Earlier this month, I attended the 9th meeting of the International Surgical Sleep Society in Munich (ISSS). The ISSS is the world’s premiere organization dedicated to sleep apnea surgery and snoring surgery. I am proud of having been the ISSS President from 2014-2017 and for organizing or co-organizing the 7th and 8th meetings in Sao Paulo, Brazil and Los Angeles. The ISSS 2018 Munich conference brought together leaders in sleep surgery from around the world, and there were so many excellent talks that there were 3 sessions running during parts of the schedule. It was incredible to share experiences with colleagues and friends from around the world, whether during my own lecture and panel discussion, those of others, or the informal discussions that occurred throughout the conference. I wanted to share just some of the new research that was most interesting to me, knowing that it is impossible to summarize the entire meeting.
Palate Surgery after Inspire Upper Airway Stimulation
No treatment works perfectly for obstructive sleep apnea, and Inspire Upper Airway Stimulation is no exception. Often patients do fantastically, but sometimes a patient does not have resolution of their sleep apnea with the system. When this occurs, we do not give up easily. We assess whether there can be improvement with adjustments of the electrical settings while looking in the airway with a flexible endoscope, watching to see how the airway opens in what I call the Palate Region and the Tongue Region. These adjustments during flexible endoscopy are first done in the office and then can also be done under sedation with the technique of drug-induced sleep endoscopy. Unfortunately the changes in electrical settings do not always provide enough improvement, so we can consider additional surgery.
Armin Steffen from the University of Lubeck in Germany presented results from a series of patients at their institution and from Maria Suurna at Weill Cornell Medical College. These patients were all undergoing treatment with Inspire Upper Airway Stimulation and had not responded to changes in the electrical settings. They showed that most of them had resolution of their sleep apnea or, at a minimum, had major improvement after undergoing soft palate surgery.
Positional Therapy Using Your Smartphone?
Snoring and obstructive sleep apnea are often worse when people sleep on their back instead of their sides or stomach. When sleep apnea is at least twice as bad when sleeping on your back compared to other body positions, it is called positional sleep apnea. It is estimated that about half of all sleep apnea (especially mild and moderate sleep apnea) is positional, paving the way for what is called positional therapy—avoiding sleeping on your back. There are many approaches to positional therapy, ranging from the use of a T-shirt with a pocket on the back for tennis balls to new devices like Night Shift and Night Balance (apparently soon to be available in the United States).
In Munich, the team from the University of Mannheim in Germany presented a study showing that a smartphone app can be used successfully to provide positional therapy. They studies the SomnoPose app that works with your iOS-compatible smartphone secured to your chest or abdomen during the night. The app will enable the phone to deliver vibration whenever someone is on their back, encouraging them to move off their back while ideally not waking them up. The delivery of the vibration is not as sophisticated as the Night Shift and Night Balance, but the cost of these apps is lower and can make positional therapy more accessible.
Updates Oral Myofunctional Therapy and Frenuloplasty—Passion on Both Sides but No Studies in Adults with OSA
While in Munich, I never adjusted to the difference in time zones. This led to my awakening at 2 am every morning and then being tired during the day. It also provided some time to work and communicate with numerous people that reached out to me after last month’s blog post indicating that there is no evidence supporting the use of oral myofunctional therapy (as practiced by most in the United States) for the treatment of obstructive sleep apnea in adults. I knew people were passionate about oral myofunctional therapy, especially those who use it to treat a number of conditions (where research does exist). However, I never assumed that my blog was actually read by so many people (my children never seem to listen to anything I say or do). With my early morning awakenings, the benefit was that I was able to communicate with everyone who reached out to respond on my blog, a Facebook group for OMT that I joined, and e-mails and texts sent directly to me. Here are the key points:
- Many people are passionate (on both sides) about oral myofunctional therapy, but my arguments were never refuted. In fact, many people–including oral myofunctional therapists (!), dentists, orthdontists, and physicians–encouraged me to make bolder statements than I did when it comes to the proposed treatment of adults with obstructive sleep apnea.
- My conclusions stand. I am no expert in oral myofunctional therapy or frenuloplasty, but I do know the value of research. There is currently no evidence supporting the use of frenuloplasty or frenectomy for the treatment of obstructive sleep apnea in adults. For oral myofunctional therapy, there are a couple of studies from Brazil with very specific exercise programs that are not being used by most therapists in the United States. As such, there is no evidence supporting oral myofunctional therapy as practiced in the United States for the treatment of adults with obstructive sleep apnea.
- My blog post is a challenge for practitioners to perform research and standardize approaches to identify what works. I am not anti-oral myofunctional therapy or opposed to new therapies, as in fact I have given many lectures to physicians and dentists on new therapies and have highlighted the Brazilian research. I have actually worked with companies on nonsurgical treatments and would be more than happy if alternative treatments worked well. However, I do believe in scientific evaluations. The comments in support of oral myofunctional therapy were personal experiences and beliefs, but that is not enough. There are countless examples of personal experience and beliefs leading people down the wrong path, and my goal in writing the post was to encourage science. Sleep surgery has faced these same challenges, and it has encouraged surgeons to increase the quality of research. Sleep surgery is far from perfect, but at least there are hundreds of studies that surgeons can use to treat patients with a scientific foundation.
- Obstructive sleep apnea is a potentially serious medical condition. I believe it is irresponsible to market unproven treatments to patients. At this time, oral myofunctional therapy (as practiced by most in the United States) and frenuloplasty in adults with sleep apnea should be considered experimental.