Tuesday, February 28, 2006

Somnoplasty for sleep apnea?

I am a [age omitted to protect identity] year old woman with sleep apnea. The following conditions were noted in the medical diagnosis: slightly elongated uvula,
deviated septum. [I] was given the CPAP which I have used for the
past 6 years. It is a nuisance, but it DID give restorative sleep for
about 4 of those years.

CPAP = continuous positive airway pressure, the treatment of choice for obstructive sleep apnea. Why is it the treatment of choice? Because (1) it works 100% of the time, and (2) as a nonsurgical treatment, it carries 0% surgical risk. (Funny how that works!)

The main problem with CPAP is compliance. About 50% of the folks who try CPAP ultimately fail to adapt to it. It is a rather unnatural, cumbersome device. Nevertheless, if you were able to use it for four years, that tells me you are in the 50% who can tolerate CPAP.

I lost about 12% of my overweight (52 lbs.) and the CPAP doc agreed that the dental device alone might do the trick. It worked OK for a while and then I had to return to the CPAP. In
the past 2 years I've experienced episodes of waking with a rapid heavy heart beat.

Are you talking about the device that thrusts your lower jaw forward? If this helped, it suggests your obstruction is at the level of the tongue base rather than the soft palate. Some folks are performing radiofrequency ablation of the tongue base, but you might have a hard time finding someone who is familiar with that procedure. A conventional somnoplasty involves radiofrequency ablation of the soft palate, not the tongue base.

I'm wondering about your math, by the way. If 52 lbs = 12% of your "overweight", this suggests you're over 400 pounds overweight.

An ENT can determine where you are obstructing with a reasonable degree of certainty by examining your airway with a flexible fiberoptic scope. This will help the ENT figure out what sorts of surgical procedures are helpful.

I have PAT, controlled well by medication. I also have abundant torae
in lower jaw . . . and one fair-sized one growing toward the back of the
roof of mouth. I realize you would have to SEE the area to evaluate
the amount of narrowing, but do you think it might be helpful to
investigate the effect of a SOMNOPLASTY on encroaching sleep apnea?
Since my stomach will not retain pain meds (even pain shots cause
vomitting), I dread the thought of the knife-blade surgery and weeks of
pain, etc., etc.

As I indicated above, an appropriate physical exam (including a fiberoptic airway exam) is essential to answering this question. Also critical are the numbers on your sleep study. If your obstructive sleep apnea is mild, somnoplasty might be an option. If your OSA is moderate to severe, somnoplasty is simply not aggressive enough to solve anything.

Would appreciate your description of somnoplasty, and your comments on
whether I should pursue that procedure.

I can describe somnoplasty for you, but I can't give you any advice as to whether you should pursue it. That's for you to discuss with your doctor.

"Somnoplasty" is a proprietary term, but it has come to refer to all radiofrequency soft palate ablation techniques. The doctor anesthetizes your soft palate with multiple local anesthetic injections. Next, he uses an insulated electrode to heat (with electrical current) the muscle of the soft palate and uvula in several different sites. Over time, the heated area scars down, shortening and stiffening the soft palate and uvula. To some degree, this decreases the volume of the tissue, too.

It's a good treatment for snoring, not so hot for OSA. It's well tolerated compared to the older technique, LAUP (laser-assisted uvulopalatoplasty), which is legendary in terms of post-procedure pain. Pain after a somnoplasty usually does not require narcotic pain medications -- Motrin usually suffices. Some of my patients need narcotics, however.

Multiple procedures are necessary. With the equipment I use, most folks require 3 or 4 separate treatments, spaced out about 4 to 6 weeks apart. Some of my patients have needed 6 or more treatments. It's less aggressive than a LAUP, and therefore less painful, but the tradeoff is, you need more separate procedures.

Risks include, but are not limited to, ulceration of the soft palate, swelling of the uvula or soft palate, more pain than you were bargaining for, and failure of the procedure to fix the problem. Your doctor would fill you in on all the other risks, too.

I hope this helps you discuss your options with your doctor.


Saturday, February 25, 2006

Get those butterflies back in your stomach, Susan!

Susan writes:

A couple of weeks I started getting something I call "ear flutters." It happens only in the late evening (every night now) except for one afternoon episode. My head/ears feel full, and a sound/sensation starts in my right ear. I can describe it as a rapid irregular beat with a tiny mallet, or a very muffled putt-putt from an old outboard motor.

Onset coincided with increased stress and a slight worsening of tinnitus. I'm guessing either my arteries are involved or a space alien has invaded my eardrum.

This is most likely myoclonus. Myoclonus, by the way, is a two bit medical word meaning "muscle twitch." You have two eensy weensy muscles in your middle ear, the tensor tympani, and the stapedius. Either can develop a twitch. Because of where they are located and what they are attached to, a twitch in either of these muscles produces a fluttering sound, and sometimes also a fluttering sensation.

According to this website, middle ear myoclonus can be a symptom of TMJ, multiple sclerosis, intracranial neoplasm, or cerebrovascular disease. That's news to me. In my experience, middle ear myoclonus tends to be idiopathic (no apparent explanation) and goes away with time and/or conservative treatment (muscle relaxants, for example).

Middle ear myoclonus must be distinguished from vascular tinnitus. Vascular tinnitus is a rhythmic sound which follows the pulse. This is a whole different ballgame, and requires a considerably different diagnostic approach.

Here's an interesting online discussion of middle ear myoclonus. One of the participants insists that cutting the muscle is the only cure. Again, relying upon my experience, surgery is rarely necessary (I have never had to refer anyone for this operation). If I ever met a patient with such persistent, intractable myoclonus, I suppose I would go ahead with the appropriate scans to rule out MS or tumor.

By the way, I agree with what Jambo and JoeM say in their first few posts regarding ENTs: unfortunately, there are a few ENTs who don't know about this condition.

Mind you, I haven't read all of their discussion, so I don't vouch for what they have to say. It will give you the opportunity to hear others' experiences, though.

Needless to say, you should find an ENT familiar with this condition and pursue it with him/her.


Saturday, February 11, 2006

Weekend Open Thread

Cough it up or blow it out. It's time for more questions.


Monday, February 06, 2006

Because I can never write enough about ear wax.

Q: One of my ears creates a lot of hard crumbly ear wax, and eventually I go deaf and have it suctioned out. (My doctor doesn't recommend syringing or peroxide treatments.)

Smart doctor. It is difficult, if not impossible, to irrigate away this type of wax.

I also occasionally get excruciating itching in that ear, which my doctor treats with GlaxoSmithKline Otomize.

I'm not familiar with that product. For itchy ears, I use a variety of steroid creams (see Itchy and Scratchy, below). Very important to rely upon cream, rather than scratching the itch, since scratching makes it itchier.

When I remember I drop olive oil (virgin of course - only the best!) into my ear to soften the wax. I note you suggest baby oil - would that be better?

I tell my patients: anything but motor oil. Vegetable oil and baby oil are equally acceptable.

But why does it happen - could there be some medical or parasitical cause that my doctor hasn't picked up? Or am I just getting old?

Sometimes I discover an explanation for a change in ear wax, such as ear surgery or radiation to the ear. Far more commonly, such changes remain a mystery. If it makes you feel any better, we see this sort of wax in all age groups, so it has nothing to do with age.