Snoring and Sleep Apnea
As one of the world’s experts in the evaluation and surgical treatment of snoring and obstructive sleep apnea,. Dr. Manish is committed to providing outstanding, comprehensive, and state of the art patient care while advancing the field through innovation and research. Dr. Manish works closely with patients to ensure that they receive the highest-quality care from a team of providers that tailors a treatment plan to them.
Snoring is sound produced during sleep, typically from vibration of structures inside the throat. Snoring can have important effects by itself. However, it can be a sign of a more-serious problem called obstructive sleep apnea that can lead to sleepiness and fatigue during the day and create serious health problems.
The adenoids also help the body fight off infection. The adenoids are the areas of soft tissue right behind the nose.
Risk factors include being male, weight gain, race and ethnicity, and the natural aging process that affects everyone (not just the elderly). The size and position of many structures of the head and neck often have important effects on the risk of developing snoring and sleep apnea.
Typically, the snoring sound comes from the back of the roof of the mouth (soft palate and uvula), but successful treatment of snoring and obstructive sleep apnea is much more complex than just focusing on that one area. Different patients have different causes. The critical importance of identifying these causes and developing personalized treatment plans is the reason why he has focused his career exclusively in this area.
Individuals who snore are often told by others that it is bothersome, but that is not always the case. Individuals with loud snoring or other signs/symptoms like sleepiness or fatigue should have a sleep study. A sleep study can be performed in a sleep laboratory or at home, and it serves multiple roles: establishing a diagnosis (snoring vs. sleep apnea) and directing appropriate treatment (different for the two conditions).
Snoring without obstructive sleep apnea has important effects on personal relationships and often disturbs the sleep of others, leading to fatigue, sleepiness, and decreased quality of life. Research suggests that snoring may also directly affect the snorer themselves, with health risks and sleepiness, but these are not as clearly documented as for obstructive sleep apnea.
Symptoms of sleep-disordered breathing may include in children younger than five:
- Snoring. Some patients (and bed partners) are more concerned with snoring than with the other two consequences of obstructive sleep apnea. Although the primary purpose of treating obstructive sleep apnea is not to improve snoring, it is often very important to patients and bed partners.
- Health impacts. When blockage in breathing occurs, patients often have drops in oxygen levels and wake themselves up with a response like an adrenaline rush. This places stress on the cardiovascular (heart), pulmonary (lung), and endocrine (metabolism) systems. Obstructive sleep apnea is strongly associated with the risks of developing hypertension, stroke, heart attack, and early death. These risks are greatest in those with more severe sleep apnea.
- Sleep disruption, fatigue, memory problems, and decreased quality of life. Sleep apnea can prevent patients from getting refreshing sleep because the blockage in breathing is often worse during deep sleep. Interestingly, the degree of sleepiness or other symptoms is not related to sleep study results, so that some patients with what is called mild obstructive sleep apnea can experience significant symptoms, and vice versa. The bottom line is that if patients are not getting good sleep, they need treatment to function well during the day.
Conservative treatments include weight loss, avoiding sleeping while lying on one’s back, and avoiding alcohol or other sedating medications. Weight loss can improve snoring and sleep apnea, especially in men, and the benefits often depends on the amount of weight loss. Although results vary, one large study estimated that a 10% weight loss was associated with a 15-25% reduction in the severity of sleep apnea. A bed partner often knows whether body position during sleep affects snoring, and a sleep study may determine how body position affects breathing patterns in sleep apnea. Finally, individuals with snoring or sleep apnea should avoid alcohol and other sedating medications within 3 hours of bed time because they produce muscle relaxation and other effects to worsen snoring, sleep apnea, and sleep quality.
Positive airway pressure (CPAP, BiPAP, or AutoPAP) is a non-surgical therapy that works by delivering air pressure to prevent blockage of breathing in the throat. It is recognized as the first-line treatment for obstructive sleep apnea because it works well in the ideal situation where patients can wear it and sleep comfortably through the night, every night. Unfortunately, many patients do not tolerate it well, and it is important that these patients undergo evaluation to improve compliance or seek alternative treatment.
Surgical treatment must be directed at the areas that are responsible for snoring and airway narrowing or complete obstruction. There is a wide range of procedures available to stop snoring and to enlarge and/or stabilize the airway to prevent blockage of breathing in the three major areas where it can occur: the nose, palate, and tongue regions. Dr.Manish have seen that often more than one of these areas is responsible and that accurate identification and treatment of the involved areas is critical.
Oral appliances represent an alternative non-surgical therapy for certain patients with snoring or obstructive sleep apnea. Dr.Manish works closely with dentists who have expertise and experience in sleep dentistry to identify patients who might benefit most from these devices. SURGICAL TREATMENT OVERVIEW
Successful surgical treatment depends on the accurate identification of the factors responsible for snoring and obstructive sleep apnea in each person. A personalized approach is required because there is no single treatment that works well for everyone. In selecting treatments for patients, Dr.Manish relies on the latest research, including his own work, concerning surgical evaluation and techniques, surgical outcomes, and potential complications.
Dr.Manish performs virtually the entire range of surgical procedures to treat snoring and obstructive sleep apnea. His goal is to achieve the best results with the lowest risks, and this is possible through the appropriate use of everything from minimally-invasive options like the Pillar Procedure to the most-involved approaches, such as tongue base reduction. He is extremely familiar with the latest developments in the field, as he gives lectures regularly about the newest available surgical treatments and work with many companies that are in the midst of developing novel technologies.
Surgical procedures enlarge and stabilize different structures around the airway to treat snoring and obstructive sleep apnea. There are three major areas that can contribute to these conditions: the nose, palate, and tongue regions. In an individual patient, often more than one of these areas are responsible. Our philosophy is to address these areas of airway obstruction in a targeted approach to achieve the best outcomes. Preoperative evaluation represents a critical opportunity to plan and tailor surgical treatment to the individual’s pattern of airway blockage rather than performing the same procedure on all patients.
In addition, there are three things to keep in mind when asking this question. First, some people (including surgeons) have looked at sleep surgery as being one procedure for everyone, primarily soft palate surgery (uvulopalatopharyngoplasty, or UPPP). In fact, as shown on this website, there are multiple other procedures available, and Dr. Manish is dedicated to training other surgeons in this country and around the world in these techniques, which are often newer and technically more challenging.
Surgical results are unpredictable when the same procedure is performed in everyone. Although it is impossible to make guarantees in medicine, many studies show that it is possible to improve surgical outcomes through careful evaluation of patients and selecting procedures that are best for an individual patient. The importance of patient evaluation is widely recognized by surgeons and others. Patient evaluation and the selection of procedures is a primary focus of Dr. Manish .
The third important thing to consider is that surgery carries risks and potential side effects. Dr. Manish takes all measures to avoid complications and minimize risks.
Snoring and obstructive sleep apnea surgery is a new and changing medical field. His specialization, experience, and research allows him to provide the most advanced patient care. This includes selecting procedures, performing procedures, or recognizing when not to have surgery at all. Dr.Manish takes pride in training other surgeons through courses and invited lectures in this country and around the world Dr.Manish takes a more careful approach, treating patients with this procedure based on a thorough understanding of his experience and that of others. The most important factor in obtaining good results for this procedure, like any treatment, is using it only in patients who would be expected to obtain the most benefit.
- Drug-Induced Sleep Endoscopy
- Nasal Procedures
- Palate Procedures
- Tongue Region Procedures
- Maxillomandibular Advancement
CHOOSING THE RIGHT SURGERY FOR SNORING AND SLEEP APNEA A thorough office evaluation is the only way for an expert in sleep surgery to choose the right surgery for you. In spite of what you may read or hear elsewhere, there is no single surgical procedure works well for everyone with snoring or obstructive sleep apnea. In all areas of medicine, cookie cutter approaches do not work because people are different. For snoring and obstructive sleep apnea, age, gender, body weight, race and ethnicity all affect treatment outcomes, as do differences in the structures of the head and neck. All of these have major implications for the results of surgery for snoring and sleep apnea, and it is important to recognize these and choose surgical and non-surgical treatments based on them.
Dr. Manish will be able to discuss treatment options following an initial evaluation. In some cases, he may recommend an evaluation called drug-induced sleep endoscopy to guide the selection of procedures.
The procedures on this site are grouped into three categories, reflecting their treatment of narrowing or blockage of the breathing passages in three regions: nasal, palate, and tongue. The evaluation process is designed to determine what areas are responsible for blockage of breathing and, more specifically, what structures are playing an important role. Experts has shown that over 60% of people have obstructive sleep apnea related to a combination of factors.
To explain this process briefly, Our approach in choosing procedures relies on what the procedures actually do and how that might improve snoring or sleep apnea in an individual patient.
For example, there are a number of procedures covered in the Palate Procedures section. Some of these procedures (Pillar Procedure, Palate Radio-frequency, and Uvulopalatoplasty) are excellent options for treating snoring or the mildest form of obstructive sleep apnea because they stiffen the soft palate and prevent vibration. For patients with obstructive sleep apnea, there are a number of different palate procedures that remove and/or reposition tissue (not just stiffening). The choice among these other palate procedures that are useful for sleep apnea is based on what may be best for individual patients, given the structure of their throat and soft palate. Some procedures have more removal of tissue, and others have more tissue repositioning in the soft palate and sides of the throat (lateral pharyngeal walls).
As discussed on the Tongue Region Procedures section, there is another set of procedures that are used primarily for obstructive sleep apnea. They can treat the structures that contribute to blockage in this region: the tongue, epiglottis, and lateral pharyngeal walls. Our research and that of other experts has shown that over 60% of patients with sleep apnea appear to have blockage of breathing in both the palate and tongue regions, typically requiring a combination of two types of procedures. In addition, this research has also suggested that different patients have tongue region blockage due to different structures, further requiring selection from among various options. Among the tongue region procedures, some are directed at the tongue (tongue radio-frequency, genioglossus advancement, lingual tonsillectomy, and midline glossectomy), and some are directed at the epiglottis (epiglottis surgery and thyroid suspension). Some of the palate procedures and hyoid suspension may also treat the lateral pharyngeal walls. Choosing among these tongue region procedures requires an evaluation to determine what structures may be playing a primary role and incorporating other aspects of physical examination, such as body weight.
Contrary to how it appears, the large number of available procedures is not designed to confuse people. These procedures accomplish different things, and the choice among them is based on the pattern of blockage in breathing and weighing the risks and benefits for an individual patient. DRUG-INDUCED SLEEP ENDOSCOPY
Successful surgical treatment of obstructive sleep apnea is based on the accurate identification of the pattern of airway obstruction and targeted, effective treatment. In the throat, there are two major areas that can be responsible: the palate and tongue regions. For many years, the primary surgical treatment for obstructive sleep apnea was soft palate surgery, and this worked well for patients with blockage of breathing in the palate region alone. Unfortunately, many patients also appear to have blockage of breathing in the tongue region, and multiple procedures have been developed to address this in the hope of improving surgical outcomes.
During drug-induced sleep endoscopy, patients receive sedation administered by an anesthesiologist in the operating room. As patients begin to snore and have some blockage of their breathing, Doctor passes a flexible telescope through one side of the nose in order to evaluate the throat and observe the potential blockage of breathing in the palate and tongue regions. This technique was described almost two decades ago and is used in centers around the world. Our research has advanced the understanding of drug-induced sleep endoscopy, and his ongoing work seeks to determine whether it predicts outcomes from surgery.Our center appreciates the opportunity to train other surgeons in this technique and other aspects of pre-surgical evaluation. There are two major reasons that patients may consider undergoing drug-induced sleep endoscopy: to obtain additional information regarding whether they seem to have blockage of breathing at the palate and/or tongue regions and to determine which specific structures seem to be playing a major role in airway obstruction. This is true for patients who are considering surgery for the first time and in those who have not obtained ideal results after previous procedures. Dr.Manish incorporates information from other evaluation techniques to make a decision with our patients and believe that drug-induced sleep endoscopy provides additional, helpful information in certain patients.
NASAL PROCEDURES: Nasal obstruction can interfere with nasal breathing during the day and night, and it can play a major role in snoring and obstructive sleep apnea. Relief of nasal obstruction can improve snoring and obstructive sleep apnea by itself and can also improve the ability of some patients to tolerate positive airway pressure therapy for obstructive sleep apnea. Treatment options include medications such as nasal saline, topical corticosteroid and antihistamine sprays, and oral medications such as antihistamines or decongestants. Non-surgical treatments can include external nasal dilators like the Breathe Right® strip for selected patients. If these are not successful by themselves, surgery can improve the nasal airway either alone or in combination with these other options. The most common nasal procedures include turbinate surgery, septoplasty, sinus surgery, and rhinoplasty and nasal valve surgery.
Specific nasal procedures are:
- Rhinoplasty & Nasal Valve Surgery
- Sinus Surgery
- Turbinate Surgery
PALATE PROCEDURES: The soft palate (roof of the mouth) and tonsils play a major role in snoring and obstructive sleep apnea. There is a wide range of treatment options. Minimally-invasive procedures like the Pillar Procedure and palate radio-frequency can be performed in the office under local anesthesia, and these can be very helpful in snoring and mild obstructive sleep apnea. Other soft palate procedures, including Uvulopalatoplasty(also known as UPPP or UP3), expansion sphincter pharyngoplasty, and lateral pharyngoplasty are performed for the treatment of obstructive sleep apnea in the operating room under general anesthesia. Although many people have attempted to utilize a single procedure to treat snoring and sleep apnea, there is no single procedure that works well for everyone. Outcomes vary widely for individual patients and procedures.
Specific palate procedures are:
- Expansion Sphincter Pharyngoplasty
- Lateral Pharyngoplasty
- Palate Radio-frequency
- Palate Surgery
- Pillar Procedure
- Uvulopalatoplasty (Laser or Cautery-Assisted)
TONGUE REGION PROCEDURES: Airway obstruction in the tongue region is common, affecting approximately 60% of patients with sleep apnea and many with snoring. While patients are awake, the muscles that surround the throat are active and keep this region open for breathing. These muscles relax during sleep, allowing the tongue and other structures to collapse and block breathing. Dr. Manish research has shown that careful patient evaluation can identify patients with tongue region obstruction. More importantly, it is possible to determine who is more or less likely to benefit from specific surgical and non-surgical treatments.
Tongue region procedures are:
- Epiglottis Surgery
- Genioglossus Advancement
- Thyroid Suspension
- Lingual Tonsillectomy
- Midline Glossectomy
- Tongue Radio-frequency