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Permalink Reply by Robert Greenbaum on August 17, 2010 at 10:03pm

Some thoughts:

If you have a dental appliance fabricated, make sure to have another sleep test performed once you have become acclimated to it. That will be the only sure way to know whether there is an improvement in your sleep.

You will most likely suffer from the shifting of teeth, including the opening of gaps between some of your teeth.

The devices are quite expensive. Shop around by phone from a list of recommended dentists.

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Permalink Reply by Jo E on August 17, 2010 at 11:56pm

I wonder if the reason so few people who underwent successful UPPPs is that they aren't here because their UPPPs were successful and they don't have too much interest in OSA any longer since they got over it. One way to decide that a person isn't going to be helped is by the Mallampati class. UPPP is generally only recommended for persons with a class of III or IV. It won't necessarily completely cure OSA by itself because there can be multiple breathing issues to deal with. I had to have a number of surgeries before I had the UPPP and two more after because I had multiple congenital problems that had to be surgically dealt with. I did not know what breathing was like until after I had those surgeries. I had to continue to use my CPAP after my UPPP. I did not realize how much my CPAP was NOT doing for me until after my UPPP. Once I had a submucous resection of the inferior turbinates, I was able to give up my CPAP. Now I use a wedge to elevate my upper body and I sleep just great without the CPAP (which, unfortunately, gave me a major issue with dry eyes, which made both me and my ophthalmologist unhappy). I don't really want to undergo more surgery, especially since my ENT says he doesn't really want me to have it (but I do qualify for it if I really want it).

One reason I bring up UPPP a lot is that I want others to understand that it can help them in the right situation. I want everyone who suffers OSA to consider ALL of the alternatives available and to make wise, informed decisions. Each treatment has both its good points and its drawbacks. Most people can be helped by CPAP or BiPAP without danger to themselves or others (provided they don't bring their children to bed with them and get their tubes wrapped around the poor, unsuspecting child). That is often the best place to start if you aren't sure about going with one of the other alternatives. (It took me some time to get up the courage to undergo the surgery!)

My mantra: Consider ALL of the alternatives!

(I just thought about it: The motto of Clan Kennedy is: "Avise la fin" - Consider the end. Consider the alternatives is more of less a version of Clan Kennedy's motto which fits great since I am a Kennedy!)

j n k said:

Jo E,

I wasn't trying to contradict you. I recently stumbled on that blog post and reply and thought it was interesting.

I am not a fan of UPPP, myself, as many here know, but I understand why some are fans of it. I believe it would be a more popular choice if it was more clearcut exactly who the best candidates are for it. One day there should be a more accurate predictive protocol and only those very likely to benefit will have it. Until then, I would recommend people be careful and recongnize it is likely they will need to remain on CPAP afterward, or will need to go back on CPAP eventually. Just because a doc guessed right about one person doesn't change the fact that it is so unsuccessful for so many. I would not get the procedure from just anybody.

I thought everyone would enjoy reading the thoughts from the discussion between the ASAA director and a highly respected ENT surgeon (who posts here from time to time) on the matter. It is controversial. That is what makes it fun to discuss! :-)

I think it is good that patients like you who are happy with their UPPP post on patient boards, since so few seem to do so. I am particularly interested in patients who are still very happy five to ten years after their UPPP and who still have an AHI below 5 without PAP therapy, as documented in a PSG.

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Permalink Reply by RockRpsgt on August 18, 2010 at 7:13am

They also have to sit through and pass a test on sleep medicine. Two of the doctors I am now working with are about to take these boards.

j n k said:

WHAT? Only 10 (TEN) hours at a sleep center to become a diplomate?!! NO WAY!!!!!:

http://www.abdsm.org/Prerequisites.aspx

"Each applicant must spend no less than ten (10) hours at an ac-credited sleep center/laboratory, documented in writing by a board-certified sleep physician (M.D., D.O. or Ph.D.) associated with that particular accredited sleep center or laboratory. The intention of this requirement is to document that the applicant has experienced direct observation of the operations of a sleep-medicine clinic. This time may include some or all of the following: direct patient interaction, observation of polysomnography preparation, data acquisition, scoring and interpretation clinical interaction, therapeutic intervention, and assessment of results of therapeutic intervention."

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Permalink Reply by Rock Conner RRT on August 18, 2010 at 10:56am

General dentists screening for OSA? Sure! General dentists treating OSA? No. For the relevant physiological processes, an MD has far more training than a DDS. I don't even think most MDs should treat sleep disorders, much less dentists.

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Permalink Reply by Jo E on August 23, 2010 at 11:25pm

I feel that all alternatives should be considered from the start. That does NOT mean they should all be TRIED by each patient! A good ENT will consider which alternatives are viable options for each patient individually. S/he will explain why s/he recommends this one for you and doesn't recommend another one. I thought I wanted a dental appliance because it sounded so much less painless than surgery and so much more convenient (and portable) than CPAP. Before I even mentioned the dental appliance, my ENT told me I couldn't have one because I already had TMJ problems that weren't causing me pain. He told me that I would end up with serious problems and a great deal of pain (and require surgery for TMJ issues) if I had a dental appliance. He wanted to do surgery on me right away for other issues, even if I did not want to have an UPPP, because I had so many other upper respiratory issues that had to be dealt with. I could not do any of those surgeries for several months because I had other medical issues that could not wait. I used CPAP for a year. During this time, I had a major orthopedic surgery, and underwent many tests for other conditions. During one cardiac test, I was wide awake, relaxed, and in a semi-reclined position. At one point, I felt my throat close up on me. I desperately tried to breathe. I couldn't get my breath until I turned my head sideways (somewhat difficult to do since my head was snugly cradled in a headreast). Later, I had to have an MRI of my brain. This was only about the fourth one I had in one 3 year period. (They finally found that the problem was not my brain, but in my legs due to damage caused by a mild case of polio.) During this MRI, they had my head in a cage because then needed more clear images than they could get with a regular MRI. During this test, I was laying flat on my back. At one point, my throat closed on me. I struggled to breathe. I could not move my head at all. The technician told me to hold still so she could get good pictures. I was still struggling to breathe. Finally, she came over, pulled me out, took the mask off and really chewed me out. I gasped for air once the mask was off and I could move my head. I told her I could not breathe since my throat closed up on me. She told me that I should have said something to her when I was having difficulty breathing. Now we had to do that part all over. She wanted me to talk to her when I couldn't even get a breath in? !?!?! Was she thinking? I don't think so! That experience was the one that put me over to the "I'm definitely going to have that UPPP when I am finished with all of this other stuff" side. I had the UPPP. After the UPPP, my CPAP finally did the job it was supposed to do. I could not stop using CPAP until the ENT did the last surgery he said I absolutely had to have.

The mantra: "Alternatives should only be considered for those who fail, or refuse to use, the gold-standard treatment" is very SHORT-SIGHTED. Alternatives should be discussed and considered from the first diagnosis. My sleep doctor's number ONE recommendation was see an ENT and have surgery. If I did not wish to have surgery, CPAP was a viable number TWO alternative for me. He made no mention of a dental device. My ENT's number ONE choice for me was surgery. Even if I did not want to have UPPP, I still needed to have surgery. He was okay with CPAP, but he still was insistant that I have the other surgeries. He was vehemently opposed to a dental device for me.
He would never make the same recommendation for every patient. It would be completely wrong to give that advice to everyone. He did say there were two other surgeries that I would qualify for if I did not experience enough relief and did not want to go back on CPAP (which I stopped after the submucous resection of the inferior turbinates). He did not strongly recommend that I have those surgeries because of the risks involved with them. If I did not experience enough relief from the UPPP and submucous resection of the inferior turbinates, he would much rather I returned to CPAP. (But he would still do the surgeries on me because I was a viable candidate for those surgeries.)

Thanks, but I'm not on CPAP, I'm not going to have those other surgeries, and I no longer fear suffocating during cardiac tests and MRIs thanks to the UPPP.


j n k said:

A nice UPPP summary from WebMD:

http://www.webmd.com/sleep-disorders/sleep-apnea/uvulopalatopharyng...

"How Well It Works : There is no good evidence on how effective UPPP is for obstructive sleep apnea. UPPP may stop snoring, but apnea episodes may continue. Limited research shows that about 40% to 60% of people who have UPPP see an improvement in their symptoms. Even if surgery successfully removes the blockage, you may still need CPAP after surgery."

My mantra: Alternatives should only be considered for those who fail, or refuse to use, the gold-standard treatment.

Or as the above link puts it: "Before considering surgery, you should try CPAP."

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Permalink Reply by Jo E on August 23, 2010 at 11:55pm

The last part of this reply got lost. It was:

I did not refuse to use your "gold-standard" treatment. I did not fail at using your "gold-standard" treatment. Your "gold-standard" treatment of CPAP failed me. CPAP did not work for me until after I had the UPPP. I could not get off of CPAP until I had the submucous resection of the inferior turbinates. Not only was CPAP inadequate for me, it also caused me to have a major case of dry eyes. My ophthalmologist was not happy with that. (Neither was I.) It took over six (very painful) months after I was off CPAP until I finally got over dry eye.



Jo E said:

I feel that all alternatives should be considered from the start. That does NOT mean they should all be TRIED by each patient! A good ENT will consider which alternatives are viable options for each patient individually. S/he will explain why s/he recommends this one for you and doesn't recommend another one. I thought I wanted a dental appliance because it sounded so much less painless than surgery and so much more convenient (and portable) than CPAP. Before I even mentioned the dental appliance, my ENT told me I couldn't have one because I already had TMJ problems that weren't causing me pain. He told me that I would end up with serious problems and a great deal of pain (and require surgery for TMJ issues) if I had a dental appliance. He wanted to do surgery on me right away for other issues, even if I did not want to have an UPPP, because I had so many other upper respiratory issues that had to be dealt with. I could not do any of those surgeries for several months because I had other medical issues that could not wait. I used CPAP for a year. During this time, I had a major orthopedic surgery, and underwent many tests for other conditions. During one cardiac test, I was wide awake, relaxed, and in a semi-reclined position. At one point, I felt my throat close up on me. I desperately tried to breathe. I couldn't get my breath until I turned my head sideways (somewhat difficult to do since my head was snugly cradled in a headreast). Later, I had to have an MRI of my brain. This was only about the fourth one I had in one 3 year period. (They finally found that the problem was not my brain, but in my legs due to damage caused by a mild case of polio.) During this MRI, they had my head in a cage because then needed more clear images than they could get with a regular MRI. During this test, I was laying flat on my back. At one point, my throat closed on me. I struggled to breathe. I could not move my head at all. The technician told me to hold still so she could get good pictures. I was still struggling to breathe. Finally, she came over, pulled me out, took the mask off and really chewed me out. I gasped for air once the mask was off and I could move my head. I told her I could not breathe since my throat closed up on me. She told me that I should have said something to her when I was having difficulty breathing. Now we had to do that part all over. She wanted me to talk to her when I couldn't even get a breath in? !?!?! Was she thinking? I don't think so! That experience was the one that put me over to the "I'm definitely going to have that UPPP when I am finished with all of this other stuff" side. I had the UPPP. After the UPPP, my CPAP finally did the job it was supposed to do. I could not stop using CPAP until the ENT did the last surgery he said I absolutely had to have.

The mantra: "Alternatives should only be considered for those who fail, or refuse to use, the gold-standard treatment" is very SHORT-SIGHTED. Alternatives should be discussed and considered from the first diagnosis. My sleep doctor's number ONE recommendation was see an ENT and have surgery. If I did not wish to have surgery, CPAP was a viable number TWO alternative for me. He made no mention of a dental device. My ENT's number ONE choice for me was surgery. Even if I did not want to have UPPP, I still needed to have surgery. He was okay with CPAP, but he still was insistant that I have the other surgeries. He was vehemently opposed to a dental device for me.
He would never make the same recommendation for every patient. It would be completely wrong to give that advice to everyone. He did say there were two other surgeries that I would qualify for if I did not experience enough relief and did not want to go back on CPAP (which I stopped after the submucous resection of the inferior turbinates). He did not strongly recommend that I have those surgeries because of the risks involved with them. If I did not experience enough relief from the UPPP and submucous resection of the inferior turbinates, he would much rather I returned to CPAP. (But he would still do the surgeries on me because I was a viable candidate for those surgeries.)

Thanks, but I'm not on CPAP, I'm not going to have those other surgeries, and I no longer fear suffocating during cardiac tests and MRIs thanks to the UPPP.


j n k said:

A nice UPPP summary from WebMD:

http://www.webmd.com/sleep-disorders/sleep-apnea/uvulopalatopharyng...

"How Well It Works : There is no good evidence on how effective UPPP is for obstructive sleep apnea. UPPP may stop snoring, but apnea episodes may continue. Limited research shows that about 40% to 60% of people who have UPPP see an improvement in their symptoms. Even if surgery successfully removes the blockage, you may still need CPAP after surgery."

My mantra: Alternatives should only be considered for those who fail, or refuse to use, the gold-standard treatment.

Or as the above link puts it: "Before considering surgery, you should try CPAP."

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Permalink Reply by Jo E on August 24, 2010 at 7:42pm

J N K,

I think we have arrived at a mutual understanding. There is no one best treatment for everyone. CPAP/BiPAP, surgery, weight loss, and dental appliances, body positioning - EACH has its place in the treatment of OSA. Many people need a combination of treatments. CPAP/BiPAP is generally harmless for most people (if you can tolerate the irritating side effects such as dry eye). Body positioning during sleep is harmless for most people. Weight loss is helpful for many people and harmful to comparatively few people. Surgical treatment and dental appliances should be given careful consideration before going that way. It took me a year to finally garner up the courage to go through with the surgery - and only after I felt like I was going to suffocate while I was awake, and also was suffering a bad case of dry eye.

My point is that I do not want anyone to talk any of the valid treatments down. Yes, I very much support the use of CPAP and BiPAP. It is a life saver for many, many people. But I don't want anyone to frighten others away from surgery. For some people, that is a very important part of their treatment. Even if it is not sufficient to cure the OSA, it might be an important step for them as it was for me.

If your ENT tells you that you are a viable candidate for UPPP or other surgery to treat your OSA, you need to give it careful consideration (and possibly, a second opinion). Surgery should NEVER be jumped into except in an emergency to save your life (or in my case, to save your vision, but that is a totally different forum!)

j n k said:

Good points, JoeE. Thanks. I learned from your perspective, and appreciate your taking the time to explain it so thoughtfully and directly. Well said.

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Permalink Reply by Jo E on August 24, 2010 at 11:37pm

I am beginning to feel very happy that I do NOT have Steven Y. Park as my doctor. I am very happy that my doctor suggested very strongly that I would be much better off if I had an UPPPP. That made my life much better than the CPAP ever did.


j n k said:

One of my favorite posts on surgical procedures and OSA was made on this board by the respected ENT surgeon Dr. Steven Y. Park

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Permalink Reply by Jo E on August 27, 2010 at 12:52am

I have been thinking: Why would PAP treatment be called the "gold standard"? Should not a "gold standard" be: (1) a cure and (2) usable and available to the majority of patients? PAP treatment fails in both ways. PAP cures nothing. Surgical can cure some people and help (but not cure) others, while it is of no benefit to others, and potentially has negative effects upon some people. Surgical intervention fits one, but not both, of the measurements. In addition, you (or your insurance) pays for the surgery once. It is available to those who have insurance, rich people, but not necessarily to everyone Dental devices treat some people, cure no one, are of no value to others, and potentially harmful to others. You pay for dental devices once (at least, until you have to replace it). You do not have to constantly purchase expensive accessories to use it. Like PAP, it does not meet the requirements of a "gold standard", but some people have had goo experience with it. Weight loss can cure some people, help some people, be of no benefit to some people, but harmless to nearly everyone. If can be relatively inexpensive to lose weight (unless you insist upoin hiring someone to plan your meals, develop your exercise routine, et cetera). Weight loss is possible for many people with OSA, but is not necessarily what will help everyone.

Then there is PAP treatment. It cures nothing! It is relatively harmless to most people, but not well tolerated by many. In addition, it inadequate for some patients. On the other hand,

PAP treatment is one of the most costly treatments of OSA available today. You or your insurance has to pay for a ridiculously expensive machine. Every six months, you have to purchase new masks and other equipment. Over time (and there will be a lot of time since you will need it every day for the rest of your life is this is the only treatment you try), it becomes incredibly expensive. Then there is the person whose insurance will not pay anything at all for PAP treatment. Just how expensive is PAP treatment when you don't have insurance or your insurance will not pay any of the cost of the treatment? Expensive enough that you are relieved that mother had surgery on her septum, her sinuses, and her throat!

Perhaps it is the "gold standard" because it is so incredibly expensive!

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Permalink Reply by Banyon on August 27, 2010 at 7:25am

Jo E,

I agree with your direction of thought. CPAP is a treatment that is successful for maybe 25% of the patients and it is a treatment that scares many more away from ever getting a diagnosis ("I would never wear a mask while sleeping" syndrome). Does such a treatment deserve the "gold standard" label?

I have to give it some great credit though, because it has already kept me alive and active three to five years beyond the age I expected to live before proper diagnosis and the beginning of treatment. Those years I would not trade for gold.

Where I disagree with you is the issue of economics. I bought a machine for about $500 which has already lasted three years and I expect it to last at least five years. I bought four masks and some hoses for about $400 and they will last at least five years. Then there is the need for a few filters and distilled water - just a few dollars each year.

I am sure my total cost for CPAP equipment and supplies will be less than $200 per year in the long run. That is very cheap for staying alive and functional.

The term "gold standard" has served a good use for me in talking to people going for their first PSG. To the uninitiated, it is a quick and clear way to help them understand it is the first treatment they should consider and the treatment for which they need solid reasons to reject.

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Permalink Reply by Rooster on August 27, 2010 at 9:45am

I personally know three people who underwent UPPP. One of them initially used CPAP and then had UPPP at age of 40. At age of 47 his OSA was back. Very unfortunately he could no longer use CPAP and is suffering with the condition.

The second did very well with the surgery but it was ineffective and he is using CPAP but not with good results. He also has annoying problems when eating and drinking. If he is not careful, things go up into his nose.

The third had UPPP last summer. I haven't seen him in a while but ran into his wife at the grocery store this summer. She told me he just did an oximetry study and was getting regular desats down to 89%. So he needs to do pursue additional steps.

For these three reasons alone, I, like jnk, recommend an approach like Dr. Parks.

This would be:

1) Full-fledged commitment to CPAP for a lenghty period of time. Includes patient self-education via internet forums and local support groups, and top-of-the-line machine with patient software. During learning period, regular visits to sleep professionals to report and lack of progress.

2) If 1) fails, then a custom fitted MAD provided by a sleep dentist should be committed to for a lengthy period of time.

3) If 1) and 2) fail, then an ENT capable of evaluating the likelihood of UPPP success matched to the patients anatomy, should be consulted. The role of the tongue must be considered before deciding on the surgery. The patient should seek self-education on the risks and side effects of UPPP.

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Permalink Reply by RockRpsgt on August 27, 2010 at 9:54am

I agree

Might not happen often fellas. Soak it in!

Rooster said:

I personally know three people who underwent UPPP. One of them initially used CPAP and then had UPPP at age of 40. At age of 47 his OSA was back. Very unfortunately he could no longer use CPAP and is suffering with the condition.

The second did very well with the surgery but it was ineffective and he is using CPAP but not with good results. He also has annoying problems when eating and drinking. If he is not careful, things go up into his nose.

The third had UPPP last summer. I haven't seen him in a while but ran into his wife at the grocery store this summer. She told me he just did an oximetry study and was getting regular desats down to 89%. So he needs to do pursue additional steps.

For these three reasons alone, I, like jnk, recommend an approach like Dr. Parks.

This would be:

1) Full-fledged commitment to CPAP for a lenghty period of time. Includes patient self-education via internet forums and local support groups, and top-of-the-line machine with patient software. During learning period, regular visits to sleep professionals to report and lack of progress.

2) If 1) fails, then a custom fitted MAD provided by a sleep dentist should be committed to for a lengthy period of time.

3) If 1) and 2) fail, then an ENT capable of evaluating the likelihood of UPPP success matched to the patients anatomy, should be consulted. The role of the tongue must be considered before deciding on the surgery. The patient should seek self-education on the risks and side effects of UPPP.

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