MMA on young patient with light apnea (25yo, AHI 11.9)

[nemui]

Hi, I'm writing this post to seek advice on potential surgical treatment of sleep apnea.

Summary: I'm 25, and have light sleep apnea (AHI=11.9). CPAP treatment didn't resolve my daytime sleepiness; and my sleep ENT doctor suggests I receive a MMA. Should I receive MMA?


Full story: I'm 25, and have a BMI of 19.5. After being pointed out that I was gasping during my sleep, I consulted a sleep specialist. I used CPAP for a year for virtually all occasions that I slept; and a sleep study showed that my AHI decreased to virtually zero (0.4) with CPAP.

However, after using the machine for a year, I was not able to feel the benefit of the machine; in fact, when I visited my sleep clinic a year later and took the Epworth test again, my score had increased.

I was referred to a sleep ENT specialist, who conducted sleep endoscopy for me. He found that I most likely have a deviated septum (nose); and that both my soft palette and tongue base inhibit my airway during my sleep.

He then laid out the surgical treatment options that exist; including a description of the conventional "phase one" treatment; but pointed out its lower success rate and likeliness of my having to receive more treatment in the near future.

An other option that he described was MMA. If I remember correctly, he suggested that my bone structure was a candidate for surgical success; and that a drastic surgery would make sense given that I was young, and my sleep endoscopy showed that my nose, soft palatte and tougue were all possibly was contributing to my apnea.

Hence, I have two sets of questions that I'm interested in understanding more, and am seeking advice:

(1) Given my light apnea, is MMA an adequate surgical option? Conventional wisdom (academic papers) seem to suggest that MMA is typically conducted on relatively older patient with more severe AHI. Does anyone have any knowledge of MMA on younger (20-30s) people?

(2) Given my light apnea, I'm not sufficiently convinced that any sleep apnea surgery would help moderate my daytime sleepiness. Is there anything I can do to be sure that sleep apnea is the primary reason for my sleepiness?

Thank you for any comments and support in advance.

***Edited my age. It was incorrect in the full description.

[kteague]

I remember lots of MMA discussion on here back in maybe 2006 or 2007. There were a couple different young men on here considering the option. The discussions were very precise with xrays of airways and the precise measurements when it is recommended and how much space would be gained by the procedure. I certainly wouldn't accept a look down the throat as absolute confirmation of the need for a radical procedure if it doesn't include precise measurements. Maybe you do have all that?

At any rate, you are very early in the discovery phase of deciding if you could benefit from an MMA, and I commend you for being out here looking for information. I am very conservative when it comes to surgery, but I can tell you of one man known of through a family member had such a tiny airway even CPAP could not keep it open. He described the procedure as brutal, but having saved his life. He had no regrets. But before you get there, here's some things I think you you should look into.

Are you getting adequate hours of sleep? Have you had your oxygen monitored while on CPAP? Have you had a sleep study while using your CPAP at your prescribed treatment level for the whole night? This could reveal any current issues that may not show up on a diagnostic or titration study. In this study you would also want to determine if your sleep stages are in the proper proportion to give you restorative sleep. Do you have any issues with spontaneous arousals that disrupt your sleep stages? Do you have limb movements disrupting your sleep? I would want it to be proven unequivocally that the daytime symptoms are caused by a sleep issue that the MMA would correct. If all else fails to give answers, ask if narcolepsy is a possibility.

In conjunction with this sleep research, assess everything about your health and lifestyle. Even if CPAP does fix your sleep, it can't fix other things that are lacking or maybe out of balance. How's your thyroid doing? How's your Vitamin D? Things like that. I do hope you continue to be diligent with your CPAP use during this time. I was unclear about that from your post. Let us know how your investigation goes.

[kaiasgram]

nemui, I have a question -- During the year you were on CPAP were you monitoring your therapy with available software? You mentioned a low AHI with a subsequent sleep study but that is just one night and I'm wondering how your therapy was actually going during that year. Were you using a machine that shows treatment data including leaks and AHI information?

I think you're very wise to be asking the questions you're asking before committing to a surgical procedure with an uncertain outcome. The findings of your ENT re your anatomical features probably do explain your sleep apnea but may have absolutely nothing to do with your persistent tiredness. If opening your airway with CPAP didn't resolve your daytime sleepiiness, what is the basis (as far as we know right now) for assuming that opening your airway via surgery would resolve it?

I would first take a closer look at your year on CPAP if you have data to look at. If you don't, then I would definitely do another trial of CPAP before doing anything else, making sure you have a data capable machine, and let's see what is actually going on with that. Even with an 'acceptable' AHI a person's therapy can be sub-optimal for a number of different reasons. I'd sure want to rule those things out before heading to the O.R.

[tan]

Hi, I'm writing this post to seek advice on potential surgical treatment of sleep apnea.

Summary: I'm 25, and have light sleep apnea (AHI=11.9). CPAP treatment didn't resolve my daytime sleepiness; and my sleep ENT doctor suggests I receive a MMA. Should I receive MMA?


Full story: I'm 24, and have a BMI of 19.5. After being pointed out that I was gasping during my sleep, I consulted a sleep specialist. I used CPAP for a year for virtually all occasions that I slept; and a sleep study showed that my AHI decreased to virtually zero (0.4) with CPAP.

However, after using the machine for a year, I was not able to feel the benefit of the machine;.

Just one question to help complete your profile: are your hands and feet usually cold?

[49er]

Did you have any Respiratory Events in addition to hypopneas and apneas? And if they weren't noted in your previous sleep study, you might want to have another one at a facility that would measure them with something like a pressure transducer. Unaddressed, they can definitely cause the problems with fatigue you are having.

49er

[nemui]

Thank you all for your responses. They have been very helpful, as I will be meeting my sleep surgery doctor soon, and wanted to learn more about what other treatment options exist/what other diseases might be to blame/what other tests I can do.

Some other tests that seem to be mentioned so far are: test that I should consult a neurologist about (brainwave study?); having my tyroid checked; and tests that I should consult a cardiologist about.

I’ll try to clarify some points. In addition to OSA, there was periodic limb movement during initial sleep study (PLM index 33.1). It is unfortunate that I slept on my back for most of the night during my sleep study; I make some effort to sleep on my side ever since I found out about OSA.

I use the Resmed S9 AutoSet with humidifier and nose mask; with the pressure range set at 10-12. According to the average of the past year form ResScan, median pressure is 10.8; 95th percentile is 11.9.

Data from ResScan suggests that I sleep 6-7 hours per night (6:28 median; 6:18 average); AHI of 0.5; Apnea index 0.2; central 0.1; obstructive 0.0; hypopnea index 0.2. There is some leaking (median 0.0; 95th percentile 24.0); but I’m rarely waken up by the leaking; and my S9 shows a smiley face each morning, so I’ve assumed that this is not an issue.

I believe using CPAP makes me feel just marginally better; although from time to time I experience light bloating which I address with Simethicone in the morning. (I’ve also tried a full face mask, but it was unbearable.)

The reason why I sought alternatives to CPAP was not necessarily because CPAP was unbearable, but because I didn’t feel all that much better with CPAP (for example, I’m more likely to have light headaches without CPAP; but it’s a common occurrence even when using CPAP as well.); at the time I reasoned that it was because having a mask on my face etc. was making my sleep lighter.

My hands and feet are not usually cold.

[tan]

Data from ResScan suggests that I sleep 6-7 hours per night (6:28 median; 6:18 average); AHI of 0.5; Apnea index 0.2; central 0.1; obstructive 0.0; hypopnea index 0.2. There is some leaking (median 0.0; 95th percentile 24.0); but I’m rarely waken up by the leaking; and my S9 shows a smiley face each morning, so I’ve assumed that this is not an issue.

Apnea is just one component. I had a low AHI during my sleep study, but my RDI was moderate - felt really bad. Leaking, yes, can be disturbing. How do your flow limitations look like? This is often overlooked but can also fragment your sleep

[Thatgirl]

I'm still new at this, so I may be missing something, but it seems like therapy would be suboptimal with the Autoset max set at 12 when 95% is 11.9. What is the advantage of having it maxed at 12?

[Pugsy]

I'm still new at this, so I may be missing something, but it seems like therapy would be suboptimal with the Autoset max set at 12 when 95% is 11.9. What is the advantage of having it maxed at 12?

First of all 95% numbers simply mean that that is where the patient was at OR BELOW for 95% of the night....not that is where was at. People often don't understand or forget the "or below" part of the definition.
There can be any number of reasons for limiting the maximum to something close to a 95% number that are very legitimate reasons and don't necessarily mean that therapy is suboptimal which I don't think it is in this situation as the AHI is already quite low.

One reason for limiting the maximum might be aerophagia control...air in the belly can be quite painful and actually make people ill...so we limit the maximum to lessen the chance that happens.
Another reason might be that widely changing pressures disturb sleep and if there is no real urgent need for the pressure to go higher than there's no sense in maybe disturbing sleep unnecessarily.

[nemui]

To update everyone on my latest situation, I've met and discussed with a few sleep-related doctors and professionals (I was introduced to some of these people through common friends, and they were giving me casual (non-medical) advice).

They suggested a number of other tests and considerations that I should make before thinking about surgery.

-Nasal congestion/clogged breathing through nose due to deviate septum: I was prescribed fluticasone (nasal spray), which is commonly used for people with nasal congestion due to allergies. The idea was to clear my nose, and see how much my stuffed nose is contributing to my sleepiness. Another doctor suggested I try those nose strips that marathon runners use.

-Using a nasal pillow: One doctor suggested I try a nasal pillow, for two reasons.
(1) According to this doctor, many people unconsciously adjust their CPAP masks during sleep; which disturbs sleep. A nasal pillow is less likely to leak, and therefore a patient is less likely to have to adjust it during sleep.
(2) Secondly, a nasal mask applies the same pressure to both inside- and outside- the nose; whereas a nasal mask applies pressure only to the inside- of the nose. Therefore, the nasal mask may help open up my congested nose as well.
In particular, this doctor suggested that I use ResMed P10; as it is light and performs well.

-Periodic Limb Movement: My sleep study suggested a PLM of 33. While it is low, one doctor suggested that he will prescribe medication to stop PLM, and see how much better I sleep.

-Sleep rhythm: After pointing out that I wake-up at 10 a.m. and sleep at 2 a.m (I am a graduate student), one doctor suggested I stabilize my sleeping pattern. In particular, he said that I should make an effort to walk 30 minutes each morning after waking up, and that this would help me obtain a better sleep rhythm.

Other considerations
-A number of people have argued that, if I don't feel much better while using CPAP, it is less likely that I'll feel better with MMA.

Again, thank you all for helpful comments and feedback.

[archangle]

Have you considered trying CPAP with a higher pressure? Sometimes that can help with things like UARS and flow limitation. It's fairly easy to try. Even with low AHI, you might still have some less obvious airflow problems.

Be sure and monitor your results to be sure you don't develop central apnea, but that's not really that common.

Have you tried a recording pulse oximeter while using CPAP? The Contec 50D plus and some other Contec pulseoxen are fairly cheap. Just be sure to get a recording pulseox.

Be careful that you and your doctor don't focus too closely on apnea and ignore other possible medical problems.

Try all the things that are cheap, simple and safe. Try sleeping in a recliner, on your stomach, on your side, etc. Try eliminating caffeine, booze, gluten, and other foods. (Not forever, just try various things for a while and see what happens.)

Check carefully for reactions on any medications you're taking, including over the counter meds and any supplements you're taking.

Have you tried taking a video of yourself in your sleep?

[Mabutu]

Hello Nemui

Just wondering if you could get a nasal endoscopy to assess the cause + degree of nasal obstruction and get him to do a Mullers manoeuvre and show you the degree of airway collapsibility . Try to find an ENT who has an interest in OSA

Have you had the X-ray called lateral cephalogram ? Its a crude assessment of airway size based on X-rays and can be ordered by your family doctor . It would be fascinating if you could post the pictures here. Best of luck

[musculus]

Hi, I'm writing this post to seek advice on potential surgical treatment of sleep apnea.

Summary: I'm 25, and have light sleep apnea (AHI=11.9). CPAP treatment didn't resolve my daytime sleepiness; and my sleep ENT doctor suggests I receive a MMA. Should I receive MMA?


Full story: I'm 25, and have a BMI of 19.5. After being pointed out that I was gasping during my sleep, I consulted a sleep specialist. I used CPAP for a year for virtually all occasions that I slept; and a sleep study showed that my AHI decreased to virtually zero (0.4) with CPAP.

However, after using the machine for a year, I was not able to feel the benefit of the machine; in fact, when I visited my sleep clinic a year later and took the Epworth test again, my score had increased.

I was referred to a sleep ENT specialist, who conducted sleep endoscopy for me. He found that I most likely have a deviated septum (nose); and that both my soft palette and tongue base inhibit my airway during my sleep.

He then laid out the surgical treatment options that exist; including a description of the conventional "phase one" treatment; but pointed out its lower success rate and likeliness of my having to receive more treatment in the near future.

An other option that he described was MMA. If I remember correctly, he suggested that my bone structure was a candidate for surgical success; and that a drastic surgery would make sense given that I was young, and my sleep endoscopy showed that my nose, soft palatte and tougue were all possibly was contributing to my apnea.

Hence, I have two sets of questions that I'm interested in understanding more, and am seeking advice:

(1) Given my light apnea, is MMA an adequate surgical option? Conventional wisdom (academic papers) seem to suggest that MMA is typically conducted on relatively older patient with more severe AHI. Does anyone have any knowledge of MMA on younger (20-30s) people?

(2) Given my light apnea, I'm not sufficiently convinced that any sleep apnea surgery would help moderate my daytime sleepiness. Is there anything I can do to be sure that sleep apnea is the primary reason for my sleepiness?

Thank you for any comments and support in advance.

***Edited my age. It was incorrect in the full description.

MMA is not "typically" conducted on relatively older people. Actually young people do better wrt the recovery process. My sleep doctor (a medical professor) has her son done MMA at age 15.

AHI is only one part of the story. RDI is a much better metric for young people. Chances are your "light" apnea will progressed to severe as you age or gradually gaining weight. If CPAP cannot adequately treat you, it's better to treat early on with surgery.

Since you are young and thin, do you have a relatively small lower jaw?