Evaluation and Management of Patients After Unsuccessful Sleep Apnea Surgery

Nasal surgery does a wonderful job at improving CPAP compliance, said Dr. Mickelson, adding that many people cannot adhere to CPAP because they cannot breathe through their noses. After nasal surgery, 70 percent of patients will be able to use CPAP without any difficulties, he said.

Oral appliances are another treatment option for postsurgical patients, particularly beneficial for patients with mild to moderate sleep apnea. Although not as effective as CPAP in managing sleep apnea, oral appliances are better tolerated and therefore provide overall comparable effectiveness.

I will use oral appliances in patients who have tried CPAP and are intolerant to it, said Dr. Jacobowitz, in patients who have failed surgery and want to be treated medically but not with CPAP, and in patients with mild to moderate sleep apnea who prefer them to CPAP.

Tod C. Huntley, MD, a head and neck surgeon at the Center for Ear Nose Throat and Allergy in Indianapolis, who is on the teaching faculty of the oral surgery department and the dental school of Indiana University, agrees that oral appliances have a larger role to play prior to and after surgery than they currently do in otolaryngologic practice.

Among the many and various oral appliances available (see illustration on page 1), Dr. Huntley suggests several criteria that otolaryngologists can use in choosing an appliance for a given patient. His preference is for appliances that are FDA-approved for sleep apnea (and not the nearly 25 approved for snoring only), that are adjustable or able to be titrated to fit the particular anatomy of a patient, and that meet the particular nuances of a given patient. He outlined the many factors that must be taken into account in deciding who might benefit most from appliance therapy and who might not be good candidates.

For example, some appliances are more easily adjustable, and therefore easier to use by patients with arthritis, he said. He also prefers appliances with a hard outer shell because they last longer and allow for less dental movement, which can be a negative side effect.

Although widely available, many otolaryngologists do not include oral appliances in their treatment options largely because they are not aware of the appliances, are not trained in their use, and remain skeptical about their role in using them, according to Dr. Huntley.

For Dr. Huntley, this is a mistake. There are a variety of treatment options to be considered for sleep apnea patients, he said. We need to broaden our tools in our tool box and understand that oral appliances are an excellent treatment option.

One-Stop Shop: The Otolaryngology Office

We [otolaryngologists] can be the medical home for the sleep apnea patient, said Dr. Jacobowitz. We can treat the patient comprehensively and provide the multiple treatment options tailored to patient preference and the patient’s type of disease.