When choosing treatment for sleep apnea patients, physicians are advised to avoid the “one size fits all” approach. “Traditionally, physicians thought the only treatment for sleep apnea is the CPAP (continuous positive airflow pressure) machine and the UP3 surgery (uvulopalatopharyngoplasty),” said Dr. Tarika Bhuta of Southview ENT in Birmingham. “We want to get the awareness out there that there are more procedures.” “The effectiveness of these (CPAP) machines is quoted as high as 95, 98 percent,” she added, “and they’ve been around for probably 30, 40 years. They’ve become more sophisticated as technology improves, and so we still feel like that is the first way to go for patients.” However, despite improvements in technology and more comfortable face masks, the CPAP compliance rate is about 50 percent. “People just cannot get used to the idea of strapping something to their face and sleeping all night with it,” Bhuta said. What about the other 50 percent of patients? “The question is: What do you do with them?” said Dr. Brian McCool, also of Southview ENT. “I think you have to present to them all the options,” including surgeries. The UP3 procedure removes some of the tissue of the soft palate and the uvula as well as any remaining tonsil tissue to open up the airway, McCool said. “The, quote, ‘success rate’ on the UP3 is about 45 to 50 percent,” he said. “One of the reasons is that it was a surgery that was used for all sleep apnea patients regardless of where their obstruction may have been. There are some other sites of obstruction in sleep apnea, such as the very back of the tongue. You can even have a closure of the throat itself.” He went on, “This procedure (UP3) may have been used on patients too broadly. It wasn’t directed at taking care of the source of the obstruction. Consequently, if you took 100 people and did this procedure on them, regardless of where their obstruction might be, I think you’re going to have a pretty low success rate.” As more information on multiple sites of obstruction becomes available, McCool and Bhuta advise physicians to be more aware of the treatment options and more selective about choosing the appropriate surgeries for their patients. “Rather than them doing a ‘one size fits all, everybody gets a UP3 surgery,’ the thinking is changing such that we understand that the UP3 is appropriate for some patients but not appropriate for everybody,” Bhuta said. “We have to do a better job of selecting the appropriate patients for the procedures that are out there.” With newer procedures, “minimally invasive” is the key phrase, she said. Rather than trimming tissue in the throat, the pillar procedure involves placing polyester implants into the soft palate, resulting in stiffened tissue that doesn’t flop back into the throat, vibrate and block the breathing passage. The pillar procedure can be done in the office and takes 20 to 30 minutes, Bhuta said. Patients can return to work the next day and have minimal side effects besides a sore throat that requires a soft diet for two days. “But again, the pillar procedure is not a ‘one size fits all,’ either,” she said. “It’s only for people who have mild sleep apnea and have a long palate.” More recently, the base of the tongue has been identified as a site of obstruction. When the patient lies down, the base of the tongue can fall back and block off the airway, McCool said. “That site had often been overlooked in the past, and I think there’s much greater awareness that the base of tongue can be a problem,” Bhuta said. “Something as simple as an oral appliance, a dental mouth guard worn at nighttime — it’s almost like a retainer — can help keep the bottom jaw forward, thereby keeping the tongue at an advanced position and keeping it from falling back. Going a little bit more invasive, there are some measures you can do under anesthesia to shrink the tissues at the base of tongue. There’s another procedure where you suture the base of tongue and advance it forward.” Some patients, usually those with moderate to severe apnea, need multiple procedures, she said. “Sometimes people have to have their deviated septum repaired in the nasal area; they have to have the UP3 procedure done and the tongue addressed to treat the problem.” Another treatment option for apnea is weight loss, McCool and Bhuta said. “Of course, weight loss and sleep apnea seems to be vicious cycle because most people who are suffering from sleep apnea have poor sleep quality,” Bhuta said. “During the day they’re not as active because they’re sluggish and they don’t have as much energy. Their activity levels decrease, and therefore their weight comes on even more. Added weight adds to the severity of their sleep apnea, and they find themselves in this cycle.” November 2007