- Upper Airway Stimulation Therapy (FDA Approved)
Inspire™ II consists of three implantable components: An Implantable Pulse Generator (IPG), a Self-Sizing Cuff Stimulation Lead, and a Pressure Sensing Lead (to sense pressure changes with breathing). The respiratory pressure waveform is monitored by the IPG algorithm and triggers stimulation therapy with breathing (respiration). The device monitors respiratory waveforms, program stimulation modes, and stimulation parameter values. These are adjusted to optimize the therapy by the physician. Patients also have ability to adjust and modify therapy.
- Nasal Airway
An abnormal nasal airway is one of the major contributors to poor sleep. An abnormal nasal airway is also one of the major predictors of failure of devices such as CPAP, mandibular advancement devices, and Provent/Theravent ™. Improving the nasal airway with medical or surgical interventions improves sleep. In some individuals nasal surgery is required. When needed, sometimes this is the only intervention required to improve CPAP tolerance. Minor improvements have marked effects. No single structural abnormality explains nasal problems in sleep disorders. A careful expert evaluation of the nasal valve, nasal septum, turbinates, sinuses, and tissues of the back of the nose is important for many individuals with sleep disorders to look for correctable medical causes or to identify structural abnormalities. If surgery is required, it is most often done under local anesthesia with a rapid return to work or other normal activity.
- Uvulopalatopharyngoplasty (UPPP)
This procedure is done for people with obstruction in the upper pharynx of the palate. UPPP may be performed in conjunction with other treatments targeted at other areas of collapse.
Various forms and surgical techniques have been developed. Surgeons at Froedtert & the Medical College of Wisconsin's Sleep Disorders Program are international leaders in the development of better reconstructive surgical procedures for OSA and snoring. The procedures which are focused on reconstructing the normal anatomy and replace the historic methods (which is still commonly performed by many surgeons) that remove the uvula, a portion of the soft palate, the tonsils, and redundant (excess) tissue from the throat. By improving airway structure (repositioning and realigning tissues) in contrast to excising and removing tissues, function and healing are better; recovery is faster; and studies show better sleep outcomes.
For modern reconstructive techniques to be successful accurate assessment of the anatomy and structure of the throat is required. Techniques to evaluate the upper airway have been pioneered by physicians and surgeons in the Sleep Disorders program. Features that are important include: the position and size of the tonsils, the anatomy of the lateral (side walls), the shape of the space behind the palate, and assessment of tissue movement with swallowing, jaw movements, and sleep.
- Surgery to Correct Obstruction of the Lower Throat
Many individuals with OSA and snoring have narrowing of the airway in the lower throat that contributes to blockage during sleep. The cause of this block often varies and for this reason multiple procedures have been developed to correct or to improve the blockage. Selecting the most suitable procedure for any patient is based on many factors. No single procedure is best for all. The following procedures modify tissues of the lower pharynx when the involved tissues are obstructive or abnormal:
- Mandibular (Lower Jaw) Advancement
This procedure moves the bone, soft tissue and muscles of the jaw forward to enlarge the airway. The amount of advancement may be limited by the natural position of the teeth. People with a backward positioning of the teeth and jaw may benefit from lower jaw advancement alone.
- Bimaxillary (Upper and Lower Jaw) Advancement
This procedure is done for people with significant jaw deficiency, morbid obesity, and those with obstructive sleep apnea who have failed more conservative treatments. The procedure involves cutting the bones of the upper and lower jaws and lengthening them a small amount. The tongue and the palate are pulled forward, enlarging the airway. The surgery also enlarges the mouth to provide more room for the tongue. Both jaws are advanced together, retaining the person’s bite. The surgery is performed through incisions inside the mouth.
- Limited Mandibular Osteotomy (Cutting the Jaw Bone) and Genioglossus Advancement
Genioglossus advancement detaches the tongue muscle from the back of the mandible (jaw bone) and move it forward to the front. Moving this attachment pulls the tongue forward and enlarges the airway. To do this, the primary tongue muscle that controls the size of the lower airway (genioglossus muscle) and a small piece of attached bone are moved. The procedure has the advantage over other mandible surgeries, that it does not surgically move the teeth and does not require braces or orthodontic procedures.
- Tongue Suspension
An alternative to mandibular advancement procedures that does not require osteotomies or skeletal adjustments is to perform tongue suspension. These procedures use an implantable device to help support the tongue and prevent collapse during sleep. Several different devices are used to perform the procedure. For most patients, a successful result requires that these procedures be performed with other procedures.
- Hyoid Myotomy
The hyoid bone is a small C-shaped bone in the upper neck above the Adam’s apple cartilage. Many muscles of the tongue and throat attach to the hyoid. In the procedure, a small portion of the middle of the hyoid bone is exposed in the neck. Hyoid Myotomy and suspension is a procedure to move this bone to increase the size of the lower airway. To do this two small bone anchored screws are place in the back of the chin and several “tethers” are passed around the hyoid bone which is then pulled forward towards the lower jaw. This procedure may be done under local anesthesia as day surgery or may be combined with other surgeries.
- Lingual Tonsillectomy
Enlargement of tonsils at the base of the tongue (lingual tonsils) may be a common contributor to airway obstruction in OSA. Removing lingual tonsils was markedly improved with the application of plasma surgical technology and endoscopic minimally invasive techniques. Many of these procedures were pioneered at Froedtert & the Medical College of Wisconsin's Sleep Disorders Program.
- Midline Glossectomy (MLG)
For many individuals, the back of the tongue is too large for the airway. For some this may be due to large lingual tonsils, and excessively small lower jaw, increased fat, or other causes. For some patients reducing the size of the tongue increases the size of the lower throat (pharyngeal) airway.
When described in the 1990’s, these procedures were done with traditional surgical tools or lasers. These resulted in excessive pain and recovery for many patients. Newer plasma and radiofrequency surgical tools provide less damaging methods to reduce the size of the tongue and to increase the airway size with lower side effects, improved healing, and faster recovery. For some patients these procedures can be done as outpatient or office based procedures.