Implants Help Sleep Apnea -- In-Depth Doctor's Interview

Ivanhoe Broadcast News Interview with
Martin Hopp, M.D., Otolaryngologist,
Cedars-Sinai Medical Center, Los Angeles, Calif.,
TOPIC: Implants Help Sleep Apnea

What is sleep apnea, and how does it affect people?

Dr. Hopp: Sleep apnea is a terrible disease, and it affects a huge amount of people. Actually, one in every 20 males has sleep apnea, and 1 in every 30 females has sleep apnea. When you sleep, you breathe through your nose and mouth. When you have sleep apnea, you can't breathe through your nose or mouth. The airway's closed. Your body tries to get a breath and no oxygen goes in. So what happens? You wake up. Your body says, "You're not getting any air -- wake up!" So the response is to come out of sleep and become awake. So every time this happens, you lose sleep. You may never get any deep sleep, because as you go further and further into sleep, your throat collapses and you wake up. You try to go into deep sleep, but your throat collapses again. So if you don't get any deep sleep, guess what you're like in the morning? (He yawns.) You can't -- you can't get out of bed. When you get out of bed, you're not very happy -- so you fight with your kids, you fight with your wife, you get to work, and you're running at half-mast. This is a disease that affects you, your performance, your relationship with your family, and it affects your wife because she can't sleep because you snore. So she's tired. This is a disease that affects two people, you and your wife.

What causes it?

Dr. Hopp: Sleep apnea is an interesting problem. The soft palate is the roof of your mouth and is the tissue that's associated to the uvula, that little thing that, wiggles in the back of your throat. The soft tissue above that is called the soft palate. And when you have sleep apnea, the soft palate collapses. In addition, the back of the tongue also collapses. Now that's very interesting, and you say that makes a lot of sense, because if you sat back in a big easy chair and had a couple of beers, just about everybody collapses. And that's true, but that's not sleep apnea. Believe it or not, you can lie on your stomach and your throat still collapses backwards. That's the problem with sleep apnea.

What is standard treatment?

Dr. Hopp: Standard treatment for sleep apnea is to try to keep the soft palate open, so one of the medical therapies is wearing a mask with continuous oxygen or air going through your nose and throat so that the soft palate doesn't fall backward -- it stays open because air is pushing it open.

So the normal procedure -- the normal treatment is using CPAP (continuous positive airway pressure), a mask that keeps the air flowing and keeps your throat open. A lot of people, however, don't tolerate it very well. It's hard to wear that at nighttime. So other treatments are a dental device -- similar to what people wear when they grind their teeth at night, but again, that's also hard to wear at nighttime if you're not used to it -- and then several surgical procedures. That's what we're here to talk about, because there's a new procedure that's really good and really easy for the patient to undergo.

Tell me what it is.

Dr. Hopp: What we're talking about today is the Pillar Procedure. And the Pillar Procedure stiffens the soft palate, so it can't flop backwards. It's kind of like putting a batten in sail or a stiffening rod in a sail so it doesn't collapse anymore and now it's stiff. If your soft palate is stiff, it doesn't fall backwards, and you don't stop breathing. So then you can sleep, you can go into deep sleep and feel good in the morning.

What are the results of this study? How many patients were in the study?

Dr. Hopp: There have been several studies. Some of them were for people who snore and some of them were for people who have sleep apnea. Now we have to remember, those are sometimes different. When we have sleep apnea, when your throat collapses, you snore. Everybody who has sleep apnea snores. But some people, they don't collapse completely. They only collapse partially. So they don't have sleep apnea. At that partial collapsing is where we see snoring, and that may just be when you're in one position or another. So there are some people who snore who don't have sleep apnea, and there are other people who'd have both. When we looked at patients who just snore, and we studied the effect of the Pillar on snoring patients, three out of every four patients markedly improved or had no snoring after putting the implant in their soft palate. So stiffening that sail stopped the snoring in three out of four patients. Now, still one out of four patients doesn't get better or doesn't have a significant effect, and you still have to help them with something else. But this is a big advance in treatment because the procedure itself is very simple. It doesn't require an operating room, we do it in the office, we do it under local anesthetic, and it's a lot different than all the other surgical procedures for treating snoring and sleep apnea. This is really an easy procedure, although some people may be a little more sensitive. Relative to all the other procedures that we've had in the past -- laser procedures, radiofrequency procedures, all of which work -- this one's a lot easier to do.

How does it work?

Dr. Hopp: The implant is a small, firm piece of bendable suture material that's wrapped up, braided into a little wad. What it does is two things. First, by placing it in the soft palate, the soft palate gets stiff. It doesn't move as easily. But secondly and more importantly, that suture material stimulates scar tissue, and the scar tissue around it acts as another stiffener. That's actually the more important part of stiffening the soft palate. So then you put the Pillar, you put the little rod in the soft palate. A lot of people don't stop snoring. It takes three months -- sometimes even six months -- before there's enough scar tissue that's stimulated by the little suture material to stop and stiffen the soft palate and to stop it from snoring. So it doesn't work immediately. Most of the time, it doesn't work immediately. Some people are actually even worse right after surgery. I wish I knew why, but I don't. But the effect of the Pillar -- of the suture material -- is an immediate effect of stiffening and the secondary effect of inducing scar tissue and stiffening tissue in the soft palate.

As a doctor who has seen this condition for years, how exciting is this for you?

Dr. Hopp: First of all, these patients who come in my office are miserable. Typically, a couple will come in and they haven't slept with each other all night for years. That's really terrible on the patient. They lose a lot of intimacy -- a lot of connections with their spouse, and it really affects people in tremendous ways. It's not unusual for people to come in and tell me they'd like to get divorced because they can't sleep together. Psychiatrists send me patients who are in couples therapy because they realize their biggest problem is they're losing intimacy of just being together in the evening, and this creates problems during the daytime. Now I have something I can offer these patients that I can do without going to the operating room, with Novocain, it's easier than a dental procedure, by far. It's Novocain in the soft palate and placement. It takes about 20 minutes to half an hour, and that's mostly because I have to wait for the Novocain to take effect.

How permanent is the Pillar Procedure?

Dr. Hopp: That's a great question. We've been doing this procedure now for about four years. And so far, it's been very effective for four years. What's great about this procedure is we know that the Pillar stimulates scar tissue over time, and so what we think is over longer periods of time that scar tissue will become even more effective. So we hope and we expect it to be even more effective with time.

So you don't have to come in and get a new set of implants?

Dr. Hopp: Not that we know of yet. Some of the other procedures would need little tune-ups, where we'd treat a patient and three to four years later their snoring would start to come back again and then they would need a tune-up procedure. So far, no tune-ups.

If the scar tissue builds up, could you, would you, or would it even be necessary to take the implant out, but continue to have the relief of symptoms anyway because of the scar tissue?

Dr. Hopp: We think the removal and the residual scar tissue would be as effective as having it in, but we don't know yet. It still hasn't been studied enough to know. I think so, but that's really a personal opinion. We don't have any good basis for that yet.

Are there any side effects, downsides?

Dr. Hopp: The question of side effects and concerns is very important. There are always side effects to anything that gets done, to any medicine, to any surgery. And everyone has to know that. The most important side effect is occasionally your body rejects these and they'll have to come out. So they'll come to the surface and we take them out. And that happens about, from what I can tell, about one in every 50 times. And the other thing that can occur is patients can feel it back there and it kind of sticks out. If that happens, again, we just take it out again. That's the beauty of this procedure is we can take it out. Especially earlier on afterward, when the scar tissue is formed, you can just take it out, let it heal, and then put it in again.

Who is a candidate for this?

Dr. Hopp: A candidate for this procedure is first, someone who's been snoring for several years, male or female. And the only thing you have to remember about snoring is besides the fact that it's male or female, it's skinny or heavy. You don't have to be heavy to have sleep apnea or snoring. I have patients who are very thin -- a marathon runner I have has very severe sleep apnea -- so body type doesn't predict sleep apnea or snoring. But if you can hear the snoring three rooms away, you need to see a doctor.

Wow.

Dr. Hopp: So if you live in an apartment and the neighbor's banging on your wall, you need to see a doctor.

Not everyone with sleep apnea has the kind that will be effectively treated with this procedure, right?

Dr. Hopp: That's right. When I told you three out of four patients get better, it's people who are snoring. The patients who have sleep apnea, again, some people who snore don't have sleep apnea -- which is good. But when you advance to sleep apnea, the procedure is effective in only two out of three patients. So two out of three patients will get better with this. One out of three won't. So it's not as effective, and it's most effective among people who have mild sleep apnea. If you have severe sleep apnea, those are the patients who don't do as well. But if you have mild sleep apnea, you will do really well with this procedure.

What kind of impact does this have on sleep apnea?

Dr. Hopp: You know, we are becoming a society that requires lots of sleeping pills. I just read an article in the paper today that reported that last year, we had the highest number of sleeping pill prescriptions written ever. And this is actually per capita. So even with the increase in the population, per person, the amount of sleeping pills has increased. There are many problems with sleep-deprived people who work and drive. At nighttime, people who are tired, they're tired in the nighttime, they're tired during the daytime. And why are they tired? Because they don't sleep at nighttime. They don't sleep because they have sleep apnea or they're snoring. They keep waking up -- so they go to work tired. They get in a car accident. They fall asleep at a stoplight -- when they're driving on the highway, they're weaving back and forth because they can't stay awake to keep their eyes on the road. This is a big problem with truck drivers who try to drive too much, and it's a big problem with people who work at nighttime. They lose their normal circadian rhythm of sleep, and when they do sleep, they don't sleep very well. There have been many problems with people who work at nighttime who don't have good sleep, and one of the examples is some of the oil disasters that we have -- some of the spills of oil in Alaska have often been attributed to people who have fallen asleep at the wheel. This is a problem that we're still trying to cure. This procedure, the Pillar Procedure, is a great step in helping these patients.

Excellent. FDA approval?

Dr. Hopp: FDA approval for this procedure was obtained seven years ago. It was initially approved for snoring. And now, after the approval for snoring -- as we say, those are two different patients. There was a national study that studied patients with sleep apnea. I happened to be in that study where we looked up patients with mild sleep apnea and also very important with the study, we controlled everything, had to go through institutional review board, controls, safety controls, so that no problem would occur. Patients underwent this as a very strict procedure, and it worked really well for people with mild sleep apnea.

What have you heard from patients who have had this problem and then you treat them with this? What's the feedback?

Dr. Hopp: The feedback for this is great. Again, the most important thing for patients to understand is it takes some time for the stiffness to occur. They gradually improve until all of the sudden, wait a minute, I'm waking up, and I feel good. I slept through the night. The most gratifying thing after a surgery like this that I find, the most gratifying thing a patient can tell me is, "Doc, doc. I'm dreaming again. I haven't dreamed in 10 years." That's deep sleep, and that's what we're trying to get for our patients.

This article was reported by Ivanhoe.com, who offers Medical Alerts by e-mail every day of the week. To subscribe, go to: http://www.ivanhoe.com/newsalert/.

END OF INTERVIEW

This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc., or any medical professional interviewed. Ivanhoe Broadcast News, Inc., assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors in different ways; always consult your physician on medical matters.

If you would like more information, please contact:

Cynthia Harding
Public Relations Director
Cedars-Sinai Medical Center
8700 Beverly Blvd.
TSB Room 210
Los Angeles, CA 90048
(310) 423-4768
cynthia.harding@cshs.org