Interaction among sleep-medicine physicians, cardiologists, and pulmonologists working in a truly multidisciplinary venue is needed to adequately assess patients with OSA
Is team assessment of obstructive sleep apnea (OSA) patients a foreign concept, to be viewed with suspicion? To answer this question, it is necessary to look at recent developments in the field. The past several years have seen the development of a plethora of newly devised or modified procedures, both surgical and nonsurgical, for treating upper-airway obstructive pathology. Most, if not all, of these developments have been specialty based.
Modifications to already existing nonsurgical procedures have produced changes in traditional sleep-medicine therapy: continuous positive airway pressure and bi-level positive airway pressure are now more commonly used, as are a newly available variety of patient interfaces. From the dental perspective, changes in the design and construction of oral appliances (patient-adjustable, custom-made oral appliances), and oral positive airway pressure, have made oral appliances appealing in the treatment of many more patients.
Despite the allure of these nonsurgical therapies, tolerance for (and long-term compliance with) the use of these devices can be less than optimal for many patients. The reason that patients and treating sleep physicians may desire surgical therapy then becomes apparent.
Hyoid advancement and suspension procedures; genioglossus skeletal advancement; tongue-base suspension sutures; radio-
frequency volumetric tissue reduction of the inferior nasal turbinates, tongue base, and (most recently) tonsils; harmonic (ultrasound) scalpel procedures; and soft-tissue channeling for the debulking of the inferior nasal turbinates have all been directed at tongue-base, tonsil, nasal, and hypopharyngeal obstructions. The cautery-assisted palatal stiffening operation, the uvulopalatal flap, Woodsons procedure, traditional uvulopalatopharyngoplasty, and heat-based tissue reduction for the soft palate have all been used for relieving soft-palate elongation and vibration (snoring) or treating retropalatal obstruction.
Against this backdrop exist the more major surgical procedures of jaw advancement and tracheostomy. Jaw-advancement (telegnathic) surgery, while more invasive than other procedures, is often considered most beneficial in terms of affecting volumetric expansion of the upper airway (at multiple levels) in one surgical procedure. Tracheostomy is still the surgical gold standard for relieving severe forms of OSA and bypassing severe upper-airway obstruction.
Many of the foregoing procedures are currently being offered to patients in the absence of concrete, validated long-term studies (and with their respective specialty biases being the paramount reason for their choice over other options). At least in the case of the newer radio-frequency devices, however, these technologies attract patients with the promise of treating a very difficult upper-airway anatomic problem in a minimally invasive (and, potentially, less risky) fashion than major surgery might.
When these newer treatments should be used is still the subject of much debate, as no meaningful long-term, randomized, prospective studies have yet been performed; for ethical reasons, it is possible that such studies will never be performed. Just as important is the fact that where these newer technologies fit into existing surgical algorithms is yet to be ascertained. While research and new technologies offer much, it is still up to the individual physician to decipher a considerable amount of diagnostic information in order to suggest the proper course(s) of therapy to an individual patient.
Unfortunately, three questions are too infrequently asked.
- Given the number of options and procedures, how is a patient to decide what form of treatment to pursue?
- Based on that patients stated desires and lifestyle, does the preferred form of treatment fit the individuals unique pattern of upper-airway and tongue-base obstruction?
- How far does the patient have to travel in order to find answers to these questions?
The difficulty comes, of course, when the patient first presents for evaluation by the particular specialist being seen (who often gives a recommendation vastly different from that offered by another type of specialist). Obviously, all physicians are influenced by their educations and professional affiliations; it must also be acknowledged that sleep medicine/therapeutics is a relatively young and multidisciplinary field. Most important, physicians are influenced by their own specific training and experience. These, unfortunately, are often too narrow in scope, falling entirely within the physicians own field. As a result, patients entering the first phase of OSA therapy may leave treatment after a single intervention, without achieving adequate therapy for their sleep-related breathing disorders or without adequate compliance with treatment. Honest clinicians must consider the result, in these cases, to be treatment failure.
While the multitude of providers and procedures often creates confusion for the patient, however, the multidisciplinary nature of this field is actually its greatest strength. In what other field of medicine does one see such a gathering of vastly different specialties, each with an important contribution to make? As long as clinicians do not allow their own choices to be overtly swayed by specialty or financial biases, and as long as they keep open minds toward other ways of thinking, patients ultimately benefit.
What is badly needed now is a method whereby a patient can easily access multiple types of specialty providers easily, in a truly multidisciplinary venue, without the burden of individual specialty bias. Interaction among the sleep-medicine physicians, cardiologists, pulmonologists, bariatricians, otolaryngologists, dentists/orthodontists, and oral and maxillofacial surgeons (in a team format) is what is needed. This is, unfortunately, not often achieved. It is time to learn to ignore individual specialty and economic self-interests and to learn to view OSA patients in the team arena. Truly, no one specialty has a corner on the OSA patient, and the sooner clinicians learn this, the sooner patients will benefit.
Kent E. Moore, MD, DDS, is chair, Steering Committee, American Association of Oral & Maxillofacial SurgeonsClinical Interest Group on Sleep-Related Breathing Disorders and Obstructive Sleep Apnea.