Sleep apnea is a common yet serious sleep disorder that affects millions of people worldwide. Characterized by repeated interruptions in breathing during sleep, it can lead to a host of health issues, including cardiovascular disease, daytime fatigue, and cognitive impairment. While Continuous Positive Airway Pressure (CPAP) therapy is the most prescribed treatment, many patients find it challenging to adhere to.

Fortunately, alternative treatments such as oral appliances, upper airway surgery, and hypoglossal nerve stimulation provide viable solutions for managing sleep apnea.

In the February 2025 issue of this newsletter, John Winkelman MD PhD, Chief of the Sleep Disorders Clinical Research Program at Massachusetts General Hospital described promising therapies that you may not be aware of. In this article, he will help you make sense of these options and how they could be viable options if you find CPAP therapy challenging. As always, consult with your primary care physician when considering alternatives to a CPAP device that has been prescribed for you.

The Basics of Sleep Apnea

Sleep apnea is classified into three primary types:
  • Obstructive Sleep Apnea (OSA): The most common form, caused by the relaxation of throat muscles that block the airway.
  • Central Sleep Apnea (CSA): A less common type where the brain fails to send proper signals to the muscles controlling breathing.
  • Complex Sleep Apnea Syndrome: A combination of both OSA and CSA.

OSA is the primary focus of alternative treatments described in this article.

For many individuals, the OSA form of sleep apnea is noticed only when sleeping on their back. Use of a mechanical device to avoid sleeping in this position can prevent OSA in such individuals. However, if this simple solution is not productive, and if CPAP is not working for you, you have other options.

Oral Appliances: A Convenient Alternative to CPAP

Oral appliances are custom-fitted devices worn in the mouth during sleep to help you maintain an open airway. They work by repositioning your lower jaw and tongue to prevent the collapse of soft tissues in your throat.

Oral appliances come in two types:

  • Mandibular Advancement Devices (MADs): these are the most common type of oral appliances. They move the lower jaw forward, creating more space in the airway.
  • Tongue-Retaining Devices (TRDs): these devices hold the tongue in a forward position to prevent it from blocking the airway.

They have many advantages, including:

  • Portability: they are compact and easy to travel with.
  • Comfort: they are less intrusive than CPAP masks.
  • Improved compliance: many people find oral appliances easier to use consistently.
  • Reduced noise: unlike CPAP machines, oral appliances are silent.

They also have some limitations, including:

  • They may not be sufficient for severe cases of OSA.
  • Regular follow-up appointments with a dentist or sleep specialist are crucial to ensure proper fit and functionality.
  • Some patients may experience jaw discomfort, excessive salivation, or dry mouth.

According to Winkelman, "Oral appliances are most effective for those with mild to moderate OSA and for those with an overbite. Insurance may not cover oral appliances and thus out of pocket expense can be substantial."

Upper Airway Surgery: A Structural Solution

If you cannot tolerate CPAP or oral appliances, surgical interventions may provide a permanent solution. Upper airway surgery involves modifying the structures of your throat and mouth to prevent airway obstruction. Recovery times vary depending on the type and extent of surgery and can range from a few days to several weeks.

Types of upper airway surgery:

  • Tonsillectomy: for those with enlarged tonsils (especially in children).
  • Uvulopalatopharyngoplasty (UPPP): the most common surgical procedure for OSA, UPPP removes excess tissue from the throat, including the uvula and parts of the soft palate.
  • Genioglossus Advancement (GA): this procedure repositions the tongue muscle attachment to prevent it from falling back into the airway.
  • Maxillomandibular Advancement (MMA): a more extensive surgery that moves the upper and lower jaws forward, enlarging the airway.
  • Radiofrequency Ablation (RFA): a minimally invasive technique that uses heat to shrink tissues in the airway.
  • Pillar Procedure: small implants are inserted into the soft palate to stiffen it and reduce airway collapse.

Benefits of surgery:

  • Long-term results: surgical solutions can offer permanent relief for some patients.
  • Improved quality of life: many patients experience significant improvements in sleep and daytime functioning post-surgery.

"ENT evaluation is necessary to assess the likelihood of success with these surgeries. These surgeries can be very effective, but the more extensive ones require substantial recovery times," Winkelman noted as limitations.

Hypoglossal Nerve Stimulation: A High-Tech Approach

Hypoglossal nerve stimulation (HNS) is an innovative treatment for moderate to severe OSA. It involves implanting a device that stimulates the hypoglossal nerve, which then protrudes the tongue in coordination with breathing, to keep the airway open during sleep. HNS is primarily recommended for patients with moderate to severe OSA who have not found success with CPAP therapy or do not have significant anatomical abnormalities that could obstruct the airway.

How HNS works:

  • Implantation: a small device is surgically implanted in the chest, with a lead attached to the hypoglossal nerve and another sensor placed near the diaphragm to coordinate tongue protrusion with breathing.
  • Activation: the device is activated at bedtime using a remote control. It delivers mild electrical stimulation to the hypoglossal nerve, causing the tongue to move forward and keep the airway open.
  • Customization: the stimulation levels can be adjusted to suit the patient's needs.

Benefits of HNS:

  • Improved compliance: high rates of patient satisfaction and adherence.
  • Minimally noticeable: the device operates quietly and is not visible during use.

Limitations of HNS:

  • Two different anesthesia episodes are required: the first for evaluation and the second for the surgery.
  • Tongue protrusion during the night can disrupt sleep.
  • HNS surgery is less likely to be of benefit for OSA in those who are more than mildly obese.

This is a new surgical approach, Winkelman noted.

Choosing the Right Treatment

The choice of treatment for OSA depends on several factors, including the severity of the condition, your preferences, and your overall health. A multidisciplinary approach involving sleep specialists, dentists, and surgeons is often necessary to determine the best course of action.

OSA is a multifaceted condition that requires individualized treatment. While CPAP remains the gold standard, alternative therapies like those mentioned in this article offer effective solutions if you cannot tolerate CPAP. By working closely with your healthcare providers, you can find a treatment plan that restores restful sleep and improves your overall health.

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