Sleep apnea


BACKGROUND: Over 10 million Americans suffer from sleep apnea. Sleep apnea is a sleep disorder characterized by abnormal pauses in breathing or instances of abnormally low breathing, during sleep. Each pause in breathing, called an apnea, can last from a few seconds to a few minutes, and may occur 5 to 30 times or more an hour. When this happens it means that the brain and the rest of the body may not get enough oxygen. Sleep apnea is diagnosed with an overnight sleep test called a polysomnogram, or "sleep study". If left untreated, sleep apnea can lead to high blood pressure, stroke, heart failure, heart attacks, diabetes, and depression. (Source: http://www.webmd.com). 

FORMS:  There are two forms of sleep apnea:

Central (CSA): Breathing is interrupted by a lack of respiratory effort.

Obstructive (OSA): Breathing is interrupted by a physical block to airflow despite respiratory effort.

TREATMENT: A breathing device referred to as CPAP, continuous positive airway pressure, is the most common treatment for moderate to severe sleep apnea in adults. A CPAP machine uses a mask that fits over your nose and mouth. The machine gently blows air into your throat. The air presses on the wall of your airway. The air pressure is adjusted so that it's just enough to stop the airway from becoming narrowed or blocked during sleep. The treatment may cause certain side effects and vary from person to person. People who have severe sleep apnea symptoms generally feel much better once they begin treatment with CPAP. (Source: www.nhlbi.nih.gov)
NEW TECHNOLOGY: Because only half of patients that opt to try a CPAP machine can tolerate it for the long haul, a new surgery is groundbreaking. Transoral robotic surgery (TORS) is a minimally invasive method that allows the surgeon to operate through the patient's mouth, without any external incisions. Employing the da Vinci® surgical system, Dr. Jeffrey Ahn uses small robotic arms and a three-dimensional magnified high resolution camera to perform the surgery, whose results are more accurate as well as more patient-friendly. (Source: http://www.parkavesinusallergy.com)

Dr. Ahn was among the first surgeons in the world to perform da Vinci transoral robotic surgeries for obstructive sleep apnea. The new robotic procedure is tailor-made for patients with an obstruction in their tongue base. The entire procedure is performed through the patient's mouth. There's no need for tracheotomy, no scarring, and the patient can go home the next day. (Source: http://www.parkavesinusallergy.com)

Jeffrey M. Ahn, MD, Director of Sleep Disorder & Robotic Surgery at NY-Presbyterian/Columbia, talks about a new surgery that could help sleep apnea sufferers get the sleep they need.

How big of a problem is Sleep Apnea?

Dr. Ahn: Obstructive sleep apnea had been a very prevalent problem all along. It's just that nowadays both public and the medical community are much more aware of it.

I think a lot of people think they may have it but all that's available is the c-pap machine.

Dr. Ahn: Some people they  think they're just snoring and sleeping well, but with the sleep study and an examination by an otolaryngologist we can tell whether it's bad enough to be treated with a c-pap machine.

What are some of the worst cases you've seen?

Dr. Ahn: There is an index that we use and calculates how many times you obstruct or how many times you are waking up during the night. Some of these patients actually obstruct more than hundred times an hour.

So there's no way that they could be getting a good night's sleep?

Dr. Ahn: Right, and more importantly it's not just a matter of getting a good night's sleep. Sleep apnea has been shown to increase the incidence of serious medical problems such as heart attack, stroke, diabetes, high blood pressure, impotence and most recently cataracts.

Is there a misconception that you have to be overweight?

Dr. Ahn: Yes, often obesity is associated with obstructive sleep apnea but I know many patients who come to my office who are not very obese at all, but they still suffer from obstructive sleep apnea. The quality of sleep is very poor. Many patients feel that they're sleeping well but they're not. You're supposed to stay in a deeper sleep for a certain amount of time during your sleep. But then these patients who suffer from severe snoring or obstructive sleep apnea they cannot stay in a deep sleep. They constantly come up to a lighter stage of sleep and as a result they are not rested so they fall asleep very easily.

Are there any other symptoms that we may not have heard of as much?

Dr. Ahn: Beingconstantly sleep deprived you can fall asleep anywhere. Some of these patients actually boast about their ability to be able to sleep anywhere and that happens only because they're sleep deprived. These patients fall asleep literally in seconds because of the sleep deprived state.

How many do you think have it but they don't know they have it?

Dr. Ahn: Well let's put it this way, according to the most recent tabulation by middle age in the fifties more than half of all men suffer from significant snoring and obstructive sleep apnea. I think only about ten percent of the patients of one fifth of them really do feel that they have obstructive sleep apnea or know that they have obstructive sleep apnea.

Now everyone probably starts with the breath right strips and then they go on to the c-pap, what else?

Dr. Ahn: We recommend the c-pap, a sleep mask for all these patients suffering from obstructive sleep apnea, but only half of the patients can actually stay with this machine in the long run. Mainly because they either take it off during sleep or they can't fall asleep.  Even if they can tolerate it, it really is not a very popular treatment for especially younger patients. It's not the very romantic thing to wear at night.

Do you suggest any other form of treatment?

Dr. Ahn: There have been over three hundred patented devices for snoring and obstructive sleep apnea and so far none of them really have been shown to be very effective.

Tell us about this new surgery, it's not really new it's just less intrusive.

Dr. Ahn: Over twelve million Americans suffer from significant obstructive sleep apnea and only half of them can stay with this  sleep machine. The other half actually goes untreated or poorly treated and these are the patients who can benefit from surgery. Often obstructive sleep apnea is caused by the excess tissue at the base of tongue and we've known this all along. The problem is there was really no good way to address that area without making a large incision in the neck or manipulating the patient's facial bone structure. This robotic surgery allows us to access that area and effectively reduce the excess tissue at the base of the tongue without having to make a large incision in the neck or changing the patient's face.

It's shaving off the side of the tongue, is that correct?

Dr. Ahn: We're shaving actually an excess lymphoid tissue, not muscles of the tongue. In the back part of our tongue there is lymphoid tissue sort of like a tonsilar tissue and all this excess tissue is obstructing the airway. Using the robot through the mouth we can effectively shave this part.

Can you tell me how it works?

Dr. Ahn: Well the base of the tongue is deep in our throat so first of all we had problems looking at that area very well. So with the robotic camera we can visualize the area very well. Because of the small area, human hands cannot fit in there very well. The robotic hands or robotic arms allow us to operate in the area because they are much smaller in a very accurate way.

It seems like it would be very painful for the patient is it?

Dr. Ahn:  No matter what we do it causes sore throat after the surgery and the patient suffers from a good ten days of bad sore throat.

Is this surgery for everybody and does it cure it?

Dr. Ahn: It's not for everybody. Everyone who has obstructive sleep apnea should try the sleep mask, the c-pap mask and only the ones who cannot tolerate the c-pap machine should be considered for this surgery. The most important point is obstructive sleep apnea is a very serious medical problem and it has to be treated whether through the sleep mask or through the surgery. If you can't tolerate the c-pap mask then you need to think about the surgical treatment, and with this robotic surgery before the surgical treatment the success rate was only about fifty percent. With this addition of the robotic technique we can increase our success rate up to eighty, eighty five, possibly ninety percent.

Is that for life?

Dr Ahn: As long as the patient can maintain the weight, it should be a permanent solution. Another advantage of the sleep apnea surgery or the robotic surgery is typically many of these patients loose about twenty pounds after the surgery which also helps for the treatment of the obstructive sleep apnea.


Jeffrey M. Ahn, M.D.,
NewYork-Presbyterian Hospital /Columbia