Hi Jake,
Current practicing sleep doc who will insert the following caveat to our discussion: like most things, it’s tough to tell over the internet what exactly is going on and what might be the best course of action. I think taking into consideration your local sleep provider’s input is wise, and educating yourself as you have will help you and your sleep doc come up with a plan (I’m always appreciative of the patient who invests the time to look at the clinical data and other options since I don’t always have time to). So BLUF, let’s talk about your situation, but make sure you consult your local doc regarding the plan. FYI this is long winded so prepare yourself, you’ve been warned.
You mention your concerns off the bat involve a conversation with an ENT about a deviated septum, which ultimately resulted in an unhelpful surgery. You briefly mentioned that you have fatigue, but I would want to know more about that and what prompted you to get checked out beyond your friend hearing you make weird sounds. Don’t get me wrong, witnessed apneas at night is an indication for getting a sleep study, but I would be willing to venture that most youngish, healthy (you mention your BF% but did not mention your BMI and neck circumference which would be helpful to me) males are likely to have other causes of fatigue or daytime sleepiness, like insufficient sleep. You also didn’t tell me how easy or difficult it is for you to fall asleep. Most patients who have problems due to OSA, and OSA alone can fall asleep on a whim, but have difficulty with maintaining sleep or waking feeling rested.
You got a sleep study and it said you had mild sleep apnea. Okay, I got it. A lot of people I see and treat have mild OSA. Something you may or may not have heard yet (that I think is really important from an expectation management perspective) is that mild OSA is just that, it’s mild. Yes, it could explain your symptoms, but I almost never rely purely on that as the cause of a patient’s excessive daytime sleepiness or fatigue. You’re healthy, so it’s unlikely for it to be something serious, but it’s worth talking it over with your sleep doc, or if s/he’s not interested in doing the work up, your primary care doctor (I’m a family medicine physician also) in evaluating for causes. Some common ones include: dysfunctional sleep due to inappropriate sleep hygiene, insufficient sleep, irregular sleep schedules, circadian misalignments, insomnia, depression, anxiety, endocrinopathies, substance abuse…the list goes on. If you haven’t gotten my drift, I wouldn’t hang my hat entirely on the OSA, just yet at least based on our very limited picture of your health in front of us.
That being said, let’s get back to what you were asking about. So is surgery a good idea? Or are oropharyngeal exercises (sometimes known as myofunctional therapy) a good idea? What about MADs? What about CPAP — what about a different mask, or setting, or machine? ALL really good questions, and why I’m interesting in typing so much here… Let’s break it down (keeping in mind this is mostly my thoughts based on current practice standards and guidelines and I won’t be sending you PUBMED links because I don’t really have the time to)
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Surgery – I appreciate that your ENT wasn’t selling his soul and saying that UPPP or the maxillomandibular advancement surgeries were their first line recommendations, because they ARE NOT first line. Yes, it’s not unreasonable to attempt to treat nasal obstruction as studies in general have supported fixing nasal obstruction for improvement of OSA (IF THAT’S THE ONLY FACTOR AT HAND). But another way to consider that is, for all my patient’s with nasal congestion, I ensure they have a solid regimen of a nasal saline and intranasal steroid daily to keep their nasopharynx as dry as possible to reduce obstruction. If you aren’t already doing that, it would be a reasonable idea to do so. It won’t fix a whopping deviated septum, but if you have airflow resistance it will certainly not hurt it. UPPP hasn’t been shown to be effective, and in fact has been harmful to patients with OSA. MMA is helpful, but ridiculously complex, and associated with high morbidity. Hence, not my or your surgeon’s first choice. No offense to any ENTs, I love you guys, especially for my pediatric OSA patients.
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Oropharyngeal exercises – Yeah this is interesting, thanks for teaching me something tonight. I looked it up, and read through a few studies including the one you posted. They are discussed briefly in the Sleep medicine Bible (Kryger if anyone’s interested) and there’s some really interesting stuff. Did you know that people who play the didgeridoo or orchestral players who play double reeded wind instruments have a lower risk of OSA? The gist here is, there is thought that doing specific speech related exercises can train your palate muscles to a point that it’s less likely to obstruct when you’re asleep (the basic problem of OSA). That being said, a few caveats I noticed off the bat: when adjusted for BMI, the difference or reduction was marginal (aka bigger necks equal bigger risks of OSA). The other thing was the exercises are highly specialized and at the current moment not something that every speech therapist or sleep physician would have a clue how to train you on. Most of the studies, both observational and randomized controlled had patient’s who had mild to moderate OSA (aka someone with a picture similar to you) which is one upside. I’m not saying that this isn’t a future option, but I would expect this to be something very difficult to find in practice (honestly, if you want to try finding someone, contact the authors of that study you cited and see if they can guide you in the right direction – and let me know what you find out).
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Mandibular advancement device (MAD) – great option for mild OSA patients, especially those with a positional component (aka someone who has far worse sleep apnea on their back). This is a reasonable option for you to consider despite me not knowing whether your OSA was worse in supine position. The potential pros: it doesn’t require wearing a mask, it’s more easily portable, and less “invasive” if sticking a hard piece of plastic molded to your teeth isn’t invasive to you. The cons: requires $$$ and some insurances won’t cover both CPAP and MADs. Requires time and coordinated efforts: a dentist trained in sleep medicine must take impressions, send them to a lab to be made, and then you must return to a sleep lab with said device after wearing it for 30-60 days to ensure it works. Not impossible, just takes time/effort. I have seen a fair number of these work out for people, but I’ve also seen people who state they chuck them under their bed on a nightly basis.
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What about CPAP? – so CPAP is the gold standard because we know it works when it comes to fixing one of the main problems in OSA, the obstructed airway part. It acts a pneumatic splint to prop that airway open when you fall asleep. IT DOES NOT solve other causes of disrupted sleep, like insomnia, circadian misalignments, nightmares, low arousal threshold (sometimes). It also requires the patient to be compliant. So if you’re using this thing, with very little leak (we’ll touch on your beard comment), at least 5-6 hours nightly, we’d expect some improvement of your symptoms if they were solely due to OSA. This is especially apparent in severe OSA patients, who sometimes we will slap a mask on in the middle of their study and they will wake up feeling like they got the best night of sleep ever. Anytime I give a mild OSA patient CPAP, I emphasize this is a trial and they need to make sure certain things are fulfilled before we can say it was a definite failure 1. They used it nightly >4 hours for several weeks (ideally 5-7 hours, and had been using it for 6-8 weeks) 2. They have very little leak 3. They’ve continued to maintain good sleep habits
Your beard? If you have severe nasal congestion despite treating it in the way I mentioned above, then yes, I’d agree a nasal mask would be a touch difficult. And with a sick beard like yours, a full face mask is going to be a bitch. But what’s more important, your sleep or your beard? If you had severe OSA, that question would read: “What’s more important, not sleeping well and feeling like shit, or your beard?”
So the answer, like most things, is complicated and requires in depth consultation beyond the time we have here online. But I think you are on the right path. Look into figuring out if there are other reasons to feel the way you do during the day, paying attention to common causes like insufficient or dysfunctional sleep. Consider looking into a MAD or picking a different mask/shaving your beard and sticking with CPAP before you look for an experimental therapy that doesn’t seem to be mainstreamed (if you find a speech therapist who does this, really let me know so I can refer my patients there). You’re mild OSA is likely to worsen slightly as you put on weight (it’s okay, there are worse things like being sarcopenic), and as you age (can’t change that one).
Good luck, and keep training.
Nate
