There are many device types, and otolaryngologists and dentists should work together to determine which is best for a given patient, he said, but they generally work by moving the mandible forward during sleep to help prevent airway collapse. “You’ll become a believer in oral appliances if you actually look at what these things do,” Dr. Gillespie said.
Explore this issue:March 2016
An analysis of 11 randomized controlled trials comparing OA to continuous positive airway pressure (CPAP) found that CPAP, which has high rates of nonadherence, typically gets the better results in terms of AHI, but OA yields better results in patient preference and usage (J Clin Sleep Med. 2014;10:215-227). One study found that after uvulopalatopharyngoplasty (UPPP), AHI improved at first but then regressed after three years. In cases in which an OA was also used, however, that regression tended to be prevented (Ir J Med Sci. 2015;184:329-334).
“If you look at any sleep apnea treatment across the board, it seems about two-thirds of people have a good response: Two-thirds respond well to surgery; two-thirds respond well to CPAP; two-thirds respond well to oral appliance,” Dr. Gillespie said. “Therefore, I think a combination will allow you to get a higher response.”
Erica R. Thaler, MD, professor of otorhinolaryngology-head and neck surgery at the University of Pennsylvania in Philadelphia, said that transoral robotic base-of-tongue surgery (TORS) for OSA can produce good results above and beyond previous surgery. Her indications for TORS are an AHI score higher than 20, with no maximum; no body-mass index cut-off, but with BMI considered when assessing a patient’s candidacy; and evidence of hypopharyngeal obstruction that is contributing to OSA.
According to data from her center recently published in The Laryngoscope, patients who had received a prior UPPP had a pre-surgery AHI of 40.3 and an AHI of 29.8 after TORS. Dr. Thaler said TORS should be a consideration (Laryngoscope. 2016;126:266-269).
Hypoglossal nerve stimulation is another option beyond UPPP, she said. The first eight patients in whom she has implanted the device have had impressive results. She presented AHI scores on the day of the implant—one with the device off, the other with it on. One patient’s index fell from 60 to less than five. Another dropped from more than 80 to approximately 10. A third patient’s index decreased from more than 100 to less than five, and Dr. Thaler acknowledged that while such an AHI would have been too high for the implant, the patient’s AHI had previously been 68.