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?
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.
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.
German scientists have potentially discovered a genetic reason why some people are morning people whereas others are night-owls.
The gene called ABCC9 dubbed “morning person” gene was identified by analyzing 4251 individuals who reported their sleeping pattern.
The ABCC9 variant type and number of copies significantly affected the number of hours of sleep. To confirm this finding, scientists modified the ABCC9 gene in the fruit fly and obtained similar results.
The gene codes for a protein that senses the energy metabolism of a cell, but how this relates to sleep is unclear. The gene is also associated with other conditions including heart disease and diabetes which probably helps explain why quality of sleep seems to be associated with these disease processes.
In the past, it was thought that poor sleep “caused” cardiovascular problems, but just maybe, sleep problems and heart problems are caused by a common genetic trigger rather than one causing the other.
Our office has produced a new video describing “where” snoring comes from determined by a simple procedure known as sedated or sleep endoscopy.
At its most basic definition, snoring is noise produced from a vibrating mucosal surface in the upper airway.
Though snoring can be defined simply, the tough question is WHERE are these vibrating mucosal surfaces? Because unless one can define WHERE the snoring is coming from, successful treatment can’t be pursued definitively.
An office exam performed while a patient is awake is suboptimal as the patient is awake… and not snoring. As such, it is an educated guess where the snoring problem is stemming from.
To this end, there are three main levels where snoring can be produced and the best way to localize a snore is to perform the exam while the patient is asleep (induced by anesthesia) and snoring!
1) Nose
2) Mouth
3) Throat
4) All of the above
Watch the video to see how each of these areas can contribute to a person’s snore as well as treatment options.
Obstructive sleep apnea (OSA) is known to cause all sorts of health problems beyond sleepiness. Medical problems include increased risk of stroke, heart attack, peripheral vascular disease, high blood pressure, etc. However, what researchers have recently found is that even if you do not have obstructive sleep apnea, if a person does not have enough “deep sleep” per night resulting in poor quality sleep, that also can increase risk of hypertension.
Researchers collected data on 784 men over the age of 65 who didn’t have high blood pressure initially and followed them over the next 3 years. At home sleep studies were obtained initially and at follow-up to look at their sleep patterns as well as their blood pressure.
What they found was that individuals with poor quality sleep, reflected by reduced slow wave sleep (deep sleep), puts individuals at significantly increased risk of developing high blood pressure, and that this effect appeared to be independent of obstructive sleep apnea.
This statement is supported by a recently published study indicating that poor sleep, whatever the cause, can be a factor leading a child to bully or display other aggressive behaviors. Among 341 kids who were evaluated, 23% had conduct problems. Of these kids with conduct issues compared to those without, a significant number had symptoms suggestive of a sleep disorder indicated by sleepiness scoring as well as snoring.
It is already known that the prefrontal cortex governs social behavior which is also influenced by sleep. As such, poor sleep can deleteriously influence the brain leading to behavior problems.
Of course, there are other factors that can contribute to sleep problems as well as bullying… such as an unstable family as well as too much technological stimulation (cell phone, internet, television, etc).
As such, as with most things, more study is needed.
But here’s my two cents… Applying some common sense here, ask anybody who has pulled an all-nighter whether they are grouchy the next day and I bet you most will say “of course, no duh”!
Well, here’s a study that supports that! (No duh!)
All kidding aside, if a child is having behavior issues, it may behoove the parents to see if obstructive sleep apnea is present which would lead to poor sleep quality. At least for kids, obstructive sleep apnea can be addressed surgically by removing the tonsils and adenoids leading to markedly improved sleep quality (and hopefully improved behavior as well!).
A new webpage has been created describing a procedure called “sleep endoscopy” or “sedated endoscopy.”
This procedure is performed on patients with obstructive sleep apnea (OSA) or severe snoring in order to determine where the source of their problem is anatomically located.
This special exam is needed in patients where such anatomic determination is not able to be made in the clinic while they are awake. As such, an anesthesiologist would put the patient to sleep using IV medications and when snoring or obstructive events happen, endoscopy is performed.
Areas that will be specifically examined during sleep endoscopy include:
Behind the palate
Uvula
Back of Tongue
Walls of the Throat
Epiglottis
Voicebox
Each of these areas may experience collapse during sleep causing obstructive or snoring symptoms.
Why is this information helpful? Well… once it is apparent where and what is the culprit causing a given patient’s problems, surgical treatment can be geared more specifically and directly to the area of concern seen during sedated endoscopy.
MSNBC published a story on Feb 1, 2011 regarding a new study suggesting a link between childhood obesity and tonsillectomy.
What they found was a greater than expected weight gain in both normal weight and overweight children after tonsillectomy over a 6-12 month period of time. In one study, the average body mass index of the kids increased by about 7 percent. In another analysis of 249 children, 50 to 75 percent of kids had weight gain after surgery. While most weight gain happened in the first year after surgery, scientists don’t know definitively whether it levels off after that.
What is unclear about this research is whether this common surgery to remove tonsils is contributing to the nationwide “epidemic” of obesity.
Several theories have been proposed:
1) One reason why tonsillectomy is performed is because of difficulty breathing. In this scenario, more calories are expended on trying to breath. After tonsillectomy, all the energy expended on breathing is now being used to gain weight instead.
2) Having difficulty swallowing food due to large tonsils may prevent children from eating very much. In this scenario, after tonsillectomy, the child can now eat without problems leading to eating more and gaining weight.
3) In young and school-age children there’s evidence of both a weight gain and a “growth spurt” after tonsillectomy that may be triggered by higher levels of growth factors.
One needs to be careful and realize that this study does NOT prove cause and effect. It suggests a possible association and the only way to know for sure if this common surgery actually causes obesity is to perform a double-blinded, placebo-controlled, prospective study… or at the very least, a prospective study (given it will be near-impossible to have a placebo group and be double-blinded… after all, you can just look to know if the tonsils were removed or not). What will likely end up being true is the fact that obesity is due to a number of factors of which tonsillectomy may play one possible role in certain pediatric populations. In the end, more study is needed.
Regardless of the cause, perhaps the best advice for parents is to have tonsillectomy done for their child only if it is absolutely necessary and if done, keep an eye on how much they are eating and to encourage healthy eating habits.
The Doctors TV show at some point in the past (not sure when), did a segment on surgery used to treat obstructive sleep apnea. The surgery portrayed was UPPP (uvulopalatopharyngoplasty). Dr. Brian Weeks, the featured otolaryngologist, removed the tonsils and uvula followed by suturing the cut mucosa to reposition the soft tissues of the patient’s throat.
This operation is a basic surgical method addressing obstructive sleep apnea. However, prior to considering surgical treatment, I typically recommend trial of CPAP for 3 months.
A new video has been created and uploaded onto our YouTube channel showing how a UPPP (uvulopalatopharyngoplasty) sleep apnea surgery is performed. This surgery is commonly performed to try and improve or even cure obstructive sleep apnea in adults. This surgery rarely is performed in kids.
Read more about UPPP here. More info about obstructive sleep apnea can be found here.
Another operation used to treat obstructive sleep apnea in adults along with UPPP is base of tongue reduction. Read about this operation here as well as watch the video here.
