 17:230, 1988 8. Cartwright RD: Prediction of effectiveness of the tongue retaining device for the control of sleep apnea syndrome. Arch Otolaryngol 111:385-388, 1985 9. Fairbanks DNF: Snoring: Surgical vs. nonsurgical management. Laryngoscope 94:1188-1192, 1984 10. Ikematsu T: Palatopharyngoplasty and partial uvelectomy, in Fairbanks DNF, Fujita J, Ikematsu T, et al: Snoring and obstructive sleep apnea. New York, NY, Raven,i987, pp 130-134 11. Fujita S, Conway W, Zorick F, et al: Surgical correction of anatomic abnormalities of obstructive sleep ap-

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nea syndrome: Uvulopalatopharyngoplasty. Otolaryngol Head Neck Surg 89:923-927, 1981 12. Fairbanks DNF: Uvulopalatopharyngoplasty complications and avoidance strategies. Otolaryngol Head Neck Surg 192:239-245, 1990 _ 13. Koopman CF, Moran WB: Surgical management of obstructive sleep apnea. Otolaryngol Clin North Am 23:787-803,199d 14. Katsantonis GP, Friedman

WH, Krebs FJ, et al: Nasopharyngeal complications following uvulopalatopharyngoplasty. Laryngoscope 96:1236-1238, 1986 15. Stevenson EW, Turner GT, Sutton FD, et al: Prognostic significance of age and tonsillectomv in uvulopalatopharyngoplasty. Laryngoscope 100:820-823, 1990 16. Fuiita S. Conwav WA. Zorick FT. et al: Evaluation of the effectiveness of uvulopalatopharyngoplasty. Laryngoscope 95:70-74,1985 17. Riley RW, Powell NB: Maxillofacial surgery and obstructive sleep apnea syndrome. Otolaryngol Clin North Am 23:809-826, 1990 18. Crumley RL, Stein M, Gamso G, et al: Determination of obstructive site in obstructive sleep apnea. Laryngoscope 97:301-308, 1987 19. Kramer BM: Other surgical procedures for obstructive sleep apnea, in Fairbanks DNF, et al: Snoring and obstructive sleep apnea. New York, NY, Raven, 1987, p 229