Sleep Apnea Surgery

1. Current Solutions

1.1. Lifestyle

1.1.1. No smoking

1.1.2. Oxygen Supplementation

1.1.3. Weight

1.1.3.1. Need: patients need a quality exercise regiment to lower BMI and reuslt in less sleep apnea events

1.1.3.2. Need: patients need a quality diet regiment to promote better sleep

1.1.4. Exercise

1.1.4.1. Need: patients need a quality exercise regiment to lower BMI and reuslt in less sleep apnea events

1.1.5. Avoid alcohol

1.1.6. Side sleeping, no back sleeping

1.1.6.1. Need: Patients need some kind of device that promotes comfortable side sleeping to avoid sleep apnea events

1.1.6.2. Need: A device that automatically adjusts patient positioning based on real-time feedback about airway alignment and comfort.

1.2. Positive Airway Devices

1.2.1. Continuous Positive Airway Pressure (CPAP)

1.2.1.1. https://my.clevelandclinic.org/health/treatments/22043-cpap-machine

1.2.1.1.1. Benefits

1.2.1.1.2. Downsides/Side Effects

1.2.1.1.3. Filters and pressurizes air, pushing it into airway, keeps the soft palate + uvula + tounge from shifting down.

1.2.1.1.4. Includes a mask to fit over nose/mouth, straps for positioning, main tube to connect mask to device, motor for air blowing, air filter Optional: humidifer, pressure settings

1.2.1.1.5. Is a continuous stream of air. At a consistent pressure. Must use everytime while sleeping, must clean everyday also.

1.2.1.1.6. Different kinds

1.2.1.2. https://noinsurancemedicalsupplies.com/blogs/blog/cpap-bipap-vpap-whats-the-difference

1.2.1.2.1. Less expensive than other machines, less specialized

1.2.1.2.2. Starting point for PAP prescription

1.2.1.2.3. Modern devices ramp up the pressure/stream to help people fall alseep, some people find one level hard to fall asleep.

1.2.1.2.4. Pressure can be very uncomfortable on exhale

1.2.1.3. https://www.mayoclinic.org/diseases-conditions/sleep-apnea/diagnosis-treatment/drc-20377636

1.2.1.3.1. Pressure needs to be adjusted with the weight of the patient. More weight means higher presssure needed to keep airways open.

1.2.1.3.2. For moderate to severe apnea, delivers air pressure through a mask device while sleeping. The air pressure is greater than the surroundings. This keeps the airways open.

1.2.1.3.3. Most common method, and most reliable.

1.2.1.3.4. Can be seen as uncomfortable especially with tension straps and large cumbersome mask.

1.2.1.3.5. Different types of masks available.

1.2.2. Bilevel Positive Airway Pressure (BPAP) / Variable Positive Airway Pressure (VPAP)

1.2.2.1. https://www.mayoclinic.org/diseases-conditions/sleep-apnea/diagnosis-treatment/drc-20377636

1.2.2.1.1. More pressure on the inhale, less on exhale.

1.2.2.2. https://noinsurancemedicalsupplies.com/blogs/blog/cpap-bipap-vpap-whats-the-difference

1.2.2.2.1. Can make patients apnea turn into central version (uncommon)

1.2.2.2.2. VPAP and BPAP Different acronyms, same treatments

1.2.2.2.3. Two different pressures: higher on inhale, lower on exhale to help with comfort

1.2.2.2.4. Usully only used when CPAP doesnt work or is so uncomfortable for user. More expensive due to added features

1.2.2.2.5. Also used with other conditions like COPD chronic obstructive pulmonary disease, cardiopulmonary, neuromuscular

1.2.3. Autotitrating Positive Airway Pressure (APAP) / Auto-CPAP / Auto-BPAP

1.2.3.1. https://www.mayoclinic.org/diseases-conditions/sleep-apnea/diagnosis-treatment/drc-20377636

1.2.3.1.1. Basically CPAP but with an auto adjust feature that changes the pressure as you sleep to ensure the airways are open. Is a range of pressures.

1.2.3.2. https://noinsurancemedicalsupplies.com/blogs/blog/cpap-bipap-vpap-whats-the-difference

1.2.3.2.1. Breathing changes at night, so the machine will change to match that. This depends on what stage of sleep cycle you are in.

1.2.3.2.2. Can either be a baseline measurement with a range that goes up or down, or more advanced that tracks your airway.

1.2.3.2.3. Same perscription scenario as BPAP/VPAP, it is more expensive

1.2.3.2.4. non-obstructive sleep apnea

1.2.4. Adaptive Servo-Ventilation (ASV)

1.2.4.1. https://www.mayoclinic.org/diseases-conditions/sleep-apnea/diagnosis-treatment/drc-20377636

1.2.4.1.1. Computer used to learn breathing patterns and uses pressure with this data to prevent breaks in breathing.

1.2.4.1.2. Only good for treatment emergent central sleep apnea.

1.2.4.1.3. Not good with those with heart failure.

1.2.4.2. https://my.clevelandclinic.org/health/procedures/asv-machine

1.2.4.2.1. Same main function as CPAP

1.2.4.2.2. Delivers air based on built-in sensing system that track the patients breathing. Adjusts airflow levels whenever needed. Done alongside a sleep study before hand and set on device.

1.2.4.2.3. Used for central sleep apnea or its complex version.

1.2.4.2.4. People with congestive heart failure can have HA

1.3. Oral Appliances

1.3.1. https://www.mayoclinic.org/diseases-conditions/sleep-apnea/diagnosis-treatment/drc-20377636

1.3.1.1. Device for keeping the throat open.

1.3.1.2. Less reliable than CPAP. Used for mild sleep apnea.

1.3.1.2.1. Need: oral appliances need to become a more reliable alternative for patients

1.3.1.3. Many different devices, usually prescribed by a dentist. Also over the counter.

1.3.1.4. Jaw forward or hold tounge in place.

1.3.2. https://my.clevelandclinic.org/health/treatments/21129-oral-appliance-therapy-for-sleep-apnea

1.3.2.1. Mandibular Advancement Devices (MADs)

1.3.2.1.1. Can have different sizes, movement, mechanism connections, materials, etc.

1.3.2.1.2. Most common

1.3.2.1.3. mandibular advancement splints mandibular advancement appliances mandibular repositioning appliances

1.3.2.1.4. Positions lower portion of the jaw more forward, which pulls the tounge along with it. This opens the airway.

1.3.2.1.5. Two pieces go over the teeth, upper and lower portion. Mechanism connects the two to pull the lower jaw forward.

1.3.2.2. Tounge-Stabilizing Devices (TSDs)

1.3.2.2.1. Good for people misisng teeth, or teeth/jaw problems

1.3.2.2.2. Tounge retaining devcies

1.3.2.2.3. Less common, uncomfortable

1.3.2.2.4. Positions the tounge more forward in the mouth.

1.3.2.2.5. Suction is the primary mechanism, A piece that sits outside and goes into the mouth pulls it forward. This opens the airway. Piece that touches the tounge is called the bulb.

1.3.2.3. Used for obstructive sleep apnea, partial upper airway blockage. Devices hold the mouth in positions to increase airflow. Opens the throat up.

1.3.2.4. Can be custom or not. Custom ones obviosuly work better for each individual.

1.3.2.4.1. Need: need a better custom/specialized solution for MADs and TSDs to fit patients

1.3.2.5. Usually used for people who dont like CPAP, definitely is worse than PAP machines in terms of effectiveness. Better for children also. Same benefits as other remedies for apnea.

1.3.2.6. Sideffects/downsides include: increased salivation, jaw pain, gum pain, dryness in some instances, bite changes, teeth damage/changes, jaw changes.

1.3.2.6.1. Need: Patients need mroe comfortable MADs and TSDs that do not interrupt normal sleep.

1.3.2.6.2. Need: Patients need MADs and TSDs that do not change structures, hurt, or cause dryness over time.

1.3.3. https://www.sleepapnea.org/treatment/oral-appliance-for-sleep-apnea/

1.3.3.1. Rapid Maxillary Expansion (RME)

1.3.3.1.1. Expander used to open the jaw over a period of time, Orthodonic device

1.3.3.1.2. Has to be custom made

1.3.3.1.3. Usually for children with apnea from sugrical reasons and poor genetics in jaw and bite

1.3.3.1.4. Tonsils and adenoids removal may warrant this

1.3.3.2. Tounge Muscle Stimulation Device

1.3.3.2.1. For mild apnea

1.3.3.2.2. Electrical signals stimulates the tounge and results in strengthening. This helps keep the airway open when asleep.

1.3.3.2.3. This is not a device you wear at night, its usally a little mouthguard you wear for a certain amount of treatment period during the day. You can slowly taper off using it after a certain amount of time/treatments.

1.4. Treat Associated Medical Problems

1.4.1. https://www.mayoclinic.org/diseases-conditions/sleep-apnea/diagnosis-treatment/drc-20377636

1.4.1.1. Weight loss

1.4.1.1.1. Need: patients need a quality exercise regiment to lower BMI and reuslt in less sleep apnea events

1.4.1.1.2. Need: patients need a quality diet regiment to promote better sleep

1.4.1.2. Heart or muscular disorders may cause sleep apnea, treating and relieving conditions like these may help.

1.4.1.3. Nasal decongestant/breathing strips

1.5. Medicine

1.5.1. https://www.webmd.com/sleep-disorders/sleep-apnea/sleep-apnea-can-medications-help

1.5.1.1. Medicines that can help

1.5.1.1.1. Acetazolamide (possibly, early studies show benefits as it hgelps you take deeper breathes)

1.5.1.1.2. Stimulants for tired in the day

1.5.1.1.3. Weightloss drugs

1.5.1.1.4. Hormones

1.5.1.1.5. Allergy medications/ nasal decongestants

1.5.1.2. Medicines that can make worse

1.5.1.2.1. Slidenafil

1.5.1.2.2. Anything that leads to weight gain

1.5.1.2.3. Barbituates

1.5.1.2.4. Opioids

1.5.1.2.5. Testosterone

1.5.1.2.6. Benzodiazepines

1.6. Snoring Devices

1.6.1. Zqueit

1.6.1.1. Positions jaw forward to widen the airway and prevent loud snoring noise

1.6.1.1.1. 1.

1.6.1.2. 2 sizes allow for both men and women to use for optimal jaw advancement

1.6.1.2.1. Need: need a better custom/specialized solution for MADs and TSDs to fit patients

1.6.1.3. When you sleep lower jaw relaxes causing it to fall back and Zquiet positions it back.

1.6.1.4. Can be pricy

1.6.1.5. Only sold online

1.6.1.6. Made of mint and themopolastic polymer

1.6.1.7. Complaints about teeth pain

1.6.1.7.1. Need: Patients need mroe comfortable MADs and TSDs that do not interrupt normal sleep.

1.6.1.7.2. Need: Patients need MADs and TSDs that do not change structures, hurt, or cause dryness over time.

1.6.1.8. OTC mandibular advancement device

1.6.1.9. Lasts for a year, but recommended to replace 4-6 months. Even 3 months

1.6.1.9.1. Need: Patients need MADs and TSDs that do not need to be replaced/disposed of over time

1.6.1.10. ZQuiet Review - Does This Anti-Snoring Mouthpiece Work? (consumerhealthdigest.com) Top 5 Anti Snoring Devices – Consumer's Guide Review (consumersguidereview.com) ZQuiet Mouthpiece Review 2024 | Sleep Foundation

1.6.2. Sleep Connection

1.6.2.1. The SLEEP CONNECTION ANTI-SNORE WRISTBAND uses nerve stimulation to train the wearer to reflexively suppress snoring.

1.6.2.2. Can change the signal strength

1.6.2.3. This bracelet is equipped with a Natural Biofeedback Mechanism that helps it to send out very delicate pulses that rearrange your body in such a way that you will no longer snore.

1.6.2.4. Made out of ABS

1.6.2.5. Turns off after 8hrs of sleep

1.6.2.6. Automatic

1.6.2.7. Monitors noise in the room

1.6.2.8. Can customize pulse frequencies

1.6.2.9. Can only buy online

1.6.2.10. 15 1 star reviews

1.6.2.11. Sleep Connection Reviews - Legit or Scam? (reviewopedia.com) Is Your Snoring Preventing You From Getting Any Rest at Night? This Incredible Wristband is the Most Effective Solution! | Official® Website (sleep-connection.store)Is Your Snoring Preventing You From Getting Any Rest at Night? This Incredible Wristband is the Most Effective Solution! | Official ® Website (sleep-connection.store) Sleep Connection Review: Real Truth about Sleep Connection (globenewswire.com)

1.6.3. Snor Away

1.6.3.1. Made from medical-grade silicone

1.6.3.2. Dual vortex technology for efficient airflow

1.6.3.3. Built-in air filters for cleaner breathing

1.6.3.4. USB rechargeable for convenience

1.6.3.5. Ergonomic design for a comfortable fit

1.6.3.6. Replacement nose plugs available in different sizes

1.6.3.7. The device is inserted into the nostrils and works by gently widening them, which helps to minimize airway resistance.

1.6.3.8. Snore Away Review: Is This the Answer to Your Snoring Problems? (consumerhealthdigest.com)

2. Anatomy

2.1. Micrognathia -small lower or recessed lower jaw.

2.2. Retrognathia-the lower jaw is in abnormal position.

2.3. Short and thick neck -narrower airway, difficult to breathe through lungs

2.4. Abnormal positioning of the hyoid-affect mechanical properties of upper airway tissue and effectiveness of pharyngeal muscles.

2.4.1. physicians need Custom-fitted appliances that help stabilize the jaw and widen the airway during sleep, improving access for visualization

2.4.2. physicians need devices to widen the cricoid cartilage to help open the airway and improve visualization during intubation

2.4.3. A device is needed that utilizes magnetic technology to hold the jaw in an advanced position during sleep, offering adjustable resistance tailored to the individual patient's requirements.

2.5. Long face-high mandible angle and steeper mandibular plane

2.5.1. physicians need a stabilizing tool to hold patients jaw in place while performing maxillomandibular advancement (MMA) to ensure proper alignments of jaws

2.6. Small, retroposed mandible-mandible is positioned abnormally

2.7. Narrow posterior airway space

2.8. Adenoid and tonsillar hypertrophy-enlargement of tonsils and adneoid causing OSA

2.9. nasal bone structure- Enlarged turbinates can contribute to sleep apnea.

3. Background on Sleep Apnea

3.1. Living With Sleep Apnea: https://www.nhlbi.nih.gov/health/sleep-apnea

3.1.1. Prevents a person from getting enough rest, which causes problems with concentrating, remembering things, making decisions and even dementia (?) in older adults

3.1.2. In children, sleep apnea can lead to problems with learning and memory which contributes to learning disabilites

3.1.3. Can cause low oxygen levels during sleep whcih causes your body to restart breathing many times during sleep which can damage organs and blood vessels

3.1.4. Raises the risk of other following conditions: asthma, cancer, chronic kidney disease, eye problems, etc.

3.2. Women: https://www.nhlbi.nih.gov/health/sleep-apnea

3.2.1. They are more at risk during pregancy and/or during and after menopause

3.2.2. Women who have polycystic ovarian syndrom (PCOS) [hormone disorder] are at higher risk

3.2.3. Can have a different subset of symptoms

3.2.3.1. anxiety, daytime sleepiness, depression, headaches, insomnia, tiredness, waking up often during sleep

3.2.4. Pregnancy

3.2.4.1. More serious issue in the third trimester of pregnancy and can improve after giving birth

3.2.4.1.1. risk increases if women are older and/or obese

3.2.4.2. Can cause certain complications during pregnancy

3.2.4.2.1. Cesarean sections, gestational diabetes, high blood pressure, low birth weight, preterm birth

3.3. Recommendations: https://www.mayoclinic.org/diseases-conditions/sleep-apnea/diagnosis-treatment/drc-20377636

3.3.1. Sleeping on side or abdomen instead of sleeping on your back. Sleeping on back causes tongue and soft palate to rest against back of throat and block airway.

3.4. Dangers of sleep apnea https://www.hopkinsmedicine.org/health/wellness-and-prevention/the-dangers-of-uncontrolled-sleep-apnea

3.4.1. If undiagnosed, sleep apnea is directly tied to an increase risk in cardiovascular and metabolic health

3.4.2. Occurs in about 3% of normal weight individuals but affects >20% of obese people according to Jonathan Jun M.D.

3.4.3. Association between sleep apnea and diseases like type 2 diabetes, strokes, etc is because the main factor behind these diseases is obesity, as these individuals are at higher risk due to their weight

3.4.4. Study in Hopkins lab found that sleep apnea is also associated with higher risks of diabetes that are independent of obesity factors

3.4.4.1. maybe research this later

3.4.5. Apnea hypopnea index (AHI): measures severity of sleep apnea

3.4.5.1. Mild OSA: 5 < AHI < 15

3.4.5.2. Moderate OSA: 15 < AHI < 30

3.4.5.3. Severe OSA: AHI > 30

3.5. What it is: - https://www.nhlbi.nih.gov/health/sleep-apnea

3.5.1. common condition where breathing stops and restars multiple times while sleeping

3.5.2. prevents the body from getting enough oxygen

3.6. Types of sleep apnea: https://www.nhlbi.nih.gov/health/sleep-apnea

3.6.1. Obstructive Sleep Apnea (OSA): upper airway becomes blocked multiple times while sleeping, redcuing or stopping airflow

3.6.2. Central Sleep Apnea (CSA): brain does not send signals needed to breathe during sleep. usually caused by conditions that affect how the brain controls airway and chest muscles that facilitate breathing

3.7. Causes and Risk Factors: https://www.nhlbi.nih.gov/health/sleep-apnea

3.7.1. Risks for OSA:

3.7.1.1. Lifestyle habits: drinking alcohol can cause the muscles of mouth and throat to be more relaxed which can be bad for the airways. Smoking can cause inflammation of upper airways.

3.7.1.2. Obesity: very common cause of sleep apnea because of increased fat deposits in the neck

3.7.1.3. Sex: more common in men than in women and also get sleep apnea at a younger age than women.

3.7.1.4. Age: the older you get, fatty tissue builds up in the neck and tongue area increasing the risk of sleep apnea

3.7.1.5. Endocrine disorders/hormone changes: any hormone changes that affect the size of face, tongue, airway, etc can increase risk of sleep apnea. People with low levels of thyroid hormones or high levels of insulin/growth hormones are at greater risk

3.7.1.6. Family history and genetics: can be inherited and genes can help determine the size of face and airways which affects risk of sleep apnea. Those with cleft lip and cleft palate and down syndrome individuals are at higher risk.

3.7.1.7. Heart or kidney failure: fluid builds up in the neck which can block the airway

3.7.1.8. Large tonsils and a thick neck: can cause the upper airways to be more easily blocked.

3.7.1.9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628457/

3.7.1.9.1. OSA - collapse of pharyngeal airway

3.7.1.9.2. Leads to blood gas disturbances

3.7.1.9.3. Loud snoring with periods of awakening from sleep. Upper range of frequency is 100 times per hour, 20-40 seconds per event

3.7.1.9.4. Dangers: somnolence (wanting to sleep), decreased cognition, back quality of life, more motor vechile accidents, adverse cardiovascular outcomes

3.7.1.9.5. Obesity

3.7.1.9.6. Gender

3.7.1.9.7. Age

3.7.1.9.8. Genetics

3.7.1.9.9. Pathophysiology

3.7.1.10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3970937/

3.7.1.10.1. **TO READ**

3.7.2. Risks for CSA:

3.7.2.1. Premature birth: babies born before 37 weeks are at a higher risk of developing breathing problems during sleep. Usually, they outgrow these problems as they age

3.7.2.2. Age: normal changes that affect how your brain controls your breathing during sleep

3.7.2.3. Family history and genetics: an example of this is if one has congenital central hypoventilation which is a disorder that affects normal breathing. People who have this disorder have shallow breaths that result in a shortage of oxygen and buildup of carbon dioxide in blood

3.7.2.4. Lifestyle habits: drinking and smoking

3.7.2.5. Opiod use: causes problems with how the brain controls sleep

3.7.2.6. Health conditions: heart failure, stroke, amyotrophic lateral sclerosis (ALS), myasthenia gravis (neuromuscular disease that affects voluntary muscles like facial ones), and changes in hormone levels

3.7.2.7. Pathophysiology

3.7.2.7.1. https://www.ncbi.nlm.nih.gov/books/NBK578199/

3.7.2.7.2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2287191/

3.7.2.7.3. https://emedicine.medscape.com/article/304967-overview#a1

3.8. Common Symptoms: https://www.nhlbi.nih.gov/health/sleep-apnea

3.8.1. Sexual dysfunction or decreased libido

3.8.2. Waking up often during the night to pee

3.8.3. In children specifically: can be overactive and may experience bedwetting, worsening asthma, and trouble paying attention in school

3.8.4. Breathing starts and stops during sleep

3.8.5. Frequent loud snoring

3.8.6. Gasping for air during sleep

3.8.7. Daytime sleepiness and tiredness

3.8.7.1. Leads to prolems learning, focusing, and reacting (can be bad if driving)

3.8.7.1.1. Need: If not able to fully get rid of sleep apnea, be able to reduce overall tiredness by a certain amount ( )

3.8.8. Dry mouth or headaches

3.9. Diagnosis: https://www.nhlbi.nih.gov/health/sleep-apnea

3.9.1. Asked to go to a sleep specialist or go to a center for a sleep study

3.9.1.1. sleep studies record brain waves and monitor your heart rate, breathing, and oxygen levels during a full night of sleep

3.9.2. Sleep diaries are common to help healthcare providers diagnose condition

3.9.3. Blood tests can be collected to check for any endocrine/hormone disorders that contribute to sleep apnea

3.9.4. Extra info about diagnosis: https://www.mayoclinic.org/diseases-conditions/sleep-apnea/diagnosis-treatment/drc-20377636

3.9.4.1. ENT good for OSA since it deals directly with the nose and/or throat

3.9.4.2. Neurologis or cardiologist more fitting for CSA since it deals more with conditions in the brain that affect with your breathing

3.9.5. Standard for diagnosis: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3480570/

3.9.5.1. Presurgical Evaluation (different modalities

3.9.5.1.1. MRI

3.9.5.1.2. Physical examination

3.9.5.1.3. A flexible fiberoptic nasopharyngoscopy to evaluate the upper airway to identify potential sites of collapse.

3.9.5.1.4. Lateral cephalogram

3.9.5.1.5. 3-dimensional cone beam computed tomographic scan

3.9.5.1.6. Sleep endoscopy

4. Detection Methods

4.1. Apple Watch Sleap Apnea

4.1.1. https://go.skimresources.com/?id=73726X1523000&isjs=1&jv=15.7.1&sref=https%3A%2F%2Fwww.macrumors.com%2F2024%2F09%2F16%2Fapple-watch-sleep-apnea-feature-150-countries%2F&url=https%3A%2F%2Fwww.apple.com%2Fhealth%2Fpdf%2Fsleep-apnea%2FSleep_Apnea_Notifications_on_Apple_Watch_September_2024.pdf&xs=1&xtz=240&xuuid=eae2ee3cfa045b0ca32c7e77a5dcc873&xjsf=other_click__auxclick%20%5B2%5D

4.1.1.1. Accelerometer-Based Breathing Analysis

4.1.1.1.1. Alogrithm that uses the accelerometer time series data to classify breathing distrubances that occur during sleep

4.1.1.1.2. Notification feature contains contains two components

4.1.1.1.3. How it looks in the health app

4.1.1.2. Preclinical Design and Algorithm Testing

4.1.1.2.1. Adult participants from multiple research sites provided informed consent via IRB-approved protocols.

4.1.1.2.2. Participants were diverse in age, biological sex, race, ethnicity, and BMI, and sleep was evaluated in both at-home and in-laboratory environments.

4.1.1.2.3. Included participants with a range of sleep apnea severity, from normal to severe.

4.1.1.2.4. Participants wore an Apple Watch while reference recordings were conducted using PSG (one night) or HSAT (one to four nights).

4.1.1.2.5. Clinical recordings were scored by certified PSG technologists according to AASM standards, using the strictest definition for hypopneas (4% oxygen desaturation).

4.1.1.2.6. Design phase included 3936 nights of recordings from 2160 participants, with some contributing multiple nights.

4.1.1.2.7. Testing phase included an additional 7220 nights from 2542 participants, with a sequestered testing set not used in the design phase.

4.1.1.2.8. Breathing Disturbances expressed as events per hour, assessed every 30 days.

4.1.1.2.9. At least 10 sleep recordings in a 30-day period with 50% elevated values trigger a notification; fewer than 10 recordings result in no notification.

4.1.1.2.10. The operating point on a receiver operating characteristic (ROC) curve had an operating point chosen to favor specificity over sensitivity to minimize false positives.

4.1.1.2.11. In the sequestered algorithm testing data set, notification performance was 66.6% for sensitivity and 95.9% for specificity.

4.1.1.3. Clinical Validation

4.1.1.3.1. Participants wore an Apple Watch for up to 30 nights and had at least two nights of HSAT recordings with a type 3 HSAT device.

4.1.1.3.2. HSAT recordings served as the ground truth for sleep apnea status.

4.1.1.3.3. Scoring process

4.1.1.3.4. Study population was a broad representation across demographic factors and sleep apnea severity, with an enriched population exceeding the real-world prevalence of moderate to severe sleep apnea.

4.1.1.3.5. Hypothesis testing

4.1.1.3.6. Accuracy Chart

4.1.1.3.7. Results

4.1.2. https://www.healthline.com/health-news/sleep-apnea-apple-watch#Takeaway

4.1.2.1. Can give overall sleep quality inforamtion

4.1.2.1.1. Need: A way to record/monitor the anatomical changes while sleeping.

4.1.2.2. Export data to a PDF file to bring to doctors

4.1.2.3. Dr. Michael O.McKinney says that the sleep apnea detection feature can provide several benefits, including early detection, improved diagnosis, and ongoing monitoring.

4.1.2.3.1. Need: A way to pinpoint the sleep cycle that is affected by sleep apnea.

4.1.2.4. Cannot replace medical professional

4.1.2.4.1. Need: Need more accurate and accessible screening tools

4.2. Boston Scientific Sleep Apnea

4.2.1. AP Scan

4.2.1.1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5889179/

4.2.1.1.1. to combat SDB - sleep disorder breathing. 80% of cardiovascular disease heart failure patients. Central sleep apnea (CSA) and Cheyne-Stokes respiration. Usually need a polygraphy or a polysomnography to diagnose.

4.2.1.1.2. Minute ventilation sensors for cardiaic implantable electronic devices (CIED)

4.2.1.1.3. AP scan - algorithim created by boston scientific used by these devices which screen for sleep apnea.

4.2.1.1.4. Study done to show effectiveness of technology.

4.2.2. Multisensor HeartLogic algorithm

4.2.3. VITALIO device

4.2.4. Seems not to be a direct solution to identify sleep apnea, rather its specific use case is for people who are prone/have dealt with some kind of heart failure

4.2.4.1. Sleep apnea common in those who exeperience heart failure

4.3. Polysymnographys (PSGs)

4.3.1. Basic Rules for Diagnosis

4.3.1.1. https://emedicine.medscape.com/article/1188764-overview#a5

4.3.1.1.1. OSA

4.3.1.1.2. CSA

4.3.1.1.3. Mixed Apnea

4.3.2. Measures

4.3.2.1. https://my.clevelandclinic.org/health/diagnostics/12131-sleep-study-polysomnography

4.3.2.1.1. Video and audio monitoring

4.3.2.1.2. Pulse oximeter - oxygen level of blood and pulse

4.3.2.1.3. Respiratory inductive plethysmography (RIP) belt - dteetcts the expansion of your abdomen and chest when you breathe

4.3.2.1.4. Breathing sensors - airmovement for the mouth and nose

4.3.2.1.5. Electro-oculography (EOG) - adhesive senors on skin around eyes to detect eye activity.

4.3.2.1.6. Electromyogram (EMG) - Track muscle movement, don't activiate muscles, but monitors them

4.3.2.1.7. Electrocardiography (EKG or ECG) - electrical activity of your heart, look for any issues in heart beat pattern

4.3.2.1.8. Electroencephalography (EEG) - Electrical activity of your brain (brain waves) Different waves for different stages of sleep.

4.3.2.2. https://emedicine.medscape.com/article/1188764-overview#a2

4.3.2.2.1. EEG - one to two channels and sometimes two occiptal channels. This helps identify arousal activity

4.3.2.2.2. EOG - two channels or eye movements. Documents REM sleep and slow rolling eye movement for sleep onset

4.3.2.2.3. EMG - one channel for atonia in REM sleep. Other channels for limb movements

4.3.2.2.4. Airflow - thermisotr channel to see y/n airflow. This is recommended for diagnosis of apneas. Nasal pressure transducer also used for airflow restriction. Used for hypopneas and airflow resistance.

4.4. Drug Induced Sleep Endoscopy

4.4.1. Patients receive sedation by an anesthesiologist in the OR. A flexible telescope is passed through one side of the nose to evaluate the throat and see any potential blockage in the palate and tongue area.

4.4.2. Done to determine whether blockage in breathing is occurring in the palate and/or tongue regions and which specific structures seem to be causing the obstruction. Used on patients who are considering surgery for the first time or those who have not gotten ideal results from previous treatments.

4.4.3. Risks

4.4.3.1. Allergic reaction (egg products, soy, or glycerol because the sedative contains these products)

4.4.3.2. Blockage or stoppage of breathing (medication given very slowly to reach the point where the patient starts snoring)

4.4.4. VOTE Classification - standard to describe findings during this procedure

4.4.4.1. Refers to the 4 main structures that play a role in blockage

4.4.4.2. Judgement is made in none, partial, or complete blockage in these 4 regions and what direction. Have to look at all 4 regions because one or more regions can be causing blockage

4.4.4.3. Velum (Soft palate)

4.4.4.4. Oropharyngeal Lateral Walls

4.4.4.5. Tongue

4.4.4.6. Epiglottis

4.4.4.6.1. 5% of patients

4.4.5. Techniques

4.4.5.1. Level of sedation needs to appropriate (not too little and not too small) and can make the procedure useless

4.4.5.2. Change in body position

4.4.5.3. Lift the lower jaw, or mandible forward (Esmarch maneuver - to determine if oral appliances can help)

4.4.6. Important Questions

4.4.6.1. Is it a good test?

4.4.6.1.1. Valid: reflects natural sleep

4.4.6.1.2. Reliable: consistent findings

4.4.6.2. Does sleep endoscopy change treatment?

4.4.6.2.1. Different plan from the awake exam?

4.4.6.2.2. Different findings?

4.4.6.3. Are findings associated with results of treatment?

4.4.6.3.1. Surgery

4.4.6.3.2. Oral appliances

4.5. Need: Patients need a better way to tell if they have a sleep apnea/snoring problem at home in order to confrim if they need treatment

5. Patient testimonials

5.1. https://www.reddit.com/r/sleep/comments/1cr04b4/life_with_sleep_apnea_is_almost_unbearable/

5.1.1. OP has moderate sleep apnea, and they have gotten jaw surgery, CPAP machines, sleeping pills. They are 24 years old but they said they feel like they are 80

5.1.1.1. Need: Patients need sugreries and treatments that do not make them feel aged

5.1.2. CPAP machine is very. noise and for those that struggle with sleeping with loud noises, it can resolve their sleep apnea issue but still not give them a good enough sleep

5.1.2.1. Someone else said they were in a sleep study where the sleep study had to be canceled becaues of how loud the machine was and they weren't able to properly do a sleep study

5.1.2.1.1. Need: Patients need a sleep apnea machine that is quiet enough to where sleep is not disturbed

5.1.2.1.2. Need: Patients and doctors need an at home sleep study method that promtes convinece and comfortability

5.1.2.2. Someone else that having an eye mask or black out curtains with ear plugs help BUT these can fall out during sleep

5.1.2.3. Another person said they don't feel like a human being because they are hooked up to so many machines

5.1.2.3.1. Need: Patients need a PAP treatment that does not cause a dehumanizing effect.

5.1.2.4. Someone else said that they newer machines are quiter than the older ones

5.1.2.5. Someone said because they are a side sleeper (which is also a recommended sleep position with those that have sleep apnea) the mask can be more uncomfortable

5.1.2.5.1. Need: For CPAP users for a more comfortable and maybe personalized fit for CPAP masks to prevent pressure sores, skin irritation, or air leaks during sleep

5.1.2.5.2. Need: Patients need more control on the mask, particularly fitting it to their face as comfortably as possible, making it more likely for patients to get better sleep

5.1.2.5.3. Need: A CPAP mask for individuals that move a lot that does not harm the person

5.1.3. Adding more things to to their sleep routine would discourange from maintaining that routine

5.1.3.1. Need: Patients need CPAP device that does not add or adds as little time as possible to their sleep routine

5.1.3.2. Need: Patients using the CPAP need a better more convient way to clean the machine and it's attachments

5.1.4. Another commenter couldn't fall asleep for a full night so their doctor recommended that even having it on for 4 hours would improve their sleep. They tried that method and they were able to build up tolerance to the machine, still don't love wearing it

5.1.4.1. Need: Patients need a more comfortable CPAP device, that allows them to sleep as normal as possible in order to reduce the possibility of quitting the treatment

5.1.5. Nasal pillows with a chin strap and a neck lift surgery were offered as other alternatives that helped people with their sleep apnea

5.1.6. Another commenter said they were diagnosed with moderate apnea 3 weeks ago and are aleady getting their second CPAP amsk. They have a history of breathing issues. Their dentist told them to get a palatial expansion so they are going to have a palate expander surgically implanted. They said they would prefer the APAP machine instead of the CPAP if they knew about it beforehand

5.1.6.1. Need: Patients need a better way to progress in PAP treatments, if one is not working then a notehr should, come quickly.

5.1.7. Commenter said they got a mouth appiance (custom fitted and shifts their jaw to open their airway) and they hhave seen improvement

5.1.7.1. Went to a sleep dentist and got imprints of their teeth and is similar to a retainer or orhtodonic headgear

5.1.7.2. Can cause TMJ so having a solution but at what cost

5.1.7.2.1. Need: need a better custom/specialized solution for MADs and TSDs to fit patients

5.1.7.2.2. Need: Patients need mroe comfortable MADs and TSDs that do not interrupt normal sleep.

5.1.7.2.3. Need: Patients need MADs and TSDs that do not change structures, hurt, or cause dryness over time.

5.1.8. Another commenter had moderate to severe OSA for over a year and they can't funciton regularly. They had CPAP therapy for a couple of weeks but that has only resulted in 2 good days. They need to play with settings to find the right one which can be exhausting for people. Want to quit job to focus on health but can't because they need to pay bills and insuranace doesn't cover anything sleep related (at least for this person)

5.1.8.1. Need: Patients need a more cost effective alternative to CPAP that brings increased comfortability.

5.1.8.2. Need: Patients need a more cost effective method of CPAP treatment

5.1.8.3. Need: Patients need better knowledge and use on PAP device settings

5.1.8.4. Need: Patients need clearer settings on CPAP devices

5.1.9. Inspire device was said to be a good alternated for those who are CPAP intolerant but they need to have a BMI under 35 and a history of CPAP intolerance

5.2. https://www.reddit.com/r/SleepApnea/comments/16thok0/what_are_some_lesser_known_signs_of_sleep_apnea

5.2.1. Irritability and acid reflux are said to be symptoms

5.2.2. Racing heart rate when waking up and struggling with falling back asleep after wakign up in the middle of the night

5.2.3. Waking up with a scratchy throat

5.2.4. Getting up to pee various time during sleep

5.2.5. Memory issues

5.2.5.1. Need: If not able to fully get rid of sleep apnea, be able to reduce overall tiredness by a certain amount ( )

5.2.6. Being sick all the time because they weren't getting enough sleep whcih affected their immune system

5.2.7. Restless leg syndrome - urge to move legs by this uncomfortable feeling, especially when siting or lying down

5.2.8. Vivid repeating dreams/having memory of dreams

5.2.9. Air hunger

5.3. https://www.reddit.com/r/SleepApnea/comments/z3pu4l/how_i_cured_my_sleep_apnea_and_my_goodbye_to_this/

5.3.1. OP supposedly "cured" their sleep apnea by cutting out bad habits (drinking and smoking) and trying to lose weight. Went through 16 different masks and found that BiPAP was more tolerable than CPAP. Tonsillectomy helped reduce their AHI score. Not eating before bed, changing diet, and exercising was also factor

5.3.2. Adjustment period to the mask can include things like sweating during sleep but is said to go away after you adjust

5.3.2.1. Need: Patients need a more comfortable CPAP device, that allows them to sleep as normal as possible in order to reduce the possibility of quitting the treatment

5.3.3. Some people used alcohol as a way to fall asleep but it can cause further heart problems and worsen their sleep apnea

5.3.3.1. Need: need a more comfortable CPAP device, that allows them to sleep as normal as possible in order to reduce the possibility of quitting the treatment

6. Issues

6.1. Gag Reflex/Pharyngeal Reflex + Palatal Reflex

6.1.1. https://www.ncbi.nlm.nih.gov/books/NBK554502/

6.1.1.1. involuntary

6.1.1.2. bilateral pharyngeal muscle contraction + elevation of soft palate

6.1.1.3. can happen by stimulation to many different areas

6.1.1.3.1. posterior pharyngeal wall

6.1.1.3.2. tonsillar area

6.1.1.3.3. base of tongue

6.1.1.4. beleived to be a thing only to prevent swallowing and choking on foreign things

6.1.1.4.1. medullary brainstem based, if do not have = brain death

6.1.1.5. glossopharyngeal nerve and the valgus nerve

6.1.1.5.1. glossopharyngeal nerve is the sesnory limb (afferent)

6.1.1.5.2. Vagus nerve is the motor limb (efferent)

6.1.1.6. posterior pharyngeal muscles

6.1.1.6.1. shown to be seperate from from msucles that swallow

6.1.1.7. Path

6.1.1.7.1. "The stimulus is provided by sensation to the posterior pharyngeal wall, the tonsillar pillars, or the base of the tongue. These sensations are carried by CN IX, which acts as the afferent limb of the reflex to the ipsilateral nucleus solitarius (also referred to as the gustatory nucleus) after synapsing at the superior ganglion located in the jugular foramen. In turn, these nuclei send fibers to the nucleus ambiguus, a motor nucleus in the rostral medulla. Efferent nerve fibers to the pharyngeal musculature traverse from the nucleus ambiguus through CN X, resulting in the bilateral contraction of the posterior pharyngeal muscles."

6.1.1.8. somatogenic

6.1.1.8.1. physical trigger

6.1.1.9. psychogenic

6.1.1.9.1. mental trigger

6.1.1.10. direct gag reflex

6.1.1.10.1. contraction of the musculature ipsilateral to the side of the stimulus

6.1.1.11. consensual gag reflex

6.1.1.11.1. contraction of the musculature on the contralateral side

6.1.1.12. Can have lack of gag reflex or hypersensitive gag reflex (HGR)

6.1.1.12.1. Lack of

6.1.1.12.2. HGR

6.1.1.13. "Following intraoral stimulation, afferent fibers from the trigeminal (CN V), glossopharyngeal (CN IX), and vagus (CN X) nerves pass to the medulla oblongata. From here, efferent impulses give rise to spasmodic and uncoordinated muscle movements characteristic of gagging. The portion of the medulla oblongata that receives these afferent impulses is also close to the vomiting, salivary, and cardiac centers, which may be stimulated during gagging.[3] This explains why gagging may be accompanied by excessive salivation, lacrimation, sweating, fainting, or even a panic attack in a minority of patients. Furthermore, neural pathways from the gagging center to the cerebral cortex allow the reflex to be modified by higher centers, thus making it possible to initiate gagging just by imagining a disagreeable experience or controlling the reflex to some extent by distractive action.[13] "

6.1.1.13.1. Diagram

6.1.2. Need: Doctors and surgeons need a better way to control and account for the gag reflex while doing awake in clinic surgeries

6.1.3. Need: Dcotors and staff need protocol for addressing patient sensitivities to gagging, ensuring a more comfortable experience for the patient.

6.1.4. Need: Doctors need to better reduce the gagging reflex in sleep apnea/snoring patients during awake procedures in order to better visualize the targeted area of the mouth.

6.1.4.1. Need: Doctors need a device or technique that minimizes the gag reflex during sleep surgery, allowing for a smoother and more efficient procedure.

6.1.5. https://en.wikipedia.org/wiki/Pharyngeal_reflex

6.1.5.1. roof of the mouth, back of the tongue, area around the tonsils, uvula, and back of the throat

6.1.5.2. prevents swallowing of objects unwated/ stops choking

6.1.5.3. not a laryngeal spasm

6.1.5.4. Reflex arc - steps in physiology to produce a reflex

6.1.5.4.1. sensory receptor, stimulus from the areas noted

6.1.5.5. sensor : glossopharyngeal nerve motor : vagus nerve sensor : trigeminal ( in soft palate stimulus)

6.1.5.5.1. Trige = palatal reflex

6.1.5.5.2. Glosso = phyarnegeal reflex

6.1.5.6. Can learn to suppress (sword swallowers for example)

6.1.5.6.1. can train soft palate to being touched, can also numb

6.1.5.7. HSG usually conditioned from a previous expereince

6.1.5.7.1. Anti-nausea medicines, sedatives, local and general anaesthetics, herbal remedies, behavioural therapies, acupressure, acupuncture, laser, and prosthetic devices can be used to manage exaggerated gag reflex

6.1.5.8. pharenygeal swallow

6.1.5.8.1. kind of like the opposite of teh gag reflex

6.1.6. https://youtu.be/PtwvnxWhWf4

6.1.6.1. a good vdieo with visuals on gag reflex

6.1.7. https://www.youtube.com/watch?v=YWIPvDoyeQU&ab_channel=RipeGlobal

6.1.7.1. Dealing with Patients with Strong Gag Reflexes | Dealing with Difficult Patients

6.1.7.1.1. more anxious = more gag reflex

6.1.7.1.2. any medication to suppress anxiety

6.1.7.1.3. acupuncture on /around the chin which will stop the gag reflex (~80 % of people.)

6.1.7.1.4. Salt on the tongue of people

6.1.7.1.5. numbing the tongue and jaws

6.1.7.1.6. rubber damn to avoid water going down the throat

6.1.7.1.7. heartless with gaggers - okay to be a gagger, it is what it is

6.1.8. 1.

6.1.9. 2.

6.1.10. 3.

6.1.11. 4.

6.1.12. 5.

6.1.13. 6.

6.1.14. An issue during surgeries in the clinic, these surgeries are with people being awake with no sedation.

6.1.15. Instruments put into the throat and mouth area cause gag reflex

6.1.15.1. Need: Surgeons need a better way to decrease patients sensitivity to the gag reflex

6.1.16. Gag reflex causes interuptions to surgery, a constant commuunication is needed between the patient and the surgeon

6.1.16.1. Need: Surgeons need a better line of communication with the patient in order to keep a hold of gag reflexes during operations

6.1.17. Can limit scope of the surgery if the gag reflex is so bad

6.1.18. A bad reflex during surgery can lead to damaged areas with tools accidently hitting areas

6.1.18.1. Need: Surgeons need better tools that wont hurt patients with unexpected movements

7. Common Complaints and limitations on current treatments

7.1. this research aimed to explore more directions and possibilities for our future projects beyond the one Dr. Commesso provided us, by collecting and listing out the common dissatisfactions mentioned via websites/from interviews.

7.1.1. Regarding the non-invasive treatment (mainly CPAP, targeting the patients):

7.1.1.1. Discomfort with the mask: Many patients find the CPAP mask uncomfortable, especially during long-term use. This discomfort can arise from a poor fit, which may lead to pressure sores, skin irritation, or leaks around the mask.

7.1.1.1.1. Cause: Ill-fitting masks or improper adjustments cause pressure points or air leaks, leading to discomfort during sleep.

7.1.1.1.2. Need: A need for CPAP users for a more comfortable and maybe personalized fit for CPAP masks to prevent pressure sores, skin irritation, or air leaks during sleep.

7.1.1.2. Dryness or irritation of the nose and throat: CPAP users often report nasal congestion, dryness, or throat irritation.

7.1.1.2.1. Cause: The airflow from the CPAP machine can dry out the nasal passages, especially if the device lacks a humidifier or if the humidifier settings are too low.

7.1.1.2.2. Need: For a solution to reduce nasal and throat dryness and irritation caused by CPAP airflow. Specific to the operation of the CPAP machine, particularly related to the airflow setting procedure and humidification features.

7.1.1.3. Noise: Loud noise that disturbs sleep or that of a bed partner.

7.1.1.3.1. Cause: Older models of CPAP devices or poor maintenance may cause the machine to be noisier, creating a barrier to restful sleep.

7.1.1.3.2. Need: for quieter CPAP machines to reduce disturbances to patients and others in the sleeping environment.

7.1.1.4. Difficulty falling asleep: It can be a struggle to adjust to the sensation of wearing a mask or the pressure of air, making it harder to fall asleep or having worse sleep quality.

7.1.1.4.1. Cause: The unfamiliar sensation of forced air pressure, along with the restriction of movement caused by the mask, can make it difficult to relax.

7.1.1.4.2. Need: decrease the conscious awareness of CPAP machines, including the sensation of wearing the mask and the airflow pressure, to help patients relax and fall asleep more easily.

7.1.1.5. Feeling claustrophobic: May induce anxiety or claustrophobia while wearing a mask during sleep.

7.1.1.5.1. Cause: Tight-fitting masks or full-face masks covering both the nose and mouth may trigger feelings of restriction or panic, especially in people prone to anxiety. (Anxiety mentioned by Dr. Commesso)

7.1.1.5.2. Need: for a solution that doesn’t end up with covering full-face and is less intimidating so to reduce the feeling of claustrophobia.

7.1.1.6. Uncomfortable air pressure: The air pressure is hard to adjust, either too high or too low.

7.1.1.6.1. Cause: Inaccurate calibration of the machine or intolerance to higher air pressures can cause discomfort, requiring adjustments to pressure settings.

7.1.1.6.2. Need: better and more customizable pressure regulation in CPAP devices to ensure that patients do not experience discomfort from air pressure being too high or too low.

7.1.1.7. Gastrointestinal discomfort: Bloating, gas, or stomach pain due to air swallowing (aerophagia) sometimes reported.

7.1.1.7.1. Cause: Air leaking from the mask or improper pressure settings can force air into the digestive system, leading to discomfort.

7.1.1.7.2. Need: A solution that fully prevents air swallowing during CPAP use.

7.1.2. Surgery Tools

7.1.2.1. Precision of Surgical Tools

7.1.2.1.1. Microdebriders: used to precisely remove excess soft tissue from the throat or airway (such as in Uvulopalatopharyngoplasty or UPPP). They have rotating blades that allow for controlled removal of tissue.

7.1.2.1.2. Electrocautery: uses electrical current to cut or remove tissue while simultaneously cauterizing blood vessels to reduce bleeding.

7.1.2.1.3. CO2 Lasers: Lasers are sometimes used in procedures like Laser-Assisted Uvulopalatoplasty (LAUP) to vaporize excess tissue --> Calibration

7.1.2.1.4. Radiofrequency Ablation (RFA): This is a minimally invasive tool that uses heat generated from radiofrequency energy to reduce tissue volume in areas of airway obstruction (e.g., base of the tongue or soft palate).

7.1.2.2. Visualization and Access

7.1.2.2.1. Endoscopes with High-Definition Cameras: Endoscopes allow the surgeon to visualize the airway in detail during procedures. They are vital for accessing hard-to-reach areas. --> Limited resolution/misalignment

7.1.2.2.2. Sinuscope: Specifically designed for viewing the sinus cavities, a sinuscope helps during nasal or sinus-related procedures that might affect breathing or sleep apnea.

7.1.2.2.3. CT/MRI Scanner: Provide image for mapping out the airway, usually used pre-surgically.

7.1.2.2.4. Laryngoscopes: Used to visualize the vocal cords and surrounding areas in the throat. They help provide access to the airway during surgeries like Uvulopalatopharyngoplasty (UPPP).

7.1.2.2.5. Mouth Gags:

7.1.2.2.6. Tongue Retractor/Depressor (Mentioned by Dr. Commesso for improvements): l ike Weider retractors or Mayo tongue depressors; but hard to control

7.1.2.2.7. Palate Retractors: Types include Jennings or Langenbeck retractors

7.1.2.2.8. Throat Packs: A sterile gauze pack placed in the throat to prevent fluids (blood, saliva) from entering the airway during surgery.

7.1.2.2.9. Suction Devices (Yankauer Suction): Used to remove saliva, blood, and other fluids from the surgical area to ensure clear visibility and a dry surgical field.

7.1.2.2.10. Nasal Speculum: Used during nasal or sinus surgeries to spread the nostrils and allow access to the nasal cavity.

7.1.2.2.11. Endotracheal Tubes: inserted to secure the airway and assist with breathing.

7.1.2.3. Post-surgery:

7.1.2.3.1. Mandibular advancement device (MAD): Snaps over top and bottom teeth. Hinges let your lower jaw ease forward, which keeps your tongue and soft palate stable, so your airway stays open while you’re asleep.

7.1.2.3.2. Tongue retaining device: Holds tongue in place to keep airway open. Less comfortable and harder to get used to.

8. Current Surgical Procedures

8.1. https://www.sleepfoundation.org/sleep-apnea/surgery-for-sleep-apnea https://pubmed.ncbi.nlm.nih.gov/20488281/ https://www.pennmedicine.org/for-patients-and-visitors/find-a-program-or-service/sleep-medicine/sleep-apnea-program/obstructive-sleep-apnea-treatment/sleep-apnea-surgery

8.1.1. Radio frequency/Ablation

8.1.1.1. https://sleep-doctor.com/surgical-treatment-overview/tongue-region-procedures/tongue-radiofrequency/

8.1.1.1.1. Tongue Region

8.1.1.2. https://sleep-doctor.com/surgical-treatment-overview/palate-procedures/palate-radiofrequency/

8.1.1.2.1. Palate Region

8.1.1.3. https://www.ncbi.nlm.nih.gov/books/NBK75613/

8.1.1.4. https://www.ncbi.nlm.nih.gov/books/NBK77143/

8.1.1.5. Effecitiveness

8.1.1.5.1. https://pmc.ncbi.nlm.nih.gov/articles/PMC6787708/#sec7-healthcare-07-00097

8.1.2. Mouth, Throat and Windpipe Surgeries

8.1.2.1. Uvulopalatopharyngolplasty (UPPP) or Upper Airway Surgery

8.1.2.1.1. Most common

8.1.2.1.2. Involves removing or shrinking parts of tonsils, uvula, and the soft palate

8.1.2.1.3. Can use minimally invasive radiofrequency

8.1.2.1.4. Laser-assisted

8.1.2.2. Tonsillectomy

8.1.2.2.1. Tonsil removal

8.1.2.3. Tracheotomy

8.1.2.3.1. Hole in the neck to connect straight to windpipe

8.1.2.4. Transpalatal Advancement Pharyngoplasty

8.1.2.4.1. Targeting the collapsed soft palate (the back of the throat)

8.1.2.5. TransOral Robotic Surgery for Obstructive Sleep Apnea (OSA TORS)

8.1.2.5.1. Widen the airway by removing excess tissue from areas of the throat that are difficult to reach with traditional surgery.

8.1.2.5.2. minimally-invasive

8.1.2.5.3. Eliminates the need for:

8.1.2.5.4. Most people recover in the hospital in about three days, fully recover after three weeks, and notice improvements after two months.

8.1.3. Nasal Surgeries

8.1.3.1. Rhinoplasty

8.1.3.1.1. Changes shape of the nose

8.1.3.2. Septoplasty

8.1.3.2.1. Straightens the septum

8.1.3.3. Endoscopic Sinus Surgery

8.1.3.3.1. Removes tissue inhibiting sinus drainage

8.1.3.4. Nasal Valve Surgery

8.1.3.4.1. Keeps nasal passage open at its narrowest point

8.1.3.5. Turbinate Surgery

8.1.3.5.1. To shrink or remove bony structures in nose called turbinates

8.1.3.6. Distraction Osteogenesis Maxillary Expansion (DOME)

8.1.3.6.1. Usually need collaboration with Orthodontist

8.1.4. Nasal Surgery 2.

8.1.4.1. Nasal obstruction can interfere with breathing and plays a role in snoring and OSA

8.1.4.1.1. 1.

8.1.4.2. Treating this can improve snoring and OSA but also help patients tolerate positive airway pressure therapy for OSA.

8.1.4.3. Medications: nasal saline, topical corticosteroid and antihistamine sprays, oral medications (antihistamines or decongestants)

8.1.4.4. Non-surgical treatments: external nasal dilators (Breathe Right strip)

8.1.5. Tongue Surgeries

8.1.5.1. Genioglossus Advancement

8.1.5.1.1. Surgically moving the genioglossus muscle foward (Tongue base advancement)

8.1.5.1.2. Success rate ranges 39%-78%

8.1.5.2. Midline Glossectomy

8.1.5.2.1. Tongue base reduction

8.1.5.2.2. Use of a laser or plasma wand remove tongue tissue

8.1.5.3. Hyiod Suspension

8.1.5.3.1. Movement of hyiod bone to move tongue

8.1.6. Pre Surgery

8.1.6.1. Evaluation includes

8.1.6.1.1. Nasopharyngoscopy

8.1.6.1.2. Sleep endoscopy

8.1.6.1.3. CT or MRI scans

8.1.7. Jaw Surgery

8.1.7.1. Maxillomandibular Advancement

8.1.7.1.1. Surgically moving the jaw foward and can be done on upper and lower jaw

8.1.7.1.2. 45 studies considered a sucess in 86% of peopel and cured obstructive sleep apnea 39%

8.1.7.1.3. Mild improvement for 99%

8.1.7.1.4. Invasive

8.1.7.2. Genioglossus Advancement

8.1.7.2.1. Treating tongue base collapse, caused by lower jaw too small, so the tongue will be set too far back, constricting airflow in throat

8.1.7.2.2. Minimally-invasive

8.1.7.2.3. Detach the chin bone and place it in a more forward position

8.1.8. Nerve Stimulation Surgeries

8.1.8.1. Hypoglossal Nerve Stimulation (HNS) or Upper Airway Stimulation

8.1.8.1.1. Surigcally implanting a device that feeds electrical current to the tongue

8.1.8.1.2. Outpatient surgery

8.1.8.1.3. Many types of HNS implants available

8.1.8.1.4. People prefer this to CPAP

8.1.8.2. Transvemous Phrenic Nerve Stimulation PNS

8.1.8.2.1. Helps regulate breathing

8.1.8.2.2. Implant stimulates phrenic nerve

8.2. https://www.sleepfoundation.org/sleep-apnea/uvulopalatopharyngoplasty

8.2.1. What is it

8.2.1.1. Removal and repostitioning of tissue within the airway to make it less likely to collapse & interfere during sleep

8.2.1.2. Enlarges airway

8.2.1.3. More than 90% of airway obstructions related to soft palate

8.2.2. Variations

8.2.2.1. Tonsillectomy

8.2.2.1.1. Removal of tonsils

8.2.2.2. Adenoidectomy

8.2.2.2.1. Removal of adenoids

8.2.2.2.2. Adenoids play a role in preventing infection and are located behind the nose at the top of the throat

8.2.2.3. Uvulopalatal flap

8.2.2.3.1. Folding of the uvula under the soft palate

8.2.2.4. Exapnsion sphincter pharyngoplasty

8.2.2.4.1. Reinforcement of the side walls of the airway by repositioning and removing tissues within the throat

8.2.2.5. Palatal advancement pharyngoplasty

8.2.2.5.1. Removal of the hard palate and adjusts the soft palate foward

8.2.2.6. Relocation pharyngolaplasty

8.2.2.6.1. Repositioning of the tissues in the throat to create tension on the sides of the airway

8.2.3. Benefits

8.2.3.1. Reduced snoring

8.2.3.2. Fewer nighttime awakening

8.2.3.3. Less tired during the day

8.2.4. Drawbacks

8.2.4.1. Post surgical pain

8.2.4.2. Bleeding

8.2.4.3. Risk of infection

8.2.4.4. Changes in voice

8.2.4.5. 1/3 report difficulty in swallowing and eating

8.2.4.6. May not eliminate the use of CPAP

8.2.4.6.1. Does not fully resolve OSA and can improve it mildly, but only for a short period of time until stronger symptoms start happening again

8.2.5. Post Surgery

8.2.5.1. Overnight hospital stay is often needed to ensure a person can swallow.

8.2.5.2. Recovery from UPPP surgery can take two-three weeks

8.2.5.2.1. Eat soft foods

8.2.5.2.2. Rinse mouth after meals

8.2.5.2.3. Pain meds

8.2.5.2.4. Avoid stenuous activity

8.2.5.3. Symptoms of OSA may temporarily become more severe due to swelling.

8.2.5.4. Follow up appointment 2-3 weeks after surgery

8.2.5.5. Follow up sleep study to detect and measure any remaining symptons of OSA

8.2.6. Preparing for UPPP

8.2.6.1. Exam of the head and neck as well as imaging to find the location of the obstruction

8.2.6.2. Primary care doctors works with surgeon to determine if surgery is safe adn beneficial.

8.2.6.3. Performed under general anesthesia

8.3. https://www.verywellhealth.com/surgery-options-for-obstructive-sleep-apnea-3015238#:~:text=Stop%20smoking%20at%20least%20four,weeks%20leading%20up%20to%20surgery

8.3.1. Pre Surgery

8.3.1.1. For a surgery to be considered you would need to have a home sleep apnea test or in-center sleep study

8.3.1.2. Assesment of OSA symptoms is conducted and treatment experience

8.3.1.3. Assessment of potenetial airway management problems during surgery

8.3.1.3.1. Length and range of motion of neck

8.3.1.3.2. Size of tongue/teeth

8.3.1.3.3. Presence of neck bone deformity

8.3.1.4. Evaluation of medical conditions associated with OSA

8.3.1.4.1. Hypertension

8.3.1.4.2. Diabetes

8.3.1.4.3. Obesity Hypoventilation Syndrome

8.3.1.5. Upper airway imaging

8.3.1.5.1. CT

8.3.1.6. Echocardiogram if there is suspicion for severe pulmonary hypertension

8.3.1.7. Consultation with cardiologist for patients with heart disease or risk

8.3.1.8. ECG and blood tests

8.3.1.9. Need: A treatment option choosing method that would result in the same treatment method no matter the doctor

8.4. https://healthy.kaiserpermanente.org/health-wellness/health-encyclopedia/he.sleep-apnea-should-i-have-surgery.aa71542#:~:text=Your%20doctor%20will%20probably%20have%20you%20try

8.4.1. Surgery can also be used to tolerate CPAP

8.4.2. Try out lifestyle changes and CPAP prior to surigical option

8.4.3. Why doctor may recommned surgeries

8.4.3.1. UPPP

8.4.3.1.1. Condition is easy to treat

8.4.3.1.2. You chose not to or cannot use CPAP

8.4.3.1.3. CPAP does not work

8.4.3.1.4. Risks

8.4.3.2. Maxillo-mandibular advancement and radiofrequency ablation

8.4.3.2.1. You chose not to or cannot use CPAP

8.4.3.2.2. Oral breathing devices do not work

8.4.3.2.3. Other forms of surgery are not right for you

8.4.3.2.4. Risks

8.4.3.3. Tracheostomy

8.4.3.3.1. You have severe sleep apnea

8.4.3.3.2. Other treatments have failed

8.4.3.3.3. Other surgeries are not right for you

8.4.3.3.4. Risks

8.5. Devices used to keep the tongue and soft palate open/out of the way

8.5.1. Mainly aim for ensuring an unobstructed airway and provide better access for surgical procedures, especially in areas like the throat, mouth, or upper airways

8.5.1.1. May vary depends on patients' anatomy; surgery types and individual clinical requirements

8.5.1.1.1. Tongue Retractors

8.5.1.1.2. Palate Retractors

8.5.1.1.3. Mouth Gags

8.5.1.1.4. Airway Devices

8.5.1.1.5. Customizable Bite Blocks

8.5.1.1.6. Endotracheal Tubes (ETT)

8.5.1.1.7. Tongue Stabilizing Devices (TSDs)

8.5.2. https://www.ncbi.nlm.nih.gov/books/NBK513220/ https://www.ncbi.nlm.nih.gov/books/NBK470198/ https://my.clevelandclinic.org/health/treatments/23502-palate-expander

8.6. Medtronic device https://www.medtronic.com/it-it/operatori-sanitari/products/ear-nose-throat/sleep-disordered-breathing/pillar-procedure-system-snoring-sleep-apnea.html

8.6.1. Pillar procedure performed in a single short office visit or combined with other procedures. Said to be a minimally invasive treatment that helsp with snoring and sleep apnea. People usually return to their day to day activities after having this done.

8.6.1.1. https://lasinusandsnoring.com/pillar-alternatives/#:~:text=As%20of%20right%20now%2C%20the,less%20discomfort%20and%20less%20downtime .

8.6.1.1.1. Not availalbe in the US anymore because the inserts are not being manufactured

8.6.2. 3 small polyester implants are inserted into the soft palate and as time passes, with the natural body's response, the implants add structural support to and stiffen the soft palate. This reduces tissue vibration that causes snoring and the palate tissue collapse and helps with sleep apnea

8.6.2.1. Why the soft palate: vibration or collapse of this area contributes to snoring and OSA. According to studies, the soft palate is thought to be involved in more than 80% of OSA and sleep apnea patients

8.6.3. How it works: takes 20 minutes and needs local anesthetic. 3 impalnts are placed at the jucntion of the hard and soft palate. Distance between the implants can be more than 2 mm from each other

8.6.3.1. Basically acts as an extension of the hard palate to reduce its tendency to vibrate which can obstruct the airway

8.6.4. Implant material: multiple polyester fibers woven together and two ultrasonic welds melt the fibers together and prevents the material from unraveling itself.

8.6.4.1. length is 18 mm and diameter is 2 mm

8.6.4.2. takes advantage of the body's natural response by having there be a fibrous capsule form around the implants (body's response to a foreign object). This causes the tissue to be stiffer than the tissue before the implant

8.6.4.3. Placed really closely together to maximize stiffness

8.6.5. Possible complications https://www.sciencedirect.com/science/article/pii/S0196070919305976

8.6.5.1. 261 cases were reported to have complications with the procedure

8.6.5.1.1. 73.6% - extruding parts

8.6.5.1.2. 47.5% - pain

8.6.5.1.3. 38.7% - foreign body sensation

8.6.5.1.4. 7.7% - infection

8.6.5.1.5. the ones who reported feeling pain and having difficulty swallowing were significantly more likely to also report having an extruding part

8.6.5.2. Implant system has been used to treat more than 45.00 patines with OSA and snoring since 2004

8.6.5.3. If the implant has a partial or full extrusion, it should be entirely removed and not reinserted into the same site

8.6.5.3.1. Possible solution but no guarantee that a complication won't occur, this could discourage some from getting it

8.6.5.4. If they reported difficulty swallowing, the surgical site is checked to see if something wrong was with the implant

8.6.5.4.1. If it wasn't, then it was only a temporary symptom

8.6.5.5. One study found that pain was described as having no more than a mild throat infection

8.6.5.6. Important to note that there were limitations on the database used as it used self reported cases, so these percentages can increase

8.7. Help Stop Snoring and Sleep Apnea with the Pillar Procedure - Pillar Procedure What Exactly Is Pillar? - Pillar Procedure Pillar Procedure - Sleep Doctor (sleep-doctor.com) Palatal implants: a new approach for the treatment of obstructive sleep apnea - PubMed (nih.gov)

8.7.1. Pillar Procedure

8.7.1.1. Insertion of small polyester rods, called “pillars,” into the soft palate at the back of the throat.

8.7.1.2. Stiffen tissue of the soft palate to reduce vibration and prevents collapse

8.7.1.3. Takes 20 minutes and usually done with local anesthetic

8.7.1.4. On the day of the procedure, the patient is given a local anesthetic to numb the area at the back of the throat. A small flexible scope may also be inserted through the nose to help guide the placement of the Pillar implants.

8.7.1.5. The procedure takes approximately 20-30 minutes to complete, and patients can usually go home shortly after the procedure. The patient may experience mild discomfort or a sore throat for a few days, but this can usually be managed with over-the-counter pain relievers.

8.7.1.5.1. 1.

8.7.1.6. Need specially trained doctor

8.7.1.7. Fifty-three patients were evaluated; the apnea hypopnea index (AHI) decreased from 25.0 +/- 13.9 to 22.0 +/- 14.8 events/hour (P = 0.05).

8.7.1.8. Not meaningful difference for patients

8.7.1.9. Risks

8.7.1.9.1. Sore throat

8.7.1.9.2. Low risk of infection

8.7.1.9.3. Implant displacement

8.7.1.9.4. Palate Perforation

8.8. https://www.bmc.org/otolaryngology/treatments/nose/treatment-options-adults-snoring Treatment Options for Adults with Snoring - ENT Health Usefulness of snoreplasty in the treatment of simple snoring and mild obstructive sleep apnea/hypopnea syndrome - Preliminary report - PubMed (nih.gov)

8.8.1. Injection Snore Plasty

8.8.1.1. The upper palate is numbed with anesthesia and a hardening agent is injected just under the skin on the top of the mouth in front of the uvula, creating a small blister.

8.8.1.2. Following injection, an inflammatory reaction is created in the tissues of the patient’s soft palate. During healing, fibrosis of the injected region occurs in which stiffening fibers of collagen are laid down within the palate. This fibrosis process stiffens the soft palate and in turn reduces snoring.

8.8.1.3. Treatment should be repeated

8.8.1.4. The most commonly used agent is sodium tetradecyl sulfate, which has also been used to treat varicose veins.

8.8.1.5. Injected Snore Plasty is an effective procedure, especially in patients manifesting persistent snoring.

9. Comparison between current solutions

10. https://www.ccjm.org/content/90/12/755 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9135849/ https://www.ncoa.org/adviser/oxygen-machines/alternative-cpap-treatments/

11. Inspire device

11.1. inspire therapy for sleep apnea is a mask freee solution for OSA.

11.1.1. componets of Inspire therapy

11.1.1.1. inspire implant: keeps airway open while sleeping

11.1.1.2. inspire remote: turns on party when ready

11.1.1.2.1. mechanism of inspire device

11.1.1.2.2. gentle pulses to the airway when patient is sleeping keeping it open at all times.

11.1.1.2.3. 1. 90-mins out paitient procedure

11.1.1.3. inspire app: tracks the sleep goals and share data with physician

11.2. drawbacks of the inspire devices

11.2.1. damage to the blood vessels near the device

11.2.2. tongue abrasion, mouth dryness,and discomfort stemming from nerve stimulator

11.2.3. discomfort near the impanted area

11.2.4. surgical device implantation therefore risks of temprory tongue weakness and can cause tongue paralysis.

11.2.5. undesirable changes in voice and swallowing function.

11.2.6. device may diplace from original position

12. Background on Snoring

12.1. https://my.clevelandclinic.org/health/diseases/15580-snoring

12.1.1. Rattling/snorting/grumbling sound in sleep.

12.1.1.1. vibrations, whistling, grumbling, snorting, rumbling

12.1.2. Snoring isnt inherently bad, but if it is too loud or disrupting sleep at all you need to take action.

12.1.2.1. Snoring also doesnt mean sleepo apnea, can have snoring without apnea events

12.1.3. Other symptoms

12.1.3.1. tossing and turning, dry or sore throat, tiredness/fatigue, headaches, irritability, focus decline

12.1.3.1.1. Can lead to increase HA and stroke if really bad

12.1.4. Causes

12.1.4.1. Blockage of airway in nose, mouth, or throat

12.1.4.1.1. Soft palate, tonsils, adenoids, tongue

12.1.4.2. Blockage leads to vibrations which makes the rumbling sound which is snoring

12.1.5. Factors

12.1.5.1. Age

12.1.5.1.1. More common in older age people, muscle tone decreases leading to more blockages and vibration

12.1.5.2. Alchol and other substances

12.1.5.2.1. Can relax muscles around airways leading to blockages and more vibrations

12.1.5.3. Anatomy

12.1.5.3.1. Enlarged adenoids

12.1.5.3.2. Big tonsils

12.1.5.3.3. Large tongue

12.1.5.3.4. Deviated septum

12.1.5.4. Sex/Gender

12.1.5.4.1. More likely in males

12.1.5.5. Genetics

12.1.5.5.1. Can run in the family

12.1.5.6. Health

12.1.5.6.1. Allergies, nasal congestion, common cold, pregnancy

12.1.5.7. Weight

12.1.5.7.1. BMI > 25

12.1.6. Diagnosis

12.1.6.1. Physical exam on the throat, mouth, and nose

12.1.6.1.1. Need: Doctors need a better method to visualize patient issues to determine which treatments are applicable and which treatment method is best for each person

12.1.6.2. Asking partners questions on sleep

12.1.6.3. Sleep studies

12.1.6.3.1. Need: Patients and doctors need a way to improve the speed at which sleep apnea and snoring diagnosis takes place

12.1.7. Treatments

12.1.7.1. Surgical

12.1.7.1.1. Remove/shrink excess tissue for vibrations or correct structural issues

12.1.7.1.2. Laser-assisted uvulopalatoplasty (LAUP)

12.1.7.1.3. Ablation (Radio frequency) Therapy

12.1.7.1.4. Septoplasty

12.1.7.1.5. Tonsillectomy

12.1.7.1.6. Adenoidectomy

12.1.7.2. Nonsurgical

12.1.7.2.1. Lifestyle

12.1.7.2.2. Medication

12.1.7.2.3. Nasal Strips

12.1.7.2.4. Oral Appliances

12.2. https://www.merckmanuals.com/professional/neurologic-disorders/sleep-and-wakefulness-disorders/snoring

12.2.1. Raspy noise from the nasopharynx, prevelance varies depending on the night

12.2.2. Ranges in sound level, more distressing to others than the individual person

12.2.3. 30% in men and 10% in women

12.2.4. Pathophysiology

12.2.4.1. soft tissue flutters, especially in the soft palate. velocity and direction of the airflow matters in snopring. Also differences in mass, stiffness and attachments of the structures.

12.2.4.2. Muscular relaxation plays a key role in fluttering, this is the only thing that can change.

12.2.4.3. Pharyngeal dialtors cannot keep the airway open when negative intraluminal pressure.

12.2.4.4. Structural factors

12.2.4.4.1. Micrognathia / retrognathia

12.2.4.4.2. Nasal septal deviation

12.2.4.4.3. Rhinitis tissue swelling

12.2.4.4.4. Obesity

12.2.4.4.5. Macroglossia

12.2.4.4.6. Enlarged Soft palate

12.2.4.4.7. Enlarged lateral pharyngeal walls

12.2.5. Primary snoring

12.2.5.1. snoring that does not have arousals in it. No oxygen level decreases, arrhythmias in sleep, and limits in airflow. Arousals - transitions to lighter sleep and or awakenings that last more that 15 seconds. They are not noticed usually.

12.2.5.2. Goal to identify snorers who might develop OSA

12.2.6. Physical Examination

12.2.6.1. Height+weight = BMI

12.2.6.2. Nasal polyps, engorged turbinates, arched palate, narrow palate, enlarged tongue tonsils soft palate lateral pharyngeal walls potror uvula, or small/wrongly displaceed mandible

12.2.6.3. Mallampati scoring (3-4 means increased OSA risk)

12.2.6.3.1. Scoring Diagram

12.2.6.4. OSA from snoring : Apnea/choking, headaches, BMI over 35, very loud snoring, hypertension

12.2.6.4.1. Epworth sleepiness score greater than 10.

12.2.7. Treatment

12.2.7.1. General

12.2.7.1.1. No alc or sedatives , head elevation, lose weight, treat nasal congestion

12.2.7.2. Appliances

12.2.7.2.1. MADs, TRDs, CPAP

12.2.7.3. Surgery

12.2.7.3.1. Fix nasal polyps, hypertrophied tonsils, deviated septum

12.2.7.3.2. Uvulopalatopharyngoplasty

12.2.7.3.3. Laser-assisted uvuloplasty

12.2.7.3.4. injection snoreplasty

12.2.7.3.5. radiofrequency ablation

12.2.7.3.6. palatal implants

12.3. Video on snoring: https://www.youtube.com/watch?v=dsPOA_Lfv0U&t=1s&ab_channel=EricJ.Kezirian%2CMD%2CMPH