Selected Podcast
Surgical Treatment Options For Sleep Apnea
Stan Chia, MD, discusses the curative options for sleep apnea patients who are not good candidates for CPAP. Options include removal of the tonsils, reducing excess tissue of the tongue, advancing the upper and lower jaw to open up the airway, and even bariatric surgery to eliminate obesity-induced apnea. Dr. Chia also provides information on the newest therapy, upper airway stimulation, which is a pacemaker-like device implanted in the chest.
Featured Speaker:
Stanley Hung-Hsuan Chia, MD
Stanley Chia, MD, FACS, is the chairman of the Department of Otolaryngology, and is associate professor of Otolaryngology at MedStar Georgetown University Hospital. He is also a highly skilled otolaryngologist at the MedStar Pituitary Center.
Transcription:
Surgical Treatment Options For Sleep Apnea
Melanie Cole (Host): While positive airway pressure therapy is generally one of the first lines of treatment for moderate to severe sleep apnea, patient compliance and adherence represents a clear problem. For those people who may have an issue adhering to their CPAP, surgery for sleep apnea may be a feasible alternative. My guest today is Dr. Stan Chia. He’s the Chair in the Department of Otolaryngology at MedStar Washington Hospital Center. Welcome to the show, Dr. Chia. First, what is sleep apnea and what are some of the adherence issues with CPAP that we keep hearing about in the media?
Dr. Stan Chia (Guest): Thank you very much for having me on the show. The continuous positive airway pressure currently is the gold standard for treating obstructive sleep apnea. However, a lot of people have difficulty keeping the mask on at night or using it consistently. The reasons why can include things like discomfort with the mask; they might feel claustrophobia with the mask; they might have trouble keeping the mask on at night because they might move around and it gets displaced; there’s also quite a bit of a pressure that’s created so that they can sometimes feel like they’re breathing in a wind tunnel; sometime the noise from the machine. So, there’s really a varied number of reasons why people have difficulty with the mask.
Melanie: So, then, if you’ve diagnosed them with sleep apnea and they’re using or not using the mask and then you say, “Well, we need to look at other options,” what do you tell them about procedural interventions for sleep apnea?
Dr. Chia: There are some surgical options that are available and the most commonly known ones include the palate procedures and removal of tonsils, but that is not a great option for just about everybody. So, if you have large tonsils or if you have an elongated soft palate, then that may be a great option to treat it but if you look at the overall success rate for that procedure, it’s actually about 40-41 percent. So, it’s not something that is applicable for every single patient that walks through the door. There’s also something that we can do to reduce some of the tissue in the back of the tongue. If people have what’s called “lingual tonsil hypertrophy” and that’s when there’s excess tissue located in the back of the tongue, you can actually use a transoral robotic approach to remove some of that tissue. So, there’s additional procedures that we can do to advance the upper and lower jaw and open up the airway at all different levels. That can sound a little bit scary to people at times because it can sometimes change the way that the face looks but it has the highest success rate of any surgery that’s available out there. Also, most people that end up undergoing this procedure end up finding that the appearance of their face either is the same or even sometimes improved because people might have a weak jaw to begin with. So, that’s definitely a surgical consideration to offer people as an alternative to the CPAP. There’s also a new therapy that’s available that’s called the “hypoglossal nerve stimulator” what this is is a pacemaker-like device that is implanted within the right chest; so just on top of the pectoralis muscle on the chest. There are three separate incisions, one of which is just over that right chest wall, another one in the right neck, and then, a third one in the side of the chest. So, it’s not a minimally invasive operation. However, it does not involve a lot of pain or discomfort. So, the way that it works is that there’s a wire that is tunneled into the chest and senses when you breathe at night and a second wire that’s tunneled underneath the skin and goes up into the neck just below the chin and wraps around the nerve that moves the tongue. Once the device is activated, it senses every time you take a breath in and causes the tongue to move forward to open up the airway. So, this is a very novel technology that’s only been available for about two years now. I was actually on the FDA approval board for this device and found that it was a very promising new technology. At this point, there’ve been hundred of patients that have undergone this procedure with a very high success rate. Personally, I’ve done about 14-15 of these procedures. The patients that have undergone the activation and are currently using the device have had a success rate of around 85%...
Melanie: Wow.
Dr. Chia: …in terms of controlling their symptoms and severely improving their sleep apnea. So, it’s really been quite successful recently.
Melanie: Do you see that this might be a permanent solution? Is it something that will stay with them for life?
Dr. Chia: It is something that is implanted just like a pacemaker, so it is something that stays in your body unless there’s a problem that we have to remove it. So, there is a battery that lasts about ten years and so the battery does need to be changed in ten years. So, that is something that has to be considered but that is essentially a lifelong procedure. One does have to keep in mind that not everybody is a candidate for this procedure, so we are fairly selective at who can actually undergo this procedure. So, you have to have a severity score of sleep apnea between 20-65. That’s determined on a sleep study that’s done before the procedure is considered. We also have to have a body mass index of less than 32. That can actually rule out quite a number of people that have sleep apnea. There are a number of people that develop sleep apnea because of obesity and when you use that as a criteria, it ends up ruling a lot of people out for being a candidate for this procedure. There’s also a minor procedure that has to be done called a “drug-induced sleep endoscopy” to determine the site of obstruction of the airway. Once you see that the pattern of collapse is favorable, then we can go ahead with the approval process to undergo this procedure.
Melanie: If you’re doing a procedure that involves some kind of tissue reduction or ablation or any of these things, is there then scar tissue that’s created, Dr. Chia? Or, are these permanent solutions? Do they have to be redone at some point?
Dr. Chia: There always is scar tissue whenever you make an incision in the body. We don’t typically see it as a problem if you’re making incisions inside the throat where the scar tissue becomes problematic or becomes uncomfortable. It’s generally a procedure that you don’t want to try to repeat but, on occasion, there are issues where you have to do revision surgeries but it’s the exception rather than the rule. So, it’s uncommon to have to do something again.
Melanie: Now, one surgery which is much more major that has been recommended for sleep apnea is bariatric surgery. What do you tell your patients if they are somebody who is obese and their sleep apnea is a result of their obesity?
Dr. Chia: That’s actually a terrific question. I refer people to bariatric surgery pretty frequently. If you have a body mass index of greater than 35, there’s quite a body of literature that shows that any surgical option is not going to be as successful. So, some of these procedures are quite involved or even painful so I tend to not like to put people through these procedures if there’s not a high likelihood that they’re going to succeed. So, if you have extremely severe sleep apnea and particularly if you have a body mass index of greater than 35, I frequently refer people to have a consultation for bariatric surgery.
Melanie: Then, wrap it up for us, Dr. Chia, in the last few minutes here and your most recommended surgical interventions and your best advice for people who suffer from sleep apnea.
Dr. Chia: So, in terms of recommendations for surgical procedures, it’s very important to have a careful evaluation of your prior history, do a careful physical examination which will include an endoscopy of the airway and possibly a drug-induced endoscopy, and then a careful discussion about what the different options are. The surgical options can include upper airway surgeries such as soft tissue surgery to reduce the soft palate or the base of the tongue, structural surgery such as upper and lower jaw advancement, or stimulation surgery such as the hypoglossal nerve stimulator. These different options are a nice complement to each other in terms of what we see anatomically and what a patient needs. So, not everybody is looking for the same thing when they look at surgical options. Once we have a discussion with the patient, we try to do what’s best for the patient in terms of what they’re looking for and what surgical expectations are expected or are made of them.
Melanie: Thank you so much. You're listening to Medical Intel with MedStar Washington Hospital Center. For more information, you can go to www.medstarwashington.org. That's www.medstarwashington.org. This is Melanie Cole. Thanks so much for listening.
Surgical Treatment Options For Sleep Apnea
Melanie Cole (Host): While positive airway pressure therapy is generally one of the first lines of treatment for moderate to severe sleep apnea, patient compliance and adherence represents a clear problem. For those people who may have an issue adhering to their CPAP, surgery for sleep apnea may be a feasible alternative. My guest today is Dr. Stan Chia. He’s the Chair in the Department of Otolaryngology at MedStar Washington Hospital Center. Welcome to the show, Dr. Chia. First, what is sleep apnea and what are some of the adherence issues with CPAP that we keep hearing about in the media?
Dr. Stan Chia (Guest): Thank you very much for having me on the show. The continuous positive airway pressure currently is the gold standard for treating obstructive sleep apnea. However, a lot of people have difficulty keeping the mask on at night or using it consistently. The reasons why can include things like discomfort with the mask; they might feel claustrophobia with the mask; they might have trouble keeping the mask on at night because they might move around and it gets displaced; there’s also quite a bit of a pressure that’s created so that they can sometimes feel like they’re breathing in a wind tunnel; sometime the noise from the machine. So, there’s really a varied number of reasons why people have difficulty with the mask.
Melanie: So, then, if you’ve diagnosed them with sleep apnea and they’re using or not using the mask and then you say, “Well, we need to look at other options,” what do you tell them about procedural interventions for sleep apnea?
Dr. Chia: There are some surgical options that are available and the most commonly known ones include the palate procedures and removal of tonsils, but that is not a great option for just about everybody. So, if you have large tonsils or if you have an elongated soft palate, then that may be a great option to treat it but if you look at the overall success rate for that procedure, it’s actually about 40-41 percent. So, it’s not something that is applicable for every single patient that walks through the door. There’s also something that we can do to reduce some of the tissue in the back of the tongue. If people have what’s called “lingual tonsil hypertrophy” and that’s when there’s excess tissue located in the back of the tongue, you can actually use a transoral robotic approach to remove some of that tissue. So, there’s additional procedures that we can do to advance the upper and lower jaw and open up the airway at all different levels. That can sound a little bit scary to people at times because it can sometimes change the way that the face looks but it has the highest success rate of any surgery that’s available out there. Also, most people that end up undergoing this procedure end up finding that the appearance of their face either is the same or even sometimes improved because people might have a weak jaw to begin with. So, that’s definitely a surgical consideration to offer people as an alternative to the CPAP. There’s also a new therapy that’s available that’s called the “hypoglossal nerve stimulator” what this is is a pacemaker-like device that is implanted within the right chest; so just on top of the pectoralis muscle on the chest. There are three separate incisions, one of which is just over that right chest wall, another one in the right neck, and then, a third one in the side of the chest. So, it’s not a minimally invasive operation. However, it does not involve a lot of pain or discomfort. So, the way that it works is that there’s a wire that is tunneled into the chest and senses when you breathe at night and a second wire that’s tunneled underneath the skin and goes up into the neck just below the chin and wraps around the nerve that moves the tongue. Once the device is activated, it senses every time you take a breath in and causes the tongue to move forward to open up the airway. So, this is a very novel technology that’s only been available for about two years now. I was actually on the FDA approval board for this device and found that it was a very promising new technology. At this point, there’ve been hundred of patients that have undergone this procedure with a very high success rate. Personally, I’ve done about 14-15 of these procedures. The patients that have undergone the activation and are currently using the device have had a success rate of around 85%...
Melanie: Wow.
Dr. Chia: …in terms of controlling their symptoms and severely improving their sleep apnea. So, it’s really been quite successful recently.
Melanie: Do you see that this might be a permanent solution? Is it something that will stay with them for life?
Dr. Chia: It is something that is implanted just like a pacemaker, so it is something that stays in your body unless there’s a problem that we have to remove it. So, there is a battery that lasts about ten years and so the battery does need to be changed in ten years. So, that is something that has to be considered but that is essentially a lifelong procedure. One does have to keep in mind that not everybody is a candidate for this procedure, so we are fairly selective at who can actually undergo this procedure. So, you have to have a severity score of sleep apnea between 20-65. That’s determined on a sleep study that’s done before the procedure is considered. We also have to have a body mass index of less than 32. That can actually rule out quite a number of people that have sleep apnea. There are a number of people that develop sleep apnea because of obesity and when you use that as a criteria, it ends up ruling a lot of people out for being a candidate for this procedure. There’s also a minor procedure that has to be done called a “drug-induced sleep endoscopy” to determine the site of obstruction of the airway. Once you see that the pattern of collapse is favorable, then we can go ahead with the approval process to undergo this procedure.
Melanie: If you’re doing a procedure that involves some kind of tissue reduction or ablation or any of these things, is there then scar tissue that’s created, Dr. Chia? Or, are these permanent solutions? Do they have to be redone at some point?
Dr. Chia: There always is scar tissue whenever you make an incision in the body. We don’t typically see it as a problem if you’re making incisions inside the throat where the scar tissue becomes problematic or becomes uncomfortable. It’s generally a procedure that you don’t want to try to repeat but, on occasion, there are issues where you have to do revision surgeries but it’s the exception rather than the rule. So, it’s uncommon to have to do something again.
Melanie: Now, one surgery which is much more major that has been recommended for sleep apnea is bariatric surgery. What do you tell your patients if they are somebody who is obese and their sleep apnea is a result of their obesity?
Dr. Chia: That’s actually a terrific question. I refer people to bariatric surgery pretty frequently. If you have a body mass index of greater than 35, there’s quite a body of literature that shows that any surgical option is not going to be as successful. So, some of these procedures are quite involved or even painful so I tend to not like to put people through these procedures if there’s not a high likelihood that they’re going to succeed. So, if you have extremely severe sleep apnea and particularly if you have a body mass index of greater than 35, I frequently refer people to have a consultation for bariatric surgery.
Melanie: Then, wrap it up for us, Dr. Chia, in the last few minutes here and your most recommended surgical interventions and your best advice for people who suffer from sleep apnea.
Dr. Chia: So, in terms of recommendations for surgical procedures, it’s very important to have a careful evaluation of your prior history, do a careful physical examination which will include an endoscopy of the airway and possibly a drug-induced endoscopy, and then a careful discussion about what the different options are. The surgical options can include upper airway surgeries such as soft tissue surgery to reduce the soft palate or the base of the tongue, structural surgery such as upper and lower jaw advancement, or stimulation surgery such as the hypoglossal nerve stimulator. These different options are a nice complement to each other in terms of what we see anatomically and what a patient needs. So, not everybody is looking for the same thing when they look at surgical options. Once we have a discussion with the patient, we try to do what’s best for the patient in terms of what they’re looking for and what surgical expectations are expected or are made of them.
Melanie: Thank you so much. You're listening to Medical Intel with MedStar Washington Hospital Center. For more information, you can go to www.medstarwashington.org. That's www.medstarwashington.org. This is Melanie Cole. Thanks so much for listening.