Perfect Methods for Treatment - 謝明吉、姜厚任顎顏面美學重建專科診所-風華整形聯合診所

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Respiratory Tract Reconstruction Center

Perfect Methods for Treatment

媒體報導治療睡眠呼吸中止

3 steps to choosing the sleep apnea treatment: suspect, exam, use of AHI score for guiding the treatment decision

As mentioned in the article "Snoring and Sleep Apnea", conservative and invasive approaches are currently available to treat OSA. When the conservativeapproaches offer little improvement, the patients might choose the invasivesurgical treatment to improve their health and quality of life. Here I will explain the pros ad cons of different surgical procedures to assist the sleep apnea patients in choosing the most suitable treatment.

It is worth mentioning that most people have the impression oforthognathic surgery as the treatment to correct orthodontic problems or craniofacialabnormalities. As a matter of fact, orthognathic surgery can also effectively treat sleep apnea byrepositioningand restructuring the facial bones. One of the representative cases is forward reposition of thejaw bonesto widen the airway behindand solve sleep disorders caused by constricted airway.

There are two types of invasive surgical for sleep apnea

Invasive surgicaltreatments for sleep apnea are divided into two types. Both types work on the constricted upper airway where the obstruction happens and causes the sleep apnea. Imagine upper airway as a cageenclosed byupper and lower jaws, inside which lies soft tissues including the tongue, palatine uvula, tonsiland soft palate. The surgicaltreatmentfor OSA is either removing the excessive tissues lying inside or expanding the cage so as to relieve the obstruction.

Figure. (Lateral view of the upper airway) The area marked with yellow solid line is the main surgicalsite for sleep apnea. The surgicaltreatment for sleep apnea either removing the excessive soft tissues lying inside the airway or expanding the airway enclosed by the bony framework. [Source: painneck website]

Uvulopalatopharyngoplasty (UPPP) removes the excessivetissues to creat free space

The surgical treatment of removingexcessivetissues to create more breathing space relies on a straight way of thinking. Uvulopalatopharyngoplasty (UPPP) is one of the surgical options to remove the excessive soft tissues.UPPP removesthe uvula (functioned to prevent choking) and tonsil (part of immune system) and shortens the soft palate (functioned to divide the respiratory and digestive pathways) to create free space. However clinical data showed the successful rate of curing sleep apnea by UPPP was less than 50%.

Besides UPPP is performed under general anesthesiaand has relatively long recovery period. Patients receiving UPPP commonly complain about the intense postoperative pain and bleeding. In addition the risk of choking is higher as the entire uvula been removed.

(Left)Uvulopalatopharyngoplasty, one of the excessive tissue removal surgicalapproaches, removes the uvula, tonsil and part of soft palate. (Right) Free breathing pace is created with UPPP but the patients are at higher risk forchoking.

A new uvulopalatal flap (UPF) technique that modifies the UPPP and reduces the choking risk was introduced. This procedure preserves the uvula and lifts it upward to open up the airway and solve the uvula muscle over-relaxing problem.Comparing to UPPP, patients receiving UPF have less postoperative pain and shorter recovery period. However the relatively little free space created by UPF techniquecontributes to the lowsuccessful rate of curing sleep apnea.

(Figure) The surgicalincision of UPF technique is right above the uvula. This procedure liftsthe uvula upward by stretching up uvula muscle to create free space. [Source:sultansurgicalcenter]

Genioglossus advancementapplies to sleep apnea caused by airway obstruction with tongue base

Genioglossus advancement (GA) is a common surgical treatment for sleep apnea. It neither removes the excessive tissueslike UPPP nortights up the excessive tissues together like UPF. During the procedure of GA, the base of the tongue is pulled forward and securedto the lower jaw so itdoesn't fall backward toobstruct the airway while sleeping. This procedure applies better to patients with mild sleep apnea.

Figure. During the procedure of GA, a small bone cut is made in the front part of the lower jaw and this piece of bone with the attachment for the tongue is pulled forward and secured to improve the airway obstruction without enlarging the airway.[Source: websitesultansurgicalcenter]

As the tongue tends to relax and fall backtoward the throat while sleeping on the back, the principle of GA is pulling forward the tongue muscles attached to the lower jaw to prevent the tongue base falling back and obstructing the airway during sleep. In another word, GA prevents the tongue falling back down to block the airway without enlarging the airway.

Orthognathic surgeryenlarges the airway by breakingthrough the boundaries of the cage and reshaping the bony framework

MaxilloMandibular Advancement (MMA) or orthognathic surgery is the only treatment that enlarges the bony framework of the airway and improved the airway obstruction caused by relaxing uvula and tongue base both falling backward

orthognathic surgery achieves enlargement of the entire airway throughrepositioning the facial bones and reshaping the bony framework with adequate angles and distance.Meanwhile the uvula is moved forward with the upper jaw and the face contour is reshaped to meet the aesthetic purpose.

In another word, nowadays only orthognathic surgery serves as multi-level surgery which targets various points of airway collapse to make improvement, unlike the above mentioned solitary procedures each with one specific anatomic target, such as UPPP to remove the uvula and tonsil or GA to pull the tongue forward. In additionorthognathic surgery reshapes the facial bones and brings the facial proportion in line with the golden ratio, which is regarded as high value added.

Figure. (Left) The patient with receding chin and short neck is considered at high risk for sleep apnea. (Right) The orthognathic surgery not only solves her long lasting airway obstruction problem but also improves her facial contour by restructuringthe facial bones, which is highly valued.

Figure. (Left) The patient who asked for medical consultation to improve her facial appearance never considered herself having sleep apnea but did feelconstantly tired during daytime. In fact the patient was considered at high risk for sleep apnea because of her receding chin and short neck. (Right) The orthognathic surgery had transformed the patient from a lethargicgirl withbeak mouth and short neck into an energetic oval face beauty.

More importantly the successful rate of orthognathic surgery for sleep apnea is higher than 95%. According to Clinical Sleep Disorders by Paul R. Carneyet al., almost 95% of 175 sleep apnea patients weresuccessfully treated with MMA.

In factorthognathic surgery is provedto be highly effective for treating sleep apnea and has becomethe futuretrend globally. In countries with the most advanced medicine, orthognathic surgery is recommended as the first line treatment for patients with moderate to severe sleep apnea. Hence many medical doctors who specialize in sleep apnea andare certified in otolaryngology will go for a second certification in oral and maxillofacial surgery so as to provide the patients with neutral and more comprehensive medical advices.

Patients with moderate to severe sleep apnea should first consider the treatment with highest successful rate

It is still common in Taiwan to use the step-by-step approachas shown in the figure to treat sleep apnea: first option is CPAP, followed byUPPP or UPF, GA as the third and the last option is MMA.

Based on my years of clinical experience, Iinterpret the step-by-step treatment scheme in a different way. MMA is located at the top of the step-by-step treatment scheme means MMA is the most difficult yet the most effectivetreatment. In another word,orthognathicsurgery should be considered as the fist line treatment for patients with moderate to severe sleep apnea.Just imagine one of your beloved family members is suffered from illness, will you choose the cheap but may-not-worktherapy, or the expensive therapy yet with the highestsuccessful rate?

In addition, orthognathic surgeryis located at the top of the step-by-step treatmentscheme also means it has a wider range of applicationand better effect covering those of the other surgical treatments, which corroborates that orthognathic surgery serves as multi-level surgery to treat sleep apnea.

During the process of MMA, the upper jaw and the attached uvula as well as the lower jaw and the attached tongue base are moved forward. MMA solves the airway obstruction caused by relaxing uvula and tongue base both falling backward and effectively enlarges the airway in both the palate and tongue regions.

Depends on individualcondition, MMA is performedwith UPF and GA to enhance the treatment effect. My treatment philosophy is "minimal surgical injury for maximal treatment effect". In my opinion, MMAenlarging the entire airway in multiple regions is the best treatment option for sleep apnea patients to avoid costly mistakes.

Snoring may seem comical, but sleep apnea is no joke. Untreated sleep apnea, a sleep disorder associated with higher risk of major diseases and accidents, can cause serious harm to the health. People, who show the signs, have higher risk or suspect to have sleep apnea shall visit sleep medicine center or related facilities to undergo evaluation and medical exam. If the diagnosis is confirmed, usually the doctor will recommend treatment options based on the apnea hypopnea index (AHI).

Orthognathicsurgery which has been proved to have high successful rate for treating sleep apnea should be considered as first line treatment option especially for the patients with moderate to severe sleep apnea. Orthognathicsurgery canenlarge the entire airway in multiple regions via restructuring the facial bony framework to relieve diverse causes of sleep apnea. The new concept of treating sleep apnea is performingorthognathic surgery at thebeginning to avoid the costly mistakes of suffering from the step-by-step treatment options then eventually go for MMA.