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Sleep Disorders

Sleep apnea treatment alternatives

05/21/2007

Question:

I have tried 3 types of cpap (nose mask, full mask, nasal pillows with chin strap) and still cannot sleep with all that gear on my face. I tried the oral appliance, but because I have TMJ the appliance gives me severe headaches. I am 57, 5`3" and weigh 138. In my 20`s I weighed 125. Could losing 10-15 lb. make a difference? I also have a herniated disc at C6-C7, could this be part of the problem? I have a deviated septum but was told it was not bad enough to warrant surgery. I`ve read about 5htp, but since I take 20mg of lexapro daily and suffer from SAD, I am concerned about any interactions. Can you give me any advice or options? Any help will be greatly appreciated.

Answer:

Based on your question, I assume you have obstructive sleep apnea (OSA) and are weighing your treatment options for this condition. As mentioned in your question, there are a number of different treatments available for OSA. Which treatment is best for a given individual depends on a number of factors, including the severity of the sleep apnea, the patient's size and airway anatomy, the patient's co-morbid conditions and the patient's willingness to accept a given treatment.

OSA is a condition where the airway partially or completely collapses during sleep. This results in fragmentation of sleep and, in some individuals, low oxygen level during sleep. The consequences of this condition can be serious and range from a poor quality of life (morning headaches, disabling sleepiness, poor concentration, irritability, etc) to increasing problems with blood pressure control, heart disease and strokes.

The primary treatment for OSA is the use of CPAP, which is very effective at keeping the airway open during sleep. It does this by "pressurizing" the airway to prevent it from collapsing. In a large number of well-done studies, CPAP therapy has been shown to be very effective at improving a number of measures of quality of life, including daytime alertness, improved concentration and improved mood. Individuals with OSA who can successfully use CPAP generally feel better! In addition, growing data suggest that CPAP may reduce some of the medical consequences associated with sleep apnea. The main problem with CPAP is that many individuals, such as yourself, have trouble adapting to sleeping with this type of device. Most times, with patience, perseverance, and appropriate trouble-shooting, individuals can learn to sleep with CPAP (or one of it's versions) and do quite well. Despite best efforts, some individuals are unable to use CPAP and thus alternative therapies must be considered.

Alternative treatments for OSA really fall into 2 main categories: oral appliances and surgery. Oral appliances generally work to advance the lower jaw, hoping to open space in the back of the throat. They tend to work best in individuals with more mild to moderate OSA and in those who may have a small or more posterior sitting jaw. Individuals who use oral appliances during sleep often tolerate them, though they can have some annoying side effects (jaw achiness, pain with chewing in the morning, headaches, drooling). In addition, if there is a history of temporomandibular joint (TMJ) disease, then these devices should be used with great caution as they put considerable stress on the TMJ and can worsen problems. It sounds like this may be what happened in your case.

For some individuals, surgery is a reasonable option. Surgery tends to be most effective in those with clear anatomic problems that are amenable to surgery (such as large tonsils, deviated septum), more mild to moderate sleep apnea and who are not obese. There are a variety of surgeries that can be considered, though they are generally tailored based upon an individual's anatomy. A tracheotomy (surgical tube placed in the neck) is usually curative for OSA, but because it is somewhat disfiguring, is reserved for severe cases that fail other treatments.

It sounds as though you have an anatomic problem (septal deviation) that surgery could correct. Furthermore, based the information you provided, I calculate a body mass index of 24 kg/m2, which places you in a normal weight range. Given these factors and your history with other treatments for OSA, surgery may be very appropriate for you.

Other treatments that have been mentioned in the literature included weight loss for those who are overweight (in some cases, this can be curative), positional therapy (avoiding sleep on your back) and medications. Unfortunately, aside from treatment to help alleviate nasal congestion, almost all other medications hoped to significantly impact OSA have failed when well-studied (this includes the serotonin active agents). Primary medication treatment for OSA is not recommended at this time.

In your case, it would be reasonable to seek the opinion of a Sleep Specialist as well as an Ear Nose and Throat specialist (ENT). Working together, they should be able to devise a successful treatment plan for your OSA.

To learn more about sleep apnea, sleepiness, or other sleep disorders, please visit the American Academy of Sleep Medicine website. In addition to information, the website contains a list of Sleep Centers across the country so that you may locate one near you. The website Sleep Education.com also contains plenty of consumer friendly information about sleep and sleep apnea. Good luck and here's to better sleep!

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Response by:

Dennis   Auckley, MD Dennis Auckley, MD
Associate Professor of Medicine
School of Medicine
Case Western Reserve University