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Hi everyone,
Sleep apnea surgeon Dr. Kasey Li just posted his response to my question - Question 60 in the "Ask A Sleep Surgeon" column on http://www.sleepnet.com in the non-cpap options section. For those of you unfamiliar with my story, I had the MMA/deviated septum surgery performed in Jan. 2010 which improved my symptoms about 40-50% but not my RDI. I was put back on cpap (now bipap) at a pressure level of 11. I suspect my optimal pressure setting is higher - around 15 cm because the use of nasal Afrin on my cpap titration possibly skewed my results. This is my opinion and is unverified. I know if MMA is not curative it can result in decreased cpap pressure which seems to be occurring in my case. Pre MMA surgery, I was still very symptomatic at a pressure of 20cm. I wanted to know if there were other surgeries that could lower your cpap pressure.
I asked him this question: You mentioned previously that MMA surgery can result in a reduction in the cpap pressure level. Are there any other surgeries that can reduce cpap pressure levels? I am particularly interested in the genioglossus advancement, hyoid advancement and MME surgeries but feel free to comment on others.
Below is his thorough, honest response. His input is always insightful and I thought I'd share it with everyone.
Hi Marie,
I will do my best to be as thorough as possible in answering your question. This is actually going to open up a can of worms...and I will be one of the very few surgeons with this view. I am not going to win any fans, but it is what it is as it is my honest opinion.
The central issue with sleep apnea surgery is that very few surgeons actually have some clues in what they are doing. The data on surgery is murky at best. What I can tell you is that there are only 3 operations that I feel comfortable as reasonable options where a majority of patients (properly selected) will improve without significant side effects.
1. Nasal surgery to improve nasal breathing and possibly improve CPAP tolerance if nasal congestion is a major problem.
2. Pharyngoplasty WITH tonsillectomy to improve sleep apnea WHEN the tonsils are VERY LARGE.
3. Maxillomandibular advancement.
Years ago, I did over a hundred genioglossus advancements with pharyngoplasty per year because I followed the phase protocol. As the number of cases piled up, I started to have more and more concern about the efficacy of the procedures. I found that only a few patients had dramatic improvement from these operations (I do get home runs from time to time, but just not nearly as many as I'd like). Many patients continued go on to the phase protocol by having MMA. However, many patients simply dropped out because they were discouraged by the results. I started to really wonder about the efficacy of genioglossus advancement. To me, there is little to no data documenting the effectiveness of this operation. I then reviewed the results of other very experienced surgeons and guess what, similar to mine. Additionally, although there are many, many published papers on the effectiveness of genioglossus advancement, they are all combined with other procedures, such as UPPP, nasal surgery...etc. So which procedure helped? I also saw 5 or 6 patients that underwent an isolated genioglossus advancement performed by an experienced surgeon. However, none of them had any appreciable improvement. A couple of patients' sleep apnea got worse after the operation. Therefore, I am always hesitant in offering genioglossus advacement. The same goes for hyoid advancement.
One may then ask, why do all those surgeons report the success of genioglossus advancement/hyoid advancement. If you examine those data, they are all combined with UPPP/nasal surgery, you will see that typically, the reported response rate is 40-60% and improvement is about 40-50% in reduction in RDI. The results are OK, but rarely a game changer. Additionally, the standard deviations are all very large, which means that some patients did not improve at all and some got worse. Making someone worse is a real concern and should be for all surgeons. By the way, sleep endoscopy DOES NOT improve the ability for surgeons to select out patients who would be favorable responders, so why do it?
I do my best to offer reasonable options for patients. If someone has very unfavorable upper airway anatomy, moderate/severe sleep apnea, no or small tonsils and no redundency in the soft palate, I would tell them that the only good option for them is the MMA. Otherwise, don't do any surgery. I know I scare off a lot of patients and they go elsewhere so they can have something less invasive, but they ended up having MMA at the end. It happens not infrequently, just look at the blogs. When UPPP with genioglossus or nasal surgery success rate is so low, why do it? Consider the risks and expenses.
MMA is often a game changer for patients, but not always. When a patient does not have a dramatic improvement from MMA, I get concerned in offering additional surgery. I like predictable, successful results. I don't like to just do surgery and see what happens. However, many patients are desperate in getting better sleep, and I understand. I am willing to work together and will try my best in doing additional surgery, as long as my patients understand that these additional surgery will be a lot less predictable and there may be no improvement.
Finally, I am very selective when it comes to MME. I only offer it to patients with very narrowed jaws. The results have been pretty good. Not as good as MMA but better than UPPP/genioglossus advancement. In general, the narrower the jaws, the better the improvement.
I am sure I will get more questions. I am happy to answer them.
Kasey Li, MD, DDS
Sleep apnea surgeon Dr. Kasey Li just posted his response to my question - Question 60 in the "Ask A Sleep Surgeon" column on http://www.sleepnet.com in the non-cpap options section. For those of you unfamiliar with my story, I had the MMA/deviated septum surgery performed in Jan. 2010 which improved my symptoms about 40-50% but not my RDI. I was put back on cpap (now bipap) at a pressure level of 11. I suspect my optimal pressure setting is higher - around 15 cm because the use of nasal Afrin on my cpap titration possibly skewed my results. This is my opinion and is unverified. I know if MMA is not curative it can result in decreased cpap pressure which seems to be occurring in my case. Pre MMA surgery, I was still very symptomatic at a pressure of 20cm. I wanted to know if there were other surgeries that could lower your cpap pressure.
I asked him this question: You mentioned previously that MMA surgery can result in a reduction in the cpap pressure level. Are there any other surgeries that can reduce cpap pressure levels? I am particularly interested in the genioglossus advancement, hyoid advancement and MME surgeries but feel free to comment on others.
Below is his thorough, honest response. His input is always insightful and I thought I'd share it with everyone.
Hi Marie,
I will do my best to be as thorough as possible in answering your question. This is actually going to open up a can of worms...and I will be one of the very few surgeons with this view. I am not going to win any fans, but it is what it is as it is my honest opinion.
The central issue with sleep apnea surgery is that very few surgeons actually have some clues in what they are doing. The data on surgery is murky at best. What I can tell you is that there are only 3 operations that I feel comfortable as reasonable options where a majority of patients (properly selected) will improve without significant side effects.
1. Nasal surgery to improve nasal breathing and possibly improve CPAP tolerance if nasal congestion is a major problem.
2. Pharyngoplasty WITH tonsillectomy to improve sleep apnea WHEN the tonsils are VERY LARGE.
3. Maxillomandibular advancement.
Years ago, I did over a hundred genioglossus advancements with pharyngoplasty per year because I followed the phase protocol. As the number of cases piled up, I started to have more and more concern about the efficacy of the procedures. I found that only a few patients had dramatic improvement from these operations (I do get home runs from time to time, but just not nearly as many as I'd like). Many patients continued go on to the phase protocol by having MMA. However, many patients simply dropped out because they were discouraged by the results. I started to really wonder about the efficacy of genioglossus advancement. To me, there is little to no data documenting the effectiveness of this operation. I then reviewed the results of other very experienced surgeons and guess what, similar to mine. Additionally, although there are many, many published papers on the effectiveness of genioglossus advancement, they are all combined with other procedures, such as UPPP, nasal surgery...etc. So which procedure helped? I also saw 5 or 6 patients that underwent an isolated genioglossus advancement performed by an experienced surgeon. However, none of them had any appreciable improvement. A couple of patients' sleep apnea got worse after the operation. Therefore, I am always hesitant in offering genioglossus advacement. The same goes for hyoid advancement.
One may then ask, why do all those surgeons report the success of genioglossus advancement/hyoid advancement. If you examine those data, they are all combined with UPPP/nasal surgery, you will see that typically, the reported response rate is 40-60% and improvement is about 40-50% in reduction in RDI. The results are OK, but rarely a game changer. Additionally, the standard deviations are all very large, which means that some patients did not improve at all and some got worse. Making someone worse is a real concern and should be for all surgeons. By the way, sleep endoscopy DOES NOT improve the ability for surgeons to select out patients who would be favorable responders, so why do it?
I do my best to offer reasonable options for patients. If someone has very unfavorable upper airway anatomy, moderate/severe sleep apnea, no or small tonsils and no redundency in the soft palate, I would tell them that the only good option for them is the MMA. Otherwise, don't do any surgery. I know I scare off a lot of patients and they go elsewhere so they can have something less invasive, but they ended up having MMA at the end. It happens not infrequently, just look at the blogs. When UPPP with genioglossus or nasal surgery success rate is so low, why do it? Consider the risks and expenses.
MMA is often a game changer for patients, but not always. When a patient does not have a dramatic improvement from MMA, I get concerned in offering additional surgery. I like predictable, successful results. I don't like to just do surgery and see what happens. However, many patients are desperate in getting better sleep, and I understand. I am willing to work together and will try my best in doing additional surgery, as long as my patients understand that these additional surgery will be a lot less predictable and there may be no improvement.
Finally, I am very selective when it comes to MME. I only offer it to patients with very narrowed jaws. The results have been pretty good. Not as good as MMA but better than UPPP/genioglossus advancement. In general, the narrower the jaws, the better the improvement.
I am sure I will get more questions. I am happy to answer them.
Kasey Li, MD, DDS
Views: 700
Replies to This Discussion
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Permalink Reply by Steven Y. Park, MD on
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Marie,
Being a sleep surgeon, I thought I had to comment on Dr. Li's answer to your question. I truly respect Dr. Li and everything he's done, and even had him on my Expert Interview program twice. But he's right in saying that his views about upper airway surgery are in the small minority.
The response rate for multilevel procedures where you perform the UPPP + genioglossus advancement + hyoid suspension ranges anywhere from 60 to 80%. I'm not sure where he gets the 40-50% figure. The UPPP alone is 40%, and your success rate will increase in proportion to how many additional procedures you do.
The question isn't does the UPPP work or the genioglossus procedure work? I agree—independently, it doesn't work most of the time, since sleep apnea is a multi-level problem. Addressing one area only out of 2 or 3 levels of obstruction is only asking for failure. I also see a lot of people coming to see me after having undergone the UPPP procedure or even multi-level surgery, and even the MMA, with less than optimal results. What I'm finding is that in many cases, there's residual palatal collapse, tongue collapse, or both. Sleep surgeons are so fearful about velepharyngeal insufficiency (leakage of air or food into the nose) that they're being too conservative. Even with the various tongue base procedures, there are a number of different options, but typically, only one option is chosen, such as radiofrequency stiffening, or the genioglossus advancement. Most often, you can see where the obstruction persists with a good endoscopic exam with the patient lying flat.
You may not like to hear this, but the more aggressively you perform soft tissues procedures, where you layer different procedures, the higher your success rate. So a genioglossus + hyoid will work better than a genioglossus alone. A hyoid + radiofrequency tongue base reduction will work better than tongue base alone. As surgeons and patients, we all want the least invasive procedure possible, so we end up performing sleep apnea procedures that end up only scratching the surface.
Of course, every patient has unique anatomy and circumstances, so not everyone will need the same set of procedures. But in general, the more the combination of procedures (especially for the tongue base), the better the results. Nasal surgery alone as a first step is something that I'll usually offer liberally, since in many cases, it allows for better CPAP or oral appliance tolerance. I also have to stress that the sleep professions can do a much better job in getting patients to benefit from CPAP. There are also a lot of misconceptions about oral appliances as well as surgery.
Having large tonsils is a positive predictor of UPPP surgery, but just like with children that undergo tonsillectomy with initial good results, the long-term results are disappointing. This is because the jaws are smaller to begin with, and you're not addressing the nose and the tongue. A recent meta-analyis of tonsillectomy showed that for sleep apnea, the long-term success rate is about 60%. Even with initial success, these people will probably go on to develop sleep apnea later in life.
There also seems to be a disconnect between our published research studies and what we see in the internet forums and blogs. Perhaps people who are dissatisfied with their procedures tend to be more vocal. You rarely see people rave about their sleep apnea surgery successes, even though they do exist.
I do agree with Dr. Li that with the way sleep surgeons are performing even multilevel procedures, it probably doesn't reach the 80% that some studies show. It's probably hovering more in the 50 to 60% range. This is why in this context, the MMA may be much more appealing, especially if you have significant jaw narrowing. Now with more advanced orthodontic techniques that can expand dental arches even in adults, we have another option in addition to all the various surgical procedures for sleep apnea.
Ultimately, for people who can't tolerate CPAP or oral appliances, it's not a matter of which surgical option is better, but which option is right for you. Some people would rather go all out with a procedure that has higher success rates, whereas some people do it in steps. Everyone's anatomy and unique circumstances will be different. But as long as we continue to debate the value of one isolated soft tissue procedure, these debates will be endless.
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