Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie Cole (Host): Welcome to UAB MedCast. I'm Melanie Cole. And joining me, we have a panel today, Dr. Brian Kinard, he's an oral and maxillofacial surgeon at UAB Medicine; and Dr. Kirk Withrow, he's the Director of Salivary and Sleep Surgery in the UAB Department of Otolaryngology, and they are here to highlight obstructive sleep apnea and the UAB Multidisciplinary Sleep Surgery team that provides patients with CPAP alternatives.

Doctors, thank you so much for joining us today, Dr. Withrow. I'd like to start with you. Can you just give us a little summary of the health burden of sleep apnea and sleep disorders in general, and what is the scope of what we're discussing here today?

Dr Kirk Withrow: Sure. As any provider would know, no matter their practice, they're going to deal with patients with sleep apnea and it affects a fairly staggering and seemingly increasing number of adults. And particularly what we are concerned with, as far as Dr. Kinard and myself, are the nearly 50% of diagnosed adults that are not able to go with the gold standard of CPAP. So, it's a a very significant burden and we aim to try to give those patients, who are not successful with that first line therapy, and often case, alternatives. And the health consequences are significant, heart disease increased, cardiovascular disease, strokes, peripheral vascular disease, memory issues. And then, there's quite a significant quality of life issue with daytime sleepiness, work performance issues, work accidents, snoring, and household discord related to bed partners and sleeping and things of that nature. So, it's a fairly consistent problem across the board.

Melanie Cole (Host): Well, thank you for that. So, Dr. Kinard, what are some of the first line treatments and conservative measures you would look to before surgical interventions are discussed? As Dr. Withrow said, this is a huge burden on the individuals. It affects the quality of life. Sometimes it's the partner who even notices it at first. Can you tell us what you would do as a first-line treatment once you have determined that this is what's going?

Dr Brian Kinard: Absolutely. I think the main struggle for this patient population is mainly accurate diagnosis and referral to a sleep medicine doctor. Once they are diagnosed with sleep apnea, as Dr. Withrow mentioned, the CPAP appliance is the first line gold standard. This results in good outcomes for a lot of patients. Unfortunately, the majority of patients cannot tolerate this for more than four hours per night. It's often difficult to use and burdensome to travel with. For these patients who fail CPAP therapy, sleep surgery is a great alternative.

Melanie Cole (Host): Well then, Dr. Withrow, why don't you tell us where in the line of apnea refractory to other interventions, and obviously as Dr. Kinard just said, people don't really adhere to the CPAP that well, so where in that line are other interventions discussed and what type of surgical options? Speak a little bit about who sleep surgery can help. And then, we'll look to Dr. Kinard, and we'll go back and forth about what that surgery entails.

Dr Kirk Withrow: Well, I think sleep surgery can help nearly anyone with sleep apnea. Now, certainly, the patients who it is most applicable to are those who are intolerant or have failed CPAP. CPAP works extremely well if you can use it. And so, I spend a good bit of time at the beginning of my clinic visits making sure that patients understand that and give it a fair go because a lot of people don't like it, but it does work well.

So once that has failed, that's when we really start considering sleep surgery in most instances. There are a few exceptions where patients may benefit from surgery upfront. But CPAP failure is mainstay in my practice. We can do different things to help with CPAP, nasal surgeries to improve nasal breathing and help CPAP compliance. And then, sleep surgeries, from my perspective, I explain it to patients in three categories: with surgery on the tissue in the throat, moving things around, removing things like tonsils, palate surgeries, things of that nature; hypoglossal nerve stimulation to keep the muscles from collapsing; or maxillofacial surgery to actually move the skeleton like Dr. Kinard will do to make more room for the tissues that are in the throat, and which of those is the ideal for each patient is highly variable, and that's really where the crux of the whole situation comes in and why it's so nice to have Dr. Kinard able to help from the craniofacial side of things, because not every patient with sleep apnea can be treated with surgery the same or from it. So, that's what makes it very complicated.

Dr Brian Kinard: I very much agree with Dr. Withrow. This is a patient-specific anatomically-driven treatment plan. For my portion, the maxillary advancement, as many as 20 to 30% of patients with sleep apnea, their sleep apnea occurs secondary to a jaw abnormality. For these patients with baseline small jaws or retrognathia, again limited airway space, limited of room for their tongue and other soft tissue structures. For these patients, my role is to expand the facial skeleton, which further expands the airway in its entirety of length. For patients without baseline jaw deformities or who have mild to moderate, sleep apnea, multiple other surgeries work well for them as well that Dr. Withrow performs.

Melanie Cole (Host): Dr. Withrow, would you like to expand on that? You and I have done a previous podcast on the hypoglossal nerve stimulator. Why don't you give us a brief overview of that?

Dr Kirk Withrow: Well, and just to go back to patient selection, there are things you can see, you know, when you walk in the room, craniofacial abnormalities that would prompt me to discuss with patients and refer them to Dr. Kinard. And of course, there are radiographic studies that can take accurate measurements of these structures. And then, we'll often do a sleep endoscopy, which is a short procedure with sedation that really tries to give us a more patient-specific look at what is actually collapsing, so that we can develop a more accurate patient-centered plan. It allows us to determine whether a patient would likely respond to a hypoglossal nerve stimulator. And it helps us to pick certain procedures, say, for the palate or the tongue. And in other instances, it can reinforce my thinking that they need maxillofacial surgery because I explain it to patients in that I can only move tissue as much as the skeleton allows it. And if the box is too small, then I can't really do too much there. And so, my chance of getting them a good outcome is diminished.

But as far as the other options, hypoglossal stimulation is one of the nice new options that we have, because it has less morbidity by far than any of our other options. Now, unfortunately, it doesn't work for every single patient, but it is a very effective option. And once we confirm patients are good candidates, you know, we will get 85% or so reduction in severity, which is getting close to what we can see in the maxillomandibular advancement literature, which is certainly one of our most effective procedures. So, it's been nice because it just gives us a lot more options to treat patients and has really, in my practice, resulted in a lot more patient engagement, because they are inclined to seek care to see what their options are when they learn about some of these newer options.

Dr Brian Kinard: That's great, Dr. Withrow. I think another great point of the modern sleep apnea protocol or the algorithm is that it's not unidirectional. So, some of these patients I work with Dr. Withdrow on, they may not initially qualify for Inspire. They'll come to my clinic for an MMA or maxillomandibular advancement. It will take care of most of their sleep apnea. But then, they'll probably have residual sleep apnea, now, they no longer have concentric collapse and now they're qualified for Inspire. So, it's not a unidirectional pathway by any means, which just helps the team environment.

Dr Kirk Withrow: We certainly should include our sleep medicine colleagues because they play a role as well, even when they have a patient who's CPAP intolerant or CPAP failure. There are many times when I might do a surgery and improve it, but again, still some residual apnea and now they're able to use CPAP. And so, working with the sleep medicine folks is hugely beneficial because they hold the data for us to know what their severity is. And so, it's a very crucial thing. And at UAB, we're just very fortunate to have a very open dialogue with the sleep medicine folks with respect to sleep surgery because it's not like that everywhere, unfortunately.

Melanie Cole (Host): Along the lines of not like that everywhere because you are specialists and incredible expertise, Dr. Kinard, in your department, they fabricate mandibular advancement devices. Can you speak a little bit about that and which patients should consider these types of devices?

Dr Brian Kinard: We have a maxillofacial prosthodontist in our department, his name is Dr. Kase. And one of the many things that he does for our patient population is fabricate the mandibular advancement devices. These devices can help patients with mild to moderate apnea who are CPAP intolerant, who aren't quite ready to undergo a surgery. The mandibular advancement device sits on your teeth and mechanically positions your bottom jaw forward to open the airway behind your tongue. This does have some side effects, however. It can cause muscle pain, sometimes tooth movement, and it's limited to just advancements of approximately four to five milimeters compared to the MMA, which can advance a person's jaws 10 to 15 millimeters if needed. So for the right patients, it's a great minimally invasive tool to improve their sleep apnea.

Melanie Cole (Host): I'd love to give you each a chance for a final thought. And Dr. Withrow, please tell other providers why they should choose UAB for sleep surgery and when and why it's so important that they refer to the experts at UAB Medicine.

Dr Kirk Withrow: Sure. We have multiple providers that basically cover all possible treatment options for sleep apnea. And I think while Dr. Kinard does maxillomandibular advancement and orthognathic surgery, and I do nerve stimulation and soft tissue surgeries primarily, and our sleep medicine folks are primarily dealing with CPAP, every one of us knows about the other option and keeps in mind. I'm by no means would recommend one of my surgeries to a patient if I felt like they were going to get a better outcome with Dr. Kinard's operation, and I think he would probably say the same.

And the same goes with our sleep medicine folks. They try CPAP and we encourage CPAP. But when it fails, we keep an open mind that it's really just what can get improvement for the patients. And so, I think having all of those options in one institution, in a pretty open dialogue and free flow between all of them is very nice for patients because they don't get lost on an island if, say, nerve stimulation isn't their best chance, then they're kind of back to where they started with no therapy. I'm going to give them something and it might not be a procedure I have. It might be with Dr. Kinard or with Dr. Kase and an oral appliance or back to sleep medicine if I feel like there's a way we can use positive airway pressure. So, I think that approach makes it nice because in that sense, not at my clinic necessarily, but at UAB, it's kind of a one-stop shop where if one thing doesn't work or isn't the best, you're going to get referred to someone else who has the expertise in what should work the best.

Melanie Cole (Host): And Dr. Kinard, last word to you, please speak about that multidisciplinary approach, which is so important, and that comprehensive program that you have at UAB Medicine, anything you would like to summarize and the key takeaways from this podcast.

Dr Brian Kinard: We're so fortunate at UAB to have such experts in the field of sleep surgery, such a collaborative team environment who are really focused on taking care of these patients. Each patient gets a patient specific treatment plan based on their anatomy and sleep history. And as a team, we come together to treat these patients in the best way possible.

Melanie Cole (Host): Thank you both so much. What a great topic and such important information. Thank you for joining us. And for more information or to refer a patient to UAB Medicine, you can call the MIST line at 1-800-UAB-MIST, or you can visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. I'm Melanie Cole.