Severe obstructive sleep apnea is more than a snoring problem. In this video, ENT surgeon Dr John Charles Hodge explains why it needs treatment, and gives an honest account of multi-level surgery, from the recovery to the results.
What is obstructive sleep apnea?
Obstructive sleep apnea (OSA) happens when the airway repeatedly narrows or closes during sleep. Severe untreated OSA carries significant cardiovascular risk and affects sleep quality, snoring and daytime tiredness.
Key points from the video
- Why treat severe OSA. Untreated severe OSA can take up to 10 years off your life, which Dr Hodge likens to smoking 20 a day. Patients also want to treat heavy snoring and poor quality sleep.
- Multi-level surgery. The standard surgical approach treats the palate, tonsils and tongue together, assuming the nose is already clear. Dr Hodge was part of the SAMS trial, a randomised controlled trial published in JAMA that showed multi-level surgery works.
- Tongue reduction. A plasma probe shrinks the tongue from within, so it looks, moves and feels the same afterwards and there is less of it falling backwards when lying down.
- An honest recovery. Recovery from palate and tonsil surgery is tough, with days three to five usually the worst. Pain is managed with a range of plans, and readmission for pain is extremely rare.
- Results. Palate surgery (UPPP) is around 75 to 80% successful. Most people are back at work by two weeks, and by six months about 95% report no ongoing throat symptoms.
Video transcript
Hi, I’m John Charles and I’m an ear, nose and throat doctor. I’m going to talk to you today about the treatment of severe obstructive sleep apnea in adults, particularly the surgical options.
So first of all, why do we treat severe obstructive sleep apnea in adults? I’m going to quote one of my sleep physician colleagues, who used to say to patients we saw, “You can either have a heart attack, a stroke, dementia, or CPAP.” That’s probably overcalling it, but it’s actually very significant. It’s like smoking 20 a day for years and hoping you’re going to get away with it. Severe OSA untreated can take up to 10 years off your lifespan. So they’re the doctor reasons to treat severe OSA.
But then there are also patient reasons. Patients come to see me not necessarily understanding the cardiovascular risks of their disease, but because they snore heavily and that has an impact on their quality of life, and also they’re tired. It’s not good quality sleep. So there are the doctor factors and the patient factors.
I’m not going to go through all the various options, but I wanted to talk to you about the standard of care with regards to surgery, and that’s multi-level surgery. I’m assuming you’ve got a clear breathing nose, and what you’re going to tackle is the palate, the tonsils and the tongue. So that’s two operations put together. If you want more information on this, you can look up a trial that I was part of called the SAMS trial, which was published in JAMA and goes through all the results. It’s the only randomised controlled trial that has looked at multi-level surgery in the treatment of severe sleep apnea, and it showed that it worked.
I’ll talk about the tongue first, because people get really freaked out about the tongue and they worry about it. Essentially I’m shrinking it to make it smaller, and I use a plasma device, which is a probe that goes into the tongue, so the surface isn’t affected. The function is the same, and afterwards the tongue looks, moves and feels the same. Most patients don’t even know they’ve had it done. Each point that you put in shrinks the tongue by about 0.8 cubic centimetres, and there are seven prescribed lesions, so the tongue loses about 5.6 cubic centimetres. So when you’re lying on your back, there’s less of the tongue falling backwards. It doesn’t hurt. Maybe simple painkillers, and it’s a day case if that’s all you’re getting done.
The focus is really the palate and the tonsils, and I’ll talk about three things: the journey, the outcome, and the functional consequences. What that means is, whether this works or doesn’t work, are you going to do anything bad to me?
So first of all, the journey. You can’t sugarcoat this. It is brutal. If this was ankle surgery, you’d stick your foot up, you’d ice it, and you’re not going to walk 10ks every day. But you can’t rest the throat. You’ve got to breathe, you’ve got to talk, you’ve got to swallow, you’ve got to burp. Initially, when you wake up, it’s painful. By the next morning most people don’t feel so bad, and think maybe I’ve overplayed it. By days three to five, it’s truly awful. Part of that is the tonsillectomy part. An adult tonsillectomy is a really brutal operation, but this is even worse because you’ve got stitches in the back. You can feel them, and it’s quite unpleasant. But you get through it. We’ve got plans A, B, C, D and E with regards to pain management. It’s extremely rare to have to bring someone back into hospital to manage their pain, so we can normally manage this in the community.
The second aspect is the outcome. If you’re going to put me through this, does it actually work? The answer is it does, but it’s not a rock star effective operation. What that means for me is that if your positive results are more than 90%, that’s a great outcome, because there’s always human variability, which means it’s not always easy to get to those high numbers. Published data on the palate surgery, which is the UP3, or uvulopalatopharyngoplasty, probably sits at about 75 to 80%. That is pretty good, especially when you’re not tolerating CPAP and you’ve got a disease that’s going to kill you. That’s a good option. The problem is that it leaves one in four or one in five patients who don’t get over the line with this initial entry level operation.
Then the bad stuff: is it going to ruin my swallow or my voice? The short answer is no. Essentially by two weeks I expect patients to be back at work. You may not be eating, drinking or tasting exactly right. If you look at the quality of life data, using visual analogue scores out of 10, where 10 is “I hate you, doc” and one is a bit of a niggle, by three months 90% of patients score zeros across the board. The remaining 10% are twos and threes: I feel like I’ve got a lump in my throat, or salt and crisps taste a little bit strange. By six months, 95% score zero. So there’s a little bit of a tail to it, but that leaves one in 20 patients saying, “Hey, doc, you told me I was going to be fine, but I’ve still got those little niggles.” And then that sort of peters out.
So there you have it. It’s a fairly brutal operation, but if it works, it’s a game changer, and the data shows you get long-term results from it. And the carrot that dangles is that you no longer need CPAP.
Talk to Dr Hodge about sleep apnea surgery
If you have severe obstructive sleep apnea and would like to discuss whether surgery may be right for you, book an appointment or get in touch with the rooms.
This information is general in nature and is not a substitute for personalised medical advice. Please speak with your GP or specialist about your individual situation.