By Robson Capasso, MD
I am fortunate enough to focus most of my clinical and academic work on the specific field I chose, treating patients with obstructive sleep apnea (OSA), and wanted to share some of my insights as awareness about the need of a proper night of sleep and demand for specialized sleep care has increased.
OSA is the medical term for the excessive airway narrowing that occurs for some people during sleep leading to airflow impairment and by consequence decrease in blood oxygen levels and recurrent arousals.
The burden ranges from embarrassment to strain of even stable relationships (as sleepless nights caused by loud snoring can take a toll even a in a super cool and understanding partner) to daytime symptoms such as sleepiness, fatigue, and even a higher chance of heart attacks or strokes associated with frequent oxygen drops.
In most cases the initial treatment approach is a combination of lifestyle and behavioral modifications including weight loss and avoidance of alcohol use at night and the use of CPAP, short for continuous positive airway pressure device. While CPAP is very effective in keeping the throat open and a great solution for some, struggling with its continued use is not uncommon.
A wealth of possible treatments from oral appliances, throat exercises, and nasal resistors (just to name) a few are available. However, some patients prefer not to use any attachments or devices while they sleep and opt for a surgical solution. And that is why I have a job…
In a likely oversimplified view, the problem of excessive narrowing during sleep is caused or worsened by an imbalance between the space size housed by the facial skeleton, the amount of soft tissue and fat contained by and around it, and the tone and strength on throat and tongue muscles. These factors interact and will lead me to choose among different strategies. There isn’t a perfect solution for all!
For some years now we have procedures for that friend with somewhat small jaws, for that roommate with big tonsils, or not uncommonly both. Many of them still require weight loss for best results via diet and exercise or bariatric surgery. While I really enjoy performing surgeries, I need to disclose that these procedures are not for every patient, and are not without side effects and risks, including—and the classic but not limited to—pain, bleeding, facial numbness, bite changes, etc.
So we are used to targeting the problem by increasing that space by moving the upper and lower jaws forward or by removing soft tissue from the palate and tongue, but a tool to increase muscle tone was an unmet need. In the recent past a number of companies have been working with this aim, and recently one got FDA approval for a device that offers increased tone for the main tongue and throat muscles via neuro-stimulation.
The solution is designed by the implant of a generator similar to a pacemaker under the skin of the chest and two leads: a sensing lead placed between the ribcage muscles which will detect increased breathing efforts during obstructive events, triggering a response by the main generator which will then stimulate the hypoglossal nerve via a second lead placed in the neck and wrapped around the nerve, causing the tongue to protrude, and by consequence the airway to open.
The procedure tends to have fairly mild side effects, most commonly transient tongue soreness. However, some may not like the idea of skin incisions and scars in the chest and neck, and to have an implant that is not MRI compatible. As someone who lives in the Silicon Valley and witnesses the pace of innovation in healthcare, I have every reason to believe that one that can be used while having an MRI scan should be around soon. Oh, and your body mass index needs to be below 32, so yes, weight loss is important. Did I mention that before?
Before you throw the CPAP away, please understand that surgeries for OSA still have inherent risks and possible side effects and patient selection is key. An evaluation performed by a surgeon with expertise in OSA including a recent sleep test and precise airway analysis, which may even require an upper airway endoscopy under sedation, will make all the difference. Some advice: read about your options and ask lots of questions about success rates, risks, benefits, and alternatives. Having your opinion as part of the decision-making process will be key to follow a plan designed precisely for you.
Robson Capasso, MD, is an associate professor and Chief of Sleep Surgery at the Department of Otolaryngology-Head and Neck Surgery, and by courtesy of Sleep Sciences and Medicine at Stanford University School of Medicine. This Center is the birthplace of sleep medicine and includes research, clinical, and educational programs that have advanced the field and improved patient care for decades. His interests include the use of smartphone applications for sleep-disordered breathing, pre-surgical evaluation and upper airway changes after surgery of sleep apnea patients, and development and validation of new medical devices and digital health concepts. To learn more, visit us at: sleep.stanford.edu.