Every night for 10 years, Tim Holler serenaded his family at bedtime with an unwelcome tune: loud snoring. He had to sleep in another room so his wife could get some rest.
"I was so loud, she couldn't even sleep with ear plugs," says the Bradenton small business owner.
A sleep study revealed Holler, 45, did more than snore loudly at night. He had obstructive sleep apnea, a dangerous condition that caused him to stop breathing hundreds of times a night and wake up gasping for breath.
"It would scare me," said Lisa Holler, Tim's wife of 14 years. "He was so embarrassed and self conscious about the loud snoring and gasping, he wouldn't travel or stay in a hotel because he worried about disturbing other people."
In obstructive sleep apnea, tissue and muscles in the back of the throat relax, narrowing the airway. The loose tissue vibrates as you drift off to sleep, causing snoring. Then, as you shift into deeper, more relaxed sleep, the tissue collapses partially or completely, blocking the airway until the brain tells you to wake up and breath.
Susan Yeatts of Tampa sometimes went as long as a minute without breathing, before she awakened gasping. She was diagnosed with obstructive sleep apnea in 1990, but believes she had the problem since birth. "My mother said I snored so badly as an infant that she couldn't keep my bassinette next to her bed," said Yeatts, now 51 and a pharmacy researcher. A sleep study confirmed that she stopped breathing an average of 73 times an hour, all night long. "I was exhausted all the time," she said. "I never got deep sleep. I was always tired."
Mild sleep apnea can usually be resolved with lifestyle changes like losing weight, not smoking, avoiding alcohol before bedtime and sleeping on your side instead of your back. Dental appliances worn during sleep that keep the lower jaw forward and the airway open, also help in some mild cases.
Mild to moderate apnea may be treated with surgery, including removal of tissue from the back of the mouth and throat, including the uvula, tonsils and adenoids; plastic rod implants are also sometimes used to stiffen the soft palate, making it less likely to vibrate.
When apnea is moderate to severe, the gold standard of treatment is continuous positive airway pressure, commonly known as CPAP. This is a machine that delivers air through a hose or tubing connected to a mask worn while you sleep. The mask fits over the nose or has prongs that fit inside the nose. The air pressure is just enough to keep the airway open and prevent apnea and snoring.
Yeatts was prescribed CPAP right after her diagnosis, but found it cumbersome, difficult to sleep with and awkward, especially as a young woman. Still, she used it on and off for 20 years.
"It worked," she admits, "But it's noisy and intrusive and it's for the rest of your life. Who wants that?"
That was Holler's biggest objection, too. "I would have to use it for the rest of my life," he said. Plus, he found that he tossed and turned too much for CPAP, which "requires you to sleep in one position, on your back, and stay there.''
"I wanted a permanent solution," he said.
Holler and Yeatts both turned to Tampa craniomaxillofacial surgeon Pat Ricalde for a radical procedure that moves the mouth, tongue and chin forward permanently to enlarge the airway.
Maxillomandibular advancement, or MMA, isn't for everyone with apnea, said Ricalde, especially those doing well with CPAP or other conservative treatment.
"The people who come to me have severe apnea and are desperate for a solution," she said. Her patients are so sleep-deprived, they aren't daunted by major surgery.
MMA involves cutting several bones in the face and reconnecting them with small titanium screws and plates. It takes about four hours, requires at least two nights in the hospital and means missing work for two weeks. They can resume normal activities and diet in five to six weeks. The hardware is permanent, but won't set off security alarms at airports, Ricalde says of a frequently asked question.
"Yes, the surgery is a big deal, but the condition—obstructive sleep apnea—is a big deal. It's more than just snoring. Their oxygen levels drop so low that, over time, it increases their risk of heart attacks, strokes and some cancers," said Ricalde.
Dr. Tapan Padhya, co-director of the sleep disorders and snoring clinic at USF Health and Tampa General Hospital says MMA is "an appropriate, accepted surgery.'' But few of his patients who are eligible have it done, "usually because of the long recovery period or insurance issues." The cost can run about $40,000.
Yeatts said it took a year before her insurance company would approve the procedure. She had the surgery six months ago.
"It's made an amazing difference," she said. "I'm happier, more alert, I can stay awake later at night and I can breath easier." She still has some numbness in her bottom lip, but said it has been slowly improving.
Holler had the surgery last April and also has some residual numbness in his lower lip and chin. "It's a weird feeling, but it was worth it," he sys.
He snores much less now and his apnea episodes have dropped from 88 an hour to just three. He and his wife are able to sleep in the same room again and recently took a family vacation for the first time in years.
Irene Maher can be reached at firstname.lastname@example.org