The Division of Sleep Surgery in the Department of Otolaryngology—Head and Neck Surgery specializes in the evaluation and surgical treatment of patients with snoring and obstructive sleep apnea. We are committed to providing outstanding, comprehensive, and state of the art patient care while advancing the field of snoring and sleep apnea surgery through innovation and research. Management of these patients requires our close collaboration with colleagues in the field of sleep medicine (at UCSF, throughout the region, and across the country), and patients should expect to receive the highest-quality care from a team of providers that tailors a treatment plan to them.

Individuals with disruptive snoring or other signs and/or symptoms of sleep disordered breathing should have a formal sleep study. This evaluation is performed either in a sleep laboratory or at home, and it typically includes assessment of breathing patterns, oxygen levels in the bloodstream, heart rhythms, leg movements, and body position during sleep. In-laboratory sleep studies (called polysomnograms) generally include additional monitoring of brain wave activity and eye movements that can determine whether an individual is sleeping and the types of sleep they experience during the night. A sleep study serves multiple purposes, including assisting in establishing a sleep disorder diagnosis (snoring and obstructive sleep apnea as well as others) and directing appropriate treatment.

Obstructive sleep apnea is characterized by repeated blockage or narrowing of the breathing passages of the nose and throat during sleep. Many patients respond to this blockage in airflow and drops in oxygen levels in the bloodstream by repeatedly waking themselves up to open up the breathing passages. As a result, there are three potential reasons to treat obstructive sleep apnea:

• Health impacts. In waking themselves up, patients generate a response akin to an adrenaline rush and have drops in their oxygen levels. These physical stresses have important negative cardiovascular, pulmonary, and metabolic health effects. Obstructive sleep apnea is strongly associated with the risks of developing hypertension, stroke, heart attack, and early death, although the risks are greatest in those with more severe disease.
• Poor sleep quality and fatigue. Sleep disruption can produce daytime sleepiness or fatigue, problems with higher-level brain functions like memory, and a decrease in quality of life. The blockage of airflow and decreases in oxygen levels tends to be more pronounced in the deeper, more restful stages of sleep. By waking themselves into lighter stages of sleep, patients may continue to sleep through the night but not experience refreshing sleep. Interestingly, the degree of sleepiness or other symptoms are not associated with the severity of obstructive sleep apnea. Individuals with only mild obstructive sleep apnea can experience significant problems in this area, and vice versa.
• 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, we understand its importance to patients and bed partners.

Snoring without obstructive sleep apnea is generally considered a social problem because the major reason for treatment is the snoring sound itself. Although there is some evidence that snoring may have some of the health risks or symptoms (such as fatigue) associated with it, these are not as clearly documented as for obstructive sleep apnea.

Conservative treatments for snoring and obstructive sleep apnea include weight loss, avoiding sleeping on one’s back (instead sleeping on one’s side or stomach), and avoidance of alcohol or other sedating medications. Weight loss can be very helpful, especially in men, and the benefits depend on the amount of weight loss. One large study estimated that a 10% weight loss was associated with a 25% reduction in the severity of obstructive sleep apnea, and a 10% weight gain led to a 30% increase in the severity. The effect of sleep position varies widely between patients. A bed partner may be able to provide the best sense of whether changes in sleep position affect snoring, but breathing patterns (for patients with obstructive sleep apnea) may only be evaluated by looking at the results from a sleep study (because patients often will shift their sleep positions during the night, with the ability to examine breathing patterns in various positions). Finally, alcohol and other sedating medications produce muscle relaxation during sleep and contribute to collapse of structures surrounding the throat, worsening breathing patterns during sleep.

Non-surgical treatment of obstructive sleep apnea typically is based on positive airway pressure (such as continuous positive airway pressure, or CPAP, or bilevel positive airway pressure, or BiPAP). Positive airway pressure therapy works by splinting open the throat, and it can relieve airway blockage well when set at an appropriate pressure. It is recognized as the first-line treatment for obstructive sleep apnea because it works in the ideal situation where patients can wear it and sleep comfortably through the night every night. However, many patients do not tolerate it well, and it is important that medical and surgical providers work with these patients in attempts to improve compliance when possible.

Surgical treatment of snoring and obstructive sleep apnea is based on a number of factors, but ultimately the treatment is directed at the areas that are responsible for narrowing or complete obstruction of the airway. Surgical procedures aim to enlarge and stabilize the airway to eliminate the narrowing or collapse. There are three major areas at which airway blockage can occur: the nose, palate, and tongue regions. In an individual patient, often more than one of these areas is responsible and can be approached during the same or different procedures. Our philosophy is to address all areas of airway obstruction to achieve the best outcomes, and our research (hyperlink) in patient evaluation suggests that this is critical in the selection of procedures and improvement in surgical outcomes. Although surgery may not (but may) achieve as much improvement in breathing patterns for patients with obstructive sleep apnea, one advantage is that there is no issue of compliance or wearing of a device. For more information, please see Surgical Treatment.

Oral appliances represent an alternative non-surgical therapy for certain patients with snoring or obstructive sleep apnea. The Divisions work closely with dentists who have expertise and experience in sleep dentistry to identify patients who might benefit most from these devices and to develop effective treatment plans.