Comment

Comment by Randy Bray on January 20, 2009 at 6:07am

Hello Dr Park, I would like to make a few comments. On Sept 17th I underwent surgery to hopefully alleviate my severe chronic obstructive sleep apnea. I was being operated on by Dr Ryan Stevens at Samaritan regional Health Center in Corvallis Oregon. I discussed every one of the surgical possibilities with Dr Stevens. After and endoscopy exam he concluded that my biggest problem was the base of my tongue. He suggested a Lingual Tonsillectomy and a UPPP. We proceeded with the surgery and I remained in the hospital for 2 days then was released for a 2 week recovery period. Probably the roughest part was that the Dr placed a loop of suture on the underside of my tongue in case I began to choke while recovering. The suture caused me to salivate like Niagra Falls and saliva leaked out of my mouth when I tried to sleep it would wake me up. After they removed that the following morning things improved. My pain was managed with Roxicet (liquid Oxycontin) and by syringes of a lidocane gel. The Lidocaine made everything numb and seemed to increase the salivation so I used it sparingly. The second night at the hospital was much more comfortable and by the following morning I was doing well enough to be released. I was cleared to eat solid food upon my release of the hospital, I could eat but it was a slow process and swallowing was difficult, more from the tissue stretching than from pain. I stayed off work for 2 weeks, the second week I was well enough to go on a 5 day trip to he Bay Area to visit family. Probably the things I can say looking back on this are: It was worth it! The pain is no worse than a bad sore throat from Tonsilitis. The end definately justified the means.

During recovery I drank warm water with meals, anything hot, cold, alcoholic or carbonated was not tolerated. I slept with CPAP for 2 weeks. After the swelling was totally reduced I quit using it. I no longer have apnea episodes, I no longer gasp and I rarely snore, when I do snore it's about 90% less than before. The only thing I've notivced is that sometimes I'll cough if I have post nasal drip, that seems to be the only thing that wakes me from a sound sleep. I have to say I look and feel better, I awake rested, alert and there's no grogginess at all. My wife is very pleased, My coworkers say I'm easier to get along with and my boss has commented that I'm more productive. I have had 2 post op checkups and Dr Stevens is elated with the results. I have an appt with the sleep Doctor and he'll decide if they want me to go through another sleep study, personally I don't think it's needed. I turned 54 today and this surgery made me feel 15 years younger. I highly recommend it.

Randy Bray,
Corvallis Oregon

Comment by Steven Y. Park, MD on January 5, 2009 at 9:32pm

Mike, as a sleep apnea surgeon, let me chime in. First of all, there's always MUCH more that can be done to help a sleep apnea patient ultimately use and benefit from CPAP. Most patients fall through the cracks, and end up giving up on CPAP altogether. This is a complex problem, mainly due to the fragmentation of our health care system, and no one wants to take responsibility for the patient. The vast majority of patients, if given an intensive training and follow-up program, can benefit from CPAP.

The problem is that in the real world, compliance is very poor. I never liked the word compliance, since it implies it's ultimately the patient's fault. Just like learning and using any skill, it takes patience and practice. Many of my patients also have nasal congestion and if you deal with this either medically or surgically, they are usually able to use CPAP more effectively.

However, there are some patients that have tried literally EVERYTHING. I have grown men in tears in my office, utterly frustrated by their inability to benefit from CPAP despite trying everything. This may be an extreme example, but for almost every patient, I insist that they try CPAP first. A dental device is another option in certain patients with mainly tongue base collapse seen on endoscopy in the office (I do this sitting up and lying flat).

In our field, too many surgeons focus too much on the soft palate, since that's where the snoring comes from. So when you perform the standard UPPP procedure, overall, there's only about a 40% chance of "success" (we'll have a discussion about what success means later—it's a long one). The problem is that the soft palate is most often not the primary source of obstruction. The tongue is usually the main culprit, and the nose gets involved as well. So to do sleep apnea surgery properly, you have to address the entire area from the tip of the nose to the voice box. When you address these areas using multi-level surgery, "success" goes up to 70-80%. If you cut your upper and lower jaws and pull them forward, then about a 90-95% chance of success (see http://www.doctorstevenpark.com under upcoming events about an interview I'm doing with one of the pioneers in this type of surgery). If you do a tracheotomy, it's 100% successful. So it's all relative—the more appropriately and aggressively you address all the potential areas of collapse, the higher your success rate.

Most of my patients don't care what the final AHI is—they just want to feel better. Getting the numbers down is important too, from an objective standpoint. But getting your number down 50% and having the patient feel much better is better than not using CPAP at all. Once patients start to sleep better, it's easier to exercise, diet and lose any weight that they have to lose. Yes, these procedures can be uncomfortable, but with proper counseling and good post-op care, most patients do fine and are happy with the results. Obviously, some do not improve, and this is usually because the procedure was not strong or aggressive enough (especially with the tongue base). You hear about not being able to use CPAP after a UPPP, but this is a rare occurrence.