Dr. Jeffrey Adams joined hosts Shannon O’Kelley, Physical Therapist and President of Integrated Rehabilitation Group, and Maury Eskenazi, radio personality from Fox Sports radio on Health Matters radio, KRKO 1380am, with thanks to Integrated Rehabilitation Group physical and hand therapy. He talked about snoring and the Pillar procedure.
Read the transcript of Dr. Adams' talk on snoring on Health Matters radio or listen here
Health Matters: Welcome back to Integrated Rehabilitation Group Health Matters Maury Eskenazi and Shannon O'Kelley. Joining us is Dr. Jeffery Adams. He's an ear, nose, and throat specialist from The Everett Clinic. We are going to talk about snoring and Pillar Procedure. I have had issues with snoring. What causes snoring?
Dr. Adams: Snoring is caused by the collapse and the movements of the things in your mouth and throat while you are breathing and sleeping. There are a number of things in your mouth and throat; your tongue; your tonsils; the roof of your mouth; the uvula, which is the thing that hangs down in the back or your mouth; and while you are asleep these things relax and collapse, and as you try to pull air through all of those things it will rattle them around and make noise, and that's what you hear when you snore.
Health Matters: That's the, that's the thing in the back of your throat, the uvula?
Health Matters: And, you also mention the roof of your mouth, and my understanding is as we age, does that get a little looser and more apt to vibrate when you move air across it?
Dr. Adams: I think as we age it does that, and as we gain weight it probably does that as well, which tends to be something that happens.
Health Matters: Weight gain seems to be a cause of snoring. Why is that?
Dr. Adams: The tissues I think are simply thicker and more redundant as we gain weight. All of the things I mentioned thicken up and are closer together and are more prone to collapsing and making for a narrower airway.
Health Matters: So, when is snoring considered unhealthy?
Dr. Adams: Snoring itself probably isn't unhealthy, but snoring can be unhealthy in a couple of different ways. First, there is a social snoring, which is whoever is sleeping next to you can't sleep, so they go down the hall and sleep someplace else. That's not very healthy. Of course, if you are in a cabin, or a hotel room, or a tent and you are trying to sleep with family or friends, likewise, socially difficult. And then, there are the real health issues. Snoring is sometimes a marker of something called obstructive sleep apnea, which is a much more serious and concerning health problem.
Health Matters: Hang on, but let's dive into that a little bit because I think it's important that we talk about snoring versus sleep apnea or obstructive sleep apnea, as you called it. So, not everybody that snores has obstructive sleep apnea?
Dr. Adams: That's correct, yes. Probably one in two people snore at least sometimes, probably half of those, maybe one in four people in the country snore habitually, at least three or four times a week, maybe every night. Maybe one in three of those has sleep apnea, especially men more commonly than women, and sleep apnea is just the collapse of those tissues to the point where you are no longer breathing, at least not very well. If collapsing enough that the oxygen levels in your body drop, those oxygen levels drop enough that your body senses it needs more oxygen and has to wake itself up a little bit. Not so that you are totally awake, but wake up enough that you take a deep breath. At that point, the cycle repeats itself, and so all night long you are cycling between good sleep where you are not breathing well and not so good sleep where you take a breath.
Health Matters: Those are the folks that may need to get looked at to have the apnea mask?
Dr. Adams: Correct. That's the first treatment for sleep apnea is to put a device on that puts positive pressure airflow into your mouth and lungs so that it works against that collapse, it inflates your mouth and throat as opposed to collapsing it.
Health Matters: The diagnosis for this is a sleep study, right?
Dr. Adams: Right.
Health Matters: What goes on during a sleep study?
Dr. Adams: Sleep study is scheduled by a sleep physician. After they see you in the office and go through the history and physical portion of things, they schedule you to spend a night at the sleep lab. At a sleep lab you will be hooked up to a number of monitors that measure your heart rate and your respirations, and eye movements, and all sorts of different things that are markers of deep sleep, poor sleep, breathing while sleeping, and they watch you sleep all night and score you on those measures.
Health Matters: As an ENT, we are going to start talking about this Pillar Procedure. What is your role? Are you going to be able to correct some snoring and also prevent sleep apnea?
Dr. Adams: The Pillar Procedure is an excellent procedure, but it's certainly not the only procedure, or even probably the first procedure for sleep apnea. It's a great procedure for snoring and for mild sleep apnea, but for more severe forms of sleep apnea there are other treatments. Again, the CPAP device is probably the first medical one. There are dental devices that dentists and oral surgeons will fix people with, and then, where an ENT physician like myself would come in would be if surgery on the mouth or throat was indicated. Namely, taking tissue away, tonsils, the roof of the mouth, the uvula, creating more room for breathing.
Health Matters: You could tell that that tissue needed to be removed by a sleep test?
Dr. Adams: The sleep test scores the sleep apnea as far as the severity of how much sleep apnea there is, and, if that severity is enough, the patient will then be a candidate for a surgery, provided they've tried and failed that CPAP therapy.
Health Matters: How do you fail a CPAP therapy? The only reason I ask, I am one of the bazillion people in the world now that has a CPAP machine, and I have had it for a while. I didn't know that there was, that was treatment #1. I didn't know there was other steps, so, how do you know you're failing CPAP?
Dr. Adams: That's an excellent question, because some people see the CPAP machine, and never quite embrace it, and put it in their closest and never use it, and don't know that there is more to be done. But, failing CPAP is simply not being able to wear it or use it for a variety of reasons, either it's uncomfortable or it's hard to adjust the settings to get the air to go through your nose and mouth as well as it should. Or, you're claustrophobic. Or, I suppose you try to make it work in your own home, socially otherwise, and you simply cannot make it work. If, for whatever reason, the CPAP mask ends up not on your face and next to you or in the closet, like I said, then you failed CPAP.
Health Matters: Okay. You know how many people that have told me they have these machines and how difficult it is just to get, you know, tossing and turning, a good sleep in. So, if you are in that situation where you failed CPAP, what’s your next course of action.
Dr. Adams: If you failed CPAP, then it's probably time to see either an ear, nose, and throat surgeon, or an oral surgeon or dentist who treats sleep apnea. The dentist or oral surgeon, again, can fit you with an oral appliance that may help, and those are getting better and better. They are variably covered by insurance, but they are good devices. The surgeon, like myself, would take a slightly different approach and either consider an in-office procedure like a Pillar Procedure, or might schedule you for surgery, again to correct some of the anatomy in your mouth and throat.
Health Matters: So, correcting the anatomy is, you're trying to, open up some airway and possibly tighten up some tissue maybe?
Dr. Adams: Correct. The basic surgery, the most basic surgery for sleep apnea is called uvulopalatopharyngoplasty or U triple P, UP3.
Health Matters: That's really cool that he pronounced that like that too.
Health Matters: Remember, I said something about doctors being really smart - that was awesome. Health Matters: That's good, yeah. UP3, is that what you call it? Dr. Adams: Yes. Dr. Adams: And that involves trimming the backmost portion of the roof of your mouth, where the uvula is and the tissues adjacent to that, as well as the tonsils, if you still have tonsils. Then, sewing that area together in such a way to create more room. The removal of the tissue creates more room in and of itself, and then the subsequent scarring and toughening up of that surrounding area makes it more rigid and less likely to collapse.
Health Matters: Is this an in-office procedure or are you in the hospital for this?
Dr. Adams: The UPPP is done in the operating room, so for some people that is done as an outpatient procedure. It is still a general anesthetic, but you go home the same day, a couple hours later - an hour and a half to a couple hours later. For some, with the severity of sleep apnea being just too much and too unsafe for an outpatient setting, that would be done in the hospital and then be a one-night hospital stay.
Health Matters: What is the recovery time? I mean, what are these folks looking at postoperatively?
Dr. Adams: It's not much fun. It's about a week of a rip-roaring sore throat, probably the mother of all sore throats for about a week, for which you are given pain medication that can help you through it, but it's a rough week. The second week is kind of a half speed week, and then you are getting back to work and school, and whatever you are doing, but it is a rough sore throat for about a week.
Health Matters: Hmmm. Then, you have this Pillar Procedure that we hear about.
Dr. Adams: Sure, that's an excellent option if the primary issue is just snoring and there is not sleep apnea to contend with. Or, if the sleep apnea is in the mild, maybe moderate category. The procedure is simply trying to stiffen the back of the palate, as opposed to removing tissue. You put implants, polyester implants, into the roof of the mouth and that stiffens that area, kind of like a batten in a sail might. So, as air travels past the roof of your mouth it doesn't flutter and vibrate like to does now.
Health Matters: Again, that is for someone who is predominantly having the snoring issue and not really the sleep apnea, so you are just strengthening that palate?
Dr. Adams: Correct. It's primarily for snoring. That's what it was designed for and subsequent studies showed that, in fact, it stiffened the palate enough that it removed some of that collapse, and, so, for mild to moderate sleep apnea with favorable anatomy that procedure can be effective for sleep apnea as well.
Health Matters: Interesting. So, after this procedure, then, there would be no snoring at all anymore?
Dr. Adams: Most of the time it makes a dramatic improvement in snoring. What they call bed partner satisfaction, it ranks about 80% after the procedure. The snoring is gone or better to the point that whoever is sleeping next to you is pretty happy.
Health Matters: Got it. And, is this an office procedure or is this a surgical-type, admit to the hospital type situation?
Dr. Adams: The Pillar Procedure is done in the office under local anesthetic.
Health Matters: And the recovery time is a lot different than the UPP, what you just described?
Dr. Adams: Exactly.
Health Matters: Wow, interesting stuff. Snoring is an obstruction or a loosening of the tissue in your airway and you can correct it by tightening it up or removing, and the outcomes are pretty good for a lot of people?
Dr. Adams: Correct. Yeah, it's really nice to get rid of the snoring, and, of course, I think you need to be a little careful to evaluate the sleep apnea piece too because that's really the more unhealthy part of it. That's done by a sleep physician.
Health Matters: Most people that have sleep apnea say they never get restful sleep, or they never feel rested.
Dr. Adams: That's exactly right. It's a real problem for people, and it can be subtle or horrible, but they are, at the very least, sleepier than they want to be, and for some that's just not as alert at work. For others, it's falling asleep while they drive, all the time, in a real dangerous sort of way.
Health Matters: Is there anything that you've found through your practice that could help prevent this? Obviously, when we talk about weight gain it's probably a problem. Is there anything else that could help?
Dr. Adams: It's important, yes, to try to stay fit and as healthy as you can because weight gain is a big risk factor for this. It’s also important to see your physician and look for other more subtle signs of sleep apnea, such as high blood pressure and heart and lung problems that go with sleep apnea because if you can find it early, it's much easier to treat than if it's left to persist for years and the weight gain gets worse, you more tired, less active, gain more weight, then the sleep apnea gets worse and you're more tired, and less active, and gain more weight, and you can see how you can kind of spiral down from there.
Health Matters: Kind of a vicious cycle.
Health Matters: And, the weight gain is really not the gain that you're having like in your abdominal areas, the fat that being deposited underneath the roof of your mouth?
Dr. Adams: It's all over, really, and so even in your abdomen and your chest, and everywhere else. The heavier you are, the harder it is to breathe, but, yes, if the fat is deposited elsewhere, it's probably going to thicken up the tissues in your mouth and throat as well. One of the markers or signs that you might have sleep apnea in a man is the neck circumference over 17 inches. So, if your shirt is 17 or better and you are snoring and you're tired you should probably see someone about sleep apnea.
Health Matters: Dr. Jeffery Adams, ear, nose, and throat specialist from The Everett Clinic. Where are you, what Everett Clinic are you at?
Dr. Adams: I'm at the main campus, right off 41st and Rucker here in Everett.
Health Matters: Pretty interesting stuff. Thanks for coming on. That's great information.