Obstructive Sleep Apnea (OSA)

Obstructive Sleep Apnea Syndrome is a condition where significant airway obstruction problems develop during sleep. The most common cause of airway obstruction involves nasal airway obstruction and/or a decrease in the oropharyngeal airway space (space between the back of the tongue and the back of the throat). Obstructions can also occur from the trachea into the pulmonary system, or caused by central nervous system pathology.

Obstructive sleep apnea (OSA) is the most common kind of sleep apnea and affects millions of people in the US. OSA is distinguished by recurrent pauses in breathing during sleep, regardless of the attempt to breathe, and is typically related to a drop in blood oxygen saturation. These interruptions in breathing are called “apneas,” which literally means “without breath.” Each pause lasts between 20 and 40 seconds, but the individual is almost never aware of their struggle to breathe, even upon waking up.

A person with OSA usually snores when asleep, will have episodes where they appear to hold their breath while sleeping, may have restless sleep, and will have daytime symptoms such as sleepiness and fatigue. People with OSA tend to become conditioned to their disorder and as a result go undiagnosed for years or even decades. Long-term OSA, if left untreated can result in high blood pressure, cardiac arrhythmias, right side heart failure, pulmonary hypertension, carbon dioxide retention, cyanosis, blood disorders, brain damage, stroke, heart attack, and premature death.

The airway of the throat is made of soft tissue that can collapse while sleeping, commonly related to decreased oropharyngeal airway and retruded jaws as well as nasal airway obstruction. This situation can create a dangerous and chronic type of obstructive sleep apnea.

Signs and symptoms of sleep apnea syndrome include:

  • Recurrent episodes of cessation of breathing while sleeping
  • Snoring
  • Frequent awakening and restless sleep
  • Mouth breathing
  • Nightmares
  • Restless or jerking legs when sleeping
  • Daytime sleepiness
  • Headaches
  • Poor work or school performance
Obstructive Sleep Apnea

Dr. Wolford can provide a comprehensive treatment plan for you. He has developed a number of techniques to treat sleep apnea syndrome and has been able to eliminate this condition in most all patients who are afflicted with it, when the causative factors involve upper airway obstruction. In fact, Dr. Wolford developed the concept and was the first surgeon to advance the jaws to cure sleep apnea. 

At your evaluation, Dr. Wolford will provide a diagnosis and detailed treatment plan for you. Treatment may involve correcting the obstructive nasal deformity, and contributory jaw deformity, as well as soft tissue procedures to provide an adequate functional airway.

Dr. Larry M. Wolford, DMD treats Airway Obstructive Sleep Apnea Syndrome (OSA). Please contact Dr. Larry Wolford’s office using our online contact form or call 214-828-9115 if you would like to schedule an appointment.

Dr. Larry Wolford / Web Decoration

Obstructive Sleep Apnea (OSA)

Obstructive Sleep Apnea

Typically, obstructive sleep apnea is identified as an issue when another person observes an episode or when its effects on the body (sequelae) become noticeable. A person with OSA usually snores when they sleep, but also will have daytime symptoms such as daytime sleepiness and fatigue, to which they can become conditioned to.

Long-term OSA, if left untreated, can even lead to severe medical conditions. As a result of becoming so accustomed to their symptoms, individuals may go undiagnosed for years or even decades, and those who sleep alone may be especially unaware of their symptoms. Without a consistent bed partner, individuals are rarely made aware of their of their condition.

What Causes Obstructive Sleep Apnea?

Obstructive sleep apnea is caused by an obstruction in the airway, but there are many sites that may induce this obstruction.

Short episodes of obstructive sleep apnea may be the result of an upper respiratory infection, which gives rise to nasal congestion along with a swelling of the throat. Short term OSA may also be caused by tonsillitis that briefly produces very enlarged tonsils. OSA is also reasonably common in acute cases of mononucleosis, which is caused by the Epstein-Barr virus and is associated with substantially enlarged lymphoid tissue. Fleeting intervals of OSA may also occur in individuals who are under the influence of a drug (such as alcohol), which may exceedingly relax the body tone and inhibit normal sleep arousal mechanisms.

Overall most cases of Obstructive Sleep Apnea are believed to be caused by:

  • Aging (natural or premature)
  • Injury to the brain (temporary or permanent)
  • Diminished muscle tone (which can be caused by drugs and alcohol, neurological problems, or other disorders)

Some people may have multiple issues causing OSA. A theory presenting long-term snoring as a cause of local nerve lesions in the pharynx also exists. Snoring is essentially a vibration of soft tissues in the upper airways, which can lead to increased soft tissue around the airway (sometimes due to obesity) and structural features that obstruct the airway.

Other factors that may increase the risk of obstructive sleep apnea include:

  • Displaying poor compliance with chemical and/or speech therapy treatments being a man with increased mass in the torso and neck areas
  • Being a post-menopausal woman being a pregnant woman
  • Having a family history of OSA (genetic component) Smoking
  • Having previous trauma to the face
  • Consuming alcohol, sedatives, or any medication that increases sleepiness (most of these drugs are muscle relaxants)

Other medical conditions that can contribute to or worsen OSA include:

  • Allergic rhinitis Nasal polyposis Nasal tumors
  • Acquired nasal deformities

Signs and Symptoms of Obstructive Sleep Apnea

Individuals with obstructive sleep apnea often suffer from unexplained, inordinate amounts of daytime sleepiness and commonly complain of feeling as if they did not sleep the night before. Other common symptoms include restless sleep and loud snoring (with intervals of silence followed by gasps).

Less common signs and symptoms of OSA include morning headaches, insomnia, difficulty focusing or concentrating, mood alterations (like anxiety, depression, irritability), memory loss or forgetfulness, elevated heart rate and/or blood pressure, diminished sex drive, inexplicable weight gain, increased urination and/or nocturia (waking up in the night to use the bathroom), intense night sweats, and recurrent heartburn or gastroesophageal reflux disease (GERD).

For adults, the most common individuals who suffer from OSA also suffer from obesity, with specific heaviness in the head and neck area. This is not always the case however, as a notable number of adults with normal body mass indexes (BMIs) have OSA as well. The reason for this is not well established, but the trademark symptom of OSA in adults is severe daytime sleepiness. Usually, an adult or adolescent with long-term OSA will fall asleep for short intervals during usual daytime activities if given the chance to sit or rest. These episodes can seem quite unexpected, as the individual may fall asleep even in the middle of conversations with others or in the midst of a social gathering.

Detrimental Effects of Obstructive Sleep Apnea

The oxygen deficiency (hypoxia) that ensues from obstructive sleep apnea may cause neural damage in the hippocampus and right frontal cortex of the brain. In people suffering from OSA, research shows signs of hippocampal atrophy, and in more than 25 percent of these patients with OSA, this hippocampal atrophy produces irreversible problems with mentally manipulating non-verbal information, with executive functions, and with working memory. Even after years of treatment, this damage cannot be reversed.

Diagnosing Obstructive Sleep Apnea

Diagnosis of obstructive sleep apnea is notably more common among people in relationships, who have a consistent bed partner to make them aware of their symptoms. Frequently, patients finally visit the doctor when their bed partner is no longer able to stand loud snoring. Often a person is diagnosed based on a combination of a detailed patient history of symptoms/medical conditions and tests, which range from lab-attended full polysomnography (sleep study) to at home single-channel recording.For preliminary assessment of obstructive sleep apnea, the Epworth sleepiness scale is a critical tool. The Epworth sleepiness scale is a survey that asks the likelihood of falling asleep in eight common situations, scaled from 0 (never) to 5 (always), and a score higher than 11 is associated with OSA

The physician will perform a complete head and neck exam to identify the site or multiple sites of obstruction. The nose may also be obstructed by septal deviation, nasal valve collapse, turbinate hypertrophy or nasal masses. The oral cavity should be examined with the tongue inside of the mouth in a relaxed position, and the tonsils should be categorized from 0 to 4, with zero being nonexistent and four being kissing. The physician should also examine the palate and uvula, because often, patients with OSA will display and elongated and thick uvula or redundant soft palate tissue. Patients with OSA may also have macroglossia, which blocks the view of the palatal structures. Also, examination of the entire pharynx could include fiberoptic nasopharyngoscopy or indirect mirror laryngoscopy.

In patients with OSA, inspection of the nasopharynx may divulge adenoid hypertrophy or another obstructing mass. The oropharynx may exhibit lingual tonsil hypertrophy or retroflexed epiglottis. While breathing in, the supraglottic structures may collapse. The Mullers maneuver can be executed while blocking the nose and the mouth as the patient breathes in. This will enable the examiner to see any pharyngeal collapse and impartially identify anterior-posterior collapse or lateral wall collapse.

Dr. Larry Wolford / Web Decoration

Obstructive Sleep Apnea (OSA)

Polysomnography is the best and most trusted way to diagnose obstructive sleep apnea. Typically, the patient must undergo an overnight, attended study performed in a sleep laboratory. During this testing, EKG, EEG, pulse oximetry, nasal and oral airflow, leg movements, and respiratory effort are all monitored and evaluated. When cessation of airflow occurs for 10 or more seconds, apneas are recorded. When airflow is diminished by 30% and a related 4% drop in oxygen saturation exists, hypopneas are recorded. A 30% decrease in airflow not related to a 4% drop in oxygen saturation is called respiratory related arousal.

The most critical numbers to review and summarize at the end of the study are the minimum oxygen saturation, apnes/hypopnea index (AHI), and the respiratory disturbance index (RDI). An RDI or AHI higher than 5 is categorized as mild obstructive sleep apnea. An RDI or AHI larger than 15 is categorized as moderate OSA and larger than 30 is considered severe OSA. Minimum oxygen saturation below 90% is categorized as abnormal, and total time below 85% should be evaluated to decide the severity of the sleep apnea. Following a positive PSG, the patient should be provided with a continuous positive airway pressure (CPAP) mask and a titration study is conducted.

Simply put:
AHI Rating
<5 Normal 5-15 Mild 15-30 Moderate >30 Severe

Home Oximetry

For patients who are considered highly likely to have OSA, a randomized controlled trial established home oximetry (a non-invasive way of monitoring blood oxygenation) may be sufficient and less complicated to acquire than formal polysomnography. High probability patients were distinguished by an Epworth Sleepiness Scale (ESS) score of 10 or higher and a Sleep Apnea Clinical Score (SACS) of 15 or higher.  Home oximetry does not measure apneic events or respiratory event-related arousals. This test does not generate an AHI value.

Pathophysiology of Obstructive Sleep Apnea

The normal sleep/wake cycle in adults is separated into REM (rapid eye movement) sleep, non-REM (NREM) sleep, and consciousness. NREM sleep is further categorized into 1, 2, and 3 NREM sleep. The deepest (stage 3 of NREM) is necessary for the physically rehabilitating effects of sleep, and in adolescents, during this period human growth hormone is released. 70% of the typical person’s total sleep is comprised of REM sleep and NREM stage 2 and is related to mental recovery and maintenance. Particularly during REM sleep, the muscle tone in the throat and neck, as well as the predominance of all skeletal muscles is almost completely narrowed, which enables the soft palate/oropharynx and tongue to relax. In the occurrence of obstructive sleep apnea, the total relaxation of these muscles blocks the flow of air to the degree spanning from light snoring to total collapse. When airflow is blocked to an amount where blood oxygen levels fall, or the physical effort to breathe is too great, neurological mechanisms prompt an immediate interruption of sleep, called a neurological arousal.

These arousals can have serious negative effects on the restorative nature of sleep, but rarely do they lead to complete awakening. In serious cases of OSA, one outcome is sleep deprivation caused by repetitive disruption and recovery of sleep activity. This disruption of sleep in stage 3 of NREM sleep can impede normal growth patterns, healing, and the immune system’s response ability, particularly in children and young adults.

Obstructive Sleep Apnea in Children

The OSA symptom of excessive sleepiness is actually quite uncommon in children with sleep apnea, although it does sometimes occur. Instead, toddlers and young children with severe OSA often display “hyperactive” behavior. In contrast with typical adult symptoms, children with OSA may also be not only very thin, but also display reduced growth and “failure to thrive.” 

Children with OSA may display deficient growth patterns for two reasons: the labor to breathe is so great that calories are burned at a fast and high rate even at rest, and the throat and nose are so obstructed that eating is not only tasteless but painful as well. In children, OSA is often caused by obstructed tonsils and adenoids and can sometimes by corrected with tonsillectomy and adenoidectomy. 

This issue can also result from excessive weight in children, and under these circumstances, symptoms of OSA more closely resemble those of adults: restlessness, exhaustion, etc. Overall, memory loss and learning deficits may occur in children with OSA and have been correlated with lowered childhood IQ scores.

Obstructive Sleep Apnea as a Post-Operative Complication

OSA can result as a serious post-operative complication that seems to be most recurrently related to pharyngeal flap surgery. After pharyngeal flap surgery, contingent with the size and position, the flap itself may cause an obstructing effect within the pharynx during sleep, inhibiting effective respiration.

The surgical treatment for velopalatal insufficiency may cause OSA as well in susceptible individuals, especially when swelling occurs in the days following surgery.

Also, patients with OSA are at an enhanced risk of several preoperative complications, even if the procedure is not on the neck and head.

Dr. Larry Wolford / Web Decoration

Obstructive Sleep Apnea (OSA)
Treatment for Obstructive Sleep Apnea

One of the first strides in treating obstructive sleep apnea is implementing any necessary behavior modifications, including smoking cessation, weight loss, altering sleeping positions, and avoidance of alcohol and sedatives.The first line of therapy is continuous positive airway pressure (CPAP), which evades most of the levels of OSA. During CPAP treatment, a machine streams a controlled amount of air through a mask worn over the nose, mouth, or both, and the supplemental pressure holds open the relaxed muscles. This treatment is effective for both moderate and severe forms of obstructive sleep apnea. For CPAP, the patient must wear a mask for 5 hours/night and 5 nights/week for optimal pressure to be attained and for the patient to be considered acquiescent. Regardless of the benefits of CPAP, some patients simply cannot tolerate the treatment, complaining of issues like excessive pressures, noise, discomfort, claustrophobia, and air leakage. Studies have shown, however, in patients who can tolerate the CPAP treatment, quality of life improves and their Epworth sleepiness score improves. Other forms of CPAP treatment include:

Variable positive airway pressure (VPAP), also known as bilevel or BiPAP, employs an electronic circuit to supervise the patient’s breathing and administers two different pressures, an increased pressure during inhalation and a decreased pressure during exhalation. This is a more expensive method of treatment and is sometimes used for patients with other coexisting respiratory issues. Automatic positive airway pressure (APAP), also known as “Auto CPAP,” is the newest form of this type of treatment and uses a computer to uninterruptedly monitor the patient’s breathing. Nasal EPAP is a device that is placed up the patient’s nose and uses the patient’s own breath to generate air pressure. This treatment is less effective than traditional CPAP.

Sometimes, oral appliances or splints are also chosen over CPAP, but they are not as effective. The device is comparable to a mouth-guard used in sports to protect teeth and is created to faintly lower the jaw down and forward comparable to the natural, relaxed position. This keeps the tongue farther away from the back of the airway and may be sufficient to improve breathing and alleviate apnea.

In 2014, the FDA granted pre-market approval for an upper airway stimulation system that measures respiration and administers mild electrical stimulation to the hypoglossal nerve to enhance muscle tone at the back of the tongue. This device will keep the tongue from collapsing at the back of the airway and is equipped with a hand held controller for the patient to switch it on and off.

There is insufficient evidence to promote medicine to treat obstructive sleep apnea, including the use of fluoextine, paroxetine, acetazolamide, and tryptophan along with others.

Patients who are non-compliant with CPAP treatment or complain of side effects may gain more from evaluation by an Otolaryngologist (ENT surgeon) for plausible surgical intervention. In the past, surgical therapies for OSA prioritized treatment of the soft palate, including snare uvulectomy, uvulopalatoplasty, uvuloplalatopharyngoplasty, laser-assisted uvuloplasty, lately radiofrequency ablation of the soft palate, and tonsillar pillar implantation.

The most popular surgical treatment for OSA is uvulopalatopharyngoplasty, which tackles the most common and probable site of obstruction and redundant tissue. This procedure includes tonsillectomy, the clipping and repositioning of the anterior and posterior tonsillar pillar, and the removal of the uvula with the generation of a smaller neouvula.

Dr. Larry M. Wolford, DMD treats Airway Obstructive Sleep Apnea Syndrome (OSA). Please contact Dr. Larry Wolford’s office using our online contact form or call 214-828-9115 if you would like to schedule an appointment.

Dr Wolford Treats Sleep Apnea

Treatment Options for OSA

The most common treatment options for OSA include:

  1. Controlled sleep posture; may be helpful is OSA occurs only when sleeping on the back.
  2. Dental devices that posture the lower jaw forward. This opens the airway only a limited amount and over time can shift the teeth and change the bite that can affect comfort and the ability to chew.
  3. CPAP type machines that force-ventilate the patient. This is not a normal sleep phisology, requires the use of a machine when sleeping, and many patients cannot tolerate it.
  4. Surgery: The most popular surgical treatment for OSA is uvulopalatopharyngoplasty, which tackles the most common and probable site of obstruction and redundant tissue.  This procedure includes tonsillectomy, the clipping and repositioning of the anterior and posterior tonsillar pillar, and the removal of the uvula with the generation of a smaller neouvula.

Who Benefits From Obstructive Sleep Apnea Surgery?

Surgery to correct airway obstruction and sleep apnea may be indicated for adults, teenagers, and children who have difficulty breathing.

Obstructive sleep apnea commonly involves difficulties in passing air through the upper airway areas due to physical obstruction or significant decrease in the functional airway spaces, causing lack of oxygen to the body and brain. The most common areas of obstruction involve the nose, mouth, and airway space at the back of the throat. (oropharynx).

Nasal airway obstruction can result from: Narrow nostrils; deviated nasal septum; hypertrophied turbinates; adenoid tissue at the back of the throat; and/or nasal polyps.

Oral airway obstruction can result from: Retruded or small jaws; receded chin; mal-occlusion; large tongue; and enlarged or excessively long soft palate and uvula.

Oropharyngeal airway obstruction can result from: Retruded jaws; enlarged or elongated soft palate and uvula; large tongue; and enlarged tonsils and adenoid tissue.

Dr. Larry M. Wolford, DMD treats Airway Obstructive Sleep Apnea Syndrome (OSA). Please contact Dr. Larry Wolford’s office using our online contact form or call 214-828-9115 if you would like to schedule an appointment.