CPAP + Oral Appliance (All-In-One) Device for OSA

A dentist colleague of mine informed me of a new device that combines CPAP mask with an oral appliance for patients with obstructive sleep apnea (CPAP Pro + Mandibular Advancement).

The unique benefits of this combo device are several-fold:

• No straps
• Keeps mouth closed
• Addresses tongue collapse that obstruct the airway by bringing jaw forward
• Can sleep in any position

This device does need to be fitted by a dentist. (For Virginia residents, Dr. Jason Woodside is familiar with this product.)

Of course, it is relatively new and we'll see if patients love this combo CPAP mask more than the traditional masks that have been on the market.

For those patients who do NOT have a problem with tongue collapse, but prefer the no-straps solution of the oral appliance, the company does make a mouthguard that fits only the upper teeth.

Sleep Apnea Surgery Malpractice Lawsuit

In November 2009, a patient underwent multi-level surgery to treat her mild-moderate obstructive sleep apnea by a Houston, TX otolaryngologist.

The surgery included:

• Uvulopalatopharyngoplasty (UPPP)
• Tonsillectomy (typically considered part of UPPP)
• Adenoidectomy
• Hyoid Myotomy
• Genioglossus Advancement

She unfortunately experienced some unspecified complications stemming from this surgery which apparently has not helped with her obstructive sleep apnea either. A malpractice lawsuit commenced and final judgement is still pending.

Let's take a closer look at the incomplete information provided.

The patient suffered from mild-moderate obstructive sleep apnea which typically means a AHI score of around 15 (< 5 is normal).

For this level of severity, simultaneous multi-level surgery is not typically performed. Rather such extensive surgery is reserved for severe obstructive sleep apnea.

Also unclear is whether any objective studies were performed prior to surgery to try and localize the levels of obstruction that required correction. Such preoperative studies include a sedated endoscopy as well as trial of CPAP usage.

Assuming patient tried and failed to use CPAP and had objective evidence for multi-level obstruction, what did each of the surgical procedures do?

UPPP, tonsillectomy, adenoidectomy address mouth-level obstruction.

Hyoid myotomy and genioglossus advancement address tongue-level obstruction (the tongue can fall backward while sleeping causing obstruction).

Complications can occur for each of these procedures mainly dealing with bleeding, hematoma, infection, or abscess formation. Swallowing problems can also occur with the hyoid myotomy and genioglossus advancement.

Read more information on obstructive sleep apnea.

Source:
Sleep apnea surgery leads to malpractice lawsuit. Southeast Texas Record. 1/23/12

Robotic Surgery for Obstructive Sleep Apnea

I came across this article the other day regarding use of the daVinci robot to perform base of tongue surgery for obstructive sleep apnea.

For those who don't know, the daVinci robot system made by Intuitive Surgical is a robotic system whereby the surgeon directs the arms of the robot to perform surgery in difficult-to-access areas of the body.

My feeling is that using a robot to perform sleep apnea surgery is way overkill akin to using a $50,000 sniper rifle to kill an ant on the wall.

Everything the daVinci robot can do can also be done without the robot with equivalent patient outcomes. In fact, without the robot, the surgery can be performed more quickly, efficiently, and with less anesthesia than with the robot.

The article also describes sedated (sleep) endoscopy to determine WHERE the obstruction occurs during sleep. The areas of obstruction can than be precisely addressed surgically. Again, this does not require a robot. In fact, I would hazard to say that even the surgeons quoted in the article does not use the robot to perform this procedure.

There are occasions where the robot may be helpful with ENT surgical procedures, but this is not one of them.

Reference:
N.J. surgeons on the cutting edge in fight against sleep apnea.