This article familiarizes the otolaryngologist with potential integrative and complementary treatment options for obstructive sleep apnea syndrome. The authors discuss current medical and surgical regimens, and then provide a review of the current literature on integrative and complementary approaches for treatment of this disorder.
Key points
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Obstructive sleep apnea syndrome (OSAS) is a common disorder characterized by reduced airflow during sleep resulting in gas exchange abnormalities and disrupted sleep.
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The goal of any treatment is reduction in sleep disruption and the apnea-hypopnea index (AHI).
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Continuous positive airway pressure (CPAP) is recommended for the treatment of moderate to severe OSAS.
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There is a lack of existing evidence showing long-term benefits of acupuncture and auricular plaster therapy, although they may help to improve the comfort and quality of life of patients.
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It seems that there are no alternatives to the conventional treatment of OSAS that provide the same positive outcomes as CPAP, surgical interventions, or oral appliances when used appropriately for selected patients.
Overview
Obstructive sleep apnea syndrome (OSAS) is a common disorder affecting children and adults. The disorder is characterized by reduced airflow during sleep resulting in gas exchange abnormalities and disrupted sleep. This can lead to serious cardiovascular compromise; neurobehavioral alterations; hypertension; and in children, growth retardation. OSAS occurs more commonly in men than in women, and predisposing risk factors include obesity, adenotonsillar hypertrophy, retrognathia, hypothyroidism, nasal obstruction, and evening alcohol ingestion. The gold standard for documenting severity of OSAS is overnight polysomnography (PSG). Once diagnosed, treatment may include continuous positive airway pressure (CPAP) devices, weight loss, oral appliances, and surgical options. The goal of any treatment is reduction in sleep disruption and the apnea-hypopnea index (AHI), with resultant improved overall health and quality of life.
Overview
Obstructive sleep apnea syndrome (OSAS) is a common disorder affecting children and adults. The disorder is characterized by reduced airflow during sleep resulting in gas exchange abnormalities and disrupted sleep. This can lead to serious cardiovascular compromise; neurobehavioral alterations; hypertension; and in children, growth retardation. OSAS occurs more commonly in men than in women, and predisposing risk factors include obesity, adenotonsillar hypertrophy, retrognathia, hypothyroidism, nasal obstruction, and evening alcohol ingestion. The gold standard for documenting severity of OSAS is overnight polysomnography (PSG). Once diagnosed, treatment may include continuous positive airway pressure (CPAP) devices, weight loss, oral appliances, and surgical options. The goal of any treatment is reduction in sleep disruption and the apnea-hypopnea index (AHI), with resultant improved overall health and quality of life.
Medical treatment approaches and outcomes for OSAS
CPAP
The diagnosis of OSAS must be established by PSG before instituting CPAP. CPAP is recommended for the treatment of moderate to severe OSAS, because it has been shown to significantly reduce sleep-related respiratory events and is the most uniformly effective therapy. Once initiated, full-night, attended studies in the laboratory are recommended for titration to the optimal pressure. CPAP is effective for the treatment of OSAS, but regular follow-up is recommended yearly to assess mask, machine, and usage issues. Baltzan and colleagues found that 17 of 101 patients undergoing PSG while using CPAP had an AHI higher than 10. Persistent apnea was found to be associated with high body mass index, higher prescribed pressures, and unresolved mask leak. Unresolved or unsuspected apnea, and the resultant daytime somnolence and neurobehavioral changes, may be an impetus for some to look at integrative treatment approaches.
Medical Approaches to OSAS
A variety of medical approaches for the treatment of OSAS have been assessed as additional modes of therapy. Weight loss in particular is shown to result in a substantial improvement in OSAS if sufficient weight is lost. In one study, a 10% weight reduction predicted a reduction in AHI by 26%. Bariatric surgery can be an adjunct to the treatment of OSAS in patients who are obese, although there are reports suggesting a recurrence of OSAS after several years even without gaining weight.
Oxygen supplementation has not been recommended as a primary treatment of OSAS, because the effect on apneas, hypopneas, and sleepiness is inconsistent.
Pharmacologic approaches to treatment have been investigated in several studies, such as serotonergic agents, REM sleep suppressant therapy, and ventilator stimulants. When evaluating these studies, Veasey and colleagues stated that few conclusions could be drawn because of design limitations and insufficient knowledge of neurochemical mechanisms through which sleep places the upper airway at risk for collapse.
Sleep positional therapies, which keep the patient in a nonsupine position during sleep, can be a supplement to primary treatments in select patients.
Oral appliances are another approach to the treatment of OSAS. Mandibular advancement devices actively reposition and support the mandible in a more anterior and open position than the physiologic resting position of the mandible. The American Academy of Sleep Medicine suggests that although oral appliances may not be as efficacious as CPAP, they are indicated for use in patients with mild to moderate OSAS who prefer oral appliances to CPAP, or who fail attempts with CPAP or behavioral methods, such as weight loss or sleep position changes. Patients fitted with an oral appliance should undergo PSG with the appliance in place after final adjustments to the fit have been performed. Regular dental visits are recommended to assess overall dental health and occlusion while the appliance is being used. Upper airway surgery may supersede use of oral appliances in those deemed to have a high potential for benefit.
Surgical treatment approaches and outcomes for sleep apnea
Surgical options include tonsillectomy, adenoidectomy, palate reduction procedures, tongue reduction procedures, mandible advancement, and tracheostomy. Surgical options are selected based on area of pharyngeal narrowing or collapse. For example, uvulopalatopharyngoplasty enlarges the retropalatal airway, whereas a midline glossectomy widens the retrolingual airway. The American Academy of Sleep Medicine suggests that a stepwise approach to surgical treatment is acceptable if the patient is advised about the likelihood of success, and the need for possible additional surgery before instituting treatment. Tracheostomy is the only operation shown to be consistently effective as a sole procedure in successfully treating obstructive sleep apnea. Clearly, this option is considered on a limited basis for those with no other recourse. For those whose symptoms persist despite surgical intervention or for those who have compliance issues with their therapy, such as CPAP or oral appliances, complementary and integrative medicine (CIM) approaches to treatment may be sought.
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