Last week, I participated in the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery. This meeting always includes a number of excellent sessions focused on surgery for snoring and obstructive sleep apnea, and this year was no exception. My favorite session was a discussion of how surgeons might choose from among the available palate surgery procedures to treat airway obstruction in what I call the Palate Region. I will admit to being biased, as this was a session that I proposed and moderated, but we were fortunate to hear from a number of surgeons who developed and/or studied the various available techniques. The panel included a number of leaders in sleep surgery, including Drs. Ed Weaver, Michel Cahali, Michael Friedman, Hsueh-Yu Li, Kenny Pang, Brian Rotenberg, and Tucker Woodson. We all presented our thoughts about how we make these decisions, based on our experience and the available research (my basic approach is summarized briefly here). The discussion was lively and interesting, and I always love sharing thoughts with my colleagues and friends. Based on the attendance of hundreds of surgeons, this was a topic that many surgeons face, without obvious answers.
Positional sleep apnea and the law of gravity
There were a number of other interesting talks, and I want to mention some of the research talks. Positional obstructive sleep apnea occurs when a patient has obstructive sleep apnea that is much more substantial when they sleep in one position, typically while laying on their back. A sleep study will generally measure how bad obstructive sleep apnea is while patients sleep in various positions, and positional sleep apnea is defined as sleep apnea that occurs with blockage of breathing at least twice as often when someone is sleeping on their back vs. other positions. In some cases, the sleep apnea will clear up completely if they can sleep on their side or stomach, but in other cases the sleep apnea is improved but not resolved. We have always felt that gravity works against us when patients sleep on their back, allowing many structures of the throat to fall back more easily. However, there has been little research in this area. Mas Takashima from Baylor College of Medicine led an interesting study involving drug-induced sleep endoscopy of patients with positional obstructive sleep apnea and those with obstructive sleep apnea in all body positions. What they showed is that patients with positional sleep apnea had much more blockage from the tongue and epiglottis when on their back compared to their side, while patients without a positional aspect to their sleep apnea had similar findings while on their back and their side. This will add substantially to our understanding of positional sleep apnea.
Obstructive sleep apnea in adults is more common among men than women, so most sleep apnea research studies, including those for surgery, have included many more men than women. On average, men and women have differences in the structure (anatomy) of their throat, and these can affect surgical outcomes. Sam Mickelson analyzed his results with the hyoid suspension procedure, often in combination with other procedures, and found that there seemed to be a better result with one of the two available techniques. This work highlights the importance of tailoring the selection of procedures to individual patients, and I think the truth may be that different people, men or women, can benefit more or less from each of the technique options.
Inspire Upper Airway Stimulation: an exciting new treatment for obstructive sleep apnea
David Steward from the University of Cincinnati shared results of Inspire Medical’s major trial of their upper airway stimulation system. In the study, 126 carefully selected patients underwent implantation of this medical device, in many ways similar to a tongue pacemaker. There was notable improvement in sleep apnea, as the average number of times there was blockage in breathing decreased from 29 to 9 per hour. Two-thirds of the patients had a substantial improvement in their sleep apnea. Of these responders, some had the device turned off and saw a return to the level of sleep apnea they had before surgery (evaluated by a sleep study). As you can imagine, the device is expensive, but the question is whether the cost is worth the benefit. DISCLAIMER: I have been retained by Inspire Medical as a consultant to participate in development of a cost-effectiveness analysis that will attempt to answer this last question.
There were a number of other outstanding talks, including more work showing that nasal blockages is not the primary issue for most patients with sleep apnea, even though it should certainly be treated because it can limit the success of all other treatments, including the Provent device placed over the nose. Other studies examined complication rates for sleep surgery, the outcomes of combined Palate Region and Tongue Region surgery, and surgical evaluation of patients. I look forward to seeing the results of these studies when they are published in the medical journal Otolaryngology–Head and Neck Surgery.