Get Rid Bad Breath

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The next area to consider is the palate area, at the level of your tonsils. In young children enlarged tonsils are the most common reason for obstructive sleep apnea, and this is easily treated with tonsillectomy (most of the time). However, as one gets older, the tonsils shrink, and the soft tissues of the throat and palate begin to stretch inwards with every apnea. Some young adults are lucky (or unlucky) enough to have persistently enlarged tonsils and in general do much is a better after tonsillectomy (with or without a palatal operation). If you have small or no tonsils your chances on a palatal operation curing you of obstructive sleep apnea is about 40% only. There are a number of ways of predicting whether or not an adult will respond to palatal surgery for sleep apnea. In general, if you have small tonsils and you can’t see at least some of your uvula (the thing that hangs down the middle of your throat) when you open your mouth, then a palatal operation alone is successful in 40%. What this means is that your tongue may also be involved.
When you have tongue involvement, this means that either your tongue falls back from a normal position sitting up to almost completely collapsed when on your back. In most people with this condition, one is breathing through a small slit about 1/8 to 1/4 of an inch wide between the back of the tongue and the back of the throat. When awake, the muscular “reflexes” keep the airway open, but during sleep (especially deep sleep), this reflex does not work, and the tongue falls back completely, leading to an apnea. Another variation might be that the tongue falls back only partially, causing a more forceful vacuum upstream, narrowing the palatal area, when can then collapse totally, or when air squeaks through a very small palatal opening, one starts to snore. This is why certain dental devices that pull the jaw forward, pulls the tongue forward, alleviating snoring.
As you can see from the above descriptions, if you place a pump on the “nasal” end of the long thin tube, and blow a gentle amount of air, the tube does not collapse. This is the basic principle behind a CPAP machine (continuous positive airway pressure). A soft padded mask is placed over your nose and a pre-measured amount of air pressure is delivered from a small bedside machine. CPAP is the first-line treatment for obstructive sleep apnea, and it works, but only if you use it. Due to obvious practical or logistical issues, many people are not able to use it consistently. Studies have shown compliance rates between 40-60%. In addition, intensive support and follow-through by the sleep medicine technicians and durable medical equipment was found to significantly increase the odds that you will do well and like your machine. Technology has advanced enough so that they are small enough to travel with, and there are hundreds of different masks, straps, and other gadgets that are available to suits one’s needs.
I strongly encourage anyone with obstructive sleep apnea to at least try CPAP first, even if you have only mild sleep apnea. Despite your hesitation about CPAP and it’s implications, once it’s tried, about 1/3 of my patients love it instantly, another third hate it, and the remainder have to get used to it and after a period of follow-up and adjustment, they can use it effectively.
Only after absolutely refusing CPAP, or if you tried it and hate it, can other options be discussed.
Before rejecting CPAP altogether, if your nose is stuffy and the pressure seems too uncomfortable, then treating your nasal congestion may allow you to use CPAP more effectively. Allergies or sinusitis may be treated with medications. A deviated nasal septum can be easily repaired. Not only can you breathe better through your nose in general, but you can use CPAP much is a more effectively.
As mentioned previously, a dental device can be made (by a dentist that specializes in this) to pull your jaw forward. This is effective in patients with mostly tongue involvement, and not appropriate for people with palatal level narrowing. The device is worn nightly, and incrementally advanced slowly to prevent jaw pain and bite changes. These devices have been shown to help significantly in appropriately selected people with mild to moderate sleep apnea.
Lastly, there are surgical options, but only if you’ve rejected or failed the other options.
Uvulopalatopharyngoplasty (or UPPP) was first described in the early 1980’s (about the same time as CPAP). Initially, they had good success rates, but over time, the success rates dropped to about 40%.
A side note about success: One of the biggest frustrations is that people use different definitions of success. The most commonly used definition in our field is a greater than 50% drop in the AHI, and that final number has to be less than 20. Unfortunately, many studies vary significantly from this definition, and others use very unorthodox ways of defining success.
Over the years, researchers have discovered that in cases where a UPPP fails, the tongue is the main culprit. Once the tongue collapse is addressed as well, the “success” rate increases to ~75%. Many subsequent studies report success rates in the 70-80% range.
There are many ways of addressing tongue collapse. At Stanford, they perform (in addition to the UPPP) a mandibular osteotomy with genioglossus advancement (MOGA), and hyoid myotomy with suspension (HMS). MOGA involves advancing the portion of your tongue that attaches to the midline lower jaw, and HMS involves pulling the hyoid bone, which is a c-shaped bone on top of your voicebox that attaches to your tongue and voicebox. Of the 25% that fail this operation, a portion went on to more definitive surgery, called a maxillo-mandibular advancement. This is a complex and long procedure that literally pulls the middle of your face and jaw bones forward. As expected, this procedure is well more than 90% effective.
An alternative to the MOGA is a procedure where a suture is attached to the midline lower jawbone, and looped around the back of the tongue, thus suspending the tongue from falling back. Results are similar to the MOGA, but much less invasive.
One last word about palatal treatments for obstructive sleep apnea: There are various modifications of the UPPP procedure, which all have their roles for selected patients. A recent alternative to the UPPP for mild obstructive sleep apnea is an implant procedure called the Pillar procedure. Three thin polyester rods are implanted into the soft palate which causes a tightening of the soft palate as it heals over weeks to months. It was originally developed for snoring, but recently received FDA approval for mild obstructive sleep apnea. For treatment options on snoring, please refer to the snoring section on this website.
If you have any questions about sleep apnea or any of the treatment options, please contact Dr. Steven Park, MD

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