People with obstructive sleep apneoa (OSA, Apnea) have disrupted sleep and low blood oxygen levels. When obstructive sleep apnea occurs, the tongue is sucked against the back of the throat and soft palate. This blocks the upper airway and airflow stops. When the oxygen level in the brain becomes low enough, the sleeper partially awakens, the obstruction in the throat clears, and the flow of air starts again, usually with a loud gasp.
Repeated cycles of decreased oxygenation lead to very serious cardiovascular problems. Additionally, these individuals suffer from excessive daytime sleepiness, depression, and loss of concentration.
Some patients have obstructions that are less severe called Upper Airway Resistance Syndrome (UARS). In either case, the individuals suffer many of the same symptoms.
The first step in treatment resides in recognition of the symptoms and seeking appropriate consultation. Referral to a Sleep Physician and undergoing a sleep study is essential to properly diagnose a sleep disorder. Oral and maxillofacial surgeons form part of the team and offer consultation and treatment options.
In addition to a detailed history,Wayne will assess the anatomic relationships in the maxillofacial region. Cephalometic (skull x-ray) analysis used to be used for assessment of OSA but this has been replaced by 3D CT scans and airway imaging which give vastly superior information on the the level of obstruction and how you will respond to different treatments. Wayne has a CT scanner in his rooms to offer a complete single appointment examination. Naso-pharyngeal exam used to be done with a flexible fiber-optic camera but now doesn’t have a role to play in OSA diagnosis or treatment, CT scanning has replaced this.
There are several treatment options available. An initial treatment usually consists of using a nasal CPAP machine that delivers pressurized air through a nasal mask to limit obstruction at night. This allows the patient to experience what a healthy sleep is like and the beneficial effects it has on them the next day. About 40% of patients find CPAP is the best option for them and stay on it long term.
An alternative to CPAP is a Mandibular Advancement Device such as the MDSA and Somnomed appliances or tongue suction devices such as the AVEO TSD. These are like mouth guards and are worn at night to hold the jaw and tongue forward. There is a degree of fine tuning in using these devices and usually a second sleep study is recommended to assess their effect. 60% of people use them long term as a cure for OSA. Wayne is familiar with the use of these appliances and will construct the most appropriate solution for each individual. An advancement splint is usually required as pre-assessment tool if patients are considering surgery.
Cost of a Somnodent Mandibular Advancement Splint is $1250
Wayne supplies the newer version called Somnomed Fusion
Surgery on the palate (UPPP = Uvulopalatopharyngoplasty) , tongue (coblation)and nose (septoplasty, turbinectomy) can be performed to help with OSA therapy, these are not a treatment for OSA but an aid to the use of CPAP or to help reduce snoring.
For snoring reduction Wayne offers The Pillar Procedure or pillar implants as the best current solution. The best success rates for any anti-snoring procedure is about 65 – 70% bed partner satisfaction (your bed partner can sleep beside you without ear plugs). The Pillar Procedure matches this and studies up to 7 years long say the effect persists. The pillar procedure can be performed under local anaesthetic in 15 minutes and you can return to work immediately. See The Pillar Procedure for more info. Cost varies on how many implants are required, for most the cost is $2100.
For Upper Airways Resistance Syndrome, maxillary (upper jaw) widening can be performed. It is called Surgically Assisted Rapid Palatal Expansion (SARPE) or Rapid Maxillary expansion (SARME) this can be done under IV sedation at a cost of $5000. You will usually need orthodontic treatment in conjunction with surgery.
To definitively treat OSA the facial skeleton usually needs to be changed, simple cases may just require the lower jaw, chin or hyoid bone to be advanced,in most cases the upper and lower jaw will be repositioned to increase the size of the airway (orthognathic or Maxillomandibular advancement surgery). This procedure is done in hospital under general anesthesia and requires a one to two day overnight stay in the hospital. Maxillo Mandibular Advancement (MMA) is considered the gold standard of surgical treatment for OSA. It has extensive research for 60 years and long term scientifically reviewed outcomes, we know it works and as yet nothing else does. The cost for MMA surgery ranges from $16,000 to $26,000 depending on the extent of surgery, private medical insurance may cover all or part of the costs. The cost may seem high but does compare favorably with the lifetime cost of CPAP or repeated oral appliances.
Surgical treatment for OSA has a chequered history with many different surgeries being offered which have been shown to not work, despite this they are still promoted (UPPP has 8% success rate, nevertheless it is still promoted for OSA). The OSA management team should always include a sleep physician and a sleep study (polysomnogram or PSG). In the past 8 years we have a better understanding of what surgery works and for who. Wayne has training in OSA and can personally provide a wide range of care from simple splint management, snoring treatment up to the full surgical options of MMA surgery. Wayne is an associate member of the Australian Sleep Association and regularly attends multidisciplinary meetings.
Wayne is the main provider for OSA MMA surgery in New Zealand and has a comprehensive process in consultation with sleep physicians for assessment, workup and treatment planning. The appeal of surgery is the opportunity “to be cured” by a single operation and not have to think about OSA again. Over the past six years of providing surgery for OSA Wayne has a Surgical Success rate for OSA of 100%
OSA is a very serious condition that needs careful attention and treatment. Most major medical insurance plans offer cover for diagnosis and part of treatment.