Vivek C. Shah, M.D., Gurpreet Singh, M.D., Pramod Kayathi, M.D., Steven Lippmann, M.D.

Obstructive sleep apnea
Obstructive sleep apnea (OSA) is a sleep-related breathing disorder involving a decrease or a temporary halt in airflow despite an effort to breathe. It occurs during sleep with pharyngeal muscle relaxation, resulting in soft tissue collapse, blocking the upper airway. This results in partial reductions (hypopneas) and/or complete pauses (apneas) in breathing, that last at least 10 seconds. Most apneas continue for up to 30 seconds, but may persist for one minute or longer. This leads to reductions in blood oxygen saturation, with oxygen levels falling as much as 40% or more in severe cases. Most people with OSA snore loudly and frequently, with periods of silence when airflow is compromised; they then emit loud chocking, snorting, or gasping sounds as the airway reopens.This induces disruption of sleep continuity and greatly compromises quality of life. The apnea-hypopnea index (AHI) is an OSA measurement that represents the combined average number of apneas and hypopneas that occur per hour of sleep.1

Non-surgical therapies
The initial therapeutic interventions for patients with mild degrees of OSA include weight loss, changing from back-sleeping to side-or-prone position sleeping, and abstaining from smoking, alcohol, or use of sedating drugs or pharmaceuticals. Continuous positive airway pressure (CPAP) is a prominently prescribed treatment for those with more severe cases of OSA.1 Utilization of a CPAP machine can effectively reduce AHI and improves sleep quality. Unfortunately, however, CPAP regimens suffer from cumbersome discomfort and inadequate adherence to therapy, sometimes resulting in treatment failure. Individuals who are non-adherent to OSA therapy have a 10% increase in mortality at five years.1 Considering other nonsurgical options, there are anterior jaw positioning devices available.2  These are removable, therapeutic oral appliances attaching mandibular teeth to maxillary dentition, and thus, not allowing posterior movement of the jaw during sleep. These jaw positioning devices minimize posterior pharyngeal obstruction by keeping the jaw in an anterior position and are inexpensive and usually well tolerated. When these therapies are ineffective, there are surgical alternatives.

Operative approaches
Surgical procedures of the soft palate to treat OSA initially focused on soft tissue volume reduction.3 The success rate with this approach is not uniformly satisfactory, and postoperative complications can be of concern; yet, in children with adeno-tonsillar hypertrophy, such operative procedures demonstrate efficacy.4 Surgical maxillamandibular advancement procedures maybe safer and effective, especially in non-obese younger people with OSA who require mandibular advancement.3 In successful cases, quality of life evidences considerable improvement. A less invasive procedure is a soft palatal implant that can be an effective, low morbidity option for patients diagnosed with mild to moderate OSA.5   These implants are placed in the upper portion of the soft palate under local anesthesia. They increase rigidity of the soft palate, relieving obstruction and are documented with high satisfaction rates.

A new innovation in OSA treatment is an implanted electrical stimulator.6,7  This small pacemaker-like device is implanted into the upper chest with wires connected to the pharynx. The system senses breathing and stimulates the hypoglossal nerve whenever respiration ceases, resulting in activation of the genioglossus muscle and moving the tongue anteriorly. It opens the airway when it should be and prevents upper airway collapse. Approved by the U.S. Food and Drug Administration for people over age 21 this year, it is a very new procedure.8  This stimulator is associated with possible complications that include infection, local pain, tongue abrasion, headache, dry mouth, and speech dysfunction. Utilization over time should verify the safety and efficacy of this electrical device.

References
1. Kakkar R, Berry R. Positive Airway Pressure Treatment for Obstructive Sleep Apnea Chest. 2007; 132(2): 1057-1072   Doi: 10. 1378/chest.06-2432
2. Nq A, Gotsopoulos H, Derendeliler A, et al. Oral appliance therapy for obstructive sleep apnea. Treat Respir Med: 2005; 4(6): 409-422
3. Holty J, Guilleminault C. Maxilomadibular advancement in treatment of obstructive sleep apnea: a systemetic review and met-analysis. Sleep Med Rev: 2010; (14): 287-297
4. Sedky K, Bennete D, Cavalloh K. Attention deficit hyperactivity disorder and sleep disordered breathing in pediatric populations: meta-analysis. Sleep Med Rev: 2014; 18(4): 349-356
5. Walker R, Levine H, Hopp M, et al. Palatal implants: A new approach for the treatment of obstructive sleep apnea. Otolaryngology-Head and Neck Surgery: 2006; 135: 549-554
6. Kezirian E, Boudewyns A, Eisele D, et al. Electrical stimulation of the hypoglossal nerve in the treatment of the obstructive sleep apnea. Sleep Med Rev: 2009; 792-1087
7. Strollo P, Scoose R, Maurer J, et al. Upper airway stimulation for obstructive sleep apnea.  N Engl J Med: 2014; 370:139-149
8. Carter D. Tiny implant may ease moderate to severe sleep apnea. The Courier-Journal (Louisville, Kentucky newspaper): 2014; October 3: D1-D2