Don’t Ignore Sleep Apnea

Sleep apnea is more than a snoring problem. In couples, it can lead to relationship problems, even divorce. Sleep apnea often goes undiagnosed in children with attention deficit hyperactivity disorder (ADHD), bedwetting, and daytime sleepiness, leading to incorrect therapies to address their conditions.

Worldwide, obstructive sleep apnea (OSA) affects more than 900 million people above the age of 30; 425 million have moderate to severe disease. We talked with Mohamed Abdelwahab, M.D., Ph.D., MUSC Health sleep surgeon who developed MUSC Health’s sleep surgery program, about the complex condition. 

Dr. Abdelwahab specializes in providing a variety of procedures for the comprehensive management of sleep apnea. Read on to learn more about the causes of OSA and treatments offered at MUSC Health for this condition.

Q. What is sleep apnea?

A. Sleep apnea is a cessation of breathing when someone is sleeping. There are three types:

1. Central sleep apnea, in which the brain is not willing to ask your respiratory muscles to work
2. Obstructive sleep apnea, in which the brain is working well, but the upper and airway muscles are collapsing when you’re sleeping.
3. A mixture of obstructive and central apneas. The obstructive type can be managed by surgical and non-surgical options.

Q. When does it begin?

A. Obstructive sleep apnea can develop at any age, from childhood through elder years, and can progress as a child gets older. It is important to raise awareness of childhood sleep apnea because it can be associated with bed wetting and ADHD. Parents get frustrated and think their child might need behavioral therapy when the reason for these conditions could be sleep apnea.
In some circumstances, patients are only aware of sleep apnea after being diagnosed with certain medical conditions such as high blood pressure or blood sugar or even after having a heart attack or a stroke.

Q. What are the symptoms of sleep apnea?

A. Snoring, daytime sleepiness, bedwetting in children, and loss of breath while sleeping are symptoms. In adults, obstructive sleep apnea is usually diagnosed only after damage has occurred, such as diabetes, hypertension, arrhythmia, stroke, heart failure, or choking.

Q. What causes sleep apnea?

A: Sleep apnea has many risk factors, including:

• Big tonsils
• A big tongue
• A small upper and/or lower jaw, and
• Weak muscle tone that can’t support an open airway

Sleep apnea is often associated with obesity and other health problems such as heart disease and diabetes. Elderly individuals who are healthy and have good jaw structure and clear nasal breathing can develop sleep apnea because of a narrowed airway caused by reduced muscle tone and a weakened palate.
It is important to note that the causes are usually multifactorial, with obstruction occurring at multiple levels or places in the airway.

Q. How is sleep apnea diagnosed?

A. A sleep study is performed in a sleep lab or, in certain cases, at home to diagnose sleep apnea. Awake and sleep endoscopy can also be performed to identify whether the cause is structural or a result of muscle collapse during sleep.

We sedate the patient and, with a high-definition camera on the tip of a small flexible tube that goes through the nose to get pictures of the airway. Once we evaluate the pictures, determine the airway collapse, and do a facial analysis, we discuss treatment options with the patient, always keeping in mind how they breathe, their facial balance, and their jaw function.

Q. How is sleep apnea treated?

A. We start with CPAP, which is the gold standard. CPAP forces air into the upper airway, and therefore, compliance is usually a problem. It also treats only the symptoms and not the root cause. Patients can choose from many options to manage their airway blockage.

Hypoglossal nerve stimulation has emerged recently as an alternative to CPAP for patients with a weaker muscle tone. A small device is inserted into the neck and upper chest to push the tongue (and palate) forward to open the airway. Surgery, however, is the primary method for fixing a patient’s risk factors for sleep apnea.

Q. What is the best surgery for sleep apnea?

A. The short answer is “it depends.” Sleep apnea is a multilevel problem, meaning that usually more than one place/level along your airway requires attention. Sleep surgery can be performed on the nose, tongue base, jaws, and throat. The type of procedure depends on a patient’s physical traits and risk factors.

With the rise of precision medicine, surgery is designed to manage these risk factors individually. For example, someone with big tonsils might benefit from a tonsillectomy and/or an adenoidectomy. Patients with smaller jaws can benefit from jaw surgery instead of tonsillectomy or upper-airway stimulation surgery.

Other types of surgery for sleep apnea include

Preservation palate surgery
We can reshape parts of the palate to restore the tension in this area, also known as the roof of the mouth, without muscle resection.

Uvulopalatopharyngoplasty
This is a widely performed procedure and involves the removal of the tonsils, the uvula, which is the soft tissue that hangs down at the back of the tongue, and part of the palate. We prefer to avoid muscle resection.

Structural septoplasty
A septoplasty opens the nasal passages by straightening the nasal septum, which could be bony or cartilaginous. This procedure can be performed along with turbinate reduction.

Turbinate reduction
Turbinates are important structures in the nose that help humidify and warm the breathed air. We prefer reduction instead of resection to preserve their function.

Nasal valve stenosis repair
Nasal valves are the narrowest part of the upper airway and are crucial to night-time nasal breathing. We provide closed and open approaches for managing obstruction.

In the closed approach, all incisions are done inside the nose. The open approach involves a small incision between the two nostrils. This is usually combined with septoplasty, where the deviated septum is corrected, and resected cartilage is used to support the nasal valves.

Maxillomandibular advancement
When patients have a small airway because of small upper and lower jaws, the best option is to surgically move the jaws forward. While recovery is more involved than other procedures, it is not as painful as other procedures and has a high success rate.

Our research shows that this procedure’s recovery is less painful when compared to other procedures, showing a high postoperative satisfaction rate. MMA is considered for patients who have severe OSA and when other procedures are not sufficient to open the entire airway. We use cutting-edge 3-dimensional printing technology to provide our patients with specific implants and precise outcomes for their breathing, bite, and facial balance.

Maxillary expansion
These procedures have been shown to improve the outcomes of other surgeries we offer, particularly jaw and nasal surgery.

Inspire and tongue-base surgery
In cases where the tongue falls backward and obstructs the airway, we can perform surgery to move the tongue forward and/or tighten the muscles that hold the tongue in place. Examples include chin advancement and hypoglossal nerve stimulation. Some patients may qualify for a tongue-base reduction.

Q. What do you advise people who think they may have a snoring/breathing problem?

A. I tell them it’s important to take your partner’s or family’s complaint seriously and get evaluated by a doctor who treats and focuses on sleep apnea. Ignoring sleep apnea is not going to make the problem go away. It will only worsen.

We prefer to see our patients after completing a sleep study that can be ordered by your primary care provider. Here at MUSC Health, our multidisciplinary team understands the physical, relational, and emotional problems that patients with sleep apnea face. As a result, we spend a long time listening to our patients and their partners.

We provide an array of treatment options while considering facial aesthetics for the younger population and potential comorbidities for the elderly. Our goal is to provide every patient with the very best care, and we can do that only when we know they’re comfortable with, and fully understand, their options and the expected outcomes. Our surgeons, therapists, and nurses are with them every step of the way.

###

Dr. Abdelwahab sees patients in Rutledge Tower, located at 135 Rutledge Ave., Charleston. To make an appointment with Dr. Abdelwahab, call 843-792-3531.